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us-ne/policy/cms/medicaid-state-plan/spa · Axiom

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ATTACHMENT 4.19-A Page 8

June 30, 2009, will be increased by .5% for the rate period beginning July 1, 2010.

10-010.03B3b_Calculation of Stable DI i lu (IME) Cost Payments: Hospitals qualify for IME payments when they receive a direct medical education payment from NMAP, and qualify for indirect medical education payments from Medicare. Recognition of indirect medical education costs incurred by hospitals are an add- on calculated by multiplying an IME factor by the operating cost payment amount.

The IME factor is the Medicare inpatient prospective payment system operating IME factor effective October 1 of the year preceding the beginning of the Nebraska rate year. The operating IME factor shall be determined using data extracted from the CMS PPS Inpatient Pricer Program. For rates effective October 1, 2009, the Department will determine the operating IME factors effective for the Medicare system on October 1, 2008 using the following formula:

{1+(Number of Intems and Residents/Available Beds)}0-405.1] + 1.35

On July 1* of each year, the Department will adopt the Medicare inpatient prospective payment system operating IME factor formulas and rate components in effect on October 1* of the previous year.

10-010.03XXx_ Calculation of MCO Medical Education Payments:

NMAP will calculate annual MCO Direct Medical Education payments and MCO Indirect Medical Education payments for services provided by NMMCP capitated plans from discharge data provided by the hospital.

1.MCO Direct Medical Education payments will be equal to the number of MCO discharges times the MCO direct medical education payment per discharge.

a. The MCO direct medical education payment per discharge is the hospital-specific weighted average fee-for-service DME payment rates for stable DRGs, unstable or low volume DRGs and transplant DRGs, as described in 10- 010.03B3a, 10-010.03B5b and 10-010.03B6b. The weighted average amount shall be based on the claims included in the Fiscal Simulation Analysis as described in 10-010.03B7a.

b. On July 1* of each year, the Department will update the Direct Medical Education payment rates. The Direct Medical Education rates will be increased or decreased based on the annual percentage change in the number of intern and resident FTEs

Transmittal # NE 10-12

Supersedes

AUG 1 8 2010 JUL - 1 2010

Approved Effective

Transmittal # NE 09-10

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Revised Stlomission 7.a7II ATTACHMENT 4.19-B

Item 13d, Page 1a STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State Nebraska

METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES

SECURE PSYCHIATRIC RESIDENTIAL REHABILITATION

Medicaid has researched the cost of an existing similar service to develop a comparable rate. Costs for treatment and rehabilitation services are contained in the Medicaid rate. The rate does not include room and board. The rate for Secure Psychiatric Residential Rehabilitation was last updated on the fee schedule June 1, 2011 and is effective for services rendered on or after that date. Except as otherwise noted in the plan, State developed fee schedule rates are the same for quasi-governmental and private providers of Secure Psychiatric Residential Rehabilitation. See fee schedule at http:/Awww.dhhs.ne.gov/med/provhome.htm.

The State Medicaid agency will have a contract with each entity receiving payment under Secure Psychiatric Residential Rehabilitation services that will require that the entity furnish to the Medicaid agency on an annual basis the following:

e Data, by practitioner, on the utilization by Medicaid beneficiaries of the services included in the unit rate,

. Cost information by practitioner type and by type of service actually delivered within the services unit,

° Provider's annual utilization data and cost information shall support that the required

type, quantity and intensity of treatment services are delivered to meet the medical needs of the clients served. Medicaid Agency or its designee may further evaluate through on site or post pay review of the treatment plans and the specific services delivered as necessary to assure compliance.

COMMUNITY SUPPORT SERVICES

Community Support Services shall be reimbursed on a direct service by service basis and billed in 15 minute increments up to a maximum of 144 units per 180 days.

The rate for community support services was last updated on January 1, 2011, and is effective for services rendered on or after that date. Any annual/periodic adjustments to the fee schedule’ are published on the agency’s website at http://www.dhhs.ne.gov/med/provhome.htm.

This rate will be the same for quasi-governmental and private providers of community support service.

The rate includes all indirect services and collateral contacts that are medically necessary rehabilitative related interventions. |

TN: No. 11-08 Supersedes Approval Date AUG 16 2011 Effective Date TN No. NE 10-17

JUN 0 1 2011

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ATTACHMENT 3.1-A Item 18, Page 2 Applies to both Categorically and Medically Needy

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM

STATE OF NEBRASKA AMOUNT, DURATION AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED

LIMITATION ON THE AMOUNT, DURATION AND SCOPE OF CERTAIN ITEMS OF PROVIDED MEDICAL AND REMEDIAL CARE AND SERVICES ARE DESCRIBED AS FOLLOWS.

Certification of Terminal fliness

The client must be certified as terminally ill with a six-month life expectancy by the Hospice medical director and the attending physician at the beginning of the first benefit period and by the Hospice medical director for all subsequent benefit periods. The hospice provider must obtain written certification of the terminal illness for each certification period even when a single election continues in effect for two or more periods.

Plan of Care

Awritten plan of care must be established and maintained for each client admitted to a hospice program. The care provided to a client must be consistent with the plan and be reasonable and necessary for the palliation or management of the terminal iliness as well as related conditions. The plan of care must be established before services are provided.

Waiver of Payment for Other Services

A client waives all rights to Medicaid payments for the duration of the election of hospice care for the following services:

Hospice care provided by a hospice other than the hospice designated by the client; and

For adult clients, any Medicaid services that are related to the treatment of the terminal condition for which hospice care elected or a related condition or that are equivalent to hospice care except for services provided:

by the designated hospice: or the client's attending physician if that physician is not an employee

of the designated hospice or receiving compensation from the hospice for those services.

TN No, NE 11-14 oe ot 20 a? Supersedes Approval Date Effective Date TN No, MS-04-02

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DEPARTMENT OF HEALTH AND HUMAN SERVICES

FORM APPROVED OMB NO. 0938-9193

HEALTH CARE BINANCING ADMINISTRATION TRANSMITTAL AND NOTICE OF APPROVAL OF 1. TRANSMITTAL NUMBER: 2. STATE STATE PLAN MATERIAL NE {1-14 Nebraska

FOR: HEALTH CARE FINANCING ADMINISTRATION

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

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

4, PROPOSED EFFECTIVE DATE 74-ll

5. TYPE OF PLAN MATERIAL (Check One):

[J NEW STATE PLAN

(] AMENDMENT 10 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 2011 § 88,i44 b, FF¥_ 2012 $ 352,576

8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT,

Attachment 3.1-A, page 7 Attachment 3.1-A, Item 18, page 2 Attachment 3.1-B, page 6

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

Attachment 3.1-A, page 7 Attachment 3.1-A, Item 18, page 2 Attachment 3.1-B, page 6

10. SUBJECT OF AMENDMENT; Concurrent curative care for children receiving hospice service.

1H, 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

kX] OTHER, AS SPECIFIED: Governor has waived review

12, S$]

gNATURE OF S$! , Ye E AGE OFE.

13. TYPED NAME: Vivianne M. Chaumont

14, TITLE: Director, Division of Medicaid and Long-Term Care

15. DATE SUBMITTED: September 26, 2011

16, RETURN TO:

Patricia (Pat) Taft

Division of Medicaid & Long-Term Care Nebraska Department of Health & Human Services 301 Centennial Mall South

Lincoln, NE 68509

__FOR REGIONAL OFFICE USE ONLY

17. DATE RECEIVED:

S eptember 21,201

PPROVED:;

18, DATE ecéon her fl OM

PLAN APPROVED — ONE COPY ATTACHED

19. EFFECTIVE DATE OF APPROVED MATERIAL: 20, SIGNASURE EOL BGC YO Duly 1, 20M 21. TYPED NAME: ~ 22. TITLE: an LMS Regional” Adminsivaker

Pp. Weidler

Sor Medicaid GAd Chi Berens HEL Lperedti ons.

Lon otha 23, REMARKS: J

FORM HCFA-179 (07-92)

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Submission 4 1a./1

Rev ised

Approved OMB#: 0938-1098

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State: Nebraska

1.4 State Medical Care Advisory Committee (42 CFR 431 .12(b))

There is an advisory committee to the Medicaid agency director on health and medical care services established in accordance with and meeting all the requirements of 42 CFR

431.12.

_X___s The State enrolls recipients in MCO, PIHP, PAHP, and/or PCCM programs. The State assures that it complies with 42 CFR 438.104(c) to consult with the Medical Care Advisory Committee in the review of marketing materials.

Tribal Consultation Requirements Section 1902(a)(73) of the Social Security Act (the Act) requires a State in which one or

more Indian Health Programs or Urban Indian Organizations furnish health care services to establish a process for the State Medicaid agency to seek advice on a regular, ongoing basis from designees of Indian health programs, whether operated by the Indian Health Service (IHS), Tribes or Tribal organizations under the Indian Self-Determination and Education Assistance Act (ISDEAA), or Urban Indian Organizations under the Indian Health Care Improvement Act (IHCIA). Section 2107(e)(1) of the Act was also amended to apply these requirements to the Children’s Health Insurance Program (CHIP). Consultation is required concerning Medicaid and CHIP matters having a direct impact on Indian health programs and Urban Indian organizations.

Please describe the process the State uses to seek advice on a regular, ongoing basis from federally-recognized tribes, Indian Health Programs and Urban Indian Organizations on matters related to Medicaid and CHIP programs and for consultation on State Plan Amendments, waiver proposals, waiver extensions, waiver amendments, waiver renewals and proposals for demonstration projects prior to submission to CMS. Please include information about the frequency, inclusiveness and process for secking such advice.

- The Division of Medicaid and Long-Term Care (MLTC) meets on a quarterly basis or as needed with the tribes (Omaha, Ponca, Santee Sioux and Winnebago) and with the CMS Native American contact to discuss relevant Medicaid/CHIP matters that impact the tribes and to invite discussion and comments for consideration.

Effective September 1, 2010, MLTC implemented a policy regarding seeking consultation from all federally recognized tribes, Indian Health Service and Urban Indian Organizations within the state regarding State Plan Amendments (SPA), proposals for demonstrations, and waivers, including proposed, extensions, amendments and renewals,

TN No: 11-15 o Supersedes Approval Date -OCT 13 2011 Effective Date 1" 0.1 201

TN No. MS 03-12

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Revised Submisstor g.1D.1

(1.4 continued)

which may have an impact on those entities. All proposed SPA’s, waivers, and demonstrations will be sent to the Tribes for comment, not just those that we believe will directly impact the tribes. However, purely technical changes that have no impact on the substance of the topic (such as pagination, renumbering of lists, etc.) will not be submitted to the Tribes.

Proposed SPA’s, waivers, and demonstrations are routed to the tribes for comment/input prior to submitting to CMS. The Division of Medicaid and Long-Term Care consults with the tribes by notifying designated tribal entities electronically via email with a description of the proposed change(s). The tribal liaison, which is a position designated by the Division of Medicaid and Long-Term Care, is responsible for maintaining a complete list of iribal contacts and their respective email and mailing addresses. The tribal contact list is updated at the tribal consultation meetings and was last updated at the tribal consultation meeting held in November, 2010, The proposed SPA, waiver, or demonstration is submitted to Tribal Clinics, Health Centers, the IHS Hospital, and to the Nebraska Urban Indian Health Coalition for comment. MLTC allows the tribes 60 days to respond. If nothing is heard from the Tribes by the end of the stated time period, MLTC is then in a position to submit the SPA, waiver or demonstration to CMS. The CMS Native American Contact is copied in this process by the MLTC to telegraph our

efforts to secure comments/input from the Tribes.

If comments are; in fact, received from the tribes, the same is relayed to the Division Director for further consideration. If one tribe has a question or concern about a SPA, waiver amendment, waiver extension, waiver renewal or demonstration proposal, that concern would be communicated and transmitted electronically via e-mail to all other tribes and tribal entities by the tribal liaison. Such communication will specify who raised the concern or comment, the specific nature of the concern or comment, and what the Department proposed to do in response to that concern or comment in an attempt to address or resolve the concern. A management decision is then made as to whether additional action (telephone conferences, meetings, research, etc.) would be appropriate under the circumstances prior to submitting the SPA, waiver or demonstration to CMS.

Comments from the Tribes, or the lack of comments/response, are reported to the CMS Native American Contact, as well as our response/resolution to those comments.

The consultation process established by the Department is based in part on face to face visits and discussions with various tribal entities and the Nebraska Department of Health and Human Services. At the November 29, 2010 meeting, discussions were initiated relating to the proposed SPA consultation process. Tribal Liaison shared the written policy of the Department as it existed at that time regarding the proposed consultation

TN No: 11-15 4 Supersedes _ Approval Date_ OCT 15 201 Effective Date 12 0.1 2011 TN No. New Page

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Q euised Submission &.]5.18

9.2

(1.4 continued)

process, Comments from the tribes regarding the process and how it might impact the tribes were noted and later expressed Lo state Medicaid management. At the November meeting, it was proposed by the Department that the tribes be given notice regarding all proposed SPA’s and waivers, not just those that the Department thought might have some impact on the tribes, Some members expressed the Department should indicate to the tribes which SPA’s and waivers had a direct impact on the tribes in its opinion, The tribes also expressed that it would be helpful to have a process in place to share comments and Department responses to those comments during the consultation process. These suggestions were discussed with Medicaid administrators and adopted by the Department. Current policy is that if one tribe has a question or concern about a SPA or waiver, that concern will be made known to all the tribal entities by the Department, as well as making it known how the Department attempted to resolve the concern,

In order to facilitate the consultation process, the Department will, in advance of the consultation meeting, provide the tribes with a formal agenda describing the SPA’s and waivers that might have relevance to the tribes, as well as other information that will be addressed by the Department. The Department will take minutes of the meeting, which will be available on request, and maintain a record of the same. The Department will ensure that a current roster of participants is kept and maintained, indicating participant’s names, addresses, telephone numbers, and with which group they are associated.

Please describe the consultation process that occurred specifically for the development and submission of this State Plan Amendment, when it occurred and

who was involved.

Initial Amendment In January of 2010, the State received guidance from CMS, SMDL# 10-001, that set forth

the general requirements expected of States to alert tribal entities to proposed State Plan Amendments, waivers, and demonstrations. On February 18, 2010, a Nebraska State/Tribal Consultation Meeting was held. Attending were representatives from the various Tribes in Nebraska, Indian health providers, the Native American Contact from CMS, the Nebraska Medicaid tribal liaison, and the Nebraska Medicaid Director. The tribal consultation issue was discussed in general terms at the meeting and the Tribes expressed a desire to become involved in the consultation process.

Following this, a written process was developed by Nebraska Medicaid outlining the process for the State to follow to secure consultation with the Tribes prior to the State

TN No: [1-15 aye Supersedes Approval Date__QCT_1 3 2011 -—- Effective Date fH Ol 2011

TN No. New Page

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Revi 5ed Submission

9.3

(1.4 continued)

submitting a SPA, waiver, or demonstration, The proposed process was reviewed and approved by Nebraska Medicaid administration. In June, 2010, the protocol for consultation was shared with Medicaid Division staff and sent to the tribal entities.

In October 2010, the State received additional guidance from CMS regarding the consultation process required with tribal entities prior to submitting a SPA, waiver, or demonstration to CMS. The additional guidance required that states give the Tribes a sixty day period to consult. The guidance suggested that states should submit to the Tribes a comprehensible summary of the effect of the proposed SPA, waiver, or demonstration rather than merely submitting the SPA, waiver, or demonstration documents. Nebraska Medicaid revised the protocol for submitting a SPA, waiver, or demonstration and securing tribal consultation and communicated to Medicaid Division staff. On November 2, 2010, the State notified all tribal entities its intent to submit a SPA regarding the tribal consultation process. The letter outlined a summary of the consultation process set forth in the revised protocol.

The tribal consultation issue was discussed in detail at a November 29, 2010 Nebraska State/Tribal Consultation Meeting. Attending were representatives from the various Tribes in Nebraska, Indian health providers, the Native American Contact from CMS, and the Nebraska Medicaid tribal liaison. The tribal consultation issue was discussed in

detail at the meeting.

Current Amendment A communication was sent to all tribal entities June 2, 2011, advising them of the

technical changes and it was also discussed at a meeting with them July 12, 2011.

TN No: 11-15 wes Supersedes Approval Date. OCT 13 2011 Effective Dato_ it. O 1 2011 TN No. New Page

According to the Paperwork Reduction Act of 1995, no persons are required to respond toa collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1098. The time required to complete this information collection is estimated to average 1 hour 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 fo: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

CMS-10293 (07/2013)

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Revised Submigsio, Ff: Io.

DEPARTMENT OF HEALTH AND HUMAN SERVICES

FORM APPROVED OMB NO. 0938-0193

HEALTH CARE FINANCING ADMINISTRATION TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL

2. STATE

1. TRANSMITTAL NUMBER: Nebraska

[1-15

FOR: HEALTH CARE FINANCING ADMINISTRATION

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

TO: REGIONAL ADMINISTRATOR HEALTH CARE FINANCING ADMINISTRATION

DEPARTMENT OF HEALTH AND HUMAN SERVICES

4. PROPOSED EFFECTIVE DATE July 1, 2011

5. TYPE OF PLAN MATERIAL (Check One):

(J NEW STATE PLAN

(] AMENDMENT TO BE CONSIDERED AS NEW PLAN

BQ) AMENDMENT

COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate Transmitiat ‘for each ginendment)

6. FEDERAL STATUTE/REGULATION CITATION:

7, FEDERAL BUDGET IMPACT: a. FFY 2011 $0 b. FFY__ 2012 $0

&. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:

Section 1.4, pages 9, 9.1, 9.2, 9.3,

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

Section I, 1.4, pages 8, 8a, 8b, 8c (TN #10-05} and page 9 (MS- 03-12)

10. SUBJECT OF AMENDMENT:

‘Tribal consultation exception for technical changes and correcting page numbers.

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

[XJ OTHER, AS SPECIFIED: Governor has waived review _

12. SIGNATUBp OF STATE AGENCY, OFFICIAL; Minune He.

16, RETURN TO:

Patricia (Pat) Taft

13. TYPED NAME: Viviarme M, Chaumont

Division of Medicaid & Long-Term Care Nebraska Department of Health & Human Services

14. TITLE: Director, Division of Medicaid and Long-Term Care

301 Centennial Mall South Lincoln, NE 68509

15. DATE SUBMITTED: August 17, 2011

FOR REGIONAL OFFICE USE ONLY

APPROVED:

18, DA! L3.2oll

17. DATE RECEIVED: August [72011

7 PLAN APPROVED ~— ONE COPY 4) PAC

(LZ 19. EFFECTIVE DATE OF APPROVED MATERIAL: 20, SIGRR E ON JiOMA Ake 31. TYPED NAME; —— Y ’ C s x : P 9 Tad, on Dames G. Scott ) - Meddcaid Gad Chidran's Heahtl Qoeretions

23. REMARKS:

FORM HCFA-179 (07-92)

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ATTACHMENT 4.19-A Page 21c

10-010.03H4 Redistribution of DSH Overpayments: As required by Section 1923()) of the Social Security Act related to auditing and reporting of Disproportionate Share

Hospital payments, the Department will implement procedures to comply with the Disproportionate Share Hospital Payments final rule issued in the December 19, 2008, Federal Register, with effective date of January 19, 2009.

Beginning in DSH State Plan Rate Year 2011, if the results of audits conducted in accordance with the DSH final rule indicate that a hospital has exceeded the hospital specific DSH limit the amount of DSH payment in excess of uncompensated care costs will be recouped. Any funds recouped shail first be recouped from Pool 1 | through 5 payments and then from Pool 6 payments and shall be redistributed to other eligible hospitals within the state, provided each hospital remains below their hospital specific DSH limit. Funds recouped from Pools 1 through 6 shall first be redistributed to each eligible hospital in the Pool in which the hospital payment was recouped. Any recouped funds that are not able to be distributed within the Pool will accumulate and be redistributed to all eligible hospitals. The Department will calculate the redistribution as follows: 1. Pool Redistribution

a. First, for each Pool in which funds were recouped beginning with Pool 1 and proceeding in Pool numerical order, each hospital's difference between their DSH payment and DSH limit will be calculated. The difference will be divided by the sum of the difference between the DSH payment and DSH limit for all hospitals in the Pool.

b. Second, the ratio resulting from such division will be multiplied times the total funding recouped for the Pool to determine each hospital's redistribution payment.

c. If the sum of the original DSH payment and redistribution payment exceeds the DSH payment limit, the payment will be reduced.

d. If payment is reduced to a hospital within a Pool, the additional funds will be redistributed prorata to eligible hospitals within the Pool. If all hospitals within the Pool have reached their DSH limit, the remaining funds will be carried forward to be redistributed to all eligible hospitals. For Pool 6, each hospital's difference between their DSH payment and DSH limit will include funds redistributed from Pools 1 through 5 above.

2. Final Redistribution

a. First, for any funds that were not redistributed for each Pool in which funds were recouped, each hospital’s (except for Pool 4 IMDs) difference between their DSH payment and DSH limit will be calculated. The difference will be divided by the sum of the difference between the DSH payment and DSH iimit for all'non-IMD hospitals.

b. Second, the ratio resulting from such division will be multiplied times the total recouped funding not already distributed to determine each hospital's redistribution payment.

c. {f the sum of the original DSH payment and redistribution payment exceeds the DSH payment limit, the payment will be reduced.

d. If payment is reduced to a hospital, the additional funds will be redistributed prorata to eligDible non-IMD hospitals within the Pool. If all non-IMD hospitals have reached their DSH limit, the federal portion of remaining funds will be retumed to CMS.

TN No. NE 11-16 MAR = 3 20i2 Supersedes Approval Date Effective Date APA ~ 4% 2071 TN No. New Page

as Ve ere

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ATTACHMENT 4.19-A- Page 21b

40-010.03H3a(6) Uncompensated Care Pool (Pool 6): Pool 6 consists of hospitals that provide services to low-income persons covered by a county administered general assistance (GA) program; or hospitals that provide services to low-income persons covered by the state administered public behavioral health system.

. 10-010,03H3a(6)(a) Total funding to Pool 6 will be the remaining balance. , of the total (federal and state) DSH funding minus the funding for Pools 1, 2, 3, 4, and 5, The Department will calculate payments as follows:

1. .DSH payments to a hospital under all other pools will be subtracted from the hospital's DSH upper payment limit before \ allocating payments under Pool 6. : 2. The costs for uncompensated care resulting from participation in - county administered general assistance (GA) program will be , reported by the county; and costs for the state administered public behavioral health system will be reported by each hospital. Reported costs will be subject to audit by the Department. 3. A ratio for each hospital will be determined based on the uncompensated cost for each hospital to the total of uncompensated cost for all hospitals in Pool 6. 4. The ratio for each hospital will be multiplied times the available funding to the Pool to yield each hospital’ annual payment amount. 5. The total computable payment will be commensurate with the charges for uncompensated care resulting from participation in county administered general assistance (GA) program; or the state administered public behavioral health system. 6. The annual payment amount will be dispersed in twelve monthly payments. 7. If payment to the hospital exceeds the disproportionate share payment limit, as established under 1923(f) of the Social Security Act, the payment will be reduced to the payment limit. 8. {f payments to hospitals under this pool exceed the total allotment - to Nebraska, the payments will be reduced prorata.

10-010.03H3b Limitations on disproportionate share payments: (1) No payments made under this section will exceed any applicable imitations upon such payments established by Section 1923 (g)(1)(A) of the Social Security Act. (2) Disproportionate share payments to all qualified hospitals for a year will not exceed the State disproportionate share hospital payment limit, as established under 1923 (f) of the Social Security Act.

TN No, 114-16 ‘ MAR = % 2012 Supersedes Approval Date Effective Date APR ~ 1 20t] TN No. MS 06-02 ; ‘

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ATTACHMENT 4,19-A Page 22

40-010.03J Out-of-State Hospital Rates: The Department pays out-of-state hospitals for hospital inpatient services at the peer group rate for a like peer group of Nebraska hospitals. The peer groups are -

1. Metro Acute Care Hospitals: Hospitals located in a Metropolitan Statistical Area (MSAs) as designated by Medicare;

3. Rural Acute Care Hospitals: All other acute care hospitals;

4. Psychiatric Hospitals and Distinct Part Units in Acute Care Hospitals: Hospitals that are licensed as psychiatric hospitals by the licensing agency of the state in which the hospital is located and distinct parts as defined in 471 NAC 10-010.03A.

5. Rehabilitation Hospitals and Distinct Part Units in Acute Care Hospitals: Hospitals that are licensed as rehabilitation hospitals by the licensing agency of the state in which the hospital is located and distinct parts as defined in 471 NAC 10-010.03A.

Operating cost payment amounts are calculated based on the appropriate peer group base payment amount. Capital-related cost payments are made based on the peer group weighted median capital per diem rate. Effective September 1,

2003, capital costs will be calculated as 96.85% of the peer group weighted median cost per day. The cost-to-charge ratio is the peer group average.

Payments for psychiatric and rehabilitation services provided by out-of-state hospitals are made on a prospective per diem. Hospitals are paid based on the peer group per diem rate for the appropriate type of service. Operating cost payment amounts are calculated based on the appropriate peer group per diem rate. Capital-related cost payments are made based on the peer group weighted median capital per diem rate.

The Department may allow payments to out-of-state hospitals for direct or indirect medical education costs at a negotiated per discharge rate.

40-010.03J1 Exception: The Administrator of the Medicaid Division may enter into an agreement with an out-of-state hospital for a rate that exceeds the rate or fee established in 471 NAC 10-010.03J only when the Medical Director of the Department has determined that-

1. The client requires specialized services that are not available in Nebraska; and

2. No other source of the specialized services can be found to provide the services at the rate established in 471 NAC 10-010.03J.

40-010.03K Out-of-Plan Services: When enrollees in the Nebraska Health Connection are provided hospital inpatient services by facilities not under contract with the Department's prepaid health care organizations, the Department contracted prepaid health care organizations are authorized, but are not required, to pay providers of hospital inpatient services who care for individuals enrolled in the Nebraska Health Connection at rates the Department would otherwise reimburse providers under 471NAC 10-010.03ff.

TN No, 11-16 = 4 ot Supersedes Approval Date WAR ~ 3 2012 Effective Date APR ~ 12041

TN No. MS-03-06

(ne-11-19-m)(attachment)(page-1)Page 1#

ATTACHMENT 4,19-B Item 5, Page 1

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

METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES

PHYSICIANS' SERVICES

For dates of service on or after August 1, 1989, NMAP pays for covered physicians’ services at the lower of: 1. The provider's submitted charge; or 2. The allowabie amount for that procedure code in the Nebraska Medicaid Practitioner Fee Schedule in effect for that date of service. The allowable amount is indicated in the fee schedule as: a. The unit value multiplied by the conversion factor (last updated on July 1, 2010); b. The invoice cost (indicated as "IC" in the fee schedule); or c. The reasonable charge for the procedure as determined by the Medicaid Division (indicated as "BR" - by report or "RNE" - rate not established - in the fee schedule). 3. Exception: The Director of the Division of Medicaid and Long-Term Care or designee may enter into an agreement for a negotiated rate with an out-of-state provider which will be based on a percentage of billed charges, not to exceed 100%, only when the Medical Director of the Division has determined that: a. The client requires specialized services that are not available in Nebraska; and b. No other source of the specialized service can be found.

The following is a listing of specialized physician services that have been previously rendered by out-of-state providers:

a. lung transplants; and

b. pediatric heart transplants.

Note: The above listing is not all-inclusive of the specialized physician services that will be reimbursed via negotiated rates in the future, as it is based on previous experience.”

The Nebraska Medicaid Practitioner Fee Schedule was last updated on July 1, 2011 and is effective for services rendered on or after that date. The fee schedule is subject to annual/periodic adjustment. All rates, including current and prior rates, are published and maintained on the agency’s website. Specifically, the fee schedule and any annual/periodic adjustments to the fee schedule are published at htto://www.dhhs ne.gov/med/practitioner fee_schedule.htm.

Physicians and non-physician care providers are subject to a site-of-service payment adjustment. A site-of-service differential that reduces the fee schedule amount for specific CPT/HCPCS codes will be applied when the service is provided in the facility setting. Based on the Medicare differential, NMAP will reimburse specific CPT/HCPCS codes with adjusted rates based on the site-of-service.

The Nebraska Medicaid Practitioner Fee Schedule is effective July 1 through June 30 of each year.

IN# 1418 _MAR 0 6 2012 Effective Date JUL 0 1 201)

Supersedes Approval Date TN #.NE 10-08

(ne-11-20)(form-cms-179)(page-1)Page 1#

DEPARTMENT OF HEALTH AND HUMAN SERVICES

FORM APPROVED OMB NO, 0938-0193

HEALTH CARE FINANCING ADMINISTRATION TRANSMITTAL AND NOTICE OF APPROVAL OF 1, TRANSMITTAL NUMBER: 2. STATE STATE PLAN MATERIAL 11-20 Nebraska

FOR: HEALTH CARE FINANCING ADMINISTRATION

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

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

4, PROPOSED EFFECTIVE DATE duly 1, 201}

5. TYPE OF PLAN MATERIAL (Check One):

([] NEW STATE PLAN

(] AMENDMENT TO BE CONSIDERED AS NEW PLAN

bd AMENDMENT

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

6. PEDERAL STATUTE/REGULATION CITATION:

7. FEDERAL BUDGET IMPACT: a FFY 2011 8( 68,755) b. FF¥ 2012 $(284,517)

8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:

Attachment 4.19-B, Item 9, page 5

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

Attachment 4.19-B, ltem 9, page 5

10. SUBJECT OF AMENDMENT;

Effective date of rates for Pediatric Feeding Disorder Clinic Intensive Day Treatment and Outpatient Treatment

11. GOVERNOR’S REVIEW (Check Ong}: (] GOVERNOR’S OFFICE REPORTED NO COMMENT (] COMMENTS OF GOVERNOR'S OFFICE ENCLOSED [-] NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL

OTHER, AS SPECIFIED: Governor has waived review

12, SIGNATURE Lous STATE AGENCY OFFICIAL:

13, TYPED NAME: Vivianne M. Chaumont

14, TITLE: Director, Division of Medicaid and Long-Term Care

15. DATE SUBMITTED: September 22, 2011

16, RETURN TO:

Patricia (Pat) Taft

Division of Medicaid & Long-Term Care Nebraska Department of Heaith & Human Services 301 Centennial Mall South

Lincoln, NE 68509

FOR REGIONAL OFFICE USE ONLY

17, DATE RECEIVED: S epleaher..24, 9a!

18 DATE APPROVED: December 22, 201!

PLAN APPROVED -- ONE COPY ATTACHED

19, EFFECTIVE DATE OF APPROVED MATERIAL:

20. as i 1

Sly | Qo 21, TYPED NAME: 22, TITLE: Adkins Assoc pegi mel Admini strata —Limathy A. Weidler Medicaid and Children's Heath Qpelt’ on 23. REMARKS:

FORM HCKA-179 (07-92)

(ne-11-23-m)(attachment)(page-3)Page 3#

• ATIACHMENT 4.19-8 Item 2a, Page 1 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State Nebraska METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES Payment for OutpaUent Hospital and Emergency Room Services: For services provided on or after July 1, 2011, the Department pays for outpatient hospital and emergency services with a rate which is the product of: 1. Seventy three (73) percent of the cost-la-charges ralio from the hospital's latest Medicare cost report (Form CMS-2552-89, Pub. 15-11. WOrksheet C); multiplied by 2. The hospital's subm~ted charges on Form CMS-1450 (UB-04). The eHectrve date of the cosHo-charges percentage is the first day of the month folk>wing the Department's receipt of the cost report. Providers shall bill outpatient hospital and emergency room services on Form CMS-1450 (UB 04) in a summary bill fannat Providers shall not exceed their usual and customary charges to non-Medicaid patients when billing the Department. Exception: All outpatient clinical laboratory services must be itemized and identified with the appropriate HCPCS procedure codes. The Department pays for clinical laboratory services based on 97.5% of the fee schedule delermined by Medicare. Payment for Outpatient HospHal and Emergency Room ServiceS Provided by Critical Access Hospitals: Effective for cost reporting periods beginning after July 1, 2011. payment for outpatient services of a CAH is ninety seven point five percent (97,5%) of the reasonable cost of providing the services, as determined under applicable Medicare principles of reimbursement, except that the following principles do not apply: the lesser of costs or charges (LCC) rule and the reasonable compensation equivalent (RCE) limits for physician services to providers. NMAP will adjust interim payments to refted elimination of any fee schedule methods for specific services, such as laboratory or radiology services, that were previously paid for under those methods. Payment for these and other ou1patient services wiD be made in at ninety seven point five percent (97.5%) of the reasonable cost of providing the services. Professional servlces must be billed by the physician or practitioner using the appropriate physician/practitioner provider number, not the facility's provider number. To avoid any Interruption of payment, NMAP will retain and continue to bill under existing provider numbers until new CAH numbers are assigned. TN No. 11-23 IolAR 0 6 20\i'Effective Date 'JUL 0 1 2011 Supersedes Approval Date TN No. NE 1Q-14

(ne-11-23-m)(attachment)(page-4)Page 4#

ATTACHMENT 4.19-8 Item 2a, Page 2 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State Nebraska METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES Payment to Hospilal·Affiliated Ambulatory Surgical Centers: The Department pays for services provided in an HAASe according to Payment for Outpatient Hospital and Emergency Room Services, unless the HAASe is a Medicare-participating ambulatory surgical center (ASC). If the HAASe is a Medicare-participaling ASC, payment is made al the rate established by Medicaid for the appropriate group of procedures. Approval of Payment for Emergencv Room Services: AI least one of the foUowing condilions must be met before the Department approves payment for use of an emergency room: 1. The patient is evaluated or treated for a medical emergency, accident, or injury (see definition of medica; emergency in NAC 10·001 .02); 2. The patient's evaluation or treatment in the emergency room results In an approved inpatient hospital admission (the emergency room charges must be displayed on the inpatient claim as charges and included in the irlpatient per diem); or 3. The patient is referred by a physician such as for allergy shots or when traveling (a written referral by the physician must be attached 10 the claim); The facility should review emergency room services and determine whether services provided in the emergency room constitute an emergency and bill accordingly. When the facdity or the Department determine services are non-emergent, the room fee for non-emergent services provided in an emergency room will be disallowed 10 50 percent of the applicab(e ratio of cost-to-charges. All other Medicaid allowable charges incurred in this type visit will be paid at 73% of the ratio of cosHcrcharges. Diagnostic and Therapeutic Services: The paymenl rate for diagnostic and therapeutic services includes payment for services required to provide the saNtee. Extra charges, such as stat fees, caU~back fees, specimen handling fees, etc., are considered administrative expenses and are included in the payment rate. Payment to a New Hospnal for Outpatient Services: See the definition of a new operational facility in 471 NAC 1()..010.03A. Payment 10 a new hospital (a operational facility) will be made al 73% of the statewide average ratio of cost 10 charges for Nebraska hOSpitals as of July 1 of Ihal year as determined by the Department. This payment is retrospective for the firS1 reporting period for the facility. This ratio will be used until the Department receives the hospital's Initial cost report. The Department shall cost·settle claims for Medlcaid·covered services which are paid by the Department using 73% of the slatewide average ratio of cost to charges. The cost settlement will be the lower of cost or charges as reflected on the hosprtal's cost report (I.e., the Department's payment must not exceed the upper limit of the provider'S charges for services). TN No. 11-23 :JUL 0 1 2011 Effective Date _____ SUper>edes Approval Date TN No. NE 10-14

(ne-11-24-m)(attachment)(page-1)Page 1#

ATTACHMENT 4.19-D Page 1

12-011 Rates for Nursing Facility Servi 12-011.01 Purpose: This section:

1. Satisfies the requirements of the State Plan for Medical Assistance and 42 CFR 447.250 through 42 CFR 447.272;

2. Adopts rate setting procedures which recognize the required level and quality of care as prescribed by all governmental entities (including, but not limited to, federal, state and local entities);

3. Establishes effective accountability for the disbursement of Medical Assistance appropriations; and

4. ~ Provides for public notice of changes in the statewide method or level of payment pursuant to the requirements of Section 1902(a)(13) of the Social Security Act.

014 itions: The following definitions apply to the nursing facility rate determination system.

Allowable Cost means those facility costs which are included in the computation of the facility's per diem. The facility's reported costs may be reduced because they are not allowable under Medicaid or Medicare regulation, or because they are limited under 471 NAC 12-011.06.

Assisted Living Rates means standard rates, single occupancy, rural or urban, per day equivalent, paid under the Home and Community-Based Waiver Services for- Aged Persons or Aduits or Children with Disabilities (see 480 NAC 5).

Department means the Nebraska Department of Health and Human Services.

Division means the Division of Medicaid and Long-Term Care.

IHS Nursing Facility Provider means an Indian Health Services Nursing Facility or a

Tribal Nursing Facility designated as an IHS provider and funded by the Title I or ill of the Indian Self-Determination and Education Assistance Act (Public Law 93-638).

Level of Care means the classification of each resident based on his/her acuity level.

Median means a value or an average of two values in an ordered set of values, below and above which there is an equal number of values.

Nursing Facility means an institution (or a distinct part of an institution) which meets the definition and requirements of Title XIX of the Social Security Act, Section 1919.

Rate Determination means per diem rates calculated under provisions of 471 NAC 12- 011.08. These rates may differ from rates actually paid for nursing facility services for Levels of Care 101, 102, 103 and 104.

Supeeeae Approved _ APR 13 ale Effective JUL - 2 agit

TN# 10-19

(ne-11-24-m)(attachment)(page-2)Page 2#

ATTACHMENT 4.19-D Page 2

Rate Payment_ means per diem rates paid under provisions of 471 NAC 12-011.08. The payment rate for Levels of Care 101, 102, 103 and 104 is the applicable rate in effect for assisted living services under the Home and Community-Based Waiver Services for Aged Persons or Adults or Children with Disabilities (see 480 NAC 5).

Revisit Fees means fees charged to health care facllities by the Secretary of Health and Human Services to cover the costs incurred under Department of Health and Human Services, Centers for Medicare and Medicaid Services, Program Management’ for conducting revisit surveys on health care facilities cited for deficiencies during Initial certification, recertification or substantiated complaint surveys.

Urban means Douglas, Lancaster, Sarpy, and Washington Counties.

Waivered Facility means facilities for which the State Certification Agency has waived professional nurse staffing requirements of OBRA 87 are classified as "waivered" if the total number of waivered days exceeds 90 calendar days at any time during the reporting period.

Weighted Resident Days means a facility's inpatient days, as adjusted for the acuity level of the residents in that facility.

Other definitions which apply in this section are included in Nebraska Department of Health and Human Services Division of Public Health's regulations in Title 175, Chapter 12, Skilled Nursing Facilities, Nursing Facilities, and Intermediate Care Facilities and appropriate federal regulations governing Title XIX and Title XVIII.

42-011,03 General_ Information: Wherever applicable, the principles of reimbursement for providers cost and the related policies under which the Medicare extended care facliity program functions (Medicare's Provider Reimbursement Manual (HIM-15) updated by "Provider Reimbursement Manual Revisions” in effect as of July 1, 2009 are used in determining the cost for Nebraska nursing facilities with exceptions noted in this section. Chapter 15, Change of Ownership, of HIM-15 is excluded in its entirety.

That portion of a provider's allowable cost for the treatment of Medicaid patients is payable under the Nebraska Medica! Assistance Program (Medicaid) except as limited in this section. The aggregate payments by the Department do not exceed amounts which would be paid under Title XVHI principles of reimbursement for extended care facilities.

Except for IHS nursing facility providers, a provider with 1,000 or fewer Medicaid inpatient days during a complete fiscal year Report Period (see 471 NAC 12-011.088) will not file a cost report. The rate paid will be based on the average base rate components, effective July 1 of

the rate period of all other providers in the same care classification, following the initial desk audits.

42: Ilo : The following items are allowable costs under Medicaid.

meeting licensure and certification standards are those costs incurred in order to:

Meet the definition and requirements for a Nursing Facility of Title XIX of the Social Security Act, Section 1919;

TN# NE 114-24 . Supersedes Approved APR 18 2012 Effective JUL-i 2011 TN# 10-19

(ne-11-24-m)(attachment)(page-3)Page 3#

ATTACHMENT 4.19-D Page 10

12-011.06K Salaries of Administrators, Owners, and Directly Related Parties: Compensation received by an administrator, owner, or directly related party is limited to a reasonable amount for the documented services provided in a necessary function. Reasonable value of the documented services rendered by an administrator is determined from Medicare regulations and administrator salary surveys for the Kansas City Region, adjusted for inflation by the federal Department of Health and Human Services (see HIM-15, Section 905.6).

Beginning with the following Calendar year base numbers for 12/31/2010, the Administrator Compensation Maximum Amounts can be calculated based on the following methodology.

Beds Beds Beds Beds Beds Calendar Year HIM% 0-74 75-99 100-149 150-200 200+ 2010 1.5% 81,490 82,954 98,569 99,544 146,388

2011

To determine the Maximum Amount for State Fiscal Year 2011, for each bed category, add 1 to the Calendar Year 2010 HIM % and multiply this amount by 50% of the Calendar Year 2010 bed total. To this amount add 50% of the Calendar Year 2010 bed total. For future years update the Calendar Year information above (A) by replacing the HIM % with the updated HIM % from HIM 15 Section 905.6.

Example: —s- 1+. .015 X 40,745 = 41,356 41,356 + 40,745 = 82,101 Administrator Maximum Amounts for Cost Reports:

Beds Beds Beds Beds Beds State Fiscal Year 0-74 75-99 100-149 150-200 200+ 2011 82,101 83,576 99,308 100,291 147,486

2012

All compensation received by an administrator is included in the Administration Cost Category, unless an allocation has prior approval from the Department. Reasonable value of the documented services rendered by an owner or directly related party who hold positions other than administrator is determined by: (1) comparison to salaries paid for comparable position(s) within the specific facility, if applicable, or, if not applicable, then (2) comparison to salaries for comparable position(s) as published by the Department of Administrative Services, Division of State Personnel in the "State of Nebraska Salary Survey”.

12-011.061L_ Administration Expense: In computing the provider's allowable cost for determination of the rate, administration expense is limited to no more than 14 percent of the total otherwise allowable Direct Nursing and Support Services Components for the facility.

This computation is made by dividing the total allowable Direct Nursing and Support Services Components, less the administration cost category, by 0.86. The resulting quotient is the maximum allowable amount for the Direct Nursing and Support Services components, including the administration cost category. If a facility's actual allowable cost for the two

components exceeds this quotient, the excess amount is used to adjust the administration cost category.

Supersedes Approved Effective

TN# NE 11-24 APR 18 2012 JUL = 2.2011

TN# 10-19

(ne-11-24-m)(attachment)(page-4)Page 4#

ATTACHMENT 4.19-D Page 13

12-011.06P Other Limitations: Other limitations to specific cost components of the rate are included in the rate determination provision of this system.

12-011.07 (Reserved)

12-011,08 Rate Determination: The Department determines rates for facllities under the following cost-based prospective methodology.

42-011.08A Rate Period: The Rate Period is defined as July 1 through June 30. Rates paid during the Rate Period are determined (see 471 NAC 12011.08D) from cost reports submitted for the Report Period ending June 30 two years prior to the end of the Rate Perlod. For example, cost reports submitted for the Report Period ending June 30, 2009 determine rates for the Rate Period July 1, 2010 through June 30, 2011.

12-011,088 Report Period: Each facility must file a cost report each year for the reporting period of July 4 through June 30.

42-011.08C Care Classifications:. A portion of each individual facility's rate may be based on the urban or non-urban location of the facility.

12-011.08D Prospective Rates: Subject to the allowable, unallowable, and limitation provisions of 471 NAC 12-011.04, 12-011.05, and 12-011,06, the Department determines facility-specific prospective per diem rates (one rate corresponding to each level of care) based on the facility's allowable costs incurred and documented during the Report Period. The rates are based on financial, acuity, and statistical data submitted by facilities, and are subject to the Component maximums.

Component maximums are computed using audited data following the initial desk audits, and are not revised based on subsequent changes to the data. Only cost reports with, a full year’s data are used in the computation. Cost reports from providers entering or leaving Medicaid during the immediately preceding Report Period are not used In the computation.

-Each facility's prospective rates consist of three components:

14. The Direct Nursing Component adjusted by the inflation factor;

2. The Support Services Component adjusted by the inflation factor; and 3. The Fixed Cost Component. . The Direct Nursing Component and the Support Services Component are subject to maximum per diem payments based on Median/Maximum computations.

TN# NE 41-24 Supersedes Approved APR 18 2012 Effective JUL — 4 2011

TN# 10-19

(ne-11-24-m)(attachment)(page-5)Page 5#

ATTACHMENT 4.19-D Page 15

42-011.08D3 Fixed Gost Component: This component of the prospective rate is computed by dividing the facility's allowable interest, depreciation, amortization, fong-term rent/lease payments, personal property tax, real estate tax, and other fixed costs by the facility's total inpatient days (see 471 NAC 12-011.06B). Rate determination for the Fixed Cost Component for an individual facility is computed using the lower of its own per diem as computed above, or a maximum per diem of $27.00 excluding personal property and reai estate

taxes. 42-011.08D4 Inflation Factor: For the Rate Period of July 1, 2011 through June

30, 2012, the Inflation factor is negative 3.91%.

12-011.08E Exception Process, An individual facility may request, on an exception basis, the Director of the Division of Medicaid and Long-Term Care to consider specific facility circumstance(s), which warrant an exception to the facility's rate computed for its Fixed Cost Component. An exception may only be requested if the facility's total fixed costs (fotal costs, not per diem rate), as compared to the immediately prior report period, have increased by ten percent or more. In addition, the facility's request must Include:

4. Specific identification of the increased cost(s) that have caused the facility's total fixed costs to increase by 10 percent or more, with justification for the reasonableness and necessity of the increase;

2. Whether the cost increase(s) are an ongoing or a one-time occurrence in the cost of operating the facility; and

3. If applicable, preventive management action that was implemented to control past and future cause(s) of identified cost increase(s).

12-011.08F Rate Payment for Levels of Care 101, 102, 103 and 104: Rates as determined for Levels of Care 101, 102, 103 and 104 under the cost-based prospective methodology of 471 NAC 42-014.08A through 12-011.08E may be adjusted for actual payment. The payment rate for Levels of Care 101, 102, 103 and 104 is the applicable rate in effect for assisted living services under the Home and Community-Based Waiver Services for Aged Persons or Adults or Children with Disabilities (see 480 NAC 5). .

42-011.08G Out-of-State Facillties. The Department pays out-of-state facilities participating in Medicaid at a rate established by that state's Medicaid program at the time of the issuance or reissuance of the provider agreements. The payment is not subject to any type of adjustment.

Supersedes Approved Effective TN# 10-19

TN NE-11-24 APR 18 2012 JUL - 12011

(ne-11-24-m)(attachment)(page-6)Page 6#

ATTACHMENT 4.19-D Page 16

12. 08H R: New Providers:

Definition: A provider is any individual or entity which fumishes Medicaid goods or services under an approved provider agreement with the Department. A new provider is an individual or entity which obtains their initial, facility-specific provider agreement to operate an existing nursing facility due to a change in ownership, or to operate a nursing facility not previously enrolled in Medicaid. For purposes of this definition, "nursing facility" means the business operation, not the physical property. A “new provider’ retains that status until the start of the prospective Rate Period corresponding to the provider's first, full twelve-month Report Period.

Example A: A new provider enters the Medicaid program on May 7, 2007. Their first full twelve- month Report Period is for the period ending June 30, 2008, which corresponds to the prospective Rate Period beginning July 1, 2009. They are a “new provider" from May 7, 2007 through June 30, 2009. .

Example B; A new provider enters the Medicaid program on duly 1, 2007. Their first full, twelve-month Report Period is for the period ending June 30, 2008, which corresponds to the prospective Rate Period beginning July 1, 2009. They are a ‘new provider” from July1, 2007 through June 30, 2009.

Definition: The “Report Period” for a fiscal year determines rates, or interim rates, for a “prospective Rate Period” two years after the Report Period, For example, Report Period 2006- 2007 determines prospective rates, or interim rates, for the 2008-2009 Rate Period.

A. Medicaid rates for new providers, except for IHS nursing facility providers are determined as follows:

14. New providers entering the Medicaid program as a result of a change of ownership:

For the Rate Period beginning on the purchase date through the following June 30, new providers entering the Medicaid program as a result of a change of ownership receive interim Medicaid rates equal to the rates of the selier in effect on the purchase date, subject to maximums and limitations applicable to the Rate Period. The interim rates are retroactively settled based on the facility's audited Medicaid cost report for the Report Period beginning on the purchase date through the following June 30, subject to maximums and limitations applicable to the Rate Period. Providers with 1,000 or fewer annualized Medicaid days during a Report Period do not file a cost report and are not subject to a retro-settlement of their rates.

For the following July 1 through June 30 Rate Period, new providers receive interim tates computed from the seller's audited cost report for the corresponding Report Period, subject to maximums and limitations applicable to the Rate Period. The interim rates are retroactively settled based on the facility's audited Medicaid cost report for the same July 1 through June 30 Report Period, subject to maximums and limitations applicable to the Rate Period. Providers with 1,000 or fewer annualized Medicaid days during a report period do not file a cost report and are not subject to a retro-settlement of their rates.

TN# NE 11-24

JUL - 22011

Supersedes Approved TN# 10-19

APRI8202 caine

(ne-11-24-m)(attachment)(page-7)Page 7#

ATTACHMENT 4.19-D Page 16a

If applicable, for the next July 1 through June 30 Rate Period, new providers receive interim Medicaid rates computed from their initial part-year, audited Medicaid cost report for the Report Period beginning on the purchase date and ending the following June 30, subject to maximums and limitations applicable to the Rate Period. The interim rates are retroactively settled based on the facility's audited Medicaid cost report for the same July 1 through June 30 Report Period, subject to maximums and limitations applicable to the Rate Period. Providers with 1,000 or fewer annualized Medicaid days during a report period do not file a cost report and are not subject to a retro-settlement of their rates.

When “new provider” status no longer applies, rates are computed under 471 NAC 42-011.08D Prospective Rates.

2. New providers entering the Medicaid program to operate a nursing facility not previously enrolled in Medicaid:

For the Rate Period beginning on the Medicaid certification date through the following June 30, new providers entering the Medicaid program to operate a nursing facility not previously enrolled in Medicaid receive interim Medicaid rates based on the average base rate components effective at the beginning of the Rate Period of all other providers in the same Care Classification, The interim rates are retroactively settled based on the facility's audited Medicaid cost report for the Report Period beginning on the Medicaid certification date and ending on the following June 30, subject to maximums and limitations applicable to the Rate Period. Providers with 4,000 or fewer annualized Medicaid days during a Report Period do not file a cost report and are not subject to a retro-settlement of their rates.

For the following July 1 through June 30 Rate Period, new providers receive initial interim rates based on the average base rate components effective at the beginning of the Rate Period of all other providers in the same Care Classification, computed using audited data following the initial desk audits. The initial interim rates are revised based on the provider's audited Medicaid cost report for their first Report Period, subject to maximums and limitations ‘applicable to the Rate Period. The revised interim rates will be issued within ten days of the completion of the initial desk audit of the facility’s cost report. The revised interim rates are retroactively settled based on the facility's audited Medicaid cost report for the same July 1 through June 30 Report Period, subject to maximums and limitations applicable to the Rate Period. Providers with 1,000 or fewer annualized Medicaid days during a report period do not file a cost report and are not subject fo a retro-settlement of their rates.

if applicable, for the next July 1 through June 30 Rate Pericd, new providers will receive interim Medicaid rates computed from their initial part-year, audited Medicaid cost report for the Report Period beginning on the Medicaid certification date and ending the following June 30, subject to maximums and limitations applicable to the Rate Period. The interim rates are retroactively settled based on the facility's audited Medicaid cost report for the same July 1 through June 30 Report Period, subject to maximums and limitations applicable to the Rate Period.

‘TN# NE 11-24 . Maden approves _APRI8 202 rgctve JUL - 12011

TN# New page

(ne-11-24-m)(attachment)(page-8)Page 8#

ATTACHMENT 4.19-D Page 16b

Providers with 1,000 or fewer annualized Medicaid days during @ report period do not file a cost report and are not subject to a retro-settlement of their rates.

When “new provider” status no longer applies, rates are computed under 471 NAC 12-011.08D Prospective Rates.

B. Medicaid rates for new IHS nursing facility providers are determined as follows:

1. New providers entering the Medicaid program as a result of a. change of ownership: For the Rate Period beginning on the purchase date through the following June 30, ‘new providers entering the Medicaid program as a result of a change of ownership receive Medicaid rates equal to the rates of the seller in effect on the purchase date, subject to maximums and limitations applicable to the Rate Period.

For the following July 1 through June 30 Rate Period, new providers receive rates computed from the seller's audited cost report for the corresponding Report Period, subject to maximums and limitations applicable to the Rate Period. :

If applicable, for the next July 1 through June 30 Rate Period, new providers receive Medicaid rates computed from their initial part-year, audited Medicaid cost report for the Report Period beginning on the purchase date and ending the following June 30, subject to maximums and limitations applicable to the Rate Period.

When “new provider’ status no longer applies, rates are computed under 471 NAC 12-011.08D Prospective Rates. :

2. New providers entering the Medicaid program to operate a nursing facility not previously enrolled in Medicaid:

For the following July 1 through June 30 Rate Period, new providers receive rates based on the average base rate components effective at the beginning of the Rate Period of ali other providers in the same Care Classification, computed using audited data following the initial desk audits.

If applicable, for the next July 1 through June 30 Rate Period, new providers will receive Medicaid rates computed from their initial part-year, audited Medicaid cost report for the Report Period beginning on the Medicaid certification date and ending

the following June 30, subject to maximums and limitations applicable to the Rate enod.

When “new provider’ status no longer applies, rates are computed under 471 NAC 12-011.08D Prospective Rates.

Supeedes - approved APR18 202 cteoive __ JUL ~ 2 2011

(ne-11-24-m)(attachment)(page-10)Page 10#

412-0 their

ATTACHMENT 4.19-D Page 18

42-011,08K Special Funding Provisions for Governmental Facilities: City or county- owned facllities are eligible to participate in the following transactions to increase reimbursement. The transaction is subject to the payment limits of 42 CFR 447,272 {payments may not exceed the amount that can reasonable be estimated to be paid under Medicare payment principles), City or county owned refers to the common meaning of ownership of the physical structure(s); the governmental entity may or may not be directly involved in the dally operation of the facility. .

1. City or county-owned facilities with a 40% or more Medicaid mix of inpatient days are eligible to receive the Federal Financial Participation share of allowable costs exceeding the applicable maximums for the Direct Nursing and the Support Services Components, This amount is computed after desk audit and determination of final rates for a Report Period by multiplying the current NMAP Federal Financial Participation percentage by the facility's allowable costs above the respective maximum for the Direct Nursing and the Support Services Components. Verification of the eligibility of the expenditures for FFP is accomplished during the audit process.

42-011,08L Special Funding Provisions for IHS Nursing Facility Providers: IHS nursing facility providers are eligible to receive the Federal Financial Participation share of allowable costs exceeding the rates paid for the Direct Nursing, Support Services and Fixed Cost Components for all Medicaid residents who are IHS eligible. This amount is computed after desk audit and determination of allowable costs for a Report Period. The amount is calculated as the NMAP Federal Financial Participation percentage times the difference between allowable costs for all Medicaid IHS eligible residents and the total amount paid for all Medicaid INS eligible residents, if greater than zero.

12-011,08M (Reserved)

Depreciation: This subsection replaces Medicare regulations on depreciation in entirety, except that provisions concerning sale-leaseback and lease-purchase

agreements (Medicare's Provider Reimbursement Manual (HIM-15), Section 110) are retained, subject to the following Medicaid depreciation regulations.

Tl 2: . TN#NE 1124 poproved __APRI8202 —eftectve __ JUL ~ 1.2011

TN# 10-19

(ne-11-24-m)(attachment)(page-11)Page 11#

ATTACHMENT 4.19-D Page 25

Facilities which provide any services other than certified nursing facility services must report costs separately, based on separate cost center records. As an alternative to separate cost center records and for shared costs, the provider may use a reasonable allocation basis documented with the appropriate statistics. All allocation. bases must be approved by the Department before the report period. A Medicare certified facility must not report costs for a level of care to the Department which have been reported for a different level of care ona Medicare cost report.

12-011.10A Disclosure of Cost Reports: Cost reports for all report periods ending October 30, 1990, or thereafter, are available for public inspection by making a written request to the Department of Health and Human Services, Division of Medicaid and Long-Term Care, Audit. The request must include the name (inctuding an individual to contact), address, and telephone number of the individual or organization making the request; the nursing facility name, location, and report period for the cost report requested; and directions for handling the request (review the reports at the Department's Lincoln State Office Building address; pick up copies at that office; or mail copies). The total fee, based on current Department policy

.dhhs.ni ipolicies/PublicRecords. must be paid. in advance. The nursing facility will receive a copy of a request to inspect its cost report.

12-011.11 Audits: The Department will perform at least one initial desk audit and may perform subsequent desk audits and/or a periodic field audit of each cost report. Selection cf subsequent desk audits and field audits will be made as determined necessary by the Department to maintain the integrity of the Nebraska Medical Assistance Program. The Department may retain an outside Independent public accounting firm, licensed to do business in Nebraska or the state where the financial records are maintained, to perform the audits. Audit reports must be completed on all field audits and desk audits. All audit reports will be retained by the Department for at least three years following the completion and finalization of the audit.

An initial desk audit will be completed on all cost reports. Care classification maximums and average base rate components are computed using audited data following the end of the Cost Report Period. Subsequent desk and field audits will not result in a revision of care classification maximums or average base rate components.

All cost reports, including those previously desk audited but excluding those previously field audited, are subject to subsequent desk audits. The primary period(s) and subject(s) to be desk-audited are indicated in a notification letter sent to the provider to initiate a subsequent desk audit. The provider must deliver copies of schedules, summaries, or other records requested by the Department as part of any desk audit.

TN #. NE 11- . INA NET veg _APRES I oie tUL- 2000 TN #. 10-19 os

(ne-11-24-m)(attachment)(page-14)Page 14#

ATTACHMENT 4.19-D Page 31

For each reporting period, the total resident days (per the MDS system) at each care level are multiplied by the corresponding weight (see 471 NAC 12-013.04). The resulting products are summed to determine the total weighted resident days per the MDS system. This total is then divided by the MDS total resident days per the MDS system. This total is then divided by the MDS total resident days and multiplied by total resident days per the facility's Nebraska Medicaid Cost Report to determine the total number of

Weighted Resident Days for the facility, which is the divisor for the Direct Nursing Component.

12-013,03 Resident Level of Care Weights: The following weighting factors shall be assigned to each resident level of care, based on the CMS RUG III 5.20 version:

Level of Casemix Casemix Index Casemix Index Care Index Value Description Value 163 RAD Rehabilitation/ADL = 17-18 1.66 162 RAC Rehabilitation/ADL = 14-16 1.31 161 RAB Rehabilitation/ADL = 9-13 1.24 160 RAA Rehabilitation/ADL = 4-8 1.07 172 SE3 Extensive Services 3/ADL >6 2.10 171 SE2 Extensive Services 2/ADL >6 1.78 170 SE1 Extensive Services 1/ADL >6 1,54 152 ssc Special Care/ADL = 17-18 11.44 151 SSB Special Care/ADL = 15-16 1.33 150 SSZ Special Care/ADL = 4-14 1.28 145 cc2 Clinically Complex w/Depression/ADL. = 17-18 1.42 144 cc1 Clinically Complex/ADL = 17-18 1.25 143 CB2 Clinically Complex w/ Depression/ADL = 12-16 1,15 142 CB1 Clinically Complex/ADL = 12-16 1.07 141 CA2 Clinically Complex w/Depression/ADL = 4-11 1.06 140 CA1 Clinically Complex/ADL = 4-11 0.95 133 1B2 Cognitive Impairment with Nursing Rehab/ADL= 6-10 0.88 132 1B1 Cognitive Impairment/ADL = 6-10 0.85 131 1A2 Cognitive Impairment with Nursing Rehab/ADL = 4-5 0.72 130 1A1 Cognitive ImpairmentADL = 4-5 0.67 123 BB2 Behavior Prob w/Nursing Rehab/ADL = 6-10 0.86 122 BB1 Behavior Prob/ADL = 6-10 0.82 121 BA2 Behavior Prob w/Nursing Rehab/ADL = 4-5 0.71 120 BA1 Behavior Prob/ADL = 4-5 0.60 115 PE2 Physical Function wiNursing Rehab/ADL = 16-18 1.00 114° «~PE1 Physical Function/ADL = 16-18 0.97 113 PD2 Physical Function w/Nursing Rehab/ADL = 11-15 0.91 112 PD1 Physical Function/ADL = 11-15 0.89 111 PC2 Physical Function w/Nursing Rehab/ADL = 9-10 0.83 110 PC1 Physical Function/ADL = 9-10 ; 0.81 Medicaid Waiver Assisted Living Levels of Care 104 PB2 Physical Function w/Nursing Rehab/ADL = 6-8 0.65 103 PB1 Physical Function/ADL = 6-8 0.63 102 PAZ Physical Function w/Nursing Rehab/ADL = 4-5 0.62 101 PA1 Physical Furiction/ADL = 4-5 0.59 Default Rate — Used When No Assessment is Available

180° STS Short Term Stay * 0.59

TN #. NE 11-24

Supersedes Approved APR 18 2012 Effective JUL — 2 2011

TN #. 10-19 .

(ne-11-24-m)(attachment)(page-16)Page 16#

ATTACHMENT 4.19-D Page 45

The facility must submit Form FA-66, "Long Term Care Cost Report," to the Department for each fiscal year ending June 30. Medicare cost reporting forms may be substituted when Form FA-66 is not otherwise required fo be submitted. Form FA-66 must be completed in accordance with 471 NAC 12-012, Completion of Form FA-66, "Long Term Care Cost Report," and 471 NAC 12-011 ff., Rates for Nursing Facility Services, as applicable. Medicare cost reports must be completed in accordance with Medicare's Provider Reimbursement Manual (HIM- 15). If the facility provides both nursing facility services and special needs services, direct accounting and/or cost allocations necessary to distribute costs between the nursing facility and the special needs unit must be approved by the Department of Health and Human Services, Long Term Care Audit Unit.

The Department shall compute the allowable cost per day from the most recent State fiscal year Form’ FA-66 or the most recent Medicare cost report, as applicable, which will be the basis from which a prospective rate is negotiated. Payment for fixed costs is limited to the lower of the individual facility's fixed cost per diem or a maximum per diem of $54.00 excluding personal property and real estate taxes. Negotiations may include, but are not limited to, discussion of appropriate inflation/deflation expectations for the rate period and significant increases/decreases in the cost of providing services that are not reflected in the applicable cost report. The cost of services generally included in the allowable per diem include, but are not limited to:

a. Room and board;

b. Preadmission and admission assessments,

c. All direct and indirect nursing services;

d. All nursing supplies, fo include trach tube and related trach care supplies, catheters, etc.;

e. All routine equipment, to include suction machine, IV poles, etc.;

f. Oxygen and related supplies;

g. Psychosocial services;

h. Therapeutic recreational services;

i. Administrative costs;

j.. Plant operations;

k. Laundry and linen supplies;

1. Dietary services, to include tube feeding supplies and pumps;

m. Housekeeping; and

n. Medical records.

TN #. NE 14-24

Supersedes

Approval Date APR 18 2012 nective Date JUL = 2 2011

TN#. MS-08-06

(ne-11-24-m)(attachment)(page-17)Page 17#

ATTACHMENT 4.19-D Page 53

31- ayment for ICF/MR Services 31-008.01 Purpose: This section:

14. Satisfies the requirements of the State Plan for Medical Assistance and 42 CFR 447, Subpart C, which provide for payment of ICF/MR services;

2. Adopts rate setting procedures which recognize the required level and quality of care as prescribed by all governmental entities (including, but not limited to, federal, state, and focal entities);

3. Establishes effective accountability for the disbursement of Medical Assistance appropriations; and

4. Provides for public notice of changes in the statewide method or level of payment pursuant to the requirements of Section 1902(a)(13) of the Social Security Act.

31-008,02 General Information: Wherever applicable, the principles of reimbursement for provider's cost and the related policies under which the Medicare extended care facllity program functions (Medicare's Provider Reimbursement Manual (HIM-15) updated by "Provider Reimbursement Manual Revisions" in effect as July 1, 2009) are used in determining the cost for Nebraska ICF/MRs with exceptions noted in this section. Chapter 15, Change of Ownership, of HIM-15 is excluded In its entirety.

That portion of a provider's allowable cost for the treatment of Medicaid patients is payable under the Nebraska Medical Assistance Program (Medicaid) except as limited in this section. The aggregate payments by the Department do not exceed amounts which would be paid under Title XVIII principles of reimbursement for extended care facilities.

31-008.03 Allowable Costs: The following items are allowable costs under Medicaid.

31-008,03A Cost of Meeting Licensure and Certification Standards: Allowable costs for meeting licensure and certification standards are those costs incurred in order to:

4. Meet the definition in 42 CFR 440.150;

2. Comply with the standards prescribed by the Secretary of Health and Human Services (HHS) in 42 CFR 442;

3. Comply with requirements established by the Nebraska Department of Health and Human Services, Division of Public Health, the agency responsible for establishing and maintaining health standards, under 42 CFR 431.610; and

4. Comply with any other state law licensing requirements necessary for providing skilled nursing or intermediate care facility, as applicable.

31-008.03B Items Included in Per Diem Rates: The following items are included in the per diem rate:

TNi# NE11-24 APR 18 2012 Supersedes Approved Effective JUL. 1 200i TN# 10-19

(ne-11-24-m)(attachment)(page-18)Page 18#

ATTACHMENT 4.19-D Page 61

31-008,05K Certificate of Need Approved Projects: Notwithstanding any other provision of 471 NAC 31-008, the fixed costs reported to the Department for a Division of Public Health Certificate of Need reviewed project must not exceed the amount that would result from the application of the approved project provisions including the estimated interest rates and asset lives.

Certificate of Need provisions recognized by’ the Department, for the purposes of rate setting, is the original project as approved, the approved project amendments submitted within 90 days of the transfer of ownership or opening of newly constructed areas, and the allowable cost overruns disclosed in a final project report submitted to the Division of Public Health within 180 days of the opening of newly constructed areas. Project amendments and project reports submitted to the Division of Public Health Certificate of Need after the periods defined above will be recognized upon approval beginning on the date that the amendment or report is received by the Division of Public Health. The added costs incurred before the date the late amendment or report is filed will not be recognized retroactively for rate setting.

ICF/MRs with 4-15 beds are excluded from Certificate of Need requirements.

31-008.05L_ Salaries _of Administrators, Owners, and Directly Related Parties: Compensation received by an administrator, owner, or directly related party is limited to a reasonable amount for the documented services provided in a necessary function. Reasonable value of the documented services rendered by an administrator is determined from Medicare regulations and administrator salary surveys for the Kansas City Region, adjusted for inflation by the federal Department of Health and Human Services (see HIM-15, Section 905.6). See 12-011.06K for Administrator compensation maximum amounts.

31-008.05M_ Administration Expense: In computing the provider's allowable cost for determination of the rate, administration expense is limited to no more than 14 percent of the total otherwise Personnel Operating and Non-Personnel Operating Cost Componenis for the facility. ra ; .

Supersedes Approved

TN# NE11-24 APRS 2012 effective YUL ~ 4 2011 TN# 10-19 |

(ne-11-24-m)(attachment)(page-19)Page 19#

ATTACHMENT 4.19-D Page 62

’ This computation is made by dividing the total allowable Personnel Operating and Non- Personnel Operating Cost Components, less the administration cost category, by 0.86. The resulting quotient is the maximum allowable amount for the Personnel Operating and Non-Personnel Operating Cost components, including the administration cost category. If a facility's actual allowable cost for the two components exceeds this quotient, the excess amount is used to adjust the administration cost category.

31-008.05N Facility Bed Size Exception: Rates for any privately-owned ICF/MR with less than 16 beds that received Medicaid reimbursement prior to July 1, 2009 will be determined based on the methodology described in 471 NAC 31-008.08C for ICF/MRs with 16 or more beds.

31 Other Limi is; Other limitations to specific cost components of the rate are included in the rate determination provision of this system.

31-008,08 Rate Determination: The Department determines rates under the following guidelines:

31-008.06A Rate Period: The Rate Period for non-State-operated ICF/MR providers is defined as July 1 through June 30. Rates paid during the Rate Period are determined from cost reports submitted for the Report Period ending June 30. two years prior to the end of the Rate Period (see 471 NAC 31-008.06C1). For example, cost reports submitted for the Report Period ending June 30, 2009 determine rates for the Rate Period July 1, 2010 through June 30, 2011.

The Rate Period for State-Operated ICF/MR providers is defined as July 1 through June 30..

31:008.06B Report Period: Each facility must file a cost report each year for the reporting period ending June 30.

1-008. for Intermediate Care Facili r_th I arded_(ICF/M Excludi O} CE/MR iders:

31 1_ICF/MR: 18 b 4

Subject to the allowable, unallowable, and limitation provisions of this system, the Department determines facility-specific prospective per diem rates based on the facility's allowable, reasonable and adequate costs incurred and documented during the Report Period. The rates are based on financial and Statistical data submitted by the facilities. Individual facility prospective rates have five components:

4. we ICF/MR Personnel Operating Cost Component adjusted by the inflation ctor;

The ICF/MR Non-Personnel Operating Cost Component adjusted by the inflation factor;

The ICF/MR Fixed Cost Component;

The ICF/MR Ancillary Cost Component adjusted by the inflation factor, and The ICF/MR Revenue Tax Cost Component.

Aho NV

Sd Approved APR18 202 crective JUL — 1.2011

TN# 10-19

(ne-11-24-m)(attachment)(page-20)Page 20#

ATTACHMENT 4.19-D Page 67

31-008.06C4b ICF/MRs with 4-15 beds:

The Non-Personnel Operating Cost Component of the Final Rate is the allowable non-personnel operating cost per day as computed for the ICF/MR provider's most recent cost report period.

31-008,08C5 ICF/MR Fixed Cost Component: This component includes the interest, depreciation, amortization, long-term rent/llease payments, personal property tax, real estate tax, gross revenue tax, and other fixed costs. The fixed cost component is the allowable fixed cost per day as computed for the facility's most recent cost report period.

31-008,06C8 ICF/MR Ancillary Cost Component: The ancillary cost component of the rate is the allowable ancillary cost per day as computed for the facility's most recent report period.

31-008.06C7_ICF/MR Inflation Factor. For the Rate Period of July 1, 2011 through June 30, 2012, the inflation factor is O%.

31-0 ICF/MR Revenue Tax 08.06C8a | i or 8

Under the {CF/MR Reimbursement Protection Act, the iCF/MR revenue tax per diem is computed as the prior report period net revenue divided by the prior report period facility resident days. (See 405 NAC 1-003.).The Tax Cost Component shall be prorated when the revenue tax is based on less than a full fiscal year’s data.

31-008.06C8b ICF/MRs with 4-15 beds:

‘Under the ICF/MR Reimbursement Protection Act, the ICF/MR revenue tax per diem is computed as the prior report period net revenue times the applicable tax percentage(s) divided by the prior report period facility resident days. (See 405 NAC 1-003.). The Tax Cost Component shall be prorated when the revenue tax is based on less than a full year’s data.

31-008.06C9 ICE/MR Exception Process: An individual facility may request, on an exception basis, the Director of the Division of Medicaid and Long-Term Care to consider specific facility circumstance(s), which warrant an exception to the facility's rate computed for its Fixed Cost Component. An exception may only be requested if the facility's total fixed costs (total costs, not per diem rate), as compared to the immediately prior report period, have increased by ten percent or more, In addition, the facility's request must include: 1. Specific identification of the increased cost(s) that have caused the facility's total fixed costs to increase by 10 percent or more, with justification for the reasonableness and necessity of the increase;

2. Whether the cost increase(s) are an ongoing or a one-time occurrence in the

cost of operating the facility; and

3. If applicable, preventive management action that was implemented to control

past and future cause(s) of identified cost increases(s}.

TN# NE 11-24 APR 18 2012

Supersedes TN# 40-19

Approved Effective JUL - 2 2014

(ne-11-24-m)(attachment)(page-21)Page 21#

ATTACHMENT 4.19-D Page 69

31-008.06D4_Non-Personnel_ Operating _Cost Component; This component includes all costs other than salaries, fringe benefits, the personnel cost portion of purchased services, and the personnel cost portion of management fees or allocated expenses for the administrative, dietary, housekeeping, laundry, plant related, and social service cost centers. The Non-Personne! Operating Cost Component of the Final Rate Is the allowable non-personnel operating cost per day as computed for the ICF/MR provider's most recent cost report period.

31-008.08D5 Fixed Cost Component: This component includes the interest, depreciation, amortization, long-term rent/lease payments, personal property tax, real estate tax, and other fixed costs. The Fixed Cost Component of the Final Rate Is the allowable fixed cast per day as computed for the ICF/MR provider's most recent cost report period.

31-008,06D8_ICF/MR Revenue Tax Cost. Component; Under the ICF/MR Reimbursement Protection Act, the ICF/MR revenue tax per diem is computed as the prior report period net revenue divided by the prior report period facility resident days. (See 405 NAC 1-003.). The Tax Cost Component shall be

prorated when the revenue tax is based on less than a full fiscal year’s data.

31-008.08E Out-of-State Facilities. The Department pays out-of-state facilities participating in Medicaid at a rate established by that state's Medicaid program at the time of the issuance or reissuance of the provider agreement. The rate will not exceed the average per diem being paid to Nebraska non-State-operated facilities for services in a similar care classification. The payment is not subject to any type of adjustment. -

31-008.08F Initial Rates for New Providers:

31-008,06F1 Initial Rates for New Providers of ICF/MRs with 16 beds or more: Providers entering Medicaid as a result of a change of Ownership-will receive rates as follows. The rate in effect at the tirie of the charige in ownership will be paid to the new provider for the remainder of the rate period. For the next rate period, the cost reports. for all owners during the report period will bé combined. The combined report will be the complete cost report for that facility and'will be used for rate determinations and limitation'deferminations. 6 ' ’

Providers entering Medicaid as a result of new construction, a facility re-opening, or a certification change from Nursing Facility to ICF/MR will receive a prospective rate equal to the average prospective rate of all Nebraska non-State- operated facilities of the same care classification. The rate will change at the beginning of a new rate period. The rate will be based on the care class average until the provider's first rate period following participation in the program for one full report period. .

Supersedes TN# 10-19

TN NE 11-24 pr 820%

sepa execne JUL 2201

(ne-11-24-m)(attachment)(page-22)Page 22#

ATTACHMENT 4.19-D Page 76

Facilities that provide any services other than certified ICF/MR services must report costs separately, based on separate cost center records. As an alternative to separate cost center records and for shared costs, the provider may use a reasonable allocation basis documented with the appropriate statistics. All allocation bases must be approved by the Department before the report period. Any Medicare certified facility must not report costs for a level of care to the Department which have been reported for a different level of care on a Medicare cost report.

31-008.08A Disclosure of Cost Reports: Cost reports for all report periods ending October 30, 1990, or thereafter, are available for public inspection by making a written request to the Department of Health and Human Services Audit Unit. The request must include the name (including an individual to contact), address, and telephone number of the individual or organization making the request, the ICF/MR name, location, and report period for the cost report requested; and directions for handling the request (review the reports at the Department's Lincoln State Office Bullding address; pick up copies from the Department; or mail copies). The total fee, based on current Department policy (http/éwww2.dhhs.ne.qov/policies/PublicRecords.odf) must be paid in advance. The ICFIMR will receive a copy of a request to inspect its cost report.

31-008.08B Descriptions of Form FA-66, "Long-Term Care Gost Report": All providers participating in Medicaid must complete Form FA-66, consisting of Schedules “General Data," A (Parts 1 and 2), B (Parts 1, 2, 3, and 4), B-1, B-2, B-3, B-4, B-5, C, D, (Parts 1, 2, and 3), D-1, E (Parts 1 and 2), E-1, .F (Parts 1.and 2) and "Certification by Officer, Owner, or Administrator." (See 471-000-41 and 471-000-42 for an example of all schedules.) For FA-66 must be completed in accordance with regulations found at 471 NAC 12-012. Form FA-66 contains the following schedules, as described:

1. General Data: This schedule provides general information concerning the provider and its financial records.

2. Schedule A, Occupancy Data: This schedule summarizes the licensed capacity and Inpatient days for all levels of care.

Part 1 identifies the certified days available, and Part 2 identifies the inpatient census data of the facility. This data fs used in determining the divisor in computing the facility's per diem rate.

3. Schedule B, Revenue and Costs: This schedule reports the revenues and costs incurred by the provider. The schedule begins with the facility's trial balance, and identifies revenue offsets, adjustments, and/or allocations necessary to arrive at the Medicaid reimbursable costs.

Part 1 identifies all revenues from patient services and any necessary offsets to Costs from these revenues. Part 2 Identifies other revenues realized by the facility and any necessary offsets to costs from these revenues. Part 3 identifies the facility's costs, summarizes the revenue offsets, summarizes the cost adjustments, and reports any necessary allocation of relmbursable costs. Part 4 summarizes the revenue and costs reported in parts 1, 2, and 3, and reports net income and identifies provision for income tax.

TN# NE 11-2 INANE 24 oroved _ APRAS 20 recive _1UL ~ 12041

TN# 10-19

(ne-11-24-m)(attachment)(page-23)Page 23#

OS Notification State/Title/Plan Number: NE 11-024 Type of Action: SPA Approval Required Date for State Notification: 05/24/2012

Fiscal Impact: FY 2011 ($1,247,016) FY 2012 ($4,988,062)

Number of Services Provided by Enhanced Coverage, Benefits or Retained Enrollment: 0

Number of Potential Newly Eligible People: 0

Eligibility Simplification: No

‘Provider Payment Increase: No

Delivery System Innovation: No Number of People Losing Medicaid Eligibility: 0 Reduces Benefits: No

Detail:

Effective July 1, 2011, this SPA proposes a 2.5% reduction in NF payment rates and proposes that ICF/MR payment rates do not receive an inflation adjustment for SFY 2012. The SPA also removes obsolete language and adds clarifying language enabling the State plan to flow from year-to-year eliminating the need for certain annual updates.

Although this SPA proposes a rate cut for NF services, the rate cut will not go into effect. The State also submitted SPA 11-029 which proposed a rate increase of 3.03% for NFs effective July 1, 2011 upon CMS approval of a new NF provider tax. On April 3, 2012, CMS approved the State’s request for a waiver of uniformity requirements and the new provider tax is effective July 1, 2011. The NIRT is processing SPA 11-029 for approval and when approved it will immediately supersede SPA 11-024. Therefore, the NF rate cut will never go into effect and the actual budget impact of SPA 11-024 is zero.

Since this SPA initially proposed a rate reduction, as part of our review we requested that the State provide information that supported their assertion that access to services would not be affected by the reduced rates. The State engaged providers, provider organizations and client representatives in 2011, and had several meetings with the Medical Assistance Advisory Committee, to communicate the Department’s fiscal limitations and legislative mandate to reduce expenditures. Providers expressed their disappointment about reductions, but understood the

(ne-11-24-m)(form-cms-179)(page-1)Page 1#

ella aalamamnemmamasiaaaaiebemiaiabiniehiaiaeiniiia nee anne 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 NE 11-24 ; Nebraska FOR: HEALTH CARE FINANCING ADMINISTRATION 3, PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) TO: REGIONAL ADMINISTRATOR 4. PROPOSED EFFECTIVE DATE HEALTH CARE FINANCING ADMINISTRATION July 1, 2011

DEPARTMENT OF HEALTH AND HUMAN SERVICES

5. TYPE OF PLAN MATERIAL (Check One): () NEW STATE PLAN

(] AMENDMENT TO BE CONSIDERED AS NEW PLAN

AMENDMENT

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

6. FEDERAL STATUTE/REGULATION CITATION:

7. FEDERAL BUDGET IMPACT: a.FFY 2011 $(1,247,016) b.FFY 2012 $(4,988,062)

8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: Attachment 4.19-D, pp 1,2,10,13,15,16,16a,16b,17,18,25,27,28,31,32,

45,53,61,62,67,69,76

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

Attachment 4.19-D, pp 1,2,10,13,15,16,17,18,188,25,27,28,31, 32,45,53,61,62,67,69,76

10. SUBJECT OF AMENDMENT: Rate reduction for nursing facilities and ICF-MR

11. GOVERNOR’S REVIEW (Check One): (] GOVERNOR'S OFFICE REPORTED NO COMMENT

OTHER, AS SPECIFIED:

({] COMMENTS OF GOVERNOR’S OFFICE ENCLOSED Governor has waived review (] NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL 12. SIGNA’ F STATE AGENCY Lis E 16. RETURN TO: devi Patricia (Pat) Taft 13. veo we Ch t Division o' of Medicaid & 1.ong-Term Care in = aumony rent of Health & Human Services

Director, Division of Medicaid and Long-Term ox

15. DATE SUBMITTED:

___ September 12, 2011 FOR TESTONAT: OFFICE USE ONLY. : 18. DATE APPROVED: 17. DATE RECEIVED: APR 13 2012 PLAN APPROVED — ONE COPY ATTACHED ; ROVED MATERIAL: 20. SIG OF REGIONAL OFFICIAL: 19. EFFECTIVE DATE OF APP RAY not f

21. TYPED NAME: Penmeof hom (PSe AL

*6 Pe bay “Dwector, Cmes

23, REMARKS:

FORM HCFA-179 (07-92)

(ne-11-25-m)(attachment)(page-4)Page 4#

ATIACHMENT 4.19-B Item 6b. Page 1 STATE PLAN UNDER TiTlE XIX OF THE SOCIAL SECURITY ACT Slate Nebraska METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES OPTOMETRISTS' SERVICES NMAP pays tOf covered optometrists' services at the lower of: 1. The provider's submitted charge; or 2. The allowable amount for that procedure code in the Nebraska Medicaid Practitioner Fee Schedule in effect for that date of service . Ttle allowable amount is indicated in the fee schedule as ' a, The unit value multiplied by the conversion (actor; b. The invoice cost (indicated as "Ie" in the fae schedule) - the provider's actual cost (including discounts) fram the providers supplier. The maximum invoice cost payable is limited to reasonable avajla~e cost; c. The maximum allowable dollar amount; or d. For clinical laboratory services, including collection of laboratory specimens by venipuncture or catheterization, payment is 97.5% of the fee schedule determined by Medicare. e. The reasonable charge for the procedure as determined by the Medicaid Division (indicated as "BR" • by report or "RNE" - rate not established - in the fee schedule). Revisions of the Fee ScheduJe: The Oepanment may adjust the fee schedule to: 1. Comply with changes in state or federal requirements: 2. Comply with changes in nationally-recognized coding systems, such as HCPCS and CPT: 3 Establish an initial allowable amount for a new procedure or a procedure that was previously identified as ''RNEw or "BR" based on information thai was not available when the fee schedule was established for the current year; and 4. Adjust the allowable amount when the Medicaid Division determines that the current allowable amount is: 3. Not appropriate for the service provided; or b. Based on errors in data or calculation. Providers w~1 be notified of changes and their effective dates NMAP pays for injections at the wholesale cost of the drug plus an administration fee determined by the Depanment. TN~. NE 11-25 JUL 0 1 2011 Sl4>ersedes App.'l)val Date MAR 0 6 2012 Effec1ive Date _____ IN #. Ms-oo-06

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- - - -- - ------ - UlirARTMl-:NT 01' III:ALTlI ,\.),,'0 1IlJM"'"" SERVICES FORM AI'PRl)VI,f) IIE,I,Lnl (;111(1, FINANCING AI)MINrSTRATION OM13 NO. 09JS-o r9.l TRANSMITTAL AND NOTICE OF APPtWVAL-OF·--- · I. TRA~SMIl1 'AL NUMBER:- 12. STATE STATt PLAN MATERIAL I J-25 Ncbrnska fOR, HI:Al.TIl CARE FINANCING ADMINISTRATION 3. PROGRAM IDENTIFICATlcJN:-TITLE XIXOFlll E --- SOCIAL SECURITY ACT (MEDICAIl)} TO: RF.(iIONAL AIJMINI STRKrO~-· '- ----·--- --- ·4.viWPOsED HrOCTIVF: n ATE HEALTH CARE PINANCING ADMINISTRATION I July J. 2011 DEPARTMENT Of ill:" LTH AND IIUMAN ~ER y"[ _ __ _ ____......._.w _ _ __•. __ <': l~S_ ----L. _ _ _______ 5, TYPE OF PLAN MATER.IAL (Check Olle): o NEW STATE PLAN 0 AMENDMENT TO BE CONSIOERED AS NEW f"LAN t8I AMENDM e NT COMPLETE 8LOCKS 6 THRU 10 IF ·n11S IS AN AMENDMl--:NT Se urUle TrQlUmjlltJf or e.uc/IIIMcndmem) 6"7EDER~\1. STATU;j-EfREGULATJON CITATION: 8. PAGE NUMBER 6~-niEjij"~ANsECTioN ORATTACHMENT: AltllChment 4.19-U, Itcm:3, ptlf:!;l! 2 Allachmcnt 4.19· 13, hel1l4b, page I Anac:hm.::nt 4.19-B, He-Ill 6~, pa:;c I AUach'llcn! 4.19-U, llem 6b, page I /Illachml'!lt 4. 19-0, Ilem 12d ~==~=;;=-.--- 10. SUOJ[CTOF AMENDME:.'NT: Laboratory fee :>c hcnulr; reduction. II . GOVERNOR'S REVIEW (Check One): o GOVERNOR'S OFFICE REPORTEil NO COMMENT o COMMENTS OF <1QVERNOR'S OFf·ICE ENCLOSED 0 1\'0 REPLY RECEIVED WIT!nN 45 DA VS OF SUHMITIAL ~1dU~~Z,~&~~~t.. _;'.;;'!~~.M.Q~".~"L___.______._____ .. 7. r EDERAL BlJlXiET IMPACT: -- a. rry 2011 $(19.471) b. Fry 20 12 £(77,8R2) _ 9. F'AGE NUMREU OF THE SUPERSEDED Pl.AN SEC.TlON OR A1-rACUMBNT (IfA,1plicl.lble) : Attlchmcnt4 .19-B, Item J, page 2 AnachmenI4.J9·B, lto.!n14b. pllge I AllachlTlenl4.19· B, Ilcm 6a, page I Altachmenl d.19·R, Item 6b, pilge I ~.\~c h men! 4, 19·8, l1em 12U fSI OTHER, AS SPEC/PlEO: Governor ha\ waive.d review ._ _ .. __-I Patricia Wall Taf'! _________....j I1jvisinn of Medicaid &. Long.Tctm Care Nebraska: Department of Hcah.h & Human Services -i1~!¥it~If.f,~t~fk~1£~~"!'.'!J..-<'~:I!'!~.9rr_---'- -1 ) 01 Ceotconi.1 Mall SOUlh 1 ' Linculn, NE 68509 15. 1 '1 F()KM HCFA- 179 (07·92)

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ATTACHMENT 4.19-D Page 13

12-011.06P_ Other Limitations: Other limitations to specific cost components of the rate are included in the rate determination provision of this system.

12-011.06Q Nursing Facility Quality Assessment: The nursing facility quality assessment is an allowable cost addressed through the Nursing Facility Quality Assessment Component.

12-011.07 (Reserved)

12-011.08 Rate Determination: The Department determines rates for facilities under the following cost-based prospective methodology.

12-011.08A Rate Period: The Rate Period is defined as July 1 through June 30. Rates paid during the Rate Period are determined (see 471 NAC 12011.08D) from cost reporis submitted for the Report Period ending June 30 two years prior to the end of the Rate Period. For example, cost reports submitted for the Report Period ending June 30, 2009 determine rates for the Rate Period July 1, 2010 through June 30, 2011.

12-011.08B Report Period: Each facility must file a cost report each year for the reporting period of July 1 through June 30.

12-011.08C Care Classifications:. A portion of each individual facility's rate may be based on the urban or non-urban location of the facility.

12-011.08D_ Prospective Rates: Subject to the allowable, unallowable, and limitation provisions of 471 NAC 12-011.04, 12-011.05, and 12-011,06, the Department determines facility-specific prospective per diem rates (one rate corresponding to each level of care) based on the facility's allowable costs incurred and documented during the Report Period. The rates are based on financial, acuity, and statistical data submitted by facilities, and are subject to the Component maximums.

Component maximums are computed using audited data following the initial desk audits, and are not revised based on subsequent changes to the data. Only cost reports with a full year's data are used in the computation. Cost reports from providers entering or leaving Medicaid during the immediately preceding Report Period are not used in the

computation.

Each facility's prospective rates consist of four components:

1. The Direct Nursing Component adjusted by the inflation factor;

2. The Support Services Component adjusted by the inflation factor; 3. The Fixed Cost Component; and

4. The Nursing Facility Quality Assessment Component.

t The Direct Nursing Component and the Support Services Component are subject to maximum per diem payments based on Median/Maximum computations.

- 2 . es poroes APR ESTP og JUL = 220 TN# NE 11-24

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ATTACHMENT 4.19-D Page 15

42-011,08D3 Fixed Cost Component: This component of the prospective rate is computed by dividing the facility's allowable interest, depreciation, amortization, long-term rent/lease payments, personal property tax, real estate tax, and other fixed costs by the facility's total inpatient days (see 471 NAC 12-011.06B). Rate determination for the Fixed Cost Component for an individual facility is computed using the lower of its own per diem as computed above, or a maximum per diem of $27.00 excluding personal property and real estate taxes.

12-011,08D4 Nursing Facility Quality Assessment Component: The Nursing Facility Quality Assessment component shall not be subject to any cost limitation or revenue offset.

The quality assessment component rate will be determined by calculating the ‘anticipated tax payments’ during the rate year and then dividing the total anticipated tax payments by ‘total anticipated nursing facility/skilled nursing facility patient days,’ including bed hold days and Medicare patient days.

For the rate year beginning July 1, 2011, the ‘anticipated tax payments’ will be determined by annualizing total facility patient days, including bed hold days, less Medicare days from the time period beginning January 1, 2011 and ending June 30, 2011. ‘Total anticipated nursing facility/skilled nursing facility patient days’ will be determined by annualizing total facility patient days, including bed hold days and Medicare days, from the time period beginning January 1, 2011 and ending June 30, 2011. Nursing Facilities will not be assessed a tax on any patient days prior to July 1, 2011.

For each subsequent rate year, total facility patient days, including bed hold days, less Medicare days, for the four most recent calendar quarters available at the time tates are determined will be used to calculate the ‘anticipated tax payments.’ Total facility patient days, including bed hold days and Medicare days, for the same four calendar quarters will be used to calculate the ‘anticipated nursing facility/skilled nursing facility patient days.’

12-011.08D5 Inflation Factor: For the Rate Period of July 1, 2011 through June 30, 2012, the inflation factor is positive 3.03%.

TN# NE 41-29

01 Supersedes Approved APR 18 2012 Effective JUL - i 2011

TN# NE 11-24

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Reprised Stlorei Si an 3.13 QO?

ATTACHMENT 3.1-A

item 12a, Page 2 of 2 Applies to both Categorically and Medically Needy

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State Nebraska LIMITATIONS - PRESCRIBED DRUGS

6. Agents when used to promote smoking cessation. (Restricted to the prescription drugs, bupropion and varenicline, and over-the-counter nicotine patches and nicotine gum. Prescription drugs are covered for Medicaid recipients who are not full-benefit dual eligible individuals. Over-the counter drugs are covered for all populations. Coverage of all prescription and over- the-counter agents is available to only those Medicaid recipients that are enrolled with and actively participating in the Nebraska Tobacco-Free Quitline.)

) The Medicaid agency will provide coverage of prescription and over-the- counter (OTC) tebacco/smoking cessation covered outpatient drugs for pregnant women as recommended in “Treating Tobacco Use and Dependence: 2008 Update: Clinical Practice Guideline’ published by the Public Health Service in May 2008 or any subsequent modification of such guideline.

Ki 7. Preseription vitamins and mineral products, except prenatal vitamins and fluoride preparations.

BJ 8 Nonprescription drugs (All drugs in this category are potential benefits, subject to medical necessity). Covered over the counter (OTC) classes include analgesics, anesthetics, anti-infammatory products, anti-asthmatics, antihistamines, anti-infectives, cough and cold preparations, eye, ear and nose preparations, gastrointestinal products, hypoglycemic, smoking deterrents, and topicals.

Xi] 9. Covered outpatient drugs which the manufacturer seeks to require as a condition of sale that associated tests or monitoring services be purchased exclusively from the manufacturer or its designee.

EF 10. Drugs described in section 107(¢}(3) of the Drug Amendments of 1962 and identical, similar, or related drugs (within the Meaning of Section 310.6(b)(1) af title 21 of the Code of Federal Regulations (DESI drugs)

11. Barbiturates

12. Benzodiazepines (generic only)

Telehealth: Pharmacy services for prescribed drugs are not covered when provided via telehealth technologies.

Supersedes Approval Date MAR 1 9 2012 Effective Date Tt TN No. MS-08-15

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Revision: HCFA-PM-91-4 August 1991 (BERC) Attachment 2.2 -A Page 11 OMB NO.: 0938- Statefferritory: Nebraska Citation 42 CFR 435.914 1902(a)(34) of the Act 1902(e)(8) and 1905(a) of the Act 1902(a)(47) and 42 CFR 438.6 2.1 (b) (1) Except as provided in items 2.1 (b)(2) and (3) below, individuals are entitled to Medicaid services under the plan during the three months preceding the month of application, if they were, or on application would have been, eligible. The effective date of prospective and retroactive eligibility is specified in Attachment 2.6-A. (2) For individuals who are eligible for Medicare cost-sharing expenses as qualified Medicare beneficiaries under section 1902(a)(1 O)(E)(i)of the Act, coverage is available for services furnished after the end of the month which the individual is first determined to be a qualified Medicare beneficiary. Attachment 2.6-A specifies the requirements for determination of eligibility for this group. rgj (3) Pregnant women are entitled to ambulatory prenatal care under the plan during a presumptive eligibility period in accordance with section 1920 of the Act. Attachment 2.6-A specifies the requirements for determination of eligibility for this group. (c) The Medicaid agency elects to enter into a risk contract that complies with 42 CFR 438.6, and that is procured through an open, competitive procurement process that is consistent with 45 CFR Part 74. The risk contract is with (check all that apply): D Qualified under Title XIII 1310 of the Public Health Service Act. rgj A Managed Care Organization that meets the definition of 1903(m) of the Act and 42 CFR 438.2. D A Prepaid Inpatient Health Plan that meets the definition of 42 CFR 438.2. D A Prepaid Ambulatory Health Plan that meets the definition of 42 CFR 438.2. D Not applicable. 42 CFR 1:8:1 4. A group or groups of individuals who would be eligible for Medicaid 435.217 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. ~ This includes PACE enrollees who reside in the community who are eligible using institutional rules. *Agency that determines eligibility for coverage. TN No. NE 12-04 Supersedes TN No. MS-03-12 Approval Date OCT 2 L1 2012 Effective Date F~ OJ ;J!)J3

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Revision: HCFA-PM-94-9 December 1994 (MB) Attachment 3.1-A Page 10 . State/Territory: Nebraska AMOUNT, DURATION AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE CATEGORICALLY NEEDY 25. Home and Community Care for Functionally Disabled Elderly Individuals, as defined described and limited in Supplement 2 to Attachment 3.1-A, and Appendices A-G to Supplement 2 to Attachment 3.1-A [8l Provided: 0 Not provided 26. Personal assistance services are those services provided to a Medicaid client who is not an inpatient or resident of a hospital, nursing facility, intermediate care facility for the mentally retarded, institution for mental disease, or prison, which are authorized on a written service plan according to individual needs identified in a written assessment. Personal assistance services are A) authorized by a Social Services Worker or designee, B) provided by qualified providers who are not legally responsible relatives, and C) are furnished inside the home, and outside the home with limitations. [8] Provided: D Not Provided t8l State Approved (Not Physician) Service Plan Allowed [8l Services Outside the Home Also Allowed [8l Limitations Described on Attachment 27. Program of All-Inclusive Care for the Elderly (PACE) services, as described in Supplement 4 to Attachment 3.1-A _lL Election of PACE: By virtue of this submittal, the State elects PACE as an optional State Plan service. No election of PACE: By virtue of this submittal, the State elects to not add PACE as an optional State Plan service 28. (i) Licensed or Otherwise State-Approved Freestanding Birth Center Provided: D No limitations r8:l With limitations D None licensed or approved Please describe any limitations: Facilities must: (a) Be specifically approved by Department of Health and Human Services, Division of Public Health to provide birthing center Services. (b) Maintain standards of care required by Department of Health and Human Services, Division of Public Health for licensure. TN No. NE 12-04 Supersedes TN No. NE 11-21 Approval Date OCT 2 L1 2012 Effective Date Feb OJ ;}/)[3 I' I !

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SUPPLEMENT 4 TO ATTACHMENT 3.1-A Page 1 OMB No.: 0939-0193 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT Staterrerritory: Nebraska I. Eligibility The State determines eligibility for PACE enrollees under rules applying to community groups. A _x_ The State determines eligibility for PACE enrollees under rules applying to institutional groups as provided for in section 1902(a)(1 O)(A)(ii)(VI) of the Act (42 CFR 435.217 in regulations). The State has elected to cover under its State plan the eligibility groups specified under these provisions in the statute and regulations. The applicable groups are: B. 1902(a)(1 O)(A)(ii)(XI) of the Act 1902(a)(1 O)(A)(ii)(X) and 1902(m)(1) and (3) of the Act 42 CFR 435.310 42 CFR 435.320 42 CFR 435.322 42 CFR 435.324 The State will use the actual maximum monthly allowable Special Needs Nursing Facility rate to reduce an individual's income to an amount at or below the medically needy income limit (MNIL) for persons who are medically needy with a Share of Cost. The State determines eligibility for PACE enrollees under rules applying to institutional groups, but chooses not to apply post-eligibility treatment of income rules to those individuals. (If this option is selected, skip to II- Compliance and State Monitoring ofthe PACE Program. C. _x_ The State determines eligibility for PACE enrollees under rules applying to institutional groups, and applies post-eligibility treatment of income rules to those individuals as specified below. Note that the post-eligibility treatment of income rules specified below are the same as those that apply to the State's approved HCBS waiver(s). D. ~ Spousal impoverishment eligibility rules are being applied. Regular Post Eligibility 1. _x_ SSI State. The State is using the post-eligibility rules at 42 CFR 435.726. Payment for PACE services is reduced by the amount remaining after deducting the following amounts from the PACE enrollee's income. (a). Sec. 435.726-States which do not use more restrictive eligibility requirements than SSI. TN No. NE 12-04 Supersedes TN No. New page Approval Date , OCT 2 L1 2012 Effective Date E~b bl ..2/J).J

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SUPPLEMENT 4 TO ATTACHMENT 3.1-A Page4 OMB No.: 0939-0193 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State/Territory: Nebraska 4. The following percentage of the following standard that is not greater than the standards above: __ % of standard. 5. The amount is determined using the following formula: 6. Not applicable (N/A) (C.) Family (check one): 1 . AFDC need standard 2. _ Medically needy income standard The amount specified below cannot exceed the higher of the need standard for a family of the same size used to determine eligibility under the State's approved AFDC plan or the medically needy income standard established under 435.811 for a family of the same size. 3. _ The following dollar amount: $ __ _ Note: If this amount changes, this item will be revised. 4. The following percentage of the following standard that is not greater than the standards above: % of standard. 5. The amount is determined using the following formula: 6. Other 7. Not applicable (N/A) (b) Medical and remedial care expenses specified in 42 CFR 435.735. Spousal Post Eligibility 3.___x_ State uses the post-eligibility rules of Section 1924 of the Act (spousal impoverishment protection) to determine the individual's contribution toward the cost of PACE services if it determines the individual's eligibility under section 1924 of the Act. There shall be deducted from the individual's monthly income a personal needs allowance (as specified below), and a community spouse's allowance, a family allowance, and an amount for incurred expenses for medical or remedial care, as specified in the State Medicaid plan. (a.) Allowances for the needs of the: 1. Individual (check one) TN No. NE 12-04 Supersedes TN No. New page (A). _ The following standard included under the State plan (check one): 1. SSI 2. Medically Needy 3. _ The special income level for the institutionalized 4. _ Percent of the Federal Poverty Level: __ 5. _ Other (specify): _________ _ Approval Date OCT 2 l! 2012 Effective Date Feb 0/ ~{))3

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Q,eu \cSru S-<biY\icss'o"" 9.;;;) t. I';) SUPPLEMENT 4 TO ATTACHMENT 3.1-A Page 5 OMB No.: 0939-0193 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State/Territory: Nebraska (B). _The following dollar amount: $ ___ _ Note: If this amount changes, this item will be revised. (C) . ..1$_ The following formula is used to determine the needs allowance: (1) For waiver clients receiving Assisted Living Services: The State protects the SSI standard. (2) For clients receiving waiver services in other eligible living arrangements: The State protects the medically needy income standard. If this amount is different than the amount used for the individual's maintenance allowance under 42 CFR 435.726 or 42 CFR 435.735, explain why you believe that this amount is reasonable to meet the individual's maintenance needs in the community: II. Rates and Payments A. The State assures that the capitated rates will be equal to or less than the cost to the agency of providing those same fee-for-service State plan approved services on a fee-for-service basis, to an equivalent non-enrolled population group based upon the following methodology. Please attach a description of the negotiated rate setting methodology and how the State will ensure that rates are less than the cost in fee- for-service. 1. 2. 3. 4. _1L Rates are set at a percent of fee-for-service costs Experience-based (contractors/State's cost experience or encounter date)(please describe) Adjusted Community Rate (please describe) Other (please describe) Rates are set at a percent of Upper Payment Limits. The State contracts with an actuarial company to develop PACE Upper Payment Limits (UPLs). The UPLs are developed based on historical Nebraska Medicaid fee- for-service (FFS) costs for individuals aged 55 and over who were either nursing home residents or eligible for HCBS waiver services based on meeting nursing facility level of care criteria. Projection factors are applied to the UPLs to reflect utilization changes, historical and prospective Medicaid program changes, and provider rate changes. The UPLs are then summarized into rate cells by eligibility category and defined geographic area. The State ensures that rates paid to PACE provider organizations are less than the cost in FFS by negotiating a rate for each rate cell set at 95% of the UPL for that cell. TN No. NE 12-04 Supersedes TN No. New page Approval Date · OCT 2 '! 2012 Effective Date Feb bJ eJIJ)..3

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SUPPLEMENT 4 TO ATTACHMENT 3.1-A Page6 OMB No.: 0939-0193 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State/Territory: Nebraska B. The State Medicaid Agency assures that the rates were set in a reasonable and predictable manner. Please list the name, organizational affiliation of any actuary used, and attestation/description for the initial capitation rates. The State contracted with Milliman, Inc., to develop its initial UPLs for calendar year 2012. The initial UPLs were developed by Shelly S. Brandel, FSA, MAAA, Actuary, and David F. Ogden, FSA, MAAA, Principal and Consulting Actuary. The UPLs are an estimate of what costs would have been to Nebraska Medicaid for PACE participants if they had not enrolled in PACE. Within each eligibility category (dually Medicaid and Medicare eligible, Medicaid only, and dually Medicaid and Medicare (Part B only} eligible}, Milliman developed separate UPLs for nursing home residents and HCBS waiver participants who meet nursing facility level of care criteria (aka PACE eligibles) by geographic area. Milliman then weighted these UPLS by the estimated distribution of individuals in each service category (based on the distribution of 2009 eligible months) to calculate the overall UPLs. The distribution of individual~ for Part B only eligibles was assumed to be the same as for dual eligibles. Data Reliance and Important Caveats In developing the UPLs, Milliman relied on data and other information provided by the State. Since the source of the data was the State's Medicaid Management Information System (MMIS), the State takes responsibility for the accuracy and validity of the base data. The following data and information was used: • Medicaid claims and eligibility data for individuals ages 55 and older, including a description of each data field and its potential use in classifying individuals into eligibility groupings of service use and Medicare eligibility; • Summary of Medicaid fee and program changes in SFY 2008 and later; and • Quarterly CMS-64 Medicaid Administrative Cost reports for SFY 2010. Base Data and Adjustments The State provided claims and eligibility data for Medicaid individuals ages 55 and over for the period January 1, 2007, through the most recent date available at the time, August, 2010. 1 . Excluded Data Milliman excluded the following data: TN No. NE 12-04 Supersedes TN No. New page ·OCT 2 ,t 2012 Approval Date - Effective Date Feb {)) r:JIJJ.3

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SUPPLEMENT 4 TO ATTACHMENT 3.1-A Page 7 OMB No.: 0939-0193 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State/Territory: Nebraska • Managed care enrollees; • Partial Medicare eligibility: Claims and eligibility data for individuals with partial Medicare eligibility (Part A or Part B only) were excluded. (Note: Milliman developed UPLs for Part B only eligibles based on the projected results for Medicaid only and dual eligibles due to a small number of individuals in the data with Part B only eligibility.) • Individuals with claims but no eligibility; and • Claims and eligibility for individuals for whom the county of residence was outside the State of Nebraska. 2. UPL Categories Milliman separated the data into eligibility groupings or "cells" as follows: • Dual eligible versus Medicaid only; • Nursing home residents versus HCBS waiver participants; and • Urban versus rural geographic areas. Regarding Medicare eligibility, individuals with full Medicare coverage (Part A and B) or no Medicare coverage were included in the analysis. As noted above, individuals with partial Medicare coverage (Part A or Part 8 only) were excluded from the analysis (Part B only UPL projections are based on the UPL results for Medicaid only and dual eligibles due to the small number of Part B only individuals in the data.) Nursing home residents were flagged as such for each month within each individual's total eligibility segment(s) if the total nursing home payments for the month were greater than $0.00. If an individual was identified as both a nursing home resident and a HCBS waiver participant for a given month, the individual was classified by Milliman as a nursing home resident for purposes of their analysis. Milliman classified data as "rural" or "urban" based on the county of residence in the eligibility file as follows: Urban: Douglas, Lancaster, Gage, Otoe, Saline, Sarpy, Saunders, Seward, and Washington counties (counties surrounding Omaha and Lincoln, Nebraska); and Rural: Remaining counties in Nebraska. TN No. NE 12-04 Supersedes TN No. New page Approval Date , OCT 2 •1 2 12 Effective Date Feb () 1 ~tJJ3 .,

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TN No. New page SUPPLEMENT 4 TO ATTACHMENT 3.1-A Page 10 OMB No.: 0939-0193 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State/Territory: Nebraska • Although the FFS data did not indicate primary care versus specialty care services, Milliman expected the level of primary care services in the PACE population to be very small given the amount of chronic care services. Therefore they did not make an adjustment to the SFY 2012 and SFY 2013 Medicare rate decreases to exclude primary care services. • For dual eligibles, the impact of Medicaid provider rate changes is difficult to predict since a significant amount of costs for many services are paid by Medicare. Milliman assumed the Medicaid provider rate change increases would be dampened by a factor of %for dual eligibles for the following services: inpatient hospital; outpatient hospital; physician; other practitioner; radiology and laboratory; clinic; DME/supplies; and transportation. 4. PACE Administrative Costs Milliman added a 3.9% allowance (as a percentage of projected 2012 claims) for PACE administrative services based on the CMS-64 data the State provided for SFY 2010. The CMS 64 reports reflect the State's current Medicaid administrative costs as a percentage of claim payments. School-based administrative costs were excluded from the calculation. There were very few individuals in the FFS with Part 8 only Medicare eligibility, therefore the historical data was not credible for purposes of UPL development. Milliman calculated the Part B only UPLs by setting the projected 2012 UPL for each service category equal to either the dual eligible UPL or the Medicaid only UPL. They linked the following service categories to the dual eligible UPL (meaning they expected that Medicare coverage would decrease the expected costs PEPM for Part B eligibles): outpatient hospital; physician; other practitioner; radiology and laboratory; clinic; pharmacy; DME/supplies; and transportation. All other service categories were linked to the Medicaid only UPL. C. The State will submit all capitated rates to the CMS Regional Office for prior approvaL TN No. NE 12-04 Supersedes TN No. New page Effective Date Feb IJJ :Jtll3 ; · i· I I· ~ ' I j. i· I I I f ,.

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Revision: HCFA-PM-94-9 (MB) ATTACHMENT 3.1-B Page 8b December 1994 StatefTerritory: Nebraska AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED MEDICALLY NEEDY GROUP(S): All groups 25. Home and Community Care for Functionally Disabled Elderly Individuals. as defined, described and limited in Supplement 2 to Attachment 3.1-A, and Appendices A-G to Supplement 2 to Attachment 3.1-A. [8J Provided D Not Provided 26. Personal assistance services are those services provided to a Medicaid client who is not an inpatient or resident of a hospital, nursing facility, intermediate cafe facility for the mentally retarded, institution for mental disease, or prison, which are authorized on a written service plan according to individual needs identified in a written assessment. Personal assistance services are A) authorized by a Social Services Worker or designee, B) provided by qualified providers who are not legally responsible relatives, and C) are furnished inside the home, and outside the home with limitations [8J Provided ~ State Approved (Not Physician) Service Plan Allowed [8J Services Outside the Home Also Allowed* [8J Limitations Described on Attachment D Not Provided 27. Program of All-Inclusive Care for the Elderly (PACE) services, as described in Supplement 4 to Attachment 3.1-A. ..X.. Election of PACE: By virtue of this submittal, the State elects PACE as an optional State Plan service. No election of PACE: By virtue of this submittal, the State elects to not add PACE as an optional State Plan service. 28. (i) Licensed or Otherwise State-Approved Freestanding Birth Centers Provided: 0 No Limitations [8J With Limitations 0 None licensed or approved . D Not Applicable (there are no licensed or State approved Freestanding Birth Centers Please describe any limitations: Facilities must: (a) Be specifically approved by Department of Health and Human Services, Division of Public Health to .provide birthing Center Services, and (b) Maintain standards of care required by Department of Health and Human Services, Division of Public Health for licensure. * Exception described on attachment TN No. NE 12-04 Supersedes Approval Date ' OCT 2 11 2012 Effective Date Feb IJ J ..2 tJ 13 TN No. 11-21 · .. ·. . . . · .. · .

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Revised Submission A213

ATTACHMENT 4.19-B . Item 9, Page 2

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

METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES

Payment for Psychiatric Day Treatment Services: Payment rates for psychiatric day treatment services for individuals age 19 and older will be on a unit basis. Rates are set annuatly for the period July 1 through June 30. Rates are set prospectively for this period and are not adjusted during the rate period. Providers are required to report their costs on an annual basis. Providers desiring to enter the program who have not previously reported their costs or that are newly Operated are to submit a budgeted cost report, estimating their anticipated annual costs.

Providers shall submit cost and statistical data on the required form based on the timeframes in 471 NAC 20-003.08. Providers shall compile data based on generally accepted accounting principles and the actual method of accounting based on the provider's fiscal year. Financial and statistical records for the period covered by the cost report must be accurate and sufficiently detailed to substantiate the data reported. If the provider fails to file a cost report as due, the Department will suspend payment. At the time the suspension is imposed, the Department will inform the provider via letter that no further payment will be made until a proper cost report is filed. In setting payment rates, the Department will consider those costs which are reasonable and necessary for the active treatment of the clients being served. Such costs will include those necessary for licensure and accreditation, meeting ail staffing standards for participation, meeting all service standards for participation, meeting ail requirements for active treatment, maintaining medical records, conducting utilization review, meeting inspection of care requirements, and discharge planning. The Department does not guarantee that all costs will be reimbursed. The cost reporting document is used by the Department only as a guide in the rate setting process. Actuai costs incurred by the providers may not be entirely reimbursed.

Psychiatric day treatment centers operated by the State of Nebraska will be reimbursed for all reasonable and necessary costs of operation, excluding educational services. State-operated centers will receive an interim payment rate, with an adjustment to actual costs following the cost reporting period.

TN #. NE 12-07 APR 25 2019 Supersedes Approval Date Effective Date jj) Q4 77 "" TN #. MS-00-06

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STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: Nebraska METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES Other Licensed Practitioners: Licensed Alcohol and Drug Counselor (LADC) Attachment 4.19-B Item 4b, Page 3 Rehabilitation Services - 42 CFR 440.130(d): Day Treatment/Intensive Outpatient Service by Direct Care Staff; Community Treatment Aide; Professional Resource Family Care; and Therapeutic Group Home Reimbursement for services is based upon a Medicaid fee schedule established by the State of Nebraska. Except as otherwise noted in the Plan, the State-developed fee schedule is the same for both governmental and private individual practitioners and the fee schedule and any annual/periodic adjustments to the fee schedule are published at http://dhhs.ne.gov/medicaid/Pages/med provhome.aspx (Division of Medicaid and Long-Term Care website). The above mentioned fee schedule is applicable to all services reimbursed via a fee schedule. The agency's rates were set as of July 1, 2012 and are effective for services provided on or after that date. The Nebraska Medicaid fee schedule outlined above will be established using the following methodologies: • If a Medicare fee exists for a defined covered procedure code, then Nebraska will set the Nebraska Medicaid fee schedule for LADC at 95 percent of the licensed Master's level rate paid under Attachment 3.1A, Item 6d for any codes permitted under their scope of practice per Nebraska state law. • Where Medicare fees do not exist for a covered code, the fee schedule will be set using a market-based pricing methodology as described below. These reimbursement methodologies will produce rates sufficient to enlist enough providers so that services under the Plan are available to individuals at least to the extent that these services are available to the general population, as required by 42 CFR 447.204. These rates comply with the requirements of Section 1902(a)(30) of the Social Security Act 42 CFR 447.200, regarding payments and consistent with economy, efficiency and quality of care. Provider enrollment and retention will be reviewed periodically to ensure that access to care and adequacy of payments are maintained. The Medicaid fee schedule will be equal to or less than the maximum allowable under the same Medicare rate, where there is a comparable Medicare rate. Room and board costs are not included in the Medicaid fee schedule. The market-based pricing methodology will be composed of provider cost modeling for four key components: direct care salary expenses, employee related expenses, program indirect expenses and administrative expenses. The analysis includes national compensation studies for Nebraska to determine the appropriate wage or salary expense for the direct care worker providing each service based on the staffing requirements and roles and responsibilities of the worker, published information related to employee related expenses and other notable cost components and cost data and fees from similar State Medicaid programs. The following list outlines the major components of the cost model to be used in fee development: (1) Staffing Assumptions and Staff Wages (2) Employee-Related Expenses- Benefits, Employer Taxes (e.g., FICA, unemployment, and workers compensation) (3) Program-Related Expenses (e.g., supplies) (4) Provider Overhead Expenses (5) Program Billable Units The fee schedule rates will be developed as the ratio of total annual modeled provider costs to the estimated annual billable units. TN# NE 12-10 Supersedes TN# 11-10 Approved NOV 3 0 2012 Effective Date ----=-~...::... ·~ :._=--0_1_ 2012 1- ! I· i

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ATTACHMENT 4.19-C STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State Nebraska

BEDHOLDING

The Nebraska Medical Assistance Program makes payments to reserve a bed in a nursing facility (NF) or an intermediate care facility for the mentally retarded (ICF/MR) during a client's absence due to hospitalization for an acute condition and for therapeutically-indicated home visits. Therapeuticaily-indicated home visits are ovemight visits with relatives and friends or visits to participate in therapeutic or rehabilitative, programs. Payment for bedholding is subject to the following conditions:

1. A held bed must be vacant and counted in the census. The census must not exceed licensed capacity;

2. For ICF/MR residents, hospital bedhoiding is limited to full per diem reimbursement for 16 days per hospitalization (hospital bedholding does not apply to hospital NF- swing-beds or fo hospitalization following a Medicare-covered (SNF) stay);

3. For NF residents, except for the months of April and May of 2012 in which payment is at full per diem reimbursement, hospital bedholding is limited to reimbursement at the applicable rate in effect for assisted living services under the Home and Community-Based Waiver for Aged Persons and Adults or Children with Disabilities for 15.days per hospitalization (hospital bedholding does not apply to hospital NF-swing-beds or to hospitalization following a Medicare-covered (SNF) stay);

4. For ICFIMR residents, therapeutic bedholding is limited to full per diem reimbursement for 36 days per calendar year.

5. For NF residents, except for the months of April and May of 2012 in which payment is. at full per diem reimbursement, therapeutic feave bedhalding is limited to the applicable rate in effect for assisted living services under the Home and Community-Based Waiver for Aged Persons and Adults or Children with Disabilities for 18 days per calendar year. Bedholding days are prorated when a client is admitted after January 1;

6. A transfer from one facility to another does not begin a new 18-day or 36-day period;

7. The client's comprehensive care plan must provide for therapeutic leave; and

8. Facility staff shail work with the client, the client's family and/or guardian to plan the use of the allowed 18 days of therapeutic leave for the calendar year.

When the limitation for therapeutic leave interferes with an approved therapeutic or rehabilitation program, the facility may submit a request for special limits of up to an additional six days per calendar year to the Medical Services Division.

TN # NE 12-14 | Supersedes Approval DateSEP 1 9 2012 Effective Date APR ~1 2012

TN # NE 12-01

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ATTACHMENT 4.19-D Page 2

Rate Payment means per diem rates paid under provisions of 471 NAC 12-011.08. The payment-rate for Levels of Care 101, 102, 103 104 and 105 is the applicable rate in effect for assisted living services under the Home and Community-Based Waiver Services for Aged Persons or Adults or Children with Disabilities (see 480 NAC 5). Except the payment for level of care 105 (bed-hold) for the months of April and May 2012 is the applicable payment rate as determined under 471 NAC 12-011.08.

Revisit Fees means fees. charged to health care facilities by the Secretary of Health and Human Services to cover the costs incurred under Department of Health and Human Services, Centers for Medicare and Medicaid Services, Program Management’ for conducting revisit surveys on health care facilities cited for deficiencies during initial certification, recertification or substantiated complaint surveys.

Urban means Douglas, Lancaster, Sarpy, and Washington Counties.

Waivered Facility means facilities for which the State Certification Agency has waived professional nurse staffing requirements of OBRA 87 are classified as “waivered" if the total number of waivered days exceeds 90 calendar days at any time during the reporting period.

Weighted Resident Days means a facility's inpatient days, as adjusted for the acuity level of the residents in that facility,

Other definitions which. apply in this section are included in Nebraska Department of Health and Human Services Division ef Public Heaith's regulations in Title 175, Chapter 12, Skilled Nursing Facitities, Nursing Facilities, and Intermediate Care Facilities and appropriate federal regulations governing Title XIX and Title XVII.

12-011.03 General Information: Wherever applicable, the principles of reimbursement far provider's cost and the related policies under which the Medicare extended care facility program functions (Medicare's Provider Reimbursement. Manual (HIM-15) updated by “Provider Reimbursement Manual Revisions" in effect as of July 1, 2009 are used in determining the cost for Nebraska nursing facilities with exceptions noted in this section. Chapter 15, Change of Ownership, of HIM- 18 is excluded in its entirety. So ne That portion of a provider's allowable cost for the treatment of Medicaid patients is payable under the Nebraska Medical Assistance Program (Medicaid) except as limited In this section. The aggregate payments by the Department do not exceed amounts which would be paid under Title XVI principles of reimbursement for extended care facilities.

12-011.04 Allowable Costs: The following items are allowable costs under Medicaid. 12-011.04A Cost of Meeting Licensure and Certification Standards: Allowable costs for

meeting licensure and certification standards are those costs incurred in order to:

Meet the definition and requirements for a Nursing Facility of Title XIX of the Social ‘Security Act, Section 1919;

TN# NE 12-11 P 2012 ; Supersedes Approved SEP 19 Effective _APR -4 2012

TN# NE 12-02

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ATTACHMENT 4.19-D Page 15a

12-011.08E Exception Process: An individual facility may request, on an exception basis, the Director of the Division of Medicaid and Long-Term Care to consider specific facility clreumstance(s), which warrant an exception to the facility's rate computed for its Fixed Cost Component. An exception may only be requested if the facility's total fixed costs (total costs, not per diem rate), as compared to the immediately prior report period, have increased by ten percent or more. In addition, the facility's request must include:

1. Specific identification of the increased cost(s) that have caused the facility's total fixed costs to increase by 10 percent or more, with justification for the reasonableness and necessity of the increase;

2. Whether the cost increase(s) are an ongoing or a one-time occurrence in the cost of operating the facility; and

3. If applicable, preventive management action that was implemented to. control past and future cause(s) of identified cost Increase(s).

12-011.08F ment for Levels of Care 101, 102, 103, 104 and 105: Rates as determined for Levels of Care 101, 102, 103 and 104 under the cost-based prospective

‘ methodology of 471 NAC 12-011.08A through 12-011.08E may be adjusted for actual payment. Level of Care 105 is used for payment of qualifying bedhold days. The payment rate for Levels of Care 101, 102, 103,104 and 105 is the applicable rate In effect for assisted living services under the Home and Community-Based Waiver Services for Aged Persons or Adults or Children with Disabilities (see 480 NAC 5), © Except the payment for level of care 105 (bed-hold) for the months of April and May 2012 is the applicable payment rate as determined under 471 NAC 12-011.08.

12-011.08G Out-of-State Facilities: The Department pays out-of-state facilities participating in Medicaid at a rate established by that state's Medicaid program at the

time of the issuance or reissuance of the provider agreements. The payment is not subject to any type of adjustment.

TN# NE 12-14 Supersedes Approved SEP 19 2012 Effective _APR -1 2012

TN# NE 12-02

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Revised Stubwnissipn 8.31.12

ATTACHMENT 4.19-B Item 5, Page 1 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State Nebraska

METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES

PHYSICIANS’ SERVICES

For dates of service on or after August 1, 1989, NMAP pays for covered physicians' services at the lower of: 1. The provider's submitted charge; or 2. The allowable amount for that procedure code in the Nebraska Medicaid Practitioner Fee Schedule in effect for that date of service. The allowable amount is indicated in the fee schedule as: a. The unit value multiplied by the conversion factor (last updated on July 1, 2010); b. The invoice cost (indicated as “IC" in the fee schedule); or c. The reasonable charge for the procedure as determined by the Medicaid Division (indicated as "BR" - by report or "RNE" - rate not established - in the fee schedule). 3. Exception: The Director of the Division of Medicaid and Long-Term Care or designee may enter into an agreement for a negotiated rate with an out-of-state provider which will be based on a percentage of billed charges, not to exceed 100%, only when the Medical Director of the Division has determined that: a. The client requires specialized services that are not available in Nebraska; and b. No other source of the specialized service can be found.

The following is a listing of specialized physician services that have been previously rendered by out-of-state providers:

a. lung transplants; and

b. pediatric heart transplants.

Note: The above listing is not all-inclusive of the specialized physician services that will be reimbursed via negotiated rates in the future, as it is based on previous experience.”

The Nebraska Medicaid Practitioner Fee Schedule was last updated on July 1, 2012 and is effective for services rendered on or after that date. The fee schedule is subject to annual/periodic adjustment. All rates, including current and prior rates, are published and maintained on the agency's website. Specifically, the fee schedule and any annual/periadic adjustments to the fee schedule are published at

http:/Awww.dhhs.ne.gov/medicaid/Pages/med_practitioner_fee schedule. aspx.

The Nebraska Medicaid Practitioner Fee Schedule is effective July 1 through June 30 of each year.

TN #, 12-13

Supersedes Approval Date NOY 05 2012 Effective Date ‘JUL 0 1 2012

TN #.NE 11-19

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STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State Nebraska ATTACHMENT 4.19-8 Item 2a, Page 1 METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES . Payment for Outpatient Hospital and Emergency Room Services: For services provided on or after July 1 I 2012, the Department pays for outpatient hospital and emergency services with a rate which is the product of: 1. Seventy four percent (74%) of the cost-to-charges ratio from the hospital's latest Medicare cost report (Form CMS-2552-89, Pub. 15-11, Worksheet C); multiplied by 2. The hospital's submitted charges on Form CMS-1450 (UB-04). The effective date of the cost-to-charges percentage is the first day of the month following the Department's receipt of the cost report. Providers shall bill outpatient hospital and emergency room services on Form CMS-1450 (UB- 04) in a summary bill format. Providers shall not exceed their usual and customary charges to non-Medicaid patients when billing the Department. Exception: All outpatient clinical laboratory services must be itemized and identified with the appropriate HCPCS procedure codes. The Department pays for clinical laboratory services based on ninety nine percent (99%) of the fee schedule determined by Medicare. Payment for Outpatient Hospital and Emergency Room Services Provided by Critical Access Hospitals: Effective for cost reporting periods beginning after July 1 I 2012, payment for outpatient services of a CAH is ninety nine percent (99%) of the reasonable cost of providing the services, as determined under applicable Medicare principles of reimbursement, except that the following principles do not apply: the lesser of costs or charges (LCC) rule and the reasonable compensation equivalent (RCE) limits for physician services to providers. NMAP will adjust interim payments to reflect elimination of any fee schedule methods for specific services, such as laboratory or radiology services, that were previously paid for under those methods. Payment for these and other outpatient services will be made in at ninety nine percent (99%) of the reasonable cost of providing the services. Professional services must be billed by the physician or practitioner using the appropriate physician/practitioner provider number, not the facility's provider number. To avoid any interruption of payment, NMAP will retain and continue to bill under existing provider numbers until new CAH numbers are assigned. TN No. 12-17 Supersedes TN No. 11-23 Approval Date MAR f110fj Effective Date JVL 0 1 2Dl2

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STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State Nebraska METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES ATIACHMENT 4.19-B Item 2a, Page 2 Payment to Hospital-Affiliated Ambulatory Surgical Centers: The Department pays for services provided in an HAASC according to Payment for Outpatient Hospital and Emergency Room Services, unless the HAASC is a Medicare-participating ambulatory surgical center (ASC). If the HAASC is a Medicare-participating ASC, payment is made at the rate established by Medicaid for the appropriate group of procedures. Approval of Payment for Emergency Room Services: At least one of the following conditions must be met before the Department approves payment for use of an emergency room: 1. The patient is evaluated or treated for a medical emergency, accident, or injury (see definition of medical emergency in NAG 1 0-001.02); 2. The patient's evaluation or treatment in the emergency room results in an approved inpatient hospital admission (the emergency room charges must be displayed on the inpatient claim as charges and included in the inpatient per diem); or 3. The patient is referred by a physician such as for allergy shots or when traveling (a written referral by the physician must be attached to the claim); The facility should review emergency room services and determine whether services provided in the emergency room constitute an emergency and bill accordingly. When the facility or the Department determine services are non-emergent, the room fee for non-emergent services provided in an emergency room will be disallowed to 50 percent of the applicable ratio of cost-to-charges. All other Medicaid allowable charges incurred in this type visit will be paid at seventy four percent (74%) of the ratio of cost-to-charges. Diagnostic and Therapeutic Services: The payment rate for diagnostic and therapeutic services includes payment for services required to provide the service. Extra charges, such as stat fees, call-back fees, specimen handling fees, etc., are considered administrative expenses and are included in the payment rate. Payment to a New Hospital for Outpatient Services: See the definition of a new operational facility in 471 NAC 10-010.03A. Payment to a new hospital (a operational facility) will be made at seventy four percent (74%) of the statewide average ratio of cost to charges for Nebraska hospitals as of July 1 of that year as determined by the Department. This payment is retrospective for the first reporting period for the facility. This ratio will be used until the Department receives the hospital's initial cost report. The Department shall cost-settle claims for Medicaid-covered services which are paid by the Department using seventy four percent (74%) of the statewide average ratio of cost to charges. The cost settlement will be the lower of cost or charges as reflected on the hospital's cost report (i.e., the Department's payment must not exceed the upper limit of the provider's charges for services). TN No. 12-17 Supersedes TN No. 11-23 Approval Date HAR 1 1 2013 Effective Date _J_UL._ 0_1_2DtZ

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ATTACHMENT 4.19-A

Page 5 40-010.03B1b Calculation of Nebraska Peer Group Base Payment Amounts:

Peer Group Base Payment Amounts are used to calculate payments for discharges with a stable DRG. Peer Group Base Payment Amounts effective October 1, 2009 are calculated for Peer Group 1, 2 and 3 hospitals based on the Peer Group Base Payment Amounts effective during SFY 2007, adjusted for budget neutrality, calculated as follows:

4. Peer Group 1 Base Payment Amounts, Excluding Children's Hospitals: Multiply the SFY 2007 Peer Group 1 Base Payment Amount of $3,844.00 by the Stable DRG budget neutrality factor.

2. Children's Hospital Peer Group 1 Base Payment Amounts, Excluding Children's Hospitals: Multiply the SFY 2007 Children's Hospital Peer Group 1 Base Payment Amount of $4,614.00 by the Stable DRG budget neutrality factor.

3. Peer Group 2 Base Payment Amounts: Multiply the SFY 2007 Peer Group 2 Base Payment Amount of $3,733.00 by the Stable DRG budget neutrality factor.

4. Peer Group 3 Base Payment Amounts: Multiply the SFY 2007 Peer Group 3 Base Payment Amount of $3,535.00 by the Stable DRG budget neutrality factor.

SFY 2007 Nebraska Peer Group Base Payment Amounts are described in 471 NAC 10-010.03B4 in effect on September 1, 2007 and 471 NAC 10-010.03B in effect on July 1, 2001.

Peer Group Base Payment Amounts will be increased by 0.5% for the rate period beginning October 1, 2009 and ending June 30, 2010. This rate increase will not be carried forward in subsequent years. Peer Group Base Payment Amounts excluding the 0.5% increase for the rate period beginning October 1, 2009 and ending June 30, 2010, will be increased by .5% for the rate period beginning July 1, 2010. The Peer Group Base Payment Amount effective July 1, 2070 will be

reduced by 2.5% effective July 1, 2011. The Peer Group Base Payment Amount ffective Jul 2011 wil 4% effective July 1, 2012.

Transmittal # 12-18

Supersedes

APR -3 2013 7 Approved, Etfectidvi © 1 2012

Transmittal # 11-22

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ATTACHMENT 4.19-A Page 8

June 30, 2009, will be increased by .5% for the rate period beginning July 1, 2010. Effective July 1, 2011, the direct medical education amount shall be

reduced by 2.5 percent. Effective July 1, 2012, the direct medical education unt si increased b rcent.

10-01 B3b_ Calculation le DRG Indirect Medical Education (IME. Cost Payments: Hospitals qualify for IME payments when they receive a direct medical education payment from NMAP, and qualify for indirect medical education payments from Medicare. Recognition of indirect medical education costs incurred by hospitals are an add-on calculated by multiplying an IME factor by the operating cost payment amount.

The IME factor is the Medicare inpatient prospective payment system operating IME factor effective October 1 of the year preceding the beginning of the Nebraska rate year. The operating IME factor shalt be determined using data extracted from the CMS PPS Inpatient Pricer Program. For rates effective October 1, 2009, the Department will determine the operating IME factors effective for the Medicare system on October 1, 2008 using the following formula:

-[(4+(Number of Interns and Residents/Available Beds)}9-405.4) * 1.35

On July 1* of each year, the Department will adopt the Medicare inpatient prospective payment system operating IME factor formulas and rate components in effect on October 1 of the previous year.

10-010.033B3¢_ Calculation of MCO Medical Education Payments: NMAP will calculate annual MCO Direct Medical Education payments and MCO

Indirect Medical Education payments for services provided by NMMCP capitated plans from discharge data provided by the hospital. MCO Direct Medical Education payments will be equal to the number of MCO discharges times the MCO direct medical education payment per discharge. The MCO direct medical education payment per discharge is the hospital- specific fee-for-service DME payment rates for stable DRGs, unstable or low volume DRGs and transplant DRGs in effect for the rate year July 1 through June 30.

Transmittal # 12-18 Supersedes

Transmittal # 11-22

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ATTACHMENT 4.19-A Page 10

40-010,03B4 Calculation of Stable DRG Capital-Related Cost Payment: Capltal- related cost payments for the building and fixtures portion of capital-related costs are paid on a per discharge basis for stable DRGs. Per discharge amounis are calculated by multiplying the capital per diem cost by the statewide average length-oi-stay for the stable DRG. Capital-related payment per diem amounts effective July 1, 2009 are calculated for Peer Group 1, 2 and 3 hospitals based on the Capital-related payment per diem amounts effective during SFY 2007, adjusted for budget neutrality; as follows:

1. Peer Group 1 Capital-Related Payment Per Diem Amounts: Multiply the SFY 2007 Peer Group 1 Capital-related payment per diem amount of $36.00 by the Stable DRG budget neutrality factor.

2. Peer Group 2 Capital-Related Payment Per Diem Amounts: Multiply the SFY 2007 Peer Group 2 Capital-related payment per diem amount of $31.00 by the Stable DRG budget neutrality factor.

3. Peer Group 3 Capital-Related Payment Per Diem Amounts: Multiply the SFY 2007 Peer Group 3 Capital-related payment per diem amount of $18.00 by the Stable DRG budget neutrality factor.

SFY 2007 Capital-Related Cost Payments are described in 471 NAC 10- 010.03B7 in effect on August 25, 2003.

Capital-Related Payment Per Diem Amounts effective July, 2010 will be reduced

by 2.5% effective July 1, 2011. Capital-Related Payment Per Diem Amounts effective July, 2011 will 2 i ic id by 1 ly 1, 2012.

10-010,03B5_Low Volume and Unstable DRG Payments: Discharges that are classified into a Low Volume or Unstable DRG are paid a Low Volume and Unstable DRG CCR payment and, if applicable, a DME payment. Low Volume and Unstable DRG discharges do not receive separate Cost Outlier Payments, IME Cost Payments or Capital-Related Cost Payments.

10-010.03B5a__Low Volume and Unstable DRG: CCR Payments are calculated by multiplying the hospital-specific Low Volume/Unstable DRG CCR by Medicaid allowed claim charges. Low Volume/Unstable DRG CCRs are calculated as follows:

1. Extract from the CMS PPS Inpatient Pricer Program for each hospital the Medicare inpatient prospective payment system operating and capital outlier CCRs effective October 1 of the year preceding the beginning of the Nebraska rate year. For rates effective July 1, 2009, the Department will extract the outlier CCRs in effect for the Medicare system on October 1, 2008.

2. Sum the operating and capital outlier CCRs.

3, Multiply the sum of the operating and capital outlier CCRs by the Low Volume / Unstable DRG budget neutrality factor.

Transmittal # 12-18

Supersedes

PR -3 2013 approves 73 8B Effective JJl ~ 1 2012

Transmittal # 11-22

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ATTACHMENT 4.19-A Page 11

On July 1 of each year, the Department will update the Low Volume/Unstable DRG CCRs based on the percentage change in Medicare outlier CCRs effective October 1 of the two previous years, before budget neutrality adjustments.

Effective July 1, 2011, the low volume/unstable DRG CCRs will be reduced by 2.5

percent, Effecti 4, 20 low _volu' le DRG CCRs will be increased by 1. nt. 10-010.03B5b Low Volume and Unstable DRG DME Payments: Low Volume and

Unstable DRG DME payments are calculated using the same methodology described in subsection 10-010.03B3a of this regulation, with the exception that in step 4, per discharge payment amounts are adjusted by the Low Volume/Unstable DRG budget neutrality factor.

On July 1* of each year, the Department will update Low Volume and Unstable DRG DME payment per discharge rates as described in 10-010.03B3a of this regulation.

10-010.03B6 Transplant DRG Payments: Transplant discharges, identified as discharges that are classified to a transplant DRG, are paid a Transplant DRG CCR payment and, if applicable, a DME payment. Transplant DRG discharges do not receive separate Cost Outlier Payments, IME Cost Payments or Capital-Related Cost

Payments. 10-010.0388a Transplant DRG CCR Payments: are calculated by multiplying the

hospital-specific Transplant DRG CCR by Medicaid allowed claim charges. Transplant DRG CCRs are calculated as follows:

4. Extract from the CMS PPS Inpatient Pricer Program for each hospital the Medicare inpatient prospective payment system operating and capital outlier CCRs effective October 1 of the year preceding the beginning of the Nebraska rate year. For rates effective October 1, 2009, the Department will extract the outlier CCRs in effect for the Medicare system on October 1, 2008.

2. Sum the operating and capital outlier CCRs.

3. Multiply the sum of the operating and capital outlier CCRs by the Transplant DRG budget neutrality factor.

On July 1 of each year, the Department will update the Transplant DRG CCRs based on the percentage change in Medicare outlier CCRs effective October 1 of

. the two previous years, before budget neutrality adjustments.

Effective July 1, 2011, the Transplant DRG CCRs will be reduced by 2.5 percent. Effecti uly 1, 2012, the Transplant DRG CCRs_will increas 41,54 percent,

410-010.03B6b Transplant DRG DME Payments: Transplant DRG DME payments are calculated using the same methodology described in subsection 10-010.03B3a of this regulation, with the exception that in step 4, DME per discharge payment amounts are adjusted by the Transplant DRG budget neutrality factor. -

On July 1" of each year, the Department will update Transplant DME payment per discharge rates as described in 10-010.0383a of this regulation.

Transmittal # 42-18 APR -3 2015

Supersedes

Approved Effective joi =} 2012

Transmittal # 11-22

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DF.PARTMJ:lNT Of HEALTH AND HUMAN SERVICES HF.ALTH CARE FINANCIN(] ADMINISTRATION TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL FOR: HEALTH CARE FINANCING ADMINISTRATION TO: REGIONAL ADM£NTSTRA TOR HEALTH CARE FINANCING ADMINISTRATION DEPARTMENT OF HEALTH AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL (Check One): I. TRANSMITTAL NUMBER: 13-12 FORM APPROVED OMA NO. 0938-0193 2. STATE Nebraska 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) 4. PROPOSED EFFECTIVE DATE December 1, 2013 0 NEW STATE PLAN 0 AMENDMENT TO BE CONSIDERED AS NEW PLAN [8:1 AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT Se arate Transmittal {or each amendment) 6. FEDERAL STATUTE/REGULATION CITATION: 7. FEDERAL BUDGET IMPACT: a. FFY 2014 $0.00 b. FFY 2015 $0.00 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION Attachment 3.1-A, Item I, page 2 of2 Attachment 3 .1-A, Item 4b, Page 9 Attachment 3.1-A, Item 13d, page I, 2, 4, 5, 6, and S I 0. SUBJECT OF AMENDMENT: Elimination of Pretreatment and Biopsychosocial Assessment II. GOVERNOR'S REVIEW (Check One): 0 GOVERNOR' S OFFICE REPORTED NO COMMENT 0 COMMENTS OF GOVERNOR'S OFFICE ENCLOSED 0 NO REPLY RECEIVED WlTHIN 45 DAYS OF SUBMITTAL OR ATTACHMENT (Jf Applicahle): Attachment 3.1-A, Item I, page 2 of2 Attachment 3.1-A, Item 4b, Page 9 Attachment 3.1-A, Item !3d, page I of5, 2 of5, 5, 6 of9, and 8 of9 t8J OTHER. AS SPECIFIED: Governor has waived review 16. RETURN TO: ---------l Nancy Keller Vivianne M. Chaumont Division of Medicaid & Long-Term Care -__:..~:::::::.:..:c::....:..:..:..:......:===---------------l Nebraska Department of Health & Human Services 14. TITLE: 301 Centennial Mall South Director, Division of Medicaid and Lon •-Term Care - ,5-. _D_A_T_E_S-'U'-B- M __;;_;;.;IT;.;.T'-E-D-:-----'-'--'-=-----''---""-----'--"-'-'------- --l Lincoln, NE 68 509 December 18, 20 I3 FOR REGIONAL OFFICE USE ONLY 17. DATE RECEIVED: 118. DATE APPROVED: PLAN APPROVED - ONE COPY ATTACHED 19. EFFECTIVE DATE OF APPROVED MATERIAL: 20. SIGNATURE OF REGIONAL OFFlCIAL: 21. TYPED NAME: 22. TITLE: 23. REMARKS: FORM HCFA-179 (07-92) December 18, 2013 March 13, 2014 December 1, 2013 James G. Scott Associate Regional Administrator for Medicaid and Children's Health Operations //s//

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ATTACHMENT 3.1-A Item 1, Page 2 of 2 Applies to Both Categorically and Medically Needy STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State Nebraska LIMITATIONS -INPATIENT HOSPITAL SERVICES 9. Has the flexibility to meet the schedules of families, guardians and caretakers as necessary; and 10. Documents the attempts to involve family in treatment. Subacute inpatient psychiatric hospital programs must have adequate staff to provide: 1. Comprehensive psychiatric diagnostic evaluations by an attending psychiatrist, nursing assessments, substance abuse assessments as needed, laboratory radiology or other diagnostic tests as necessary. 2. Physical examination and the ability to meet the basic medical needs of the patient. 3. Individual, group, and family psychotherapy by a licensed practitioner. Medication initiation and management services by a psychiatrist. 4. An organized, supervised milieu, psycho-educational services and other support services appropriate. Subacute inpatient psychiatric programs must have adequate staff to meet the needs of the patients served. Essential positions available to the program are: 1. A clinical/program director; 2. Nursing services; 3. Psychotherapy services by a licensed practitioner; 4. Licensed addiction and drug abuse services as needed and appropriate by a licensed individual skilled and trained to treat substance abuse issues; 5. Psycheducational services as necessary; 6. Case Management services. Providers of subacute inpatient hospital services must consider the following conditions to be determine the necessity for treatment. 1. Can the patient benefit from longer term evaluation, stabilization, and treatment services? 2. Is the client moderate to high risk to harm self or others? 3. Does the client have symptoms consistent with a current version of the DSM diagnosis? 4. Does the client have the ability to respond to intensive structured intervention services? 5. Is the client of moderate to high risk to relapse or have symptom reoccurrence? 6. Does the client have a high need of professional structure and intervention services? 7. Can the client be treated with short term intervention services? All subacute inpatient psychiatric services must be prior authorized by the Department or by the Department's contracted designee. Transmittal# NE 13-12 Supersedes Transmittal# NE-08-02 Approved ___ _ Effective ____ _ December 1, 2013 March 13, 2014

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ATTACHMENT 3.1~A Item 4b, Page 9 Applies to both Categorically and Medically Needy STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: Nebraska LIMITATIONS- EARLY AND PERIODIC SCREENING AND DIAGNOSIS AND TREATMENT OF CONDITIONS FOUND Services shall be medically necessary and shall be recommended by a psychologist, LIMHP or physician according to an individualized treatment plan, which addresses the eligible individual's assessed needs. An Initial Diagnostic Interview is a comprehensive assessment that identifies the clinical need for treatment and the most effective treatment intervention/level of care to meet the medical necessity needs of the client. The IDI is completed prior to service provision and the IDI documentation accompanies the referral information to the rehabilitation program provider. The recommendations of the licensed supervising practitioner following the Initial Diagnostic Interview serves as the treatment plan until the comprehensive treatment plan is developed. The treatment plan shall specify the frequency, amount and duration of services. The treatment plan shall be signed by the psychologist, licensed mental health practitioner or physician responsible for developing the plan. The plan will specify a timeline for reevaluation of the plan that is at least an annual redetermination. A new treatment plan with a different rehabilitation strategy shall be developed if there is no measure able reduction of disability or restoration of functional level. Agencies and practitioners shall maintain case records that include a copy of the treatment plan, the name of the individual, dates of services provided, nature, content and units of rehabilitation services provided, and progress made toward functional improvement and goals in the treatment plan. Rehabilitation services shall meet the following requirements: • If provided at a work site, the rehabilitation service shall not be job tasks oriented. • Any services or components of services which the basic nature is to supplant housekeeping, homemaking, or basic services for the convenience of a person receiving covered services (including housekeeping, shopping, child care, and laundry services} are not covered. • Services shall not be provided in an Institution for Mental Disease (IMD). • Room and board is excluded from any services or rates provided in a residential setting. • Transportation of children is not included in rehabilitation services or rates. • Education services are not included in or eligible for payment by the Medicaid Program, and do not apply toward the hours of minimum treatment activities for any service in this section. Practitioners shall be familiar with each youth's IEP and coordinate with the youth and the youth's school to achieve the IEP. Education services may not be the primary reason for rehabilitation admission or treatment. Academic education services, when required by law, shall be available. TN No.NE 13-12 Supersedes TN No. 11-10 Approval Date: ___ _ Effective Date ___ _ December 1, 2013 March 13, 2014

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ATTACHMENT 3.1-A

Item 13d, Page 1

Applies to both Categorically and Medically Needy

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State Nebraska

LIMITATIONS – REHABILITATIVE SERVICES

Community-Based Comprehensive Psychiatric Rehabilitation and Support Services Program

The following rehabilitative psychiatric services are covered for adult clients who have been diagnosed with severe and persistent major mental illness:

1. Community Support; 2. Day Rehabilitation; and 3. Psychiatric Residential Rehabilitation.

The services must be medically necessary. These services are designed to rehabilitate individuals who are experiencing severe and persistent mental illness in the community and thereby avoid more restrictive levels of care such as psychiatric inpatient hospitalization or nursing facility.

Clients must be assessed by a Nebraska licensed mental health practitioner who can diagnose major mental illness prior to referral, prior authorization and prior to admission to these services. Based on the assessment, the licensed mental health practitioner of the program will supervise the development of a treatment, recovery and rehabilitation plan that identifies rehabilitative and mental health/substance abuse services needed by the client.

Licensed Mental Health Practitioners in the program must meet the requirements of a Nebraska Licensed Mental Health Practitioner as identified by DHHS Division of Public Health, Licensure Unit. Non-licensed staff must prove competency in the treatment of individuals with a mental health diagnosis. Non-licensed staff must meet the requirements for education and experience as defined in each service.

Psychiatric Rehabilitation Agencies must have acquired accreditation by a national accrediting agency such as Joint Commission of Accreditation of Hospitals Organizations (JCAHO), Commission on Accreditation (COA), or Commission on Accreditation of Rehabilitation Facilities (CARF).

The State assures that rehabilitative services are not provided in institutions for mental diseases (IMD).

The State assures that the following programs meet the requirements for rehabilitative services set forth in CFR 440.130(d): Community Support, Day Rehabilitation, and Psychiatric Residential Rehabilitation.

TN No. NE 13-12 Supersedes Approval Date ___________ Effective Date ____________ TN No. 13-23 Revised Submission 2.24.14 December 1, 2013 March 13, 2014

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ATTACHMENT 3.1-A Item 13d, Page 2 Applies to both Categorically and Medically Needy STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State Nebraska LIMITATIONS- REHABILITATIVE SERVICES Community Support Community Support is a rehabilitation recovery service delivered by a skilled, trained community support worker under the supervision of a licensed mental health practitioner to individuals suffering from Severe and Persistent Mental Illness (SPMI). The service is delivered through a mental health agency that has achieved and maintained national accreditation by JCAHO, COA, orCARF. Community-Support is designed to: 1. Provide/develop the necessary services and supports to enable clients to reside in the community; 2. Maximize the client's community participation, community and daily living skills, and quality of life; 3. Facilitate communication and coordination between mental health rehabilitation providers that serve the same client; and 4. Decrease the frequency and duration of hospitalization. Community Support Program components: 1. A Treatment Recovery and Rehabilitation Plan developed within 30 days of admission and with updates of the plan every 90 days and reviewed and approved by a licensed mental health practitioner/clinical supervisor. 2. Individualized rehabilitation and recovery services provided by a community support worker according to the plan. 3. Supervision of the community support worker's services delivery by a licensed mental health practitioner. 4. Staff training supervised by the agency's licensed mental health practitioner at the time of initial employment and on an ongoing basis. Community Support services: 1. Assist in coordination of a medical and mental health service. 2. Coordination of all communication with community based supports, including family, education, prevocational and social outlets. 3. Monitor medication adherence and report any barriers. 4. Understand and support use of client's relapse prevention plan. 5. Assist in development of problem solving skills and age appropriate independence TN No. NE 13-12 Supersedes TN No. 09-03 Approval Date ____ _ Effective Date ____ _ December 1, 2013 March 13, 2014

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ATTACHMENT 3.1-A Item 13d, Page 4 Applies to both Categorically and Medically Needy STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State Nebraska LIMITATIONS- REHABILITATIVE SERVICES Day Rehabilitation Program components: 1. Review of the diagnostic assessment completed by a community based mental health practitioner who can diagnose major mental illness. The Diagnostic Assessment is the clinical information used to refer the client into the program and is reviewed by the program's licensed mental health practitioner. 2. A licensed mental health practitioner (clinical supervisor) completes a comprehensive assessment within 30 days of admission. 3. The licensed mental health practitioner completes the treatment, recovery and rehabilitation plan in the first 30 days following admission which is reviewed and updated every 90 days. 4. Rehabilitation services are delivered in the therapeutic milieu at least 3 hours to 5 hours of services per day. Service availability includes weekend and evening activity as the client's rehabilitative needs are identified. Day Rehabilitation services: 1. Assist in building daily living skills and time management. 2. Coordinate a prevocational activities to encourage ability for employment 3. Teaching social skills through planned activities. 4. Teaching medication management and it's effectiveness. 5. Assisting in health care access and assist in understanding health care insurance. 6. Skill building in the use of public transportation. 7. Teach money management and financial issues. Direct Care Staff (non:licensed) must have a high school diploma at a m1mmum and have demonstrated skills and competencies in the treatment of individuals with mental health disorders. Direct care staff are directly supervised by individuals licensed as a Licensed Mental Health Practitioner. Residential Rehabilitation Residential Rehabilitation is a 24-hour program that allows a client suffering from severe and persistent mental illness to recover in a rehabilitative setting which includes 20 hours of on-site rehabilitation services and 25 hours off-site services. The agency providing the service must have acquired and maintain national accreditation such as JCAHO, COA, CARF, and be licensed as a Mental Health Center. Room and board are not included in the service. Residential Rehabilitation Program components: 1. A community-based diagnostic assessment by a licensed practitioner who can diagnose major mental illness as a referral into the program. Prior authorization is required for admission. TN No. NE 13-12 Supersedes TN No. 09-03 Approval Date ____ _ Effective Date ___ _ December 1, 2013 March 13, 2014

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ATTACHMENT 3.1-A Item 13d, Page 5 Applies to both Categorically and Medically Need STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State Nebraska LIMITATIONS- REHABILITATIVE SERVICES 2. The development of a treatment, recovery and rehabilitation plan developed within 30 days of admission, reviewed and approved by the clinical supervisor who is a licensed mental health practitioner. 3. Service delivery provided by trained direct care staff under the supervision of a licensed clinical supervisor (licensed mental health practitioner). One direct care staff must be available per each 1 0 clients. Specific rehabilitation services are: 1. Assist in arranging medical and psychiatric care and management of appointments. 2. Teaching relapse prevention skills and revisiting the relapse plan with the client. 3. Teaching time management and daily living skills. 4. Social skill development through encouraging healthy relationship building and social activities. 5. Teaching survival skills, such as meal preparation, nutrition, housekeeping activities and other daily management. 6. Money management and budgeting. 7. Prevocational skill development. Psychiatric Residential Rehabilitation is designed to: 1. Increase the client's functioning so that s/he can eventually live successfully in the residential setting of his/her choice, capabilities, and resources; and 2. Decrease the frequency and duration of hospitalization. Non-licensed staff must hold a Bachelor's degree or higher in psychology, sociology, or a related field or two years of coursework in the human services field or two years recovery experience with demonstrated competencies and skills in treatment of individuals with mental health diagnosis. Non licensed staff are supervised by a Nebraska Licensed Mental Health Practitioner who is the Program Supervisor. Secure Psychiatric Residential Rehabilitation Services Secure Psychiatric Residential Rehabilitation Services is a service provided to individuals who have psychiatric symptoms and dysfunctions which cause severe disability. The target population is unable to live outside a high level of 24-hour care. These individuals require a secure setting at times for safety of self and others. TN No. NE 13-12 Supersedes TN No. 09-03 Approval Date ____ _ Effective Date ____ _ December 1, 2013 March 13, 2014

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ATTACHMENT 3.1-A Item 13d, Page 6 Applies to both Categorically and Medically Needy STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State Nebraska LIMITATIONS- REHABILITATIVE SERVICES ASSERTIVE COMMUNITY TREATMENT Assertive Community Treatment is a service-delivery model for providing comprehensive community-based psychiatric treatment and rehabilitation services and is intended for individuals with psychiatric illnesses that are most severe and persistent. The service is a multidisciplinary and mobile mental health team who functions interchangeably to provide the rehabilitation and treatment services designed to enable the consumer to live successfully in the community in an independent or semi-independent arrangement. With the same team providing treatment and rehabilitation services, the complex interaction of symptoms and psychosocial functioning are addressed more efficiently and effectively across time. The content, amount, timing and kinds of service provided vary among clients and for each client across time. Team service intensity is individualized based upon continual assessment of need and adjustment to the treatment plan. The services must be medically necessary.· These services are designed to rehabilitate individuals who are experiencing severe and persistent mental illness in the community and thereby avoid more restrictive levels of care such as psychiatric inpatient hospitalization or nursing facility. Rehabilitative psychiatric services do not include treatment for a primary diagnosis of substance abuse. Assertive Community Treatment services must be recommended by a licensed mental health professional prior to receiving these services. An assessment must be completed to receive the service(s). The licensed mental health professional will develop service need recommendations that identify rehabilitative and mental health services needed by the client. The completed service needs assessment and service recommendations will be reviewed and approved by a supervising mental health practitioner (psychiatrist or licensed psychologist). Provider Qualifications: Providers of rehabilitative psychiatric services must be licensed/ certified by the Nebraska Department of Health and Human Services as providers of community-based comprehensive psychiatric rehabilitation and support services. Providers must be under contract with the Nebraska Health and Human Service System through the Regional Governing Boards as defined in Neb. Rev. Stat. §83-158.01 to §83-169 and §71-5001 to §71-5052 to provide one or more of the covered services and must demonstrate the capacity to fulfill and abide by all contractual requirements. The provider must complete a Medicaid provider agreement and obtain a Medicaid approved provider number. Providers are required to meet all applicable licensure and certification requirements, hold a current license/certification and adhere to scope of practice definitions of licensure/certification boards. TN No. NE 13-12 Supersedes TN No. MS 03-04 Approval Date ____ _ Effective Date ____ _ December 1, 2013 March 13, 2014

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ATTACHMENT 3.1-A Item 13d, Page 8 Applies to both Categorically and Medically Needy STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State Nebraska LIMITATIONS - REHABILITATIVE SERVICES Assertive Community Treatment includes the following components: 1. Completion of a comprehensive assessment of client need and the development of an appropriate treatment, rehabilitation and service plan; 2. Direct and provide needed treatment and rehabilitation services in a culturally sensitive and competent manner. The mandatory treatment and rehabilitative interventions include: a. Treatment and Service Plan Coordination: An individualized treatment and service plan developed by the treatment team to diagnose, treat, and rehabilitate the client's medical symptoms and remedial functional impairments; b. Crisis Assessment and Management: Immediate medical interventions to assess and treat an acute exacerbation of medical symptoms and/or remedial functional impairments; c) Symptom Assessment and Management: Initial and ongoing assessment of the client's medical symptoms and remedial functional impairments. The assessment includes, but is not limited to, relevant history, previous treatment, current medical conditions and medications; d) Individual Contacts: Staff interventions with the client or their family to facilitate communication and client skill building necessary to support the client in the community and minimize the adverse effects of the illness. The specific focus of family contact is to facilitate the effective treatment and rehabilitation of the client; e) Active Treatment Interventions: Active treatment interventions include individual therapy, group therapy, family therapy and substance abuse counseling; f) Medication Prescription, Administration and Monitoring; g) Activities of Daily Living: Medical and remedial services designed to rehabilitate and develop the general skills and behaviors needed for the client to engage in substantial gainful activity and use of daily living skills. These include problem solving, individualized assistance and support and skill training; h) Social Interpersonal Relationship and Leisure Time Skill Training: Remedial interventions (problem solving, role playing, modeling and support, etc.) designed to minimize the adverse effects of severe mental illness (examples: isolation, poor peer selection, poor decision making, depression, substance abuse, anxiety). Interventions include activities required to help the client improve communication skills, develop assertiveness, increase self-esteem, develop social skills and meaningful personal relationships, plan appropriate and productive use of leisure time and TN No. NE 13-12 Supersedes TN No. MS 03-04 Approval Date ___ _ Effective Date ___ _ December 1, 2013 March 13, 2014

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STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State Nebraska ATTACHMENT 4.19-B Item 5, Page 1 METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES PHYSICIANS' SERVICES For dates of service on or after August 1, 1989, NMAP pays for covered physicians' services at the lower of: 1. The provider's submitted charge; or 2. The allowable amount for that procedure code in the Nebraska Medicaid Practitioner Fee Schedule in effect for that date of service. The allowable amount is indicated in the fee schedule as: a. The unit value multiplied by the conversion factor (last updated on July 1, 2013); b. The invoice cost (indicated as "IC" in the fee schedule); or c. The reasonable charge for the procedure as determined by the Medicaid Division (indicated as "BR" - by report or "RNE" - rate not established - in the fee schedule). 3. Exception: The Director of the Division of Medicaid and Long-Term Care or designee may enter into an agreement for a negotiated rate with an out-of-state provider which will be based on a percentage of billed charges, not to exceed 100%, only when the Medical Director of the Division has determined that: a. The client requires specialized services that are not available in Nebraska; and b. No other source of the specialized service can be found. The following is a listing of specialized physician services that have been previously rendered by out-of-state providers: a. lung transplants; and b. pediatric heart transplants. Note: The above listing is not all-inclusive of the specialized physician services that will be reimbursed via negotiated rates in the future, as it is based on previous experience." The Nebraska Medicaid Practitioner Fee Schedule was last updated on July 1, 2013 and is effective for services rendered on or after that date. The fee schedule is subject to annual/periodic adjustment. All rates, including current and prior rates, are published and maintained on the agency's website. Specifically, the fee schedule and any annual/periodic adjustments to the fee schedule are published at http:l/www.dhhs.ne.gov/med/practitioner fee schedule.htm. Physicians and non-physician care providers are subject to a site-of-service payment adjustment. A site-of-service differential that reduces the fee schedule amount for specific CPT/HCPCS codes will be applied when the service is provided in the facility setting. Based on the Medicare differential, NMAP will reimburse specific CPT/HCPCS codes with adjusted rates based on the site-of-service. The Nebraska Medicaid Practitioner Fee Schedule is effective July 1 through June 30 of each year. TN#. 13-19 Supersedes TN #.NE 12-13 Approval Date S E P Z 0 2013 Effective Date J U L -·1 2013

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Page 1 of 2 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 General Eligibility Requirements Eligibility Process S94 42 CFR 435, Subpart J and Subpart M Eligibility Process The state meets all the requirements of 42 CFR 435, Subpart J for processing applications, determining and verifying eligibility, and furnishing Medicaid. ✔ Application Processing Indicate which application the agency uses for individuals applying for coverage who may be eligible based on the applicable modified adjusted gross income standard. The single, streamlined application for all insurance affordability programs, developed by the Secretary in accordance with section 1413(b)(1)(A) of the Affordable Care Act An alternative single, streamlined application developed by the state in accordance with section 1413(b)(1)(B) of the Affordable Care Act and approved by the Secretary, which may be no more burdensome than the streamlined application developed by the Secretary. An attachment is submitted. An alternative application used to apply for multiple human service programs approved by the Secretary, provided that the agency makes readily available the single or alternative application used only for insurance affordability programs to individuals seeking assistance only through such programs. An attachment is submitted. Indicate which application the agency uses for individuals applying for coverage who may be eligible on a basis other than the applicable modified adjusted gross income standard: The single, streamlined application developed by the Secretary or one of the alternate forms developed by the state and approved by the Secretary, and supplemental forms to collect additional information needed to determine eligibility on such other basis, submitted to the Secretary. An attachment is submitted. An application designed specifically to determine eligibility on a basis other than the applicable MAGI standard which minimizes the burden on applicants, submitted to the Secretary. An attachment is submitted. The agency's procedures permit an individual, or authorized person acting on behalf of the individual, to submit an application via the internet website described in 42 CFR 435.1200(f), by telephone, via mail, and in person. The agency also accepts applications by other electronic means: Yes No Transmittal Number: NE 13-0028-MM2 Approval Date: March 13, 2014 Effective Date: October 1, 2013

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Page 2 of 2 Medicaid Eligibility Indicate the other electronic means below: Name of Method Description + Email An applicant or beneficiary can email their application to the Medicaid agency. x The agency has procedures to take applications, assist applicants and perform initial processing of applications for the eligibility groups listed below at locations other than those used for the receipt and processing of applications for the title IV-A program, including Federally-qualified health centers and disproportionate share hospitals. ✔ Parents and Other Caretaker Relatives Pregnant Women Infants and Children under Age 19 Redetermination Processing Redeterminations of eligibility for individuals whose financial eligibility is based on the applicable modified adjusted gross income standard are performed as follows, consistent with 42 CFR 435.916: ✔ Once every 12 months ■ Without requiring information from the individual if able to do so based on reliable information contained in the individual's account or other more current information available to the agency ■ If the agency cannot determine eligibility solely on the basis of the information available to it, or otherwise needs additional information to complete the redetermination, it provides the individual with a pre-populated renewal form containing the information already available. ■ Redeterminations of eligibility for individuals whose financial eligibility is not based on the applicable modified adjusted gross income standard are performed, consistent with 42 CFR 435.916 (check all that apply): ■ Once every 12 months Once every 6 months Other, more often than once every 12 months Coordination of Eligibility and Enrollment The state meets all the requirements of 42 CFR 435, Subpart M relative to coordination of eligibility and enrollment between Medicaid, CHIP, Exchanges and other insurance affordability programs. The single state agency has entered into agreements with the Exchange and with other agencies administering insurance affordability programs. ✔ PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. Transmittal Number: NE 13-0028-MM2 Approval Date: March 13, 2014 Effective Date: October 1, 2013

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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 Transmittal Number: NE 13-0029-MM3 Approval Date: January 10, 2014 Effective Date: January 1, 2014

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Page 1 of 5 Medicaid Administration OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 State Plan Administration Designation and Authority A1 42 CFR 431.10 Designation and Authority State Name: Nebraska As a condition for receipt of Federal funds under title XIX of the Social Security Act, the single state agency named below submits the following state plan for the medical assistance program, and hereby agrees to administer the program in accordance with the provisions of this state plan, the requirements of titles XI and XIX of the Act, and all applicable Federal regulations and other official issuances of the Department. Name of single state agency: Nebraska Department of Health and Human Services Type of Agency: Title IV-A Agency Health Human Resources Other Type of Agency The above named agency is the single state agency designated to administer or supervise the administration of the Medicaid program under title XIX of the Social Security Act. (All references in this plan to "the Medicaid agency" mean the agency named as the single state agency.) The state statutory citation for the legal authority under which the single state agency administers the state plan is: The legal authority under which the agency administers the plan on a Statewide basis is Sections 68-901 through 68-926. Laws 2006 LB 1248 Section 1. The single state agency supervises the administration of the state plan by local political subdivisions. Yes No The certification signed by the state Attorney General identifying the single state agency and citing the legal authority under which it administers or supervises administration of the program has been provided. ✔ An attachment is submitted. The state plan may be administered solely by the single state agency, or some portions may be administered by other agencies. The single state agency administers the entire state plan under title XIX (i.e., no other agency or organization administers any portion of it). Yes No Transmittal Number: NE 13-0030-MM4 Approval Date: March 6, 2014 Effective Date: January 1, 2014

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Page 2 of 5 Medicaid Administration The entity or entities that have responsibility for determinations of eligibility for families, adults, and for individuals under 21 are: The Medicaid agency Single state agency under Title IV-A (in the 50 states or the District of Columbia) or under Title I or XVI (AABD) in Guam, Puerto Rico, or the Virgin Islands An Exchange that is a government agency established under sections 1311(b)(1) or 1321(c)(1) of the Affordable Care Act The entity that has responsibility for determinations of eligibility for the aged, blind, and disabled are: The Medicaid agency Single state agency under Title IV-A (in the 50 states or the District of Columbia) or under Title I or XVI (AABD) in Guam, Puerto Rico, or the Virgin Islands An Exchange that is a government agency established under sections 1311(b)(1) or 1321(c)(1) of the Affordable Care Act The Federal agency administering the SSI program The entity or entities that have responsibility for conducting fair hearings with respect to denials of eligibility based on the applicable modified adjusted gross income standard are: Medicaid agency An Exchange that is a government agency established under sections 1311(b)(1) or 1321(c)(1) of the Affordable Care Act An Exchange appeals entity, including an entity established under section 1411(f) of the Affordable Care Act The agency has established a review process whereby the agency reviews appeals decisions made by the Exchange or Exchange appeals entity or other state agency, but only with respect to conclusions of law, including interpretations of state or federal policies. Yes No State Plan Administration Organization and Administration A2 42 CFR 431.10 42 CFR 431.11 Organization and Administration Provide a description of the organization and functions of the Medicaid agency. The Nebraska Department of Health and Human Services is organized into Operations and six Divisions, which includes a Chief Executive Officer that provides oversight of the Operations and Divisions, as well as reporting to the Governor. The six divisions are the Division of Medicaid & Long-Term Care, the Division of Behavioral Health, the Division of Children & Family Services, the Division of Developmental Disabilities, the Division of Public Health, and the Division of Veteran's Homes. The Division of Medicaid & Long-Term Care manages the development and approval of Medicaid policy so that all Divisions operate using the same policies.

Fair hearings for Medicaid or CHIP eligibility are handled by the Department of Health and Human Services Legal Services Division. The current process is defined below: 1. Eligibility workers prepare evidence and summary testimony for eligibility fair hearings. 2. The hearing officers, under the Legal Services Division, hear all fair hearings for Medicaid and CHIP eligibility as well as coverage and claims hearings. 3. The Director of the Division of Medicaid and Long-Term Care has all final sign off authority for fair hearings. Transmittal Number: NE 13-0030-MM4 Approval Date: March 6, 2014 Effective Date: January 1, 2014

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Page 3 of 5 Medicaid Administration

The Division of Medicaid & Long-term Care within the Department of Health and Human Services is composed of three sections - the Claims & Program Integrity Section, Initiatives & Eligibility Section, and the Program Section. The Director of the Division of Medicaid & Long-Term Care has administrative authority over the operations and functions of the Medicaid program including the issuance of policies. The Division of Medicaid and Long-Term Care is responsible for all Medicaid and CHIP eligibility determinations.

The Initiatives & Eligibility Section is managed by a Deputy Director. The section is organized into four units: Medicaid Information Technology Initiatives, Eligibility Policy & Program Accuracy, Eligibility Business Operations, and Eligibility Field Operations.

The Medicaid Information Technology Initiatives is responsible for enhanced funding requests to CMS for MMIS related projects, SMHP and EHR, MMIS System Change Requests, and large MMIS-related projects.

The Eligibility Policy Unit is responsible for Medicaid & CHIP eligibility policies, Program Accuracy, and administering CHIP.

The Eligibility Business Operations Unit is responsible for Medicaid Eligibility operational processes and procedures. Operations include development and system change implementation of Information Systems Applications such as: web, eligibility and enrollment systems (N-FOCUS and MMIS), Interfaces, Federal Data Hub, Document Imaging, and Call Center Services which includes Interactive Voice Response, Automated Call Distribution, Contact Center Data Management, and Call Quality Recording Management. Business Operations is responsible for data and performance reporting. This team also includes the Medicaid Quality Team and performs data analysis for Nebraska Medicaid Programs.

The Eligibility Field Operations Unit is responsible for hiring, training and supervising support staff, social service workers, social services leads, social services supervisors, and administrators who are located in multiple sites throughout the State of Nebraska. Those individuals are responsible for prompt and accurate eligibility determinations of individuals for the Medicaid and CHIP program. Interested parties can contact an eligibility worker: • Online; • Contacting our customer service centers; or • Contacting a local office.

The Claims & Program Integrity Section is managed by a Deputy Director. The Section is organized into two units: the Claims Unit and the Program Integrity Unit.

The Medicaid Claims Unit is responsible for provider enrollment; claims payment, data entry, screening, and electronic data interchange (EDI).

The Program Integrity Unit is responsible for the Health Insurance Premium Payment (HIPP) program, the Medicaid Management Information System (MMIS), estate recovery and third party liability (TPL), and Coordination of Benefits-Health & Causality.

The Program Unit is managed by a Deputy Director. The section is organized into three units: Policy, Managed Care and Waiver Services, and State Unit on Aging and Education and Community Living Unit.

The Policy Unit is responsible for Operations and Community & Facility Services.

The Managed Care and Waiver Services Unit is responsible for Home & Community-Based Services Waiver and Managed Care.

The State Unit on Aging and Community Living Unit is responsible for Money Follows the Person, Early Development Network, MIIPS, NEBMAC, and State Unit on Aging. Upload an organizational chart of the Medicaid agency. An attachment is submitted. Transmittal Number: NE 13-0030-MM4 Approval Date: March 6, 2014 Effective Date: January 1, 2014

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Page 4 of 5 Medicaid Administration 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. Nebraska’s Executive branch is led by Nebraska’s elected Governor. The Governor provides oversight for the Department of Administrative Services, the Department of Agriculture, the Department of Banking and Finance, the Department of Economic Development, the Department of Education, the Department of Environmental Quality, the Department of Insurance, the Department of Labor, the Department of Motor Vehicles, the Department of Natural Resources, the Department of Revenue, the Department of Roads, the Emergency Management Agency, Health and Human Services, Nebraska Energy Office, the Nebraska State Historical Society, Nebraska State Jobs, Nebraska Travel and Tourism Division, and the State Unit on Aging.

Medicaid and Long-Term Care is a division of the Department of Health and Human Services. All Divisions within the Department of Health and Human Services provide support to each other. Entities that determine eligibility other than the Medicaid Agency (if entities are described under Designation and Authority) Remove Type of entity that determines eligibility: Single state agency under Title IV-A (in the 50 states or the District of Columbia) or under Title I or XVI (AABD) in Guam, Puerto Rico, or the Virgin Islands An Exchange that is a government agency established under sections 1311(b)(1) or 1321(c)(1) of the Affordable Care Act The Federal agency administering the SSI program Provide a description of the staff designated by the entity and the functions they perform in carrying out their responsibility. Add Entities that conduct fair hearings other than the Medicaid Agency (if are described under Designation and Authority) Remove Type of entity that conducts fair hearings: An Exchange that is a government agency established under sections 1311(b)(1) or 1321(c)(1) of the Affordable Care Act An Exchange appeals entity, including an entity established under section 1411(f) of the Affordable Care Act Provide a description of the staff designated by the entity and the functions they perform in carrying out their responsibility. Add Supervision of state plan administration by local political subdivisions (if described under Designation and Authority) Is the supervision of the administration done through a state-wide agency which uses local political subdivisions? Yes No State Plan Administration Assurances A3 Transmittal Number: NE 13-0030-MM4 Approval Date: March 6, 2014 Effective Date: January 1, 2014

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Page 5 of 5 Medicaid Administration 42 CFR 431.10 42 CFR 431.12 42 CFR 431.50 Assurances The state plan is in operation on a statewide basis, in accordance with all the requirements of 42 CFR 431.50. ✔ All requirements of 42 CFR 431.10 are met. ✔ There is a Medical Care Advisory Committee to the agency director on health and medical services established in accordance with meeting all the requirements of 42 CFR 431.12. ✔ The Medicaid agency does not delegate, to other than its own officials, the authority to supervise the plan or to develop or issue policies, rules, and regulations on program matters. ✔ Assurance for states that have delegated authority to determine eligibility: There is a written agreement between the Medicaid agency and the Exchange or any other state or local agency that has been delegated authority to determine eligibility for Medicaid eligibility in compliance with 42 CFR 431.10(d). Assurances for states that have delegated authority to conduct fair hearings: There is a written agreement between the Medicaid agency and the Exchange or Exchange appeals entity that has been delegated authority to conduct Medicaid fair hearings in compliance with 42 CFR 431.10(d). When authority is delegated to the Exchange or an Exchange appeals entity, individuals who have requested a fair hearing are given the option to have their fair hearing conducted instead by the Medicaid agency. Assurance for states that have delegated authority to determine eligibility and/or to conduct fair hearings: The Medicaid agency does not delegate authority to make eligibility determinations or to conduct fair hearings to entities other than government agencies which maintain personnel standards on a merit basis. PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. Transmittal Number: NE 13-0030-MM4 Approval Date: March 6, 2014 Effective Date: January 1, 2014

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9 Approved OMB#: 0938-1098

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State: Nebraska

1.4 Tribal Consultation Requirements Section 1902(a)(73) of the Social Security Act (the Act) requires a State in which one or more Indian Health Programs or Urban Indian Organizations furnish health care services to establish a process for the State Medicaid agency to seek advice on a regular, ongoing basis from designees of Indian health programs, whether operated by the Indian Health Service (IHS), Tribes or Tribal organizations under the Indian Self-Determination and Education Assistance Act (ISDEAA), or Urban Indian Organizations under the Indian Health Care Improvement Act (IHCIA). Section 2107(e)(I) of the Act was also amended to apply these requirements to the Children’s Health Insurance Program (CHIP). Consultation is required concerning Medicaid and CHIP matters having a direct impact on Indian health programs and Urban Indian organizations.

The Division of Medicaid and Long-Term Care (MLTC) meets on a quarterly basis or as needed with the tribes (Omaha, Ponca, Santee Sioux and Winnebago) and with the CMS Native American contact to discuss relevant Medicaid/CHIP matters that impact the tribes and to invite discussion and comments for consideration.

________________________________________________________________________ TN No: NE 13-0030 Supersedes Approval Date ___________ Effective Date ____________ TN No. 11-15

March 6, 2014 January 1, 2014

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Page 1 of 4 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Non-Financial Eligibility State Residency S88 42 CFR 435.403 State Residency The state provides Medicaid to otherwise eligible residents of the state, including residents who are absent from the state under certain conditions. ✔ Individuals are considered to be residents of the state under the following conditions: Non-institutionalized individuals age 21 and over, or under age 21, capable of indicating intent and who are emancipated or married, if the individual is living in the state and: ■ Intends to reside in the state, including without a fixed address, or ■ Entered the state with a job commitment or seeking employment, whether or not currently employed. ■ Individuals age 21 and over, not living in an institution, who are not capable of indicating intent, are residents of the state in which they live. ■ Non-institutionalized individuals under 21 not described above and non IV-E beneficiary children: ■ Residing in the state, with or without a fixed address, or ■ The state of residency of the parent or caretaker, in accordance with 42 CFR 435.403(h)(1), with whom the individual resides. ■ Individuals living in institutions, as defined in 42 CFR 435.1010, including foster care homes, who became incapable of indicating intent before age 21 and individuals under age 21 who are not emancipated or married: ■ Regardless of which state the individual resides, if the parent or guardian applying for Medicaid on the individual's behalf resides in the state, or ■ Regardless of which state the individual resides, if the parent or guardian resides in the state at the time of the individual's placement, or ■ If the individual applying for Medicaid on the individual's behalf resides in the state and the parental rights of the institutionalized individual's parent(s) were terminated and no guardian has been appointed and the individual is institutionalized in the state. ■ Individuals living in institutions who became incapable of indicating intent at or after age 21, if physically present in the state, unless another state made the placement. ■ Individuals who have been placed in an out-of-state institution, including foster care homes, by an agency of the state. ■ Any other institutionalized individual age 21 or over when living in the state with the intent to reside there, and not placed in the institution by another state. ■ IV-E eligible children living in the state, or ■ Transmittal Number: NE 13-0031-MM5 Approval Date: March 14, 2014 Effective Date: January 1, 2014

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Page 1 of 3 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Non-Financial Eligibility Citizenship and Non-Citizen Eligibility S89 1902(a)(46)(B) 8 U.S.C. 1611, 1612, 1613, and 1641 1903(v)(2),(3) and (4) 42 CFR 435.4 42 CFR 435.406 42 CFR 435.956 Citizenship and Non-Citizen Eligibility The state provides Medicaid to citizens and nationals of the United States and certain non-citizens consistent with requirements of 42 CFR 435.406, including during a reasonable opportunity period pending verification of their citizenship, national status or satisfactory immigration status. ✔ 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 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 verification of their citizenship, nationality or satisfactory immigration status consistent with requirements of 1903(x), 1137(d), 1902(ee) of the SSA and 42 CFR 435.406, and 956.

■ The reasonable opportunity period begins on and extends 90 days from the date the notice of reasonable opportunity is received by the individual. The agency provides for an extension of the reasonable opportunity period if the individual is making a good faith effort to resolve any inconsistencies or obtain any necessary documentation, or the agency needs more time to complete the verification process. Yes No The agency begins to furnish benefits to otherwise eligible individuals during the reasonable opportunity period on a date earlier than the date the notice is received by the individual. Yes No The state provides Medicaid coverage to all Qualified Non-Citizens whose eligibility is not prohibited by section 403 of PRWORA (8 U.S.C. §1613). Yes 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. Yes No Transmittal Number: NE 13-0032-MM6 Approval Date: March 14, 2014 Effective Date: January 1, 2014

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Page 2 of 3 Medicaid Eligibility Pregnant women Individuals under age 21: Individuals under age 21 Individuals under age 20 Individuals under age 19 An individual is considered to be lawfully residing in the United States if he or she is lawfully present and otherwise meets the eligibility requirements in the state plan. ■ An individual is considered to be lawfully present in the United States if he or she: ■ 1. Is a qualified non-citizen as defined in 8 U.S.C. 1641(b) and (c); 2. Is a non-citizen in a valid nonimmigrant status, as defined in 8 U.S.C. 1101(a)(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 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 a non-citizen who belongs to one of the following classes: Granted temporary resident status in accordance with 8 U.S.C. 1160 or 1255a, respectively; ■ Granted Temporary Protected Status (TPS) in accordance with 8 U.S.C. §1254a, and individuals with pending applications for TPS who have been granted employment authorization; ■ Granted employment authorization under 8 CFR 274a.12(c); ■ Family Unity beneficiaries in accordance with section 301 of Pub. L. 101-649, as amended; ■ Under Deferred Enforced Departure (DED) in accordance with a decision made by the President; ■ Granted Deferred Action status; ■ Granted an administrative stay of removal under 8 CFR 241; ■ Beneficiary of approved visa petition who has a pending application for adjustment of status; ■ 5. Is an individual with a pending application for asylum under 8 U.S.C. 1158, or for withholding of removal under 8 U.S.C.1231, or under the Convention Against Torture who - Has been granted employment authorization; or ■ Is under the age of 14 and has had an application pending for at least 180 days; ■ 6. Has been granted withholding of removal under the Convention Against Torture; 7. Is a child who has a pending application for Special Immigrant Juvenile status as described in 8 U.S.C. 1101(a)(27)(J); 8. Is lawfully present in American Samoa under the immigration laws of American Samoa; or 9. Is a victim of severe trafficking in persons, in accordance with the Victims of Trafficking and Violence Protection Act of 2000, Pub. L. 106-386, as amended (22 U.S.C. 7105(b)); Transmittal Number: NE 13-0032-MM6 Approval Date: March 14, 2014 Effective Date: January 1, 2014

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Page 1 of 3 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Presumptive Eligibility by Hospitals S21 42 CFR 435.1110 One or more qualified hospitals are determining presumptive eligibility under 42 CFR 435.1110, and the state is providing Medicaid coverage for individuals determined presumptively eligible under this provision. Yes No The state attests that presumptive eligibility by hospitals is administered in accordance with the following provisions: ✔ 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 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 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 No 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 ■ Adult Group, if covered by the state ■ Individuals above 133% FPL under Age 65, if covered by the state ■ Individuals Eligible for Family Planning Services, if covered by the state ■ Former Foster Care Children ■ Certain Individuals Needing Treatment for Breast or Cervical Cancer, if covered by the state ■ Other Family/Adult groups: Eligibility groups for individuals age 65 and over Eligibility groups for individuals who are blind Eligibility groups for individuals with disabilities Other Medicaid state plan eligibility groups Demonstration populations covered under section 1115 The state establishes standards for qualified hospitals making presumptive eligibility determinations. Transmittal Number: NE 13-0033-MM7 Approval Date: July 9, 2014 Effective Date: January 1, 2014

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Page 2 of 3 Medicaid Eligibility 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: Hospitals determining presumptive eligibility for individuals will need to show those individuals following up with a valid Medicaid application at a rate of 95% or higher.

The State will continuously assess hospital performance data and quality.

That is to say, of the individuals determined eligible under the presumptive eligibility program who file a valid Medicaid application, 95% are approved for Medicaid.

The State will continuously assess hospital performance data and quality.

Hospitals will not be disqualified for failing to meet the standards for the first 12 months of the individual hospital's implementation. Effective 12 months after the hospital's implementation, the hospital will be subject to disqualification for not meeting the standard. Individuals within the hospital are not exempt from the disqualification. The presumptive period begins on the date the determination is made. ■ The end date of the presumptive period is the earlier of: ■ The date the eligibility determination for regular Medicaid is made, if an application for Medicaid is filed by the last day of the month following the month in which the determination of presumptive eligibility is made; or The last day of the month following the month in which the determination of presumptive eligibility is made, if no application for Medicaid is filed by that date. Periods of presumptive eligibility are limited as follows: ■ No more than one period within a calendar year. No more than one period within two calendar years. No more than one period within a twelve-month period, starting with the effective date of the initial presumptive eligibility period. Other reasonable limitation: The state requires that a written application be signed by the applicant, parent or representative, as appropriate. Transmittal Number: NE 13-0033-MM7 Approval Date: July 9, 2014 Effective Date: January 1, 2014

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Page 3 of 3 Medicaid Eligibility 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. An attachment is submitted. 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) ■ Household income must not exceed the applicable income standard for the group for which the individual's presumptive eligibility is being determined, if an income standard is applicable for this group. ■ State residency Citizenship, status as a national, or satisfactory immigration status The state assures that it has communicated the requirements for qualified hospitals, and has provided adequate training to the hospitals. A copy of the training materials has been included. ✔ 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 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. Transmittal Number: NE 13-0033-MM7 Approval Date: July 9, 2014 Effective Date: January 1, 2014

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Division of Medicaid & Long Term-Care Presumptive Medicaid Eligibility MS-91 (29021) 12/13 Page 1 Section 1: This entire form should be completed by an accepted Medicaid Presumptive Eligibility Provider. Please list all members of the family living in the home together. Parents in the home include biological, step, or adoptive. If more space is needed, attach an additional sheet of paper. Address: Phone: Name Date of Birth Gender M/F Pregnant? Y/N Fetal Number Expected Due Date (MM/DD/YYYY) Section 4 DO NOT COMPLETE THIS SECTION BEFORE COMPLETING SECTIONS 2 AND 3 ON PAGE 2. I (The qualiﬁed Presumptive Eligibility provider) certify that the following individuals have been determined to be presumptively eligible. (Do not complete Section 4 if the client is determined ineligible.) Name Category of Eligibility Date of Birth (MM/DD/YYYY) *Note: A presumptively eligible pregnant woman is eligible for ambulatory care only. *Pregnancy providers may only authorize eligiblity for pregnant women. Provider Information: Please note: Only persons certiﬁed as approved providers may authorize presumptive eligibility Name: Medicaid Provider Number: Address: Phone: Signature (Provider may sign only after client has been approved and signed page 2) Date of PE Determination: NOTICE TO PROVIDERS: Please accept this form as proof of temporary Medical coverage. To check Medical presumptive eligibility please call the Medicaid Eligibility Line (NMES) at 1-800-642-6092 Please Note: There may be a delay in Presumptively Eligible cases appearing as eligible. Be advised that pregnant women are eligible for ambulatory care only. NOTICE TO APPLICANT: Show this form to providers of services as proof of medical coverage. You will NOT be issued a Medicaid card. This coverage is temporary. If you are interested in receiving full Medicaid coverage, you MUST complete a Medicaid application. Transmittal Number: NE 13-0033-MM7 Approval Date: July 9, 2014 Effective Date: January 1, 2014

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Division of Medicaid & Long Term-Care Presumptive Medicaid Eligibility MS-91 (29021) 12/13 Page 2 Section 2: Complete this section for household members. *Citizenship/Immigration status along with SSN/A Number are only required for individuals requesting assistance. Name (Last, First) US Citizen OR qualiﬁed alien under the Federal Immigration and Nationality Act (Y/N) Social Security Number or Immigration Status and A Number Tax Filing Status (See options) Relationship to applicant Nebraska Resident (Y/N) SELF Tax Filing Status Abbreviations: Single Tax Filer - S Married Filing Jointly - MJ Married Filing Seperately - MS Tax Dep. of a Parent - DP Tax Dep. of Other - DO Non Tax Filer - NF Section 3: Declaration of Income (Please note what deductions were used in the computation.) 1. Total Monthly Gross Income $______________________________ 4. Total Countable Income $______________________________ 2. Total Net Self-Employment Income $______________________________ 5. Total Deductions $______________________________ 3. Total Monthly Unearned Income $______________________________ 6. Line 4 minus Line 5 $______________________________ Compare line 6 to the FPL for the individual’s Medicaid category and household size to determine eligibility. When this form is signed I agree that for the purpose of complying with Neb. Rev. State 4-108 through 4-114, I hereby attest that my response and the information provided on this from and any related application for public beneﬁts are true, complete, and accurate and I understand that this information may be used to verify my lawful presence in the United States. This information may be veriﬁed by USCIS (formerly known as INS) through the submission of information from the application to USCIS, and that the submitted information received from USCIS may affect the household’s eligibility and level of beneﬁts. I understand my responsibilities and agree to fulﬁll them. I under- stand I may have to provide proof of what I have said. If written proof is not available, I agree to give the name or organization so that the Department of Health and Human Services may obtain the necessary proof. I will cooperate fully with state and federal personnel in a Quality Control Review. I authorize the release of the Social Security Numbers provided on this form to the Department of Health and Human Services to use for the purposes mentioned in the Rights and Responsibilities. NOTICE OF APPEAL RIGHTS: This is not an application for Medical Assistance. If you want Medical Assistance you are required to com- plete an application by the last day of the month following the date of presumptive determination listed in Section 4 of this document. Failure to apply will cause this presumptive eligibility to end without notice. You will be responsible for medical expenses incurred from this date forward. If for any other reasons the agency determines that you are ineligible for Medical Assistance, this presumptive eligibility will end without notice. These actions are not subject to appeal. To apply for Medical Assistance, go to ACCESSNebraska.ne.gov or call 1-855-632-7633. SIGN HERE: (Signature or Mark of Applicant - Witness if mark) Date: SIGN HERE: (Signature of Witness if needed) Transmittal Number: NE 13-0033-MM7 Approval Date: July 9, 2014 Effective Date: January 1, 2014

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Absent Parent: A parent who is not in the home where his/her child(ren) is living. Affordable Care Act (ACA): The Patient Protection and Affordable Care Act of 2010, as amended by the Health Care and Education Reconciliation Act of 2010, as amended by the Three Percent Withholding Repeal and Job Creation Act. Ambulatory Prenatal Care: services related to the pregnancy excluding inpatient hospital services, nursing home services, labor and delivery services, and services furnished to deliver or remove an embryo/fetus from the mother or services following such a procedure. Applicant: An individual who is seeking an eligibility determination for him/herself through an application submission or a transfer from another agency or insurance affordability program. Application: The single streamlined application submitted by or on behalf of an individual via an agency approved format. Terms and Definitions 13 Application Date: For new and reopened cases, the date a properly signed application is received. When adding a program to a properly signed application, this is the date that the new program is requested. Application Signature: Applications may be signed in writing, telephonic signature, or by electronic signature. Application Submission: Applications may be submitted in person, by mail, by telephone, by fax, or by electronic submission. Approval/Rejection Date: The date that the new or reopened case is determined eligible or rejected by the Nebraska Department of Health and Human Services. Child Support: Money that is: Ordered by a court of competent jurisdiction on behalf of a minor child; or Paid by the noncustodial parent without a court order. Client: An individual who has been determined eligible for and is currently receiving Medicaid. Department: The Nebraska Department of Health and Human Services. Terms and Definitions 14 Transmittal Number: NE 13-0033-MM7 Approval Date: July 9, 2014 Effective Date: January 1, 2014

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Dependent Child: A child from birth to age 17 or who is age 18 and a full‐time student in secondary school (or equivalent vocational or technical training, if before attaining age 19 the child may be reasonably expected to complete such school or training. Is deprived of parental support by reason of the death, absence from the home, physical or mental incapacity, or unemployment/underemployment of both parents (neither parent is employed more than 100 hours in a month). Eligibility Determination: An approval or denial of eligibility as well as a renewal or termination of eligibility. Family Size Using Modified Adjusted Gross Income (MAGI) Methodology: Means the number of persons counted as members of an individual’s household. When determining the family size of individuals who have a pregnant woman in their household, the family size is counted as the pregnant woman plus the number of children she is expected to deliver. Federal Poverty Level (FPL): The federal poverty level updated periodically by the Federal Government as in effect for the applicable budget period used to determine an individual’s eligibility. Terms and Definitions 15 Former Foster Care: An individual upon their 19th birthday up to their 26th birthday who was in foster care in Nebraska and was receiving Medicaid when they aged out. Home: Any shelter which the individual owns and uses as his/her principal place of residence. The home includes any land on which the house is located and any related outbuildings necessary to the operation of the home. Household Size Using MAGI Methodology: The group of individuals that will be used to determine family size for a particular applicant and whose income may be counted toward the applicant’s total household income for purposes of determining his or her eligibility for Medicaid and CHIP. See 477 NAC 14‐001. Household Income Using MAGI Methodology: The sum of an individual’s MAGI plus the MAGI of tax dependents in the family if required to file a tax return. See 477 NAC 15‐001. Incapacity (Physical or Mental): Any physical or mental illness, impairment, or defect which is so severe as to substantially reduce or eliminate the parent’s ability to provide support or care for a child(ren). The incapacity must be expected to last at least 30 days. Note: Age itself is not considered an incapacity. Terms and Definitions 16 Transmittal Number: NE 13-0033-MM7 Approval Date: July 9, 2014 Effective Date: January 1, 2014

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Lawfully Residing: Qualified alien pregnant woman and children who are lawfully present in the United States and who are residents of the state in which they are applying under Nebraska’s residency rules. Legal Guardian: An individual appointed by a court of competent jurisdiction to be in charge of the affairs of a person who cannot effectively manage his/her own affairs because of his/her age or incapacity. Minor Parent: An individual age 18 or younger, with a child. Modified Adjusted Gross Income (MAGI): The methodology used to determine financial eligibility. Non‐Applicant: An individual who is not seeking an eligibility determination for himself or herself and is included in an applicant’s or client’s household to determine eligibility for such applicant or client. Non‐Filer: Individuals who do not intend either to file taxes or to be claimed as a tax dependent. Parental Deprivation: Two‐parent families must meet the Hundred‐Hour rule, disability, or have a physical or mental incapacity in order to be eligible for Medicaid as determined by Social Security or the State Review Team (SRT). A single parent household meets deprivation. Terms and Definitions 17 Parent/Caretaker Relative: A relative of a dependent child by blood, adoption, or marriage with whom the child is living, who assumes primary responsibility for the child’s care, and who is one of the following: The child’s father, mother, grandfather, grandmother, brother, sister, stepfather, stepmother, stepbrother, stepsister, uncle, aunt, first cousin, nephew, or niece. The spouse of such parent or relative, even after the marriage is terminated by death or divorce. Another relative of the child based on blood, adoption, or marriage recognized by the State of Nebraska, or an adult with whom the child is living and who has verified guardianship/conservatorship of the child. Pregnant Woman: A woman during pregnancy and the post‐partum period. Rejected Case: A case in which an application was completed and signed, but the applicant did not meet the categorical, procedural, or financial requirements of the program. Terms and Definitions 18 Transmittal Number: NE 13-0033-MM7 Approval Date: July 9, 2014 Effective Date: January 1, 2014

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Household Size for a Tax Filer: The first step in determining MAGI‐based eligibility is to determine the household size for each individual. The method for counting individuals depends on whether the person is a tax filer, a non‐tax filer, or a tax dependent. A Tax Filer is the individual who files a tax return and is not expected to be claimed as a tax dependent. When determining household size for MAGI‐based eligibility, it is important to know who intends to file a tax return. This information is asked of each individual in the application. Household size for a Tax Filer: The individual expected to file a tax return PLUS all persons whom the individual expects to claim as tax dependents. Household and Unit Size 31 Tax Dependents A Tax Dependent is an individual for whom another individual claims a deduction for a personal exemption for a taxable year. For eligibility determination, a tax dependent is part of the household of the tax filer claiming the individual as a tax dependent, except when: The individual expects to be claimed as a tax dependent of someone other than a spouse or parent (biological, adopted, or step). The individual is under the age 19, a full time student in secondary school and will graduate before age 19, who expects to be claimed by one parent as a tax dependent and is living with both parents, but the parents are not expected to file a joint return. The individual is under age 19, a full time student in secondary school and will graduate before age 19, who expects to be claimed as a tax dependent by a non‐ custodial parent. To be considered a non‐custodial parent, a court order, binding separation, divorce or custody agreement establishing custody must exist. In no such order exists, or in the event of a shared custody agreement the custodial parent is the parent with whom the child spends most nights. Household and Unit Size 32 Transmittal Number: NE 13-0033-MM7 Approval Date: July 9, 2014 Effective Date: January 1, 2014

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DEPARTMENT OF HEALTH AND HUMAN SF.RV JCI:iS HEALTH CARE FINANCING ADMINISTRATION FORM APPROVED OMB NO. 0938.0193 TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL 1. TRANSMIITAL NUMBER: 14-017 2. STATE Nebraska FOR: HEALTH CARE FINANCING ADMJNISTRA TION TO: REGIONAL ADMINISTRATOR HEALTH CARE FINANCING ADMINISTRA TTON DEPARTMENT OF HEALTH AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL (Check One): 3. PROGRAM IDENTIFlCA TION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) 4. PROPOSED EFFECTIVE DATE July 1,2014 0 NEW STATE PLAN 0 AMENDMENT TO BE CONSIDERED AS NEW PLAN lgj AMENDMENT COMPLETE BLOCKS 6 THRU 10 JF THIS IS AN AMENDMENT 'Se arate Transmittal or each amendment 6. FEDERAL STATUTE/REGULATION CITATION: 7. FEDERAL BUDGET IMPACT: a. FFY 2014 $42,616.69 b. FFY 20 15 $229,035.82 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable): Supplement 4 to Attachment 3.1-A, pages 5-1 1 Supplement 4 to Attachment 3.1-A, pages 5-11 I 0. SUBJECT OF AMENDMENT: Program of All Inclusive Care for the Elderly (PACE) Upper payment limits (UPLs) are being revised II. GOVERNOR'S REVfEW (Check One}: 0 GOVERNOR'S OFFICE REPORTED NO COMMENT 0 COMMENTS OF GOVERNOR'S OFFICE ENCLOSED [8l OTHER, AS SPECIFfED: Governor has waived review 0 NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMfTTAL 12. SIGN TURE OF STATE AGENCY OFFICIAL: 16. RETURN TO: ---=-=- -'----------i Nancy Keller Courtne Miller Division of Medicaid & Long-Term Care ---,-,.-=...::=..::,:.::.L..:.:.~:.:.._----------------i Nebraska Department of Health & Human Services 14. TITLE: 301 Centennial Mall South Director, Division of Medicaid and Lon -Term Care --:-:15=-. -=o-:-A-=T=E:'-::S-::-! U=B=-=-M'-::I=T=T=E~D;..;;. : ~=.;.;.;.:;....:.;__;;_...,;.;;__.._;;;....;.;.;;.;;.;;_;;;..;,;.;;..;'-------i Lincoln, NE 68509 Se tcmber 30, 2014 FOR REGIONAL OFFICE USE ONLY 17. DATE RECEIVED: 118. 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: FORM HCF A-179 (07-92} 5-6 September 30, 2014 * Pen and ink changes per state request dated 12.11.14. * December 16, 2014 July 1, 2014 James G. Scott Associate Regional Administrator for Medicaid and Children's Health Operations //s//

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SUPPLEMENT 4 TO ATTACHMENT 3.1-A Page 5 OMS No.: 0939-0193 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State/Territory: Nebraska (B). _The following dollar amount: $-~- Note: If this amount changes, this item will be revised. (C). L The following formula is used to determine the needs allowance: (1) For waiver clients receiving Assisted Living Services: The State protects the SSI standard. (2) For clients receiving waiver services in other eligible living arrangements: The State protects the medically needy income standard. If this amount is different than the amount used for the individual's maintenance allowance under 42 CFR 435.726 or 42 CFR 435.735, explain why you believe that this amount is reasonable to meet the individual's maintenance needs in the community: II. Rates and Payments A. The State assures that the capitated rates will be equal to or less than the cost to the agency of providing those same fee-for-service State plan approved services on a fee-for-service basis, to an equivalent non-enrolled population group based upon the following methodology. Please attach a description of the negotiated rate setting methodology and how the State will ensure that rates are less than the cost in fee- for-service. 1. 2. 3. 4._L Rates are set at a percent of fee-for-service costs Experience-based (contractors/State's cost experience or encounter date)(please describe) Adjusted Community Rate (please describe) Other (please describe) Rates are set at a percent of Upper Payment Limits. The State contracts with an actuarial company to develop PACE Upper Payment Limits (UPLs). The UPLs are developed based on historical Nebraska Medicaid fee- for-service (FFS) costs for individuals aged 55 and over who were either nursing home residents or eligible for HCBS waiver services based on meeting nursing facility level of care criteria. Projection factors are applied to the UPLs to reflect utilization changes, historical and prospective Medicaid program changes, and provider rate changes. The UPLs are then summarized into rate cells by eligibility category and defined geographic area. The State ensures that rates paid to PACE provider organizations are less than the cost in FFS by negotiating a rate for each that are less than the UPL. TN No. NE 14-017 Supersedes TN No-NE 12-04 Approval Date Effective Date ____ _ Revised Submission 11.20.2014 December 16, 2014 July 1, 2014

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SUPPLEMENT 4 TO ATTACHMENT 3.1-A Page 6 OMB No.: 0939-0193 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT StatefT errito ry: Nebraska B. The State Medicaid Agency assures that the rates were set in a reasonable and predictable manner. Please list the name, organizational affiliation of any actuary used, and attestation/description for the capitation rates. The State contracted with a certified actuary, to develop its UPLs. The UPLs are an estimate of what costs would have been to Nebraska Medicaid for PACE participants if they had not enrolled in PACE. Within each eligibility category (dually Medicaid and Medicare eligible, Medicaid only, dually Medicaid and Medicare (Part B only) eligible and Qualified Medicare Beneficiary (QMB)), the actuary developed separate UPLs for nursing home residents and HCBS waiver participants who meet nursing facility level of care criteria (aka PACE eligibles} by geographic area Data Reliance and Important Caveats In developing the UPLs, the actuary relied on data and other information provided by the State. Since the source of the data was the State's Medicaid Management Information System (MMIS), the State takes responsibility for the accuracy and validity of the base data. The following data and information was used: • Medicaid claims and eligibility data for individuals ages 55 and older, including a description of each data field and its potential use in classifying individuals into eligibility groupings of service use and Medicare eligibility; • Summary of Medicaid fee and program changes in SFY 2012 and later; and • Quarterly CMS-64 Medicaid Administrative Cost reports for FFY 2013 C. The State will submit all capitated rates to the CMS Regional Office for prior approval. Ill. Enrollment and Disenrollment The State assures that there is a process in place to provide for dissemination of enrollment and disenrollment data between the State and the State Administering Agency. The State assures that it has developed and will implement procedures for the enrollment and disenrollment of participants in the State's management information system, including procedures for any adjustment to account for the difference between the estimated number of participants on which the prospective monthly payment was based and the actual number of participants in that month. TN No. NE 14-017 Supersedes TN No NE 12-04 Approval Date Effective Date ___ _ Revised Submission 12.11.2014 December 16, 2014 July 1, 2014

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DEPARTMENT OF HEALTH AND HUMAN SERVICES HEAL TH CARE FINANCING ADMINISTRATION TRANSMITTAL AND NOTICE OF APPROVAL OF ST A TE PLAN MATERIAL FOR: HEALTH CARE FINANCING ADMINISTRATION TO: REGIONAL ADMINISTRATOR HEALTH CARE FINANCING ADMINISTRATION DEPARTMENT OF HEALTH AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL (Check One): 1. TRANSMITTAL NUMBER: 15-0005 FORM APPROVED OMS NO. 0938-0193 2. STATE Nebraska 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) 4. PROPOSED EFFECTIVE DATE July I, 2015 O NEW ST ATE PLAN O AMENDMENT TO BE CONSIDERED AS NEW PLAN ÜAMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT Se arale Transmittal or each amendment) 6. FEDERAL STATUTE/REGULATION CITATION: 7. FEDERAL BUDGET IMPACT: a. FFY 2015 $269,142.00 b. FFY 2016 $1,149 464.00 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION Attachment 4.19-B, Item I, pages 1-3; Att. 4.19-B, Item la; Att. 4.19-B, Item 2a, page 4; Att. 4.19-B, Item 4b, page 3; Att. 4.19-B, Item 5, page 1; Att. 4.19-B, Item 9, Page 5; Att. 4.19-B, Item 13d, Page la; Att. 4.19-B, Item 24a; Att. 4.19-B, Item 27 10. SUBJECT OF AMENDMENT: SFY 16 Practitioner Services 11. GOVERNOR'S REVIEW (Check One): O GOVERNOR'S OFFICE REPORTED NO COMMENT O COMMENTS OF GOVERNOR'S OFFICE ENCLOSED ONO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL OR ATTACHMENT (If Applicable): Attachment 4.19-B, Item !,pages 1-3;Att. 4.19-B,Item la; Att. 4.19-B, Item 2a, page 4; Att. 4.19-B, Item 4b, page 3; Att. 4.19-B, Item 5, page I; Att. 4.19-B, Item 9, Page 5; Att. 4.19-B, Item 13d, Page la; Att. 4.19-B, Item 24a; Att. 4.19-B, Item 27 Ü OTHER, AS SPECIFIED: Governor has waived review 16. RETURN TO: --:J1.'.--= -- - - ----1 Nancy Keller Division of Medicaid & Long-Term Care ----Þ------------ - - ----1 Nebraska Depatiment of Health & Human Services 301 Centennial Mall South __ D_i_re_c _toß r ,'-D_i _v1_· s_io_n _o_f_M_e_d1_· c_ai_d _a _nd _L_on_..._-T_e_rm_C_a_ re ____ -t Lincoln, NE 68509 15. DATE SUBMITTED: Auoust 26 2015 FOR REGIONAL OFFICE USE ONLY 17. DA TE RECEIVED: 118. DATE APPROVED: PLAN APPROVED - ONE COPY ATTACHED 19. EFFECTIVE DATE OF APPROVED MATERIAL: 20. SIGNATURE OF REGIONAL OFFICIAL: 2 l. TYPED NAME: 22. TITLE: 23. RE'MARKS: FORM HCF A-179 (07-92) August 26, 2015 November 23, 2015 July 1, 2015 //s// James G. Scott Associate Regional Administrator for Medicaid and Children's Health Operations

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ATTACHMENT 4.19-8 Item 1, page 1 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State Nebraska When services which are reimbursed per a fee schedule, except as otherwise noted in the plan, state-developed fee schedule rates are the same for both governmental and private providers. Except for Clinical Laboratory services and Injectable Drugs, the agency's rates were set as of July 1, 2015, and are effective for services on or after that date. All rates are published at: http://dhhs.ne.gov/medicaid/Pages/med practitioner fee schedule.aspx. • The fee schedule amounts for Clinical Laboratory services are based on 100% Medicare Clinical Laboratory Fee Schedule. The Department shall update the Clinical Laboratory fee schedule using the most current calendar update as published by the Centers for Medicare and Medicaid Services. • The fee schedule amounts for lnjectables are based on 100% Medicare Drug fee schedule. The Department shall update the lnjectables Fee Schedule using the most current calendar update as published by the Centers for Medicare and Medicaid Services. • Injectable medications approved by the Medicaid Medical Director but not included on the Medicare Drug Fee Schedule will be reimbursed at the estimated acquisition cost (EAC) used to reimburse pharmacy claims. • The agency's fee schedule rate was set as of July 1, 2015 and is effective for services provided on or after that date. • Payment methods for each service are defined in Attachment 4.198, Methods and Standards for Establishing Payment Rates, as referenced below. Service Attachment CHIROPRACTORS' SERVICES ATTACHMENT 4.19-8 Item 6c, Page 1 of 2 PHYSICIANS' SERVICES ATTACHMENT 4.19-8 Item 5, Page 1 and 2 OPTOMETRISTS' SERVICES ATTACHMENT 4.19-8 Item 6b, Page 1 MENTAL HEAL TH SERVICES ATTACHMENT 4.19-8 Item 9, Page 1 of 4 PHYSICAL THERAPY ATTACHMENT 4.19-8 Item 11a, Page 1 of 2 OCCUPATIONAL THERAPY ATTACHMENT 4.19-8 Item 11 b, Page 1 of 2 TN # NE 15-0005 Supersedes TN# NE 14-009 Effective Date July 1,2015 July 1,2015 July 1,2015 July 1, 2015 July 1, 2015 July 1, 2015 Approval Date November 23, 2015 Effective Date July 1, 2015

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ATTACHMENT 4.19-B Item 2a, Page 4 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State Nebraska METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES OUTPATIENT HOSPITAL SERVICES NMAP pays for covered psychiatric partial hospitalization services at the lower of: 1. The provider's submitted charge; or 2. The allowable amount for that procedure code in the Nebraska Medicaid Practitioner Fee Schedule in effect for that date of service. The allowable amount is indicated in the fee schedule as: a. The unit value multiplied by the conversion factor; b. The invoice cost (indicated as "IC" in the fee schedule); c. The maximum allowable dollar amount; or d. The reasonable charge for the procedure as determined by the Medicaid Division (indicated as "BR" - by report or "RNE" - rate not established - in the fee schedule). Except as otherwise noted in the plan, state developed fee schedule rates are the same for both governmental and private providers of psychiatric partial hospitalization services. The agency's fee schedule rate was set as of July 1, 2015 and is effective for services provided on or after that date. All rates are published on the agency's website at http://dhhs.ne.gov/medicaid/Pages/med practitioner fee schedule.aspx. Revisions of the Fee Schedule: The Department reserves the right to adjust the fee schedule to: 1. Comply with changes in state or federal requirements; 2. Comply with changes in nationally-recognized coding systems, such as HCPCS and CPT; 3. Establish an initial allowable amount for a new procedure based on information that was not available when the fee schedule was established for the current year; and 4. Adjust the allowable amount when the Medicaid Division determines that the current allowable amount is: a. Not appropriate for the service provided; or b. Based on errors in data or calculation. The Department may issue revisions of the Nebraska Medicaid Fee Schedule during the year that it is effective. Providers will be notified of the revisions and their effective dates. TN# NE 15-0005 Supersedes TN# NE 14-009 Approval Date November 23, 2015 Effective Date July 1, 2015

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STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: Nebraska METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES ATTACHMENT 4.19-8 Item 4b, Page 3 Other Licensed Practitioners: Licensed Alcohol and Drug Counselor (LADC) Rehabilitation Services - 42 CFR 440.130(d): Day Treatment/Intensive Outpatient Service by Direct Care Staff; Community Treatment Aide; Professional Resource Family Care; and Therapeutic Group Home Reimbursement for services is based upon a Medicaid fee schedule established by the State of Nebraska. Except as otherwise noted in the Plan, state-developed fee schedule rates are the same for both governmental and private providers of substance abuse services. The agency's fee schedule rate was set as of July 1, 2015 and is effective for services provided on or after that date. All rates are published on the agency's website at http://dhhs.ne.gov/medicaid/Pages/med practitioner fee schedule.aspx The Nebraska Medicaid fee schedule outlined above will be established using the following methodologies: • If a Medicare fee exists for a defined covered procedure code, then Nebraska will set the Nebraska Medicaid fee schedule for LADC at 95 percent of the licensed Master's level rate paid under Attachment 3.1A, Item 6d for any codes permitted under their scope of practice per Nebraska state law. • Where Medicare fees do not exist for a covered code, the fee schedule will be set using a market-based pricing methodology as described below. These reimbursement methodologies will produce rates sufficient to enlist enough providers so that services under the Plan are available to individuals at least to the extent that these services are available to the general population, as required by 42 CFR 447.204. These rates comply with the requirements of Section 1902(a)(30) of the Social Security Act 42 CFR 447.200, regarding payments and consistent with economy, efficiency and quality of care. Provider enrollment and retention will be reviewed periodically to ensure that access to care and adequacy of payments are maintained. The Medicaid fee schedule will be equal to or less than the maximum allowable under the same Medicare rate, where there is a comparable Medicare rate. Room and board costs are not included in the Medicaid fee schedule. The market-based pricing methodology will be composed of provider cost modeling for four key components: direct care salary expenses, employee related expenses, program indirect expenses and administrative expenses. The analysis includes national compensation studies for Nebraska to determine the appropriate wage or salary expense for the direct care worker providing each service based on the staffing requirements and roles and responsibilities of the worker, published information related to employee related expenses and other notable cost components and cost data and fees from similar State Medicaid programs. The following list outlines the major components of the cost model to be used in fee development: (1) Staffing Assumptions and Staff Wages (2) Employee-Related Expenses - Benefits, Employer Taxes (e.g., FICA, unemployment, and workers compensation) (3) Program-Related Expenses (e.g., supplies) (4) Provider Overhead Expenses (5) Program Billable Units The fee schedule rates will be developed as the ratio of total annual modeled provider costs to the estimated annual billable units. TN # NE 15-0005 Supersedes TN# NE 14-009 Approval Date November 23, 2015 Effective Date July 1, 2015

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STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State Nebraska ATTACHMENT 4.19-8 Item 5, Page 1 METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES PHYSICIANS' SERVICES For dates of service on or after August 1, 1989, Nebraska Medicaid pays for covered physicians' services at the lower of: 1. The provider's submitted charge; or 2. The allowable amount for that procedure code in the Nebraska Medicaid Practitioner Fee Schedule in effect for that date of service. The allowable amount is indicated in the fee schedule as: a. The unit value multiplied by the conversion factor (last updated on July 1, 2015); b. The invoice cost (indicated as "IC" in the fee schedule); or c. The reasonable charge for the procedure as determined by the Medicaid Division (indicated as "BR" - by report or "RNE" - rate not established - in the fee schedule). 3. Exception: The Director of the Division of Medicaid and Long-Term Care or designee may enter into an agreement for a negotiated rate with an out-of-state provider which will be based on a percentage of billed charges, not to exceed 100%, only when the Medical Director of the Division has determined that: a. The client requires specialized services that are not available in Nebraska; and b. No other source of the specialized service can be found. The following is a listing of specialized physician services that have been previously rendered by out-of-state providers: a. lung transplants; and b. pediatric heart transplants. Note: The above listing is not all-inclusive of the specialized physician services that will be reimbursed via negotiated rates in the future, as it is based on previous experience. Except as otherwise noted in the plan, state-developed fee schedule rates are the same for both governmental and private providers of physicians' services. The agency's fee schedule rate was set as of July 1, 2015 and is effective for services provided on or after that date. All rates are published on the agency's website at http://dhhs.ne.gov/medicaid/Pages/med practitioner fee schedule.aspx. Physicians and non-physician care providers are subject to a site-of-service payment adjustment. A site-of-service differential that reduces the fee schedule amount for specific CPT/HCPCS codes will be applied when the service is provided in the facility setting. Based on the Medicare differential, Nebraska Medicaid will reimburse specific CPT/HCPCS codes with adjusted rates based on the site-of-service. TN# NE 15-0005 Supersedes TN# NE 14-009 Approval Date November 23, 2015 Effective Date July 1, 2015

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STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State Nebraska ATTACHMENT 4.19-B Item 13d, Page 1 a METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES SECURE PSYCHIATRIC RESIDENTIAL REHABILITATION Medicaid has researched the cost of an existing similar service to develop a comparable rate. Costs for treatment and rehabilitation services are contained in the Medicaid rate. The rate does not include room and board. Except as otherwise noted in the plan, state-developed fee schedule rates are the same for both governmental and private providers of Secure Psychiatric Residential Rehabilitation Services. The agency's fee schedule rate was set as of July 1, 2015 and is effective for services provided on or after that date. All rates are published at http://dhhs.ne.gov/medicaid/Pages/med practitioner fee schedule.aspx. The State Medicaid agency will have an agreement with each entity receiving payment under Secure Psychiatric Residential Rehabilitation services that will require that the entity furnish to the Medicaid agency on an annual basis the following: • Data, by practitioner, on the utilization by Medicaid beneficiaries of the services included in the unit rate, • Cost information by practitioner type and by type of service actually delivered within the services unit, • Provider's annual utilization data and cost information shall support that the required type, quantity and intensity of treatment services are delivered to meet the medical needs of the clients served. Medicaid Agency or its designee may further evaluate through on site or post pay review of the treatment plans and the specific services delivered as necessary to assure compliance. COMMUNITY SUPPORT SERVICES Community Support Services shall be reimbursed on a direct service by service basis and billed in 15 minute increments up to a maximum of 144 units per 180 days. Except as otherwise noted in the plan, state-developed fee schedule rates are the same for both governmental and private providers of community support services. The agency's fee schedule rate was set as of July 1, 2015 and is effective for services provided on or after that date. All rates are published on the agency's website at http://dhhs.ne.gov/medicaid/Pages/med practitioner fee schedule.aspx. This rate will be the same for quasi-governmental and private providers of community support service. The rate includes all indirect services and collateral contacts that are medically necessary rehabilitative related interventions. TN # NE 15-0005 Supersedes TN # NE 14-009 Approval Date November 23, 2015 Effective Date July 1, 2015

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Medicaid Eligibility State Name: Nebraska Transmittal Number: NE - 15 - 0011 OMB Control Number: 0938-1148 Expiration date: 10/31/2014 Eligibility Groups - Options for Coverage Reasonable Classification of Individuals undet. A2e 21 S52 42 CFR 435.222 l 902(a)(lO)(A)(ii)(I) l 902(a)(lO)(A)(ii)(IV) Reasonable Classification of Individuals under Age 21 - The state elects to cover one or more reasonable classifications of individuals under age 21 who are not mandatorily eligible and who have income at or below a standard established by the state and in accordance with provisions described at 42 CFR 435.222. (e Yes No [ZJ The state attests that it operates this eligibility group in accordance with the following provisions: e Individuals qualifying under this eligibility group must qualify under a reasonable classification by meeting the following criteria: e Be under age 21, or a lower age, as defined within the reasonable classification. e Have household income at or below the standard established by the state, if the state has an income standard for the • reasonable classification. e Not be eligible and enrolled for mandatory coverage under the state plan. e MAGI-based income methodologies are used in calculating household income. Please refer as necessary to SlO MAGI Based Income Methodologies, completed by the state. The state covered at least one reasonable classification under this eligibility group under its Medicaid state plan as of December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013, with income standards higher (including disregarding all income) than the current mandatory income standards for the individual's age. (e Yes No The state also covered at least one reasonable classification under this group in the Medicaid state plan as of March 23, 2010 with income standards higher (including disregarding all income) than the current mandatory income standards for the individual's age. (e Yes No Page 1 of 8 Transmittal Number: 15-0011 Supersedes Number: 15-0006

Approval Date: November 10, 2015 Effective Date: November 1, 2015

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DEPARTMENT OF HEALTH AND HUMAN SERVICES HEALTH CARE FINANCING ADMINISTRATION

FORM APPROVED OMB NO. 0938-0193

TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL

FOR: HEALTH CARE FINANCING ADMINISTRATION

2. STATE Nebraska

1. TRANSMITTAL NUMBER: 15-0012

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

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

4, PROPOSED EFFECTIVE DATE 452015 *January 1, 2016

5. TYPE OF PLAN MATERIAL (Check One):

(NEW STATE PLAN

(J AMENDMENT TO BE CONSIDERED AS NEW PLAN

J AMENDMENT

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

6. FEDERAL STATUTE/REGULATION CITATION: * 42 CFR 435.232

7. FEDERAL BUDGET IMPACT: a. FFY 2016 $0.00 b, FFY 2017 $0.00

8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:

,Attachement 2.6-A, Page 14 Attactmrent 26-A; Page tA

Supplement I to Attachment 2.6-A, pages 8 and 9 Supplement 6 to Attachment 2.6-A

Supplement 10 to Attachment 2.6-A, page 1

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

Attachement 2.6-A, Page 14

‘Attachment 2.6-A,-Page- 14b-

Supplement 1 to Attachment 2.6-A, pages 8 and 9 Supplement 6 to Attachment 2.6-A

Supplement 10 to Attachment 2.6-A, page |

10. SUBJECT OF AMENDMENT: Technical Corrections for Non-MAGI Based Categories

*spenddown for the Medically Needy, burial trust, and

standards for optional supplementary payments.

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

&J OTHER, AS SPECIFIED: Governor has waived review

gee) 9 12, SIGNATURE OF STATE/AGENCY OFFICIAL: (G=EYPED NAME:

Calder Lynch

14, TITLE: [ z : a

Director, Division of Medicaid and Long-Term Care

15. DATE SUBMITTED: December 30, 2015

16. RETURN TO:

Nancy Keller

Division of Medicaid & Long-Term Care Nebraska Department of Health & Human Services 301 Centennial Mall South

Lincoln, NE 68509

FOR REGIONAL OFFICE USE ONLY

17. DATE RECEIVED: December 30, 2015

18. DATE APPROVED: March 28, 2016

PLAN APPROVED — ONE COPY ATTACHED

19. EFFECTIVE DATE OF APPROVED MATERIAL: January 1, 2016

20. SIGNATURE OF REGIONAL OFFICIAL:

21. TYPED NAME: James G. Scott

22. TITLE: Associate Regional Administrator for

Medicaid-and Children's Health. Operations

23, REMARKS:

*Per state request, pen and ink changes made to box 6 adding a citation, the effective date amended in box 4, page removed as annotated in boxes 8 and 9 removing Attachment 2.6-A, page 14b, and in box 10 the expansion of the subject.

FORM HCFA-179 (07-92)

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AlternativeBenefitPlan OMBControlNumber: 09381148 StateName:ebraska N Attachment3.1-L- TransmittalNumber:NE-19-0001 AlternativeBenefitPlanPopulationsABP1 IdentifyanddefinethepopulationthatwillparticipateintheAlternativeBenefitPlan. AlternativeBenefitPlanPopulationName:NebraskaPrimeAlternativeBenefitPlan IdentifyeligibilitygroupsthatareincludedintheAlternativeBenefitPlan'spopulation, andwhichmaycontainindividualsthatmeetany targetingcriteriausedtofurtherdefinethepopulation. EligibilityGroupsIncludedintheAlternativeBenefitPlanPopulation: Enrollmentis AddEligibilityGroup: mandatoryorRemove voluntary? AddRemove AdultGroupMandatory Enrollmentisavailableforallindividualsintheseeligibilitygroup(s). No TargetingCriteriaselectallthatapply): IncomeStandard. Disease/Condition/Diagnosis/Disorder. Other. OtherTargetingCriteria (Describe): ebraskaPrimeAlternativeBenefitPlanisprovidedto19and20yearolds, andindividualsage21through64whohavebeen N determinedtobeMedicallyFrailandindividualswhobecomepregnantintheadultgrouppriortotheirnextannualeligibility renewal. GeographicArea TheAlternativeBenefitPlanpopulationwillincludeindividualsfromtheentirestate/territory. Yes Anyotherinformationthestate/territorywishestoprovideaboutthepopulation (optional) PRADisclosureStatement AccordingtothePaperworkReductionActof1995, nopersonsarerequiredtorespondtoacollectionofinformationunlessitdisplaysa validOMBcontrolnumber. ThevalidOMBcontrolnumberforthisinformationcollectionis0938-1148. Thetimerequiredtocomplete thisinformationcollectionisestimatedtoaverage5hoursperresponse, includingthetimetoreviewinstructions, searchexistingdata resources, gatherthedataneeded, andcompleteandreviewtheinformationcollection. Ifyouhavecommentsconcerningtheaccuracyof thetimeestimate(s) orsuggestionsforimprovingthisform, pleasewriteto: CMS, 7500SecurityBoulevard, Attn: PRAReportsClearance Officer, MailStopC4-26-05, Baltimore, Maryland21244-1850. V.20181119 TN: NE19-0001 EffectiveDate: 10/01/2020 SupersedingPage: NewApproval Date: 07/06/2020 Page1of1

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AlternativeBenefitPlan OMBControlNumber: 09381148 StateName:ebraska N Attachment3.1-L- TransmittalNumber:NE-19-0001 VoluntaryBenefitPackageSelectionAssurances - EligibilityGroupunder ABP2a Section1902(a)(10)(A)(i)( VIII) oftheAct Thestate/territoryhasfullyaligneditsbenefitsintheAlternativeBenefitPlanusingEssentialHealthBenefitsandsubjectto1937 requirementswithitsAlternativeBenefitPlanthatisthestate’sapprovedMedicaidstateplanthatisnotsubjectto1937 Yes requirements. Thereforethestate/territoryisdeemedtohavemettherequirementsforvoluntarychoiceofbenefitpackagefor individualsexemptfrommandatoryparticipationinasection1937AlternativeBenefitPlan. ExplainhowthestatehasfullyaligneditsbenefitsintheAlternativeBenefitPlanusingEssentialHealthBenefitsandsubjectto1937 requirementswithitsAlternativeBenefitPlanthatisthestate’sapprovedMedicaidstateplanthatisnotsubjectto1937requirements. ebraskahasfullyalignedthebenefitsinitsNebraskaPrimeABPwiththeapprovedMedicaidStatePlanbyusingduplicationand N addingtheremainingMedicaidcoveredservicesbyincludingadditionalSection1937coveredbenefits. Benefitsprovidedbythebase benchmarkplanthatarenotincludedintheMedicaidStatePlanweresubstitutedforStatePlanbenefitsnotprovidedinthebase benchmarkplan. TheEHBcategorywheresubstitutionoccurredmeetsthestandardofactuarialequivalence. PRADisclosureStatement AccordingtothePaperworkReductionActof1995, nopersonsarerequiredtorespondtoacollectionofinformationunlessitdisplaysa validOMBcontrolnumber. ThevalidOMBcontrolnumberforthisinformationcollectionis0938-1148. Thetimerequiredtocomplete thisinformationcollectionisestimatedtoaverage5hoursperresponse, includingthetimetoreviewinstructions, searchexistingdata resources, gatherthedataneeded, andcompleteandreviewtheinformationcollection. Ifyouhavecommentsconcerningtheaccuracyof thetimeestimate(s) orsuggestionsforimprovingthisform, pleasewriteto: CMS, 7500SecurityBoulevard, Attn: PRAReportsClearance Officer, MailStopC4-26-05, Baltimore, Maryland21244-1850. V.20160722 Page1of1 TN: NE19-0001 EffectiveDate: 10/01/2020 SupersedingPage: NewApproval Date: 07/06/2020

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AlternativeBenefitPlan OMBControlNumber: 09381148 StateName:ebraska N Attachment3.1-L- TransmittalNumber:NE-19-0001 SelectionofBenchmarkBenefitPackageorBenchmark-EquivalentBenefitPackageABP3.1 Selectoneofthefollowing: Thestate/territoryisamendingoneexistingbenefitpackageforthepopulationdefinedinSection1. Thestate/territoryiscreatingasinglenewbenefitpackageforthepopulationdefinedinSection1. Nameofbenefitpackage:NebraskaPrimeAlternativeBenefitPlan SelectionofEHB-BenchmarkPlan Thestate/territorymustselectanEHB-benchmarkplanasthebasisforprovidingEssentialHealthBenefitsinits BenchmarkorBenchmark-EquivalentPackage. BCBSofNebraska: BluePridePlusOption102Gold EHB-benchmarkplanname: o N TheEHB-benchmarkplanisthesameastheSection1937Coverageoption: IndicatetheEHB-benchmarkoptionasdescribedat45CFR156.111(b)(2)(B) thestate/territorywilluseasitsEHB- benchmarkplan: State/TerritoryisselectingoneofthebelowoptionstodesignanEHBpackagethatcomplieswiththerequirementsfor theindividualinsurancemarketunder45CFR156.100through156.125. State/TerritoryisselectingtheEHB-benchmarkplanusedbythestate/territoryforthe 2017planyear. State/TerritoryisselectingoneoftheEHB-benchmarkplansusedforthe2017planyearbyanother state/territory. State/ TerritoryselectsthefollowingEHB-benchmarkplanusedforthe2017planyearbutwill replacecoverageofoneormoreofthecategoriesofEHBwithcoverageofthesamecategoryfrom the2017EHB-benchmarkplanofoneormoreotherstates Selectasetofbenefitsconsistentwiththe10EHBcategoriestobecomethenewEHB-benchmark plan. (CompleteandsubmittheABP5: BenefitsDescriptionformtodescribethesetofbenefits.) TypeofEHB-benchmarkplan: Largestplanbyenrollmentofthethreelargestsmallgroupinsuranceproductsinthestate's smallgroupmarket. Anyofthelargestthreestateemployeehealthbenefitplansbyenrollment. AnyofthelargestthreenationalFEHBPplanoptionsopentoFederalemployeesinall geographiesbyenrollment. Largestinsuredcommercialnon-MedicaidHMO. Page1of3 TN: NE19-0001 EffectiveDate: 10/01/2020 SupersedingPage: NewApproval Date: 07/06/2020

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AlternativeBenefitPlan Assurances Thestate/territoryassurestheEHBplanmeetsthescopeofbenefitsstandardsat45CFR156.111(b), doesnotexceed generosityofmostgenerousamongasetofcomparisonplans, providesappropriatebalanceofcoverageamong10 EHBcategories, andthescopeofbenefitsisequalto, orgreaterthan, thescopeofbenefitsprovidedunderatypical employerplanasdefinedat45CFR156.111(b)(2). Thestate/territoryassuresthatallservicesintheEHB-benchmarkplanhavebeenaccountedforthroughoutthebenefit chartfoundinABP5. Thestate/territoryassurestheaccuracyofallinformationinABP5depictingamount, durationandscopeparametersof servicesauthorizedinthecurrentlyapprovedMedicaidStatePlan. SelectionoftheSection1937CoverageOption Thestate/territoryselectsasitsSection1937CoverageoptionthefollowingtypeofBenchmarkBenefitPackageorBenchmark- EquivalentBenefitPackageunderthisAlternativeBenefitPlan (checkone): BenchmarkBenefitPackage. Benchmark-EquivalentBenefitPackage. Thestate/territorywillprovidethefollowingBenchmarkBenefitPackage (checkonethatapplies): TheStandardBlueCross/BlueShieldPreferredProviderOptionofferedthroughtheFederalEmployeeHealthBenefit Program (FEHBP). Stateemployeecoveragethatisofferedandgenerallyavailabletostateemployees (StateEmployeeCoverage): AcommercialHMOwiththelargestinsuredcommercial, non-Medicaidenrollmentinthestate/territory (Commercial HMO): Secretary-ApprovedCoverage. Thestate/territoryoffersbenefitsbasedontheapprovedstateplan. Thestate/territoryoffersanarrayofbenefitsfromthesection1937coverageoptionand/orbasebenchmarkplan benefitpackages, ortheapprovedstateplan, orfromacombinationofthesebenefitpackages. Thestate/territoryoffersthebenefitsprovidedintheapprovedstateplan. Benefitsincludeallthoseprovidedintheapprovedstateplanplusadditionalbenefits. Benefitsarethesameasprovidedintheapprovedstateplanbutinadifferentamount, durationand/orscope. Thestate/territoryoffersonlyapartiallistofbenefitsprovidedintheapprovedstateplan. Thestate/territoryoffersapartiallistofbenefitsprovidedintheapprovedstateplanplusadditionalbenefits. Pleasebrieflyidentifythebenefits, thesourceofbenefitsandanylimitations: 1) Thestateassuresthatallservicesinthebasebenchmarkhavebeenaccountedforthroughoutthebenefitchart foundinABP5; and (2) ThestateassurestheaccuracyofallinformationinABP5depictingamount, duration, and scopeparametersofservicesauthorizedinthecurrentlyapprovedMedicaidStatePlan. OtherInformationRelatedtoSelectionoftheSection1937CoverageOptionandtheEHB-BenchmarkPlan (optional): SeeNebraskaPrimeAlternativeBenefitPlanABP5. Page2of3 TN: NE19-0001 EffectiveDate: 10/01/2020 SupersedingPage: NewApproval Date: 07/06/2020

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AlternativeBenefitPlan Otherinformationregardingthisbenefit, includingthespecificnameofthesourceplanifitisnotthebase benchmarkplan: Servicesprovidedbycommunitymentalhealthcentersarelimitedtomedicallynecessaryacutepsychiatric services. Daytreatmentservicesarelimitedtoahalf-dayorfull-dayrate, establishedonthebasisofeach facility'scostreportwhichisreviewedannually. The "facilityfee" includespaymentforservicesanditemsprovidedbyanASCinconnectionwitha coveredsurgicalprocedure. Priorauthorizationisrequiredfortheevaluationandtreatmentofinfantsandchildrenwhofailtoeatand/or drinkasufficientquantityorvarietyoffoodsorliquidstomeettheirnutritionaland/orhydrationneedsby hospitalaffiliatedclinicsorfree-standingclinics. BenefitProvided: Source: Remove HospiceCare StatePlan1905(a) ProviderQualifications: Authorization: AuthorizationrequiredinexcessoflimitationMedicaidStatePlan AmountLimit: DurationLimit: oneOther N ScopeLimit: Theclientmustbecertifiedasterminallyillwithasix-monthlifeexpectancybytheHospicemedical directorandtheattendingphysicianatthebeginningofthefirstbenefitperiodandbytheHospicemedical directorforallsubsequentperiods. Otherinformationregardingthisbenefit, includingthespecificnameofthesourceplanifitisnotthebase benchmarkplan: Aclientmayelecttoreceivehospicecareduringoneormoreofthefollowingelectionperiods: aninitial 90-dayperiod, asubsequent90-dayperiod, aninitial60-dayperiod, asubsequent60-dayperiod, andathird 60-dayperiod. Additional60-daybenefitperiodsmustbeapprovedasanexceptionunderthepriorauthorization provision. BenefitProvided: Source: Remove HomeHealthServices StatePlan1905(a) ProviderQualifications: Authorization: PriorAuthorizationMedicaidStatePlan AmountLimit: DurationLimit: oneOther N ScopeLimit: Other Otherinformationregardingthisbenefit, includingthespecificnameofthesourceplanifitisnotthebase benchmarkplan: Coverageforallhomehealthagencyservicesisbasedonmedicalnecessity, andmustbenecessaryto TN: NE19-0001 EffectiveDate: 10/01/2020 SupersedingPage: NewApproval Date: 07/06/2020 Page3of45

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AlternativeBenefitPlan 12. BaseBenchmarkBenefitsNotCoveredduetoSubstitutionorDuplicationCollapseAll BaseBenchmarkBenefitthatwasSubstituted: Source: Remove PrimaryCareVisittoTreatanInjuryorIllness BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: Duplication: CoveredunderNebraskaMedicaidStatePlanasPhysician'sServicesandOtherPractitioner ServicesinEHB1: AmbulatoryPatientServices. BaseBenchmarkBenefitthatwasSubstituted: Source: Remove SpecialistVisit BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: Duplication: CoveredunderNebraskaMedicaidStatePlanasPhysician'sServicesandOtherPractitioner ServicesinEHB1: AmbulatoryPatientServices. BaseBenchmarkBenefitthatwasSubstituted: Source: Remove OutpatientSurgeryPhysician/SurgicalServices BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: Duplication: CoveredunderNebraskaMedicaidStatePlanasPhysician'sServicesandOtherPractitioner ServicesinEHB1: AmbulatoryPatientServices. BaseBenchmarkBenefitthatwasSubstituted: Source: Remove HospiceServices BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: Duplication: CoveredunderNebraskaMedicaidStatePlanasHospiceCareinEHB1: AmbulatoryPatient Services. BaseBenchmarkPlan: Thecoveredpersonmusthavealifeexpectancyofsixmonthsorlessas documentedinwritingbytheattendingphysician. Thehospiceservicesmustbeorderedbyaphysician. Servicesprovidedmustbeappropriateforpalliativesupportormanagementofacoveredpersonswith terminalmedicalillness. BaseBenchmarkBenefitthatwasSubstituted: Source: Remove UrgentCareCenterorFacilities BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: Duplication: CoveredunderNebraskaMedicaidStatePlanasOutpatientHospitalServicesandClinic ServicesinEHB1: AmbulatoryPatientServices. TN: NE19-0001 EffectiveDate: 10/01/2020 SupersedingPage: NewApproval Date: 07/06/2020 Page24of4

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AlternativeBenefitPlan BaseBenchmarkBenefitthatwasSubstituted: Source: Remove EmergencyRoomServices BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: Duplication: CoveredunderNebraskaMedicaidStatePlanasEmergencyHospitalServicesinEHB2: EmergencyServices. BaseBenchmarkBenefitthatwasSubstituted: Source: Remove EmergencyTransportation/Ambulance BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: Duplication: CoveredunderNebraskaMedicaidStatePlanasTransportationServices: EmergencyinEHB 2: EmergencyServices. BaseBenchmarkBenefitthatwasSubstituted: Source: Remove HomeHealthCareServices BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: Duplication: CoveredunderNebraskaMedicaidStatePlanasHomeHealthServicesEHB1: Ambulatory PatientServices. BaseBenchmarkPlan: Limitedto60days. BaseBenchmarkBenefitthatwasSubstituted: Source: Remove InpatientHospitalServices BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: Duplication: CoveredunderNebraskaMedicaidStatePlanasInpatientHospitalServicesEHB3: Hospitalization. BaseBenchmarkBenefitthatwasSubstituted: Source: Remove InpatientPhysicianandSurgicalServices BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: Duplication: CoveredunderNebraskaMedicaidStatePlanasInpatientHospitalServices: EHB3: Hospitalization. BaseBenchmarkBenefitthatwasSubstituted: Source: Remove SkilledNursingFacility BaseBenchmark TN: NE19-0001 EffectiveDate: 10/01/2020 SupersedingPage: NewApproval Date: 07/06/2020 Page25of4

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AlternativeBenefitPlan Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: Duplication: CoveredunderNebraskaMedicaidStatePlanasShort-TermNursingFacilityServicesinEHB 7: RehabilitativeandRehabilitativeServicesandDevices. BaseBenchmarkPlan: 60day(s) peryear Exclusions: Skillednursingfacilitycaredoesnotinclude: a) supportiveservicesforastabilizedcondition; b) carewhichcanbelearnedandgivenbyunlicensedoruncertifiedmedicalpersonnel; c) routinehealthcareservices; d) generalmaintenanceorsupervisionofroutinedailyactivities; or e) routineadministrationoforalornonprescriptiondrugs. BaseBenchmarkBenefitthatwasSubstituted: Source: Remove PrenatalandPostnatalCare BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: Duplication: CoveredunderNebraskaMedicaidStatePlanasOutpatientHospitalServices-Maternity, PhysicianServices-Maternity, OtherPractitioner'sServices-Maternity, Nurse-midwifeServices, Free StandingBirthCenterServices, InpatientHospitalServices-Maternity, TobaccoCessation-Maternity, HomeHealthServices-Maternity, ExtendedServicesforPregnantWomeninEHB4: Maternityand NewbornCare. BaseBenchmarkBenefitthatwasSubstituted: Source: Remove DeliveryandAllInpatientServicesforMaternity BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: Duplication: CoveredunderNebraskaMedicaidStatePlanasInpatientHospitalServices-Maternity, Nurse- midwifeServices, FreeStandingBirthCenterServicesinEHB4: MaternityandNewbornCare. BaseBenchmarkBenefitthatwasSubstituted: Source: Remove BasicDentalCare - Child BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: Duplication: CoveredunderNebraskaMedicaidStatePlanasMedicaid StatePlanEPSDTBenefitsin EHB10: PediatricServices - includingoralandvision. BaseBenchmarkPlan: Limit: 2exam(s) peryear. BaseBenchmarkBenefitthatwasSubstituted: Source: Remove WellBabyVisitsandCare BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: Duplication: CoveredunderNebraskaMedicaidStatePlanasMedicaid StatePlanEPSDTBenefitsin EHB10: PediatricServices - includingoralandvision. TN: NE19-0001 EffectiveDate: 10/01/2020 SupersedingPage: NewApproval Date: 07/06/2020 Page26of4

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AlternativeBenefitPlan BaseBenchmarkBenefitthatwasSubstituted: Source: Remove DentalCheck-upforChildren BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: Duplication: CoveredunderNebraskaMedicaidStatePlanasMedicaid StatePlanEPSDTBenefitsin EHB10: PediatricServices - includingoralandvision. BaseBenchmarkBenefitthatwasSubstituted: Source: Remove EyeGlassesforChildren BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: Duplication: CoveredunderNebraskaMedicaidStatePlanasMedicaid StatePlanEPSDTBenefitsin EHB10: PediatricServices - includingoralandvision. BaseBenchmarkBenefitthatwasSubstituted: Source: Remove RoutineEyeExamforChildren BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: Duplication: CoveredunderNebraskaMedicaidStatePlanasMedicaid StatePlanEPSDTBenefitsin EHB10: PediatricServices - includingoralandvision. BaseBenchmarkBenefitthatwasSubstituted: Source: Remove LaboratoryOutpatientandProfessionalServices BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: Duplication: CoveredunderNebraskaMedicaidStatePlanasOtherLaboratoryandX-rayServicesinEHB 8: LaboratoryServices. BaseBenchmarkBenefitthatwasSubstituted: Source: Remove X-raysandDiagnosticImaging BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: Duplication: CoveredunderNebraskaMedicaidStatePlanasOtherLaboratoryandX-rayServicesinEHB 8: LaboratoryServices. BaseBenchmarkBenefitthatwasSubstituted: Source: Remove Imaging (CT/PETScans, MRIs) BaseBenchmark TN: NE19-0001 EffectiveDate: 10/01/2020 SupersedingPage: NewApproval Date: 07/06/2020 Page27of4

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AlternativeBenefitPlan Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: Duplication: CoveredunderNebraskaMedicaidStatePlanasOtherLaboratoryandX-rayServicesinEHB 8: LaboratoryServices. BaseBenchmarkBenefitthatwasSubstituted: Source: Remove Mental/BehavioralHealthOutpatientServices BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: Duplication: CoveredunderNebraskaMedicaidStatePlanasOutpatientHospitalServices: MH/SUD, Physician'sServices: MH/SUD, ClinicServices: MH/SUD, OtherPractitioner'sServices: MH/SUD, RehabilitativeServices: MH/SUDandHomeHealthServices: MH/SUDinEHB5: MentalHealthand SubstanceUseDisorderServices. BaseBenchmarkBenefitthatwasSubstituted: Source: Remove Mental/BehavioralHealthInpatientServices BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: Duplication: CoveredunderNebraskaMedicaidStatePlanasInpatientHospitalServices: MH/SUD, Physician'sServices: MH/SUD, ClinicServices: MH/SUD, OtherPractitioner'sServices: MH/SUD, RehabilitativeServices: MH/SUDinEHB5: MentalHealthandSubstanceUseDisorderServices. BaseBenchmarkPlan: Excludesprogramsthattreatobesityorgamblingaddictionandresidentialtreatment programs. Exclusionsinclude: programsforco-dependency; employeeassistance; probation; prevention; educational orself-help; programswhichtreatobesity, gambling, ornicotineaddiction; CustodialCareforMental Illnessand/orSubstanceDependenceandAbuse; halfwayhouseorSubstanceDependenceandAbuse maintenanceprograms; programsorderedbytheCourtdeterminedtobenotMedicallyNecessary. BaseBenchmarkBenefitthatwasSubstituted: Source: Remove SubstanceAbuseDisorderOutpatientServices BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: Duplication: CoveredunderNebraska's1915(b)(3) waiverservicesasOutpatientHospitalServices: MH/ SUD, Physician'sServices: MH/SUD, ClinicServices: MH/SUD, OtherPractitioner'sServices: MH/SUD, HomeHealthServices: MH/SUDinEHB5: MentalHealthandSubstanceUseDisorderServices. BaseBenchmarkBenefitthatwasSubstituted: Source: Remove SubstanceAbuseDisorderInpatientServices BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: Duplication: CoveredunderNebraska's1915(b)(3) waiverservicesasInpatientHospitalServices: MH/ TN: NE19-0001 EffectiveDate: 10/01/2020 SupersedingPage: NewApproval Date: 07/06/2020 Page28of4

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AlternativeBenefitPlan SUD, Physician'sServices: MH/SUD, ClinicServices: MH/SUD, OtherPractitioner'sServices: MH/SUD inEHB5: MentalHealthandSubstanceUseDisorderServices. BaseBenchmarkBenefitthatwasSubstituted: Source: Remove DurableMedicalEquipment BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: Duplication: CoveredunderNebraskaMedicaidStatePlanasHomeHealthServices: MedicalSupplies, Equipment, andAppliancesinEHB7: RehabilitativeandHabilitativeServices. BaseBenchmarkBenefitthatwasSubstituted: Source: Remove Chemotherapy BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: Duplication: CoveredunderNebraskaMedicaidStatePlanasPhysician'sServicesinEHB1: Ambulatory PatientServices. BaseBenchmarkBenefitthatwasSubstituted: Source: Remove ProstheticDevices BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: Duplication: CoveredunderNebraskaMedicaidStatePlanasHomeHealthServices: ProstheticDevices andHomeHealthServices:MedicalSupplies, Equipment, andAppliancesinEHB7: Rehabilitativeand HabilitativeServices. BaseBenchmarkBenefitthatwasSubstituted: Source: Remove Transplant BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: Duplication: CoveredunderNebraskaMedicaidStatePlanasInpatientHospitalServicesinEHB3: Hospitalization. BaseBenchmarkBenefitthatwasSubstituted: Source: Remove OtherPractitionerOfficeVisit (RN, PA) BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: Duplication: CoveredunderNebraskaMedicaidStatePlanasPhysician'sServicesandOtherPractitioner ServicesinEHB1: AmbulatoryPatientServices. TN: NE19-0001 EffectiveDate: 10/01/2020 SupersedingPage: NewApproval Date: 07/06/2020 Page29of4

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AlternativeBenefitPlan BaseBenchmarkBenefitthatwasSubstituted: Source: Remove utritionalCounseling N BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: Duplication: CoveredunderNebraskaMedicaidStatePlanasNutritionServicesinEHB9: Preventative andWellnessServicesandChronicDiseaseManagement. BaseBenchmarkPlan: Onlyfordiabetesmanagement. BaseBenchmarkBenefitthatwasSubstituted: Source: Remove RehabilitativeOTandRehabilitativePT BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: Duplication: CoveredunderNebraskaMedicaidStatePlanasHomeHealthServices: PT, OT, ST, & Audiology, PhysicalTherapyandrelatedservices: PT, and PhysicalTherapyandrelatedservices: OT, and ServicesforIndividualswithspeech, hearing, andlanguagedisordersinEHB7: Rehabilitativeand HabilitativeServices. BaseBenchmarkPlan: Limit: 45visit(s) peryear Explanation: Limitstorehabandhabcombined: Physical, occupationalorspeechtherapyservices, chiropracticorosteopathicphysiotherapy (combinedlimitto45sessionspercalendaryear). BaseBenchmarkBenefitthatwasSubstituted: Source: Remove RehabilitativeSpeechTherapy BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: Duplication: CoveredunderNebraskaMedicaidStatePlanasHomeHealthServices: PT, OT, ST, & Audiology, PhysicalTherapyandrelatedservices: ST, servicesforindividualswithspeech, hearing, and languagedisordersinEHB7: RehabilitativeandHabilitativeServices. BaseBenchmarkPlan: Limit: 45visit(s) peryear Explanation: Limitstorehabandhabcombined: Physical, occupationalorspeechtherapyservices, chiropracticorosteopathicphysiotherapy (combinedlimitto45sessionspercalendaryear). BaseBenchmarkBenefitthatwasSubstituted: Source: Remove OutpatientRehabilitationServices BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: Duplication: CoveredunderNebraskaMedicaidStatePlanasHomeHealthServices: PT, OT, ST, & Audiology, PhysicalTherapyandrelatedservices: PT, PhysicalTherapyandrelatedservices: OT, Physical Therapyandrelatedservices: ST, andinEHB7: RehabilitativeandHabilitativeServices. BaseBenchmarkPlan: 45treatment(s) peryear TN: NE19-0001 EffectiveDate: 10/01/2020 SupersedingPage: NewApproval Date: 07/06/2020 Page30of4

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AlternativeBenefitPlan Limitsapplytorehabandhabcombined: physical, occupationalorspeechtherapyservices, chiropracticor osteopathicphysiotherapy (combinedlimitto45sessionspercalendaryear). BaseBenchmarkBenefitthatwasSubstituted: Source: Remove HabilitationServices BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: Duplication: CoveredunderNebraskaMedicaidStatePlanasHomeHealthServices: PT, OT, ST, & Audiology, PhysicalTherapyandrelatedservices: PT, PhysicalTherapyandrelatedservices: ST, Physical Therapyandrelatedservices:OTinEHB7: RehabilitativeandHabilitativeServices. BaseBenchmarkPlan: Limit: 45treatment(s) peryear Autismexclusions: Servicesfortreatmentofaustismspectrumdisorders, including, butnotlimitedto appliedbehavioralanaylsisandearlyintensivebehavioralintervention. Servicesforautismspectrmdisordersorpervasivedevelopmentalconditions, developmentaldelaysor sensoryintegrationdisorders...unlessotherwiserequiredbylaworspecificallycoveredelsewhereinthis contract. Explanations: NebraskasupplementedthisEHBcategoryforHabilitativeServices: "Healthcareservices thathelpapersonkeep, learn, orimproveskillsandfunctioningfordailyliving. Theseservicesmay includephysicalandoccupationaltherapy, speechlanguage pathologyandotherservicesforpeoplewith disabilitiesinavarietyofinpatientand/oroutpatientsettings." Quantitativelimitsonservicesapplyto outpatient, only. BaseBenchmarkBenefitthatwasSubstituted: Source: Remove ChiropracticCare BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: Duplication: CoveredunderNebraskaMedicaidStatePlanasChiropracticServicesinEHB1: Ambulatory PatientServices. BaseBenchmarkPlan: Limit: 20visit(s) peryear. Chiropracticphysiotherapyhasacombinedlimitwith PT, OTandspeechtherapiesof45sessionspercalendaryear. Chiropracticmanipulativeadjustmentshave acombinedlimitwithosteopathicphysiotherapyof20sessionspercalendaryear. BaseBenchmarkBenefitthatwasSubstituted: Source: Remove Dialysis BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: Duplication: CoveredunderNebraskaMedicaidStatePlanasClinicServices, OutpatientHospitalServices, andPhysicianServicesinEHB1: AmbulatoryPatientServicesandInpatientHospitalServicesinEHB3: Hospitalization. TN: NE19-0001 EffectiveDate: 10/01/2020 SupersedingPage: NewApproval Date: 07/06/2020 Page31of4

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AlternativeBenefitPlan BaseBenchmarkBenefitthatwasSubstituted: Source: Remove AccidentalDental BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: Duplication: CoveredunderNebraskaMedicaidStatePlanasClinicServices, OutpatientHospitalServices, andPhysicianServicesinEHB1: AmbulatoryPatientServicesandInpatientHospitalServicesinEHB3: Hospitalization. BaseBenchmarkPlan: Benefitsarelimitedtotreatmentprovidedwithin12monthsoftheinjury. Benefits arenotavailablefororthodonticsordentalimplants. Benefitsshallnotbeprovidedforsuchserviceswhen theinjuryoccursastheresultofeating, biting, orchewing. BaseBenchmarkBenefitthatwasSubstituted: Source: Remove Radiation BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: Duplication: CoveredunderNebraskaMedicaidStatePlanasPhysicianServicesinEHB1: Ambulatory PatientServicesandInpatientHospitalServicesinEHB3: Hospitalization. BaseBenchmarkBenefitthatwasSubstituted: Source: Remove InfusionTherapy BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: Duplication: CoveredunderNebraskaMedicaidStatePlanasPhysicianServicesinEHB1: Ambulatory PatientServicesandInpatientHospitalServicesinEHB3: Hospitalization. BaseBenchmarkBenefitthatwasSubstituted: Source: Remove ReconstructiveSurgery BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: Duplication: CoveredunderNebraskaMedicaidStatePlanasPhysicianServicesinEHB1: Ambulatory PatientServicesandInpatientHospitalServicesinEHB3: Hospitalization. BaseBenchmarkPlan: Availableonlypost-mastectomyorwhenrequiredtorestore, reconstructorcorrect anybodilyfunctionthatwaslost, impairedordamagedasaresultofinjuryorillness. BaseBenchmarkBenefitthatwasSubstituted: Source: Remove DiabetesEducation BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: Substitution: DiabetesEducationwasremovedandreplacedinEHB9: PreventativeandWellnessServices andChronicDiseaseManagementbysubstitutionwiththeactuarialvalueofFamilyPlanningServices & TN: NE19-0001 EffectiveDate: 10/01/2020 SupersedingPage: NewApproval Date: 07/06/2020 Page32of4

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AlternativeBenefitPlan Replacementprostheticappliancesarecoveredwhen: 1. Theclient'sdentalhistorydoesnotshowthatpreviousprostheticapplianceshavebeenunsatisfactoryto theclient; and 2. Theclientdoesnothaveahistoryoflostprostheticappliances; and 3. Arepairwillnotmaketheexistingdentureorpartialwearable; or 4. Arelinewillnotmaketheexistingdentureorpartialwearable; or 5. Arebasewillnotmaketheexistingdentureorpartialwearable. Partialdenturesforclientsarecoveredthatdonothaveadequateocclusion. Priorauthorizationisrequiredforreplacement/completedentures, maxillaryresinbasepartials, andflipper partials. Other1937BenefitProvided: Source: Remove EyeglassesSection1937CoverageOptionBenchmarkBenefit Package ProviderQualifications: Authorization: OtherMedicaidStatePlan AmountLimit: DurationLimit: 1Every24months ScopeLimit: Other: Exams: Eyeexaminationsarecoveredforclientsage21andolderonceevery24months. Morefrequent eyeexaminationswillalsobecoveredwhenreasonableandappropriate. Eyeglassframes: Eyeglassframesarecoveredunderthefollowingconditions: 1. Theclient'sfirstpairofprescriptioneyeglasses; or 2. Sizechangeduetogrowth; or 3. Aprescribedlenschangeonlyifnewlensescannotbeaccommodatedbythecurrent frame; or 4. Theclient'scurrentframeisnolongerusableduetoirreparablewear/damage; breakage orloss. Replacementofframesislimitedtooneperyearforclients21yearsandolder. Apairofeyeglassesiscoveredforadults (21andolder) whenoneoftheaboveconditionsismet withina24-monthperiod. Eyeglasslenses: Eyeglasslensesunderthefollowingconditions: 1. Theclient'sfirstpairofprescriptioneyeglasses; or 2. Changeinsizeduetogrowth; or 3. Whennewlensesarerequiredduetoanewprescriptionwhentherefractioncorrectionmeetsoneofthe followingcriteria: a. Achangeof0.50dioptersinthemeridianofgreatestchangewhenplacedonanopticalcross; b. Achangeinaxisinexcessof10degreesfor0.50cylinder, fivedegreesfor0.75cylinder; or c. Achangeofprismcorrectionof1/2prismdiopterverticallyortwoprismdioptershorizontallyormore. Forpersons21andolder, apairoflensesiscoveredwithina24monthperiodwhenanyoneoftheabove medicalreasonsexist. Lensesmustmeetthespecificationsforeyeglasslensesandcoveragecriteria. TN: NE19-0001 EffectiveDate: 10/01/2020 SupersedingPage: NewApproval Date: 07/06/2020 Page38of4

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AlternativeBenefitPlan Contactlensservicesarecoveredonlywhenprescribedforcorrectionofkeratoconus, monocularaphakia, orotherpathologicalconditionsoftheeyewhenusefulvisioncannotbeobtainedwitheyeglasses. Contact lenses arenotcoveredwhenprescribedforroutinecorrectionofvision. Servicesnotcovered: Sunglasses, multiplepairsofeyeglassesforthesameindividual, non-spectacle mountedaids, hand-heldorsinglelensspectaclemountedlowvisionaids, andtelescopicandother compoundlenssystems, andreplacementinsurance. Other1937BenefitProvided: Source: Remove PrivateDutyNursingServicesSection1937CoverageOptionBenchmarkBenefit Package ProviderQualifications: Authorization: OtherMedicaidStatePlan AmountLimit: DurationLimit: OtherOther ScopeLimit: None Other: Thefollowinglimitationsareappliedtonursingservices (RNandLPN) foradultsage21andolder: 1. Perdiemreimbursementfornursingservicesforthecareofventilator-dependentclientsshallnotexceed theaverageventilatorperdiemofallNebraskanursingfacilitieswhichareprovidingthatservice. This averageshallbecomputedusingnursingfacility'sventilatorinterimrateswhichareeffectiveJanuary1of eachyear, andareapplicableforthatcalendaryearperiod. 2. Perdiemreimbursementforallotherin-homenursingservicesshallnotexceedtheaveragecase-mixper diemfortheExtensiveSpecialCare2case-mixreimbursementlevel. Thisaverageshallbecomputedusing theExtensiveSpecialCare2case-mixnursingfacilityinterimrateswhichareeffectiveJanuary1ofeach yearandapplicableforthatcalendaryearperiod. Underspecialcircumstances, theperdiemreimbursementmayexceedthismaximumforashortperiodof time - forexample, arecentreturnfromahospitalstay. However, inthesecases, the30-dayaverageofthe in-homenursingperdiemsshallnotexceedthemaximumabove. (The30daysaredefinedtoincludethe dayswhicharepaidinexcessofthemaximumplusthosedaysimmediatelyfollowing, totaling30.) Other1937BenefitProvided: Source: Remove CaseManagementSection1937CoverageOptionBenchmarkBenefit Package ProviderQualifications: Authorization: OtherMedicaidStatePlan AmountLimit: DurationLimit: NoneNone ScopeLimit: Foraged, blind, anddisabledindividuals, AFDC-relatedindividuals, andindividualswithdevelopmental disabilities. TN: NE19-0001 EffectiveDate: 10/01/2020 SupersedingPage: NewApproval Date: 07/06/2020 Page39of4

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AlternativeBenefitPlan OMBControlNumber: 09381148 StateName:ebraska N Attachment3.1-L- TransmittalNumber:NE-19-0001 BenefitsAssurancesABP7 EPSDTAssurances Ifthetargetpopulationincludespersonsunder21, pleasecompletethefollowingassurancesregardingEPSDT. Otherwise, skiptothe PrescriptionDrugCoverageAssurancesbelow. Thealternativebenefitplanincludesbeneficiariesunder21yearsofage.Yes Thestate/territoryassuresthatthenoticetoanindividualincludesadescriptionofthemethodforensuringaccesstoEPSDTservices 42CFR440.345). Thestate/territoryassuresEPSDTserviceswillbeprovidedtoindividualsunder21yearsofagewhoarecoveredunderthestate/ territoryplanundersection1902(a)(10)(A) oftheAct. IndicatewhetherEPSDTserviceswillbeprovidedonlythroughanAlternativeBenefitPlanorwhetherthestate/territorywillprovide additionalbenefitstoensureEPSDTservices: ThroughanAlternativeBenefitPlan. ThroughanAlternativeBenefitPlanwithadditionalbenefitstoensureEPSDTservicesasdefinedin1905(r). OtherInformationregardinghowESPDTbenefitswillbeprovidedtoparticipantsunder21yearsofage (optional): PrescriptionDrugCoverageAssurances Thestate/territoryassuresthatitmeetstheminimumrequirementsforprescriptiondrugcoverageinsection1937oftheActand implementingregulationsat42CFR440.347. CoverageisatleastthegreaterofonedrugineachUnitedStatesPharmacopeia (USP) categoryandclassorthesamenumberofprescriptiondrugsineachcategoryandclassasthebasebenchmark. Thestate/territoryassuresthatproceduresareinplacetoallowabeneficiarytorequestandgainaccesstoclinicallyappropriate prescriptiondrugswhennotcovered. Thestate/territoryassuresthatwhenitpaysforoutpatientprescriptiondrugscoveredunderanAlternativeBenefitPlan, itmeetsthe requirementsofsection1927oftheActandimplementingregulationsat42CFR440.345, exceptforthoserequirementsthatare directlycontrarytoamount, durationandscopeofcoveragepermittedundersection1937oftheAct. Thestate/territoryassuresthatwhenconductingpriorauthorizationofprescriptiondrugsunderanAlternativeBenefitPlan, it complieswithpriorauthorizationprogramrequirementsinsection1927(d)(5) oftheAct. OtherBenefitAssurances Thestate/territoryassuresthatsubstitutedbenefitsareactuariallyequivalenttothebenefitstheyreplacedfromthebasebenchmark plan, andthatthestate/territoryhasactuarialcertificationforsubstitutedbenefitsavailableforCMSinspectionifrequestedbyCMS. Thestate/territoryassuresthatindividualswillhaveaccesstoservicesinRuralHealthClinics (RHC) andFederallyQualifiedHealth Centers (FQHC) asdefinedinsubparagraphs (B) and (C) ofsection1905(a)(2) oftheSocialSecurityAct. Page1of2 TN: NE19-0001 EffectiveDate: 10/01/2020 SupersedingPage: NewApproval Date: 07/06/2020

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AlternativeBenefitPlan Thestate/territoryassuresthatpaymentforRHCandFQHCservicesismadeinaccordancewiththerequirementsofsection 1902(bb) oftheSocialSecurityAct. Thestate/territoryassuresthatitwillcomplywiththerequirementofsection1937(b)(5) oftheActbyproviding, effectiveJanuary1, 2014, toallAlternativeBenefitPlanparticipantsatleastEssentialHealthBenefitsasdescribedinsection1302(b) ofthePatient ProtectionandAffordableCareAct. Thestate/territoryassuresthatitwillcomplywiththementalhealthandsubstanceusedisorderparityrequirementsofsection 1937(b)(6) oftheActbyensuringthatthefinancialrequirementsandtreatmentlimitationsapplicabletomentalhealthorsubstance usedisorderbenefitscomplywiththerequirementsofsection2705(a) ofthePublicHealthServiceActinthesamemannerassuch requirementsapplytoagrouphealthplan. Thestate/territoryassuresthatitwillcomplywithsection1937(b)(7) oftheActbyensuringthatbenefitsprovidedtoAlternative BenefitPlanparticipantsinclude, foranyindividualdescribedinsection1905(a)(4)(C), medicalassistanceforfamilyplanning servicesandsuppliesinaccordancewithsuchsection. Thestate/territoryassurestransportation (emergencyandnon-emergency) forindividualsenrolledinanAlternativeBenefitPlanin accordancewith42CFR431.53. Thestate/territoryassures, inaccordancewith45CFR156.115(a)(4) and45CFR147.130, thatitwillprovideasEssentialHealth Benefitsabroadrangeofpreventiveservicesincluding: “A” and “B” servicesrecommendedbytheUnitedStatesPreventiveServices TaskForce; AdvisoryCommitteeforImmunizationPractices (ACIP) recommendedvaccines; preventivecareandscreeningfor infants, childrenandadultsrecommendedbyHRSA'sBrightFuturesprogram/project; andadditionalpreventiveservicesforwomen recommendedbytheInstituteofMedicine (IOM). PRADisclosureStatement AccordingtothePaperworkReductionActof1995, nopersonsarerequiredtorespondtoacollectionofinformationunlessitdisplaysa validOMBcontrolnumber. ThevalidOMBcontrolnumberforthisinformationcollectionis0938-1148. Thetimerequiredtocomplete thisinformationcollectionisestimatedtoaverage5hoursperresponse, includingthetimetoreviewinstructions, searchexistingdata resources, gatherthedataneeded, andcompleteandreviewtheinformationcollection. Ifyouhavecommentsconcerningtheaccuracyof thetimeestimate(s) orsuggestionsforimprovingthisform, pleasewriteto: CMS, 7500SecurityBoulevard, Attn: PRAReportsClearance Officer, MailStopC4-26-05, Baltimore, Maryland21244-1850. V.20160722 Page2of2 TN: NE19-0001 EffectiveDate: 10/01/2020 SupersedingPage: NewApproval Date: 07/06/2020

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AlternativeBenefitPlan OMBControlNumber: 09381148 StateName:ebraska N Attachment3.1-L- TransmittalNumber:NE-19-0001 ServiceDeliverySystemsABP8 Providedetailonthetypeofdeliverysystem(s) thestate/territorywillusefortheAlternativeBenefitPlan'sbenchmarkbenefitpackageor benchmark-equivalentbenefitpackage, includinganyvariationbytheparticipants' geographicarea. Typeofservicedeliverysystem(s) thestate/territorywilluseforthisAlternativeBenefitPlan(s). Selectoneormoreservicedeliverysystems: Managedcare. ManagedCareOrganizations (MCO). PrepaidInpatientHealthPlans (PIHP). PrepaidAmbulatoryHealthPlans (PAHP). PrimaryCareCaseManagement (PCCM). Fee-for-service. Otherservicedeliverysystem. ManagedCareOptions ManagedCareAssurance Thestate/territorycertifiesthatitwillcomplywithallapplicableMedicaidlawsandregulations, includingbutnotlimitedtosections 1903(m), 1905(t), and1932oftheActand42CFRPart438, inprovidingmanagedcareservicesthroughthisAlternativeBenefit Plan. ThisincludestherequirementforCMSapprovalofcontractsandratespursuantto42CFR438.6. ManagedCareImplementation PleasedescribetheimplementationplanfortheAlternativeBenefitPlanundermanagedcareincludingmember, stakeholder, and provideroutreachefforts. ewmembersareauto-enrolledinoneofthethreeMCOsaftereligibilitydeterminationbasedonapre-determinedalgorithm. All N memberswillhave90daysfrominitialMCOassignmenttoselectadifferentMCO, andchoicecounselinginselectingthePlanthat bestfitsthemember'sneedsisavailablethroughtheEnrollmentBrokerandwebsitewww.neheritagehealth.com. MemberswhoarebeingtransitionedfromMedicallyNeedywithaShareofCostintoHeritageHealthAdultwillbeauto-assignedtoan MCObytheState'sconflict-freeEnrollmentBrokerifnotalreadyenrolledinanMCO. Memberswillhave90daysfrominitialMCO assignmenttoselectadifferentMCO, andchoicecounselinginselectingthePlanthatbestfitsthemember'sneedsisavailablethrough theEnrollmentBrokerandwebsitewww.neheritagehealth.com. Parentcaretakerswitha5% disregardandmemberswhoarebeingtransitionedintoHeritageHealthAdultwillmaintainenrollmentin theircurrentMCO. NebraskacurrentlyhasarobustpopulationofproviderswhoparticipateinMedicaidandarecontractedwithHeritageHealthplans. All NebraskaManagedCareOrganizationshaveprovidedtheStatewithdetailedplansonensuringadequateaccesstoservicesfortheAdult Group. AllMCOswillalsohavetoattesttonetworkadequacypriortotheadditionoftheMedicaidAdultGrouppopulation. MCO: ManagedCareOrganization Themanagedcaredeliverysystemisthesameasanalreadyapprovedmanagedcareprogram. Yes TN: NE19-0001 EffectiveDate: 10/01/2020 SupersedingPage: NewApproval Date: 07/06/2020 Page1of3

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AlternativeBenefitPlan OMBControlNumber: 09381148 StateName:ebraska N Attachment3.1-L- TransmittalNumber:NE-19-0001 EmployerSponsoredInsuranceandPaymentofPremiumsABP9 Thestate/territoryprovidestheAlternativeBenefitPlanthroughthepaymentofemployersponsoredinsurancefor participants withsuchcoverage, withadditionalbenefitsandservicesprovidedthroughaBenchmarkorBenchmark-EquivalentBenefit No Package. Thestate/territoryotherwiseprovidesforpaymentofpremiums. Yes Provideadescriptionincludingthepopulationcovered, theamountofpremiumassistancebypopulation, requiredcontributions, cost-effectivenesstestrequirements, andbenefitsinformation. ParticipationinNebraska'sHealthInsurancePremiumPayment (HIPP) Programisvoluntary. IndividualsenrolledintheHIPP programareaffordedthesamebeneficiaryprotectionsprovidedtoallotherMedicaidenrollees. Inadditiontothebenefitswrap, whichisprovidedtoensurethatindividualsenrolledintheHIPPprogramreceiveallservicesandbenefitsavailableunderthe MedicaidStateplan, theNebraskaMedicaidalsoprovidesawraptoanycost-sharingthatexceedsthecost-sharingdescribedinthe StateplanuptotheMedicaidallowabletakingintoaccounttheamountpaidbytheprimaryinsurance. Nebraskawillbefollowing thecost-effectivenessmethodologyasfoundintheapprovedStatePlan, Attachment4.22-C, pages1-3. OtherInformationRegardingEmployerSponsoredInsuranceorPaymentofPremiums: PRADisclosureStatement AccordingtothePaperworkReductionActof1995, nopersonsarerequiredtorespondtoacollectionofinformationunlessitdisplaysa validOMBcontrolnumber. ThevalidOMBcontrolnumberforthisinformationcollectionis0938-1148. Thetimerequiredtocomplete thisinformationcollectionisestimatedtoaverage5hoursperresponse, includingthetimetoreviewinstructions, searchexistingdata resources, gatherthedataneeded, andcompleteandreviewtheinformationcollection. Ifyouhavecommentsconcerningtheaccuracyof thetimeestimate(s) orsuggestionsforimprovingthisform, pleasewriteto: CMS, 7500SecurityBoulevard, Attn: PRAReportsClearance Officer, MailStopC4-26-05, Baltimore, Maryland21244-1850. V.20160722 Page1of1 TN: NE19-0001 EffectiveDate: 10/01/2020 SupersedingPage: NewApproval Date: 07/06/2020

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DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Kansas City Regional OŰce 601 E. 12th Street, Suite 355 Kansas City, MO 64106 Division of Medicaid and Children's Health Operations March 10, 2020 Mr. Jeremy Brunssen, Interim Director Division of Medicaid and Long Term Care Nebraska Department of Health and Human Services 301 Centennial Mall South Lincoln Nebraska, NE 68509 Re: Approval of State Plan Amendment NE-19-0002 Dear Mr. Jeremy Brunssen, Interim Director: On April 01, 2019, the Centers for Medicare and Medicaid Services (CMS) received Nebraska State Plan Amendment (SPA) NE-19-0002 to add coverage for the eligibility group for adults with income below 133% of the FPL under Section 1902(a)(10)(A)(viii) of the Social Security Act.. We approve Nebraska State Plan Amendment (SPA) NE-19-0002 on March 10, 2020 with an eſective date(s) of October 01, 2020. CMS appreciated the opportunity to discuss our informal questions and recommendations related to Nebraska’s eligibility and FMAP SPAs and responses to the Request for Additional Information (RAI). The additional information has provided CMS with valuable insight into Nebraska’s program integrity function and Medicaid expansion oversight activities.

CMS plans to maintain regular communications and a collaborative partnership with the state, including the provision of program integrity-related technical assistance and guidance throughout the Medicaid expansion implementation process as needed. As part of this partnership, CMS looks forward to receiving the following documents that will help ensure beneţciary eligibility and other determinations are accurate and appropriate FMAP claiming occurs:

• The complete and ţnal Master Test Plan that incorporates satisfactory responses to CMS recommendations for additional information needed • The staſ training materials for the Adult Group • The oversight plan for the Program Integrity provisions of managed care contracts and other delivery system contracts • The state’s internal Corrective Action Plan related to procedural accuracy rate as measured in Nebraska’s Medicaid Eligibility Quality Assurance (QA) Annual Report 2019

Please provide these deliverables as the state completes them and no later than the date of Medicaid expansion implementation, October 1, 2020.

If you have any questions or would like technical assistance in the planning, implementation and evaluation of your program integrity and oversight activities, please contact Stephanie Kaminsky by e-mail at Stephanie.Kaminsky@cms.hhs.gov.

Name Date Created No items available If you have any questions regarding this amendment, please contact Barbara Cotterman at barbara.cotterman@cms.hhs.gov. Sincerely, James G. Scott, Director Division of Program Operations Group Division of Medicaid and Children's Health Operations Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | NE2019MS0003O | NE-19-0002 Package Header Package ID NE2019MS0003O Submission Type OŰcial Approval Date 3/10/2020 SPA ID NE-19-0002 Initial Submission Date 4/1/2019 Eſective Date N/A

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Submission - Tribal Input MEDICAID | Medicaid State Plan | Eligibility | NE2019MS0003O | NE-19-0002 Package Header Package ID NE2019MS0003O Submission Type OŰcial Approval Date 3/10/2020 Superseded SPA ID N/A SPA ID NE-19-0002 Initial Submission Date 4/1/2019 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: 1/31/2019 An email was transmitted with attachments for consultation. Date of solicitation/consultation: Method of solicitation/consultation: 1/31/2019 An email was transmitted with attachments for consultation. 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: 1/31/2019 An email was transmitted with attachments for consultation. 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 Ballot Initiative 427 Medicaid Expansion Coverletter and Summary 3/28/2019 3:23 PM EDT Indicate the key issues raised (optional) Yes No Yes No The state has solicited advice from Indian Health Programs and/or Urban Indian Organizations, as required by section 1902(a)(73) of the Social Security Act, and in accordance with the state consultation plan, prior to submission of this SPA. All Indian Health Programs All Urban Indian Organizations All Indian Tribes Access Quality Cost Payment methodology Eligibility

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AlternativeBenefitPlan StateName:NebraskaOMBControlNumber: 09381148 Attachment3.1-L- NE190014 TransmittalNumber:-- AlternativeBenefitPlanPopulationsABP1 IdentifyanddefinethepopulationthatwillparticipateintheAlternativeBenefitPlan. AlternativeBenefitPlanPopulationName:NebraskaBasicAlternativeBenefitPlan IdentifyeligibilitygroupsthatareincludedintheAlternativeBenefitPlan'spopulation, andwhichmaycontainindividualsthatmeetany targetingcriteriausedtofurtherdefinethepopulation. EligibilityGroupsIncludedintheAlternativeBenefitPlanPopulation: Enrollmentis AddEligibilityGroup: mandatoryorRemove voluntary? AddAdultGroupMandatory Remove Enrollmentisavailableforallindividualsintheseeligibilitygroup(s). No TargetingCriteriaselectallthatapply): IncomeStandard. Disease/Condition/Diagnosis/Disorder. Other. OtherTargetingCriteria (Describe): NebraskaBasicAlternativeBenefitPlanisprovidedtonon-pregnantindividualsage21through64. NebraskaBasic AlternativeBenefitPlanisalsoprovidedtoindividualseligiblefortheadultexpansionpopulationthroughthepresumptive eligibilitydeterminationprocess. GeographicArea TheAlternativeBenefitPlanpopulationwillincludeindividualsfromtheentirestate/territory. Yes Anyotherinformationthestate/territorywishestoprovideaboutthepopulation (optional) PRADisclosureStatement AccordingtothePaperworkReductionActof1995, nopersonsarerequiredtorespondtoacollectionofinformationunlessitdisplaysa validOMBcontrolnumber. ThevalidOMBcontrolnumberforthisinformationcollectionis0938-1148. Thetimerequiredtocomplete thisinformationcollectionisestimatedtoaverage5hoursperresponse, includingthetimetoreviewinstructions, searchexistingdata resources, gatherthedataneeded, andcompleteandreviewtheinformationcollection. Ifyouhavecommentsconcerningtheaccuracyof thetimeestimate(s) orsuggestionsforimprovingthisform, pleasewriteto: CMS, 7500SecurityBoulevard, Attn: PRAReportsClearance Officer, MailStopC4-26-05, Baltimore, Maryland21244-1850. V.20181119 TN: NE19-0014 EffectiveDate: 10/01/2020 Superseding: NewApproval Date: Page1of1

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AlternativeBenefitPlan OMBControlNumber: 09381148 StateName:ebraska N Attachment3.1-L- TransmittalNumber:NE-19-0014 VoluntaryBenefitPackageSelectionAssurances - EligibilityGroupunder ABP2a Section1902(a)(10)(A)(i)( VIII) oftheAct Thestate/territoryhasfullyaligneditsbenefitsintheAlternativeBenefitPlanusingEssentialHealthBenefitsandsubjectto1937 requirementswithitsAlternativeBenefitPlanthatisthestate’sapprovedMedicaidstateplanthatisnotsubjectto1937 No requirements. Thereforethestate/territoryisdeemedtohavemettherequirementsforvoluntarychoiceofbenefitpackagefor individualsexemptfrommandatoryparticipationinasection1937AlternativeBenefitPlan. Theseassurancesmustbemadebythestate/territoryiftheAdulteligibilitygroupisincludedintheABPPopulation. Thestate/territoryshallenrollallparticipantsinthe "Individualsatorbelow133% FPLAge19through64" (section1902(a)(10)(A) i)( VIII)) eligibilitygroupintheAlternativeBenefitPlanspecifiedinthisstateplanamendment, exceptasfollows: Abeneficiaryin theeligibilitygroupatsection1902(a)(10)(A)(i)( VIII) whoisdeterminedtomeetoneoftheexemptioncriteriaat45CFR440.315 willreceiveachoiceofabenefitpackagethatiseitheranAlternativeBenefitPlanthatincludesEssentialHealthBenefitsandis subjecttoall1937requirementsoranAlternativeBenefitPlanthatisthestate/territory’sapprovedMedicaidstateplannotsubjectto 1937requirements. Thestate/territory’sapprovedMedicaidstateplanincludesallapprovedstateplanprogramsbasedonanystate planauthority, andapproved1915(c) waivers, ifthestatehasamendedthemtoincludetheeligibilitygroupatsection1902(a)(10)(A) i)( VIII). Thestate/territorymusthaveaprocessinplacetoidentifyindividualsthatmeettheexemptioncriteriaandthestate/territorymust complywithrequirementsrelatedtoprovidingtheoptionofenrollmentinanAlternativeBenefitPlandefinedusingsection1937 requirements, oranAlternativeBenefitPlandefinedasthestate/territory'sapprovedMedicaidstateplanthatisnotsubjecttosection 1937requirements. Onceanindividualisidentified, thestate/territoryassuresitwilleffectivelyinformtheindividualofthefollowing: a)EnrollmentinthespecifiedAlternativeBenefitPlanisvoluntary; b)TheindividualmaydisenrollfromtheAlternativeBenefitPlandefinedsubjecttosection1937requirementsatanytimeand insteadreceiveanAlternativeBenefitPlandefinedastheapprovedstate/territoryMedicaidstateplanthatisnotsubjecttosection 1937requirements; and c)Whattheprocessisfortransferringtothestateplan-basedAlternativeBenefitPlan. Thestate/territoryassuresitwillinformtheindividualof: a)ThebenefitsavailableasAlternativeBenefitPlancoveragedefinedusingsection1937requirementsascomparedtoAlternative BenefitPlancoveragedefinedasthestate/territory'sapprovedMedicaidstateplanandnotsubjecttosection1937requirements; and b)ThecostsofthedifferentbenefitpackagesandacomparisonofhowtheAlternativeBenefitPlansubjectto1937requirements differsfromtheAlternativeBenefitPlandefinedastheapprovedMedicaidstate/territoryplanbenefits. Howwillthestate/territoryinformindividualsabouttheiroptionsforenrollment? (Checkallthatapply) Letter Email Other Page1of3 TN: NE19-0014 EffectiveDate: 10/01/2020 Superseding: NewApproval Date:

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AlternativeBenefitPlan Describe: IndividualswhoarecategoricallyeligibleforMedicaidincludingchildren, parentsandcaretakerrelatives, andindividualswho areblindordisabledwillreceiveNebraska'sMedicaidStatePlanbenefits. Individualswhoareorbecomemedicallyfrailwill defaulttoNebraska'sPrimeAlternativeBenefitPlanwhichalignswithNebraska'sMedicaidStatePlanbenefits. Individuals whobecomepregnantwhileenrolledintheadultgroupbeforetheirregulareligibilityrenewalwilldefaulttoNebraska'sPrime AlternativeBenefitPlanwhichalignswithNebraska'sMedicaidStatePlanbenefits. Provideacopyoftheletter, emailtextorothercommunicationtextthatwillbeusedtoinformindividualsabouttheiroptionsfor enrollment. Anattachmentissubmitted. Whendid/willthestate/territoryinformtheindividuals? MedicallyfrailindividualsandindividualswhobecomepregnantwhileenrolledintheAdultGroupandbeforetheirregulareligibility renewalwilldefaulttoNebraska'sPrimeAlternativeBenefitPlanwhichalignswithNebraska'sMedicaidStatePlanbenefits. Anotice ofactionwillbesentinformingtheindividualthattheyarenoweligibleforNebraska'sPrimeAlternativeBenefitPlanifnotalready enrolled. Pleasedescribethestate/territory'sprocessforallowingindividualsintheSection1902(a)(10)(A)(i)( VIII) eligibilitygroupwhomeet exemptioncriteriatodisenrollfromtheAlternativeBenefitPlandefinedusingsection1937requirementsandenrollintheAlternative BenefitPlandefinedasthestate/territory'sapprovedMedicaidstateplan. MedicallyfrailindividualsandindividualswhobecomepregnantwhileenrolledintheAdultGroupandbeforetheirregulareligibility renewalwilldefaulttoNebraska'sPrimeAlternativeBenefitPlanwhichalignswithNebraska'sMedicaidStatePlanbenefits. Thestate/territoryassuresitwilldocumentintheexemptindividual'seligibilityfilethattheindividual: a)Wasinformedinaccordancewiththissectionpriortoenrollment; b)Wasgivenampletimetoarriveataninformedchoice; and c)ChosetoenrollinAlternativeBenefitPlancoveragesubjecttosection1937requirementsordefinedasthestate/territory's approvedMedicaidstateplan, whichisnotsubjecttosection1937requirements. Wherewilltheinformationbedocumented? (Checkallthatapply) Intheeligibilitysystem. Inthehardcopyofthecaserecord. Other Whatdocumentationwillbemaintainedintheeligibilityfile? (Checkallthatapply) Copyofcorrespondencesenttotheindividual. SigneddocumentationfromtheindividualconsentingtoenrollmentintheAlternativeBenefitPlan. Other Describe: TheeligibilitysystemwillshowthattheindividualdefaultedtoNebraska'sPrimeAlternativeBenefitPlanwhichalignswith Page2of3 TN: NE19-0014 EffectiveDate: 10/01/2020 Superseding: NewApproval Date:

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AlternativeBenefitPlan OMBControlNumber: 09381148 StateName:ebraska N Attachment3.1-L- TransmittalNumber:NE-19-0014 EnrollmentAssurances - MandatoryParticipantsABP2c Theseassurancesmustbemadebythestate/territoryifenrollmentismandatoryforanyofthetargetpopulationsorsub-populations. WhenmandatorilyenrollingeligibilitygroupsinanAlternativeBenefitPlan (BenchmarkorBenchmark-EquivalentPlan) thatcouldhave exemptindividuals, priortoenrollment: Thestate/territoryassuresitwillappropriatelyidentifyanyindividualsintheeligibilitygroupsthatareexemptfrommandatory enrollmentinanAlternativeBenefitPlanorindividualswhomeettheexemptioncriteriaandaregivenachoiceofAlternative BenefitPlancoveragedefinedusingsection1937requirementsorAlternativeBenefitPlancoveragedefinedasthestate/territory's approvedMedicaidstateplan, notsubjecttosection1937requirements. Howwillthestate/territoryidentifytheseindividuals? (Checkallthatapply) Reviewofeligibilitycriteria (e.g., age, disorder/diagnosis/condition) Describe: Onlyindividualsage21through64andeligiblefortheAdultGroupwillbeenrolledinNebraska'sBasicAlternativeBenefit Plan. IndividualswhoareorbecomeMedicallyFrailorbecomepregnantwhileeligiblefortheAdultGroupwilldefaultto Nebraska'sPrimeAlternativeBenefitPlan, whichalignswithNebraska'sMedicaidStatePlanbenefits. Individualswhobecome pregnantwhileenrolledintheAdultGroupwillremainintheAdultGroupuntiltheirnexteligibilityrenewal, atwhichtime theywillbeenrolledinthepregnantwomengroupifappropriate. Allotherindividualswillbereviewedonthebasisoftheir eligibilityatapplication, change, orrenewal, andwillbeplacedintheircorrectcategoryofeligibilityandassessedforMedical Frailtyifappropriate. TheStatewillreviewforMedicalFrailtyusingestablishedclinicalreviewguidelines. Self-identification Describe: IndividualsintheAdultGroupwillautomaticallyenrollinNebraska'sBasicAlternativeBenefitPlanwhentheyaredetermined eligibleunlessalreadyidentifiedasbeingexempt. Individualsortheirrepresentativecanself-identifyasexemptfrom Nebraska'sBasicAlternativeBenefitPlanortheindividual'smanagedcareorganizationcanrefertheindividualtotheStatefor anexemption. OtherdivisionswithintheDepartmentofHealthandHumanServicesmayrefertheindividualtotheMedicaid agencyforassessment. TheStatewillreviewforMedicalFrailtyusingestablishedclinicalreviewguidelines. Other Describe: ThemanagedcareorganizationswillsendelectronicinformationtotheStatebasedonclaimsdataapprovedbytheStateto meetMedicallyFrailcriteriaassetforthat42CFR440.315andfurtherdefinedbytheState. WhentheStatereceivesan indicatorthattheindividualmeetsMedicallyFrailcriteria, theStatewillautomaticallyenrolltheindividualinNebraska's PrimeAlternativeBenefitPlanwhichalignswithNebraska'sMedicaidStatePlanbenefits. TheStatewillreviewforMedical Frailtyusingestablishedclinicalreviewguidelines. Thestate/territorymustinformtheindividualtheyareexemptormeettheexemptioncriteriaandthestate/territorymustcomplywith allrequirementsrelatedtovoluntaryenrollmentor, forbeneficiariesinthe “Individualsatorbelow133% FPLAge19through64” eligibilitygroup, optionalenrollmentinAlternativeBenefitPlancoveragedefinedusingsection1937requirementsorAlternative BenefitPlancoveragedefinedasthestate/territory'sapprovedMedicaidstateplan. Page1of3 TN: NE19-0014 EffectiveDate: 10/01/2020 Superseding: NewApproval Date:

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AlternativeBenefitPlan Thestate/territoryassuresthatforindividualswhohavebecomeexemptfromenrollmentinanAlternativeBenefitPlan, thestate/ territorymustinformtheindividualtheyarenowexemptandthestate/territorymustcomplywithallrequirementsrelatedto voluntaryenrollmentor, forbeneficiariesinthe “Individualsatorbelow133% FPLAge19through64” eligibilitygroup, optional enrollmentinAlternativeBenefitPlancoveragedefinedusingsection1937requirements, orAlternativeBenefitPlancoverage definedasthestate/territory'sapprovedMedicaidstateplan. Howwillthestate/territoryidentifyifanindividualbecomesexempt? (Checkallthatapply) Reviewofclaimsdata Self-identification Reviewatthetimeofeligibilityredetermination Provideridentification Changeineligibilitygroup Other Describe: ThemanagedcareorganizationswillsendelectronicinformationtotheStatebasedonclaimsdataapprovedbytheStateto meetMedicallyFrailcriteriaassetforthat42CFR440.315andfurtherdefinedbytheState. WhentheStatereceivesan indicatorthattheindividualmeetsMedicallyFrailcriteria, theStatewillautomaticallyenrolltheindividualinNebraska's PrimeAlternativeBenefitPlanwhichalignswithNebraska'sMedicaidStatePlanbenefits. TheStatewillreviewforMedical Frailtyusingestablishedclinicalreviewguidelines. Howfrequentlywillthestate/territoryreviewtheAlternativeBenefitPlanpopulationtodetermineifindividualsareexemptfrom mandatoryenrollmentormeettheexemptioncriteria? Monthly Quarterly Annually Adhocbasis Other Thestate/territoryassuresthatitwillpromptlyprocessallrequestsmadebyexemptindividualsfordisenrollmentfromthe AlternativeBenefitPlanandhasinplaceaprocessthatensuresexemptindividualshaveaccesstoallstandardstate/territoryplan servicesor, forbeneficiariesinthe “Individualsatorbelow133% FPLAge19through64” eligibilitygroup, optionalenrollmentin AlternativeBenefitPlancoveragedefinedusingsection1937requirements, orAlternativeBenefitPlancoveragedefinedasthestate/ territory'sapprovedMedicaidstateplan. DescribetheprocessforprocessingrequestsmadebyexemptindividualstobedisenrolledfromtheAlternativeBenefitPlan: IndividualseligiblefortheAdultGroupandenrolledinNebraska'sBasicAlternativeBenefitPlanwhobecomeexemptwillbedefaulted toNebraska'sPrimeAlternativeBenefitPlanwhichalignswithNebraska'sMedicaidStatePlanbenefits. OtherInformationRelatedtoEnrollmentAssuranceforMandatoryParticipants (optional): Page2of3 TN: NE19-0014 EffectiveDate: 10/01/2020 Superseding: NewApproval Date:

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AlternativeBenefitPlan OMBControlNumber: 09381148 StateName:ebraska N Attachment3.1-L- TransmittalNumber:NE-19-0014 SelectionofBenchmarkBenefitPackageorBenchmark-EquivalentBenefitPackageABP3.1 Selectoneofthefollowing: Thestate/territoryisamendingoneexistingbenefitpackageforthepopulationdefinedinSection1. Thestate/territoryiscreatingasinglenewbenefitpackageforthepopulationdefinedinSection1. Nameofbenefitpackage:NebraskaBasicAlternativeBenefitPlan SelectionofEHB-BenchmarkPlan Thestate/territorymustselectanEHB-benchmarkplanasthebasisforprovidingEssentialHealthBenefitsinits BenchmarkorBenchmark-EquivalentPackage. BCBSofNebraska: BluePridePlusOption102Gold EHB-benchmarkplanname: o N TheEHB-benchmarkplanisthesameastheSection1937Coverageoption: IndicatetheEHB-benchmarkoptionasdescribedat45CFR156.111(b)(2)(B) thestate/territorywilluseasitsEHB- benchmarkplan: State/TerritoryisselectingoneofthebelowoptionstodesignanEHBpackagethatcomplieswiththerequirementsfor theindividualinsurancemarketunder45CFR156.100through156.125. State/TerritoryisselectingtheEHB-benchmarkplanusedbythestate/territoryforthe 2017planyear. State/TerritoryisselectingoneoftheEHB-benchmarkplansusedforthe2017planyearbyanother state/territory. State/ TerritoryselectsthefollowingEHB-benchmarkplanusedforthe2017planyearbutwill replacecoverageofoneormoreofthecategoriesofEHBwithcoverageofthesamecategoryfrom the2017EHB-benchmarkplanofoneormoreotherstates Selectasetofbenefitsconsistentwiththe10EHBcategoriestobecomethenewEHB-benchmark plan. (CompleteandsubmittheABP5: BenefitsDescriptionformtodescribethesetofbenefits.) TypeofEHB-benchmarkplan: Largestplanbyenrollmentofthethreelargestsmallgroupinsuranceproductsinthestate's smallgroupmarket. Anyofthelargestthreestateemployeehealthbenefitplansbyenrollment. AnyofthelargestthreenationalFEHBPplanoptionsopentoFederalemployeesinall geographiesbyenrollment. Largestinsuredcommercialnon-MedicaidHMO. Page1of3 TN: NE19-0014 EffectiveDate: 10/01/2020 Superseding: NewApproval Date:

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AlternativeBenefitPlan Assurances Thestate/territoryassurestheEHBplanmeetsthescopeofbenefitsstandardsat45CFR156.111(b), doesnotexceed generosityofmostgenerousamongasetofcomparisonplans, providesappropriatebalanceofcoverageamong10 EHBcategories, andthescopeofbenefitsisequalto, orgreaterthan, thescopeofbenefitsprovidedunderatypical employerplanasdefinedat45CFR156.111(b)(2). Thestate/territoryassuresthatallservicesintheEHB-benchmarkplanhavebeenaccountedforthroughoutthebenefit chartfoundinABP5. Thestate/territoryassurestheaccuracyofallinformationinABP5depictingamount, durationandscopeparametersof servicesauthorizedinthecurrentlyapprovedMedicaidStatePlan. SelectionoftheSection1937CoverageOption Thestate/territoryselectsasitsSection1937CoverageoptionthefollowingtypeofBenchmarkBenefitPackageorBenchmark- EquivalentBenefitPackageunderthisAlternativeBenefitPlan (checkone): BenchmarkBenefitPackage. Benchmark-EquivalentBenefitPackage. Thestate/territorywillprovidethefollowingBenchmarkBenefitPackage (checkonethatapplies): TheStandardBlueCross/BlueShieldPreferredProviderOptionofferedthroughtheFederalEmployeeHealthBenefit Program (FEHBP). Stateemployeecoveragethatisofferedandgenerallyavailabletostateemployees (StateEmployeeCoverage): AcommercialHMOwiththelargestinsuredcommercial, non-Medicaidenrollmentinthestate/territory (Commercial HMO): Secretary-ApprovedCoverage. Thestate/territoryoffersbenefitsbasedontheapprovedstateplan. Thestate/territoryoffersanarrayofbenefitsfromthesection1937coverageoptionand/orbasebenchmarkplan benefitpackages, ortheapprovedstateplan, orfromacombinationofthesebenefitpackages. Thestate/territoryoffersthebenefitsprovidedintheapprovedstateplan. Benefitsincludeallthoseprovidedintheapprovedstateplanplusadditionalbenefits. Benefitsarethesameasprovidedintheapprovedstateplanbutinadifferentamount, durationand/orscope. Thestate/territoryoffersonlyapartiallistofbenefitsprovidedintheapprovedstateplan. Thestate/territoryoffersapartiallistofbenefitsprovidedintheapprovedstateplanplusadditionalbenefits. Pleasebrieflyidentifythebenefits, thesourceofbenefitsandanylimitations: 1) Thestateassuresthatallservicesinthebasebenchmarkhavebeenaccountedforthroughoutthebenefitchart foundinABP5; and (2) ThestateassurestheaccuracyofallinformationinABP5depictingamount, duration, and scopeparametersofservicesauthorizedinthecurrentlyapprovedMedicaidStatePlan. OtherInformationRelatedtoSelectionoftheSection1937CoverageOptionandtheEHB-BenchmarkPlan (optional): SeeNebraskaBasicAlternativeBenefitPlanABP5. Page2of3 TN: NE19-0014 EffectiveDate: 10/01/2020 Superseding: NewApproval Date:

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AlternativeBenefitPlan Otherinformationregardingthisbenefit, includingthespecificnameofthesourceplanifitisnotthebase benchmarkplan: Servicesprovidedbycommunitymentalhealthcentersarelimitedtomedicallynecessaryacutepsychiatric services. Daytreatmentservicesarelimitedtoahalf-dayorfull-dayrate, establishedonthebasisofeach facility'scostreportwhichisreviewedannually. The "facilityfee" includespaymentforservicesanditemsprovidedbyanASCinconnectionwitha coveredsurgicalprocedure. Priorauthorizationisrequiredfortheevaluationandtreatmentofinfantsandchildrenwhofailtoeatand/or drinkasufficientquantityorvarietyoffoodsorliquidstomeettheirnutritionaland/orhydrationneedsby hospitalaffiliatedclinicsorfree-standingclinics. BenefitProvided: Source: Remove HospiceCare StatePlan1905(a) ProviderQualifications: Authorization: AuthorizationrequiredinexcessoflimitationMedicaidStatePlan AmountLimit: DurationLimit: oneOther N ScopeLimit: Theclientmustbecertifiedasterminallyillwithasix-monthlifeexpectancybytheHospicemedical directorandtheattendingphysicianatthebeginningofthefirstbenefitperiodandbytheHospicemedical directorforallsubsequentperiods. Otherinformationregardingthisbenefit, includingthespecificnameofthesourceplanifitisnotthebase benchmarkplan: Aclientmayelecttoreceivehospicecareduringoneormoreofthefollowingelectionperiods: aninitial 90-dayperiod, asubsequent90-dayperiod, aninitial60-dayperiod, asubsequent60-dayperiod, andathird 60-dayperiod. Additional60-daybenefitperiodsmustbeapprovedasanexceptionunderthepriorauthorization provision. BenefitProvided: Source: Remove HomeHealthServices StatePlan1905(a) ProviderQualifications: Authorization: PriorAuthorizationMedicaidStatePlan AmountLimit: DurationLimit: oneOther N ScopeLimit: Other Otherinformationregardingthisbenefit, includingthespecificnameofthesourceplanifitisnotthebase benchmarkplan: Coverageforallhomehealthagencyservicesisbasedonmedicalnecessity, andmustbenecessaryto TN: NE19-0014 EffectiveDate: 10/01/2020 Superseding: NewApproval Date: Page3of42

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AlternativeBenefitPlan 12. BaseBenchmarkBenefitsNotCoveredduetoSubstitutionorDuplicationCollapseAll BaseBenchmarkBenefitthatwasSubstituted: Source: Remove PrimaryCareVisttoTreatanInjuryorIllness BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: Duplication: CoveredunderNebraskaMedicaidStatePlanasPhysician'sServicesandOtherPractitioner ServicesinEHB1: AmbulatoryPatientServices. BaseBenchmarkBenefitthatwasSubstituted: Source: Remove SpecialistVisit BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: Duplication: CoveredunderNebraskaMedicaidStatePlanasPhysician'sServicesandOtherPractitioner ServicesinEHB1: AmbulatoryPatientServices. BaseBenchmarkBenefitthatwasSubstituted: Source: Remove OutpatientFacilityFee (e.g., ambulatorysurgery) BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: Duplication: CoveredunderNebraskaMedicaidStatePlanasClinicServicesinEHB1: Ambulatory PatientServicesandFreestandingBirthCenterServicesinEHB4: MaternityandNewbornCare. BaseBenchmarkBenefitthatwasSubstituted: Source: Remove OutpatientSurgeryPhysician/SurgicalServices BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: Duplication: CoveredunderNebraskaMedicaidStatePlanasPhysician'sServicesandOtherPractitioner ServicesinEHB1: AmbulatoryPatientServices. BaseBenchmarkBenefitthatwasSubstituted: Source: Remove HospiceServices BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: Duplication: CoveredunderNebraskaMedicaidStatePlanasHospiceCareinEHB1: AmbulatoryPatient Services. BaseBenchmarkPlan: Thecoveredpersonmusthavealifeexpectancyofsixmonthsorlessas documentedinwritingbytheattendingphysician. Thehospiceservicesmustbeorderedbyaphysician. Servicesprovidedmustbeappropriateforpalliativesupportormanagementofacoveredpersonswith terminalmedicalillness. TN: NE19-0014 EffectiveDate: 10/01/2020 Superseding: NewApproval Date: Page24of4

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AlternativeBenefitPlan BaseBenchmarkBenefitthatwasSubstituted: Source: Remove UrgentCareCenterorFacilities BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: Duplication: CoveredunderNebraskaMedicaidStatePlanasOutpatientHospitalServicesandClinic ServicesinEHB1: AmbulatoryPatientServices. BaseBenchmarkBenefitthatwasSubstituted: Source: Remove EmergencyRoomServices BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: Duplication: CoveredunderNebraskaMedicaidStatePlanasEmergencyHospitalServicesinEHB2: EmergencyServices. BaseBenchmarkBenefitthatwasSubstituted: Source: Remove EmergencyTransportation/Ambulance BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: Duplication: CoveredunderNebraskaMedicaidStatePlanasTransportationServices: EmergencyinEHB 2: EmergencyServices. BaseBenchmarkBenefitthatwasSubstituted: Source: Remove HomeHealthCareServices BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: Duplication: CoveredunderNebraskaMedicaidStatePlanasHomeHealthServicesEHB1: Ambulatory PatientServices. BaseBenchmarkPlan: Limitedto60days. BaseBenchmarkBenefitthatwasSubstituted: Source: Remove InpatientHospitalServices BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: Duplication: CoveredunderNebraskaMedicaidStatePlanasInpatientHospitalServicesEHB3: Hospitalization. BaseBenchmarkBenefitthatwasSubstituted: Source: Remove InpatientPhysicianandSurgicalServices BaseBenchmark TN: NE19-0014 EffectiveDate: 10/01/2020 Superseding: NewApproval Date: Page25of4

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AlternativeBenefitPlan Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: Duplication: CoveredunderNebraskaMedicaidStatePlanasInpatientHospitalServices: EHB3: Hospitalization. BaseBenchmarkBenefitthatwasSubstituted: Source: Remove SkilledNursingFacility BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: Duplication: CoveredunderNebraskaMedicaidStatePlanasShort-TermNursingFacilityServicesinEHB 7: RehabilitativeandRehabilitativeServicesandDevices. BaseBenchmarkPlan: 60day(s) peryear Exclusions: Skillednursingfacilitycaredoesnotinclude: a) supportiveservicesforastabilizedcondition; b) carewhichcanbelearnedandgivenbyunlicensedoruncertifiedmedicalpersonnel; c) routinehealthcareservices; d) generalmaintenanceorsupervisionofroutinedailyactivities; or e) routineadministrationoforalornonprescriptiondrugs. BaseBenchmarkBenefitthatwasSubstituted: Source: Remove PrenatalandPostnatalCare BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: Duplication: CoveredunderNebraskaMedicaidStatePlanasOutpatientHospitalServices-Maternity, PhysicianServices-Maternity, OtherPractitioner'sServices-Maternity, Nurse-midwifeServices, Free StandingBirthCenterServices, InpatientHospitalServices-Maternity, TobaccoCessation-Maternity, HomeHealthServices-Maternity, ExtendedServicesforPregnantWomeninEHB4: Maternityand NewbornCare. BaseBenchmarkBenefitthatwasSubstituted: Source: Remove DeliveryandAllInpatientServicesforMaternity BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: Duplication: CoveredunderNebraskaMedicaidStatePlanasInpatientHospitalServices-Maternity, Nurse- midwifeServices, FreeStandingBirthCenterServicesinEHB4: MaternityandNewbornCare. BaseBenchmarkBenefitthatwasSubstituted: Source: Remove LaboratoryOutpatientandProfessionalServices BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: Duplication: CoveredunderNebraskaMedicaidStatePlanasOtherLaboratoryandX-rayServicesinEHB 8: LaboratoryServices. TN: NE19-0014 EffectiveDate: 10/01/2020 Superseding: NewApproval Date: Page26of4

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AlternativeBenefitPlan BaseBenchmarkBenefitthatwasSubstituted: Source: Remove X-raysandDiagnosticImaging BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: Duplication: CoveredunderNebraskaMedicaidStatePlanasOtherLaboratoryandX-rayServicesinEHB 8: LaboratoryServices. BaseBenchmarkBenefitthatwasSubstituted: Source: Remove Imaging (CT/PETScans, MRIs) BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: Duplication: CoveredunderNebraskaMedicaidStatePlanasOtherLaboratoryandX-rayServicesinEHB 8: LaboratoryServices. BaseBenchmarkBenefitthatwasSubstituted: Source: Remove Mental/BehavioralHealthOutpatientServices BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: Duplication: CoveredunderNebraskaMedicaidStatePlanasOutpatientHospitalServices: MH/SUD, Physician'sServices: MH/SUD, ClinicServices: MH/SUD, OtherPractitioner'sServices: MH/SUD, RehabilitativeServices: MH/SUDandHomeHealthServices: MH/SUDinEHB5: MentalHealthand SubstanceUseDisorderServices. BaseBenchmarkBenefitthatwasSubstituted: Source: Remove Mental/BehavioralHealthInpatientServices BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: Duplication: CoveredunderNebraskaMedicaidStatePlanasInpatientHospitalServices: MH/SUD, Physician'sServices: MH/SUD, ClinicServices: MH/SUD, OtherPractitioner'sServices: MH/SUD, RehabilitativeServices: MH/SUDinEHB5: MentalHealthandSubstanceUseDisorderServices. BaseBenchmarkPlan: Excludesprogramsthattreatobesityorgamblingaddictionandresidentialtreatment programs. Exclusionsinclude: programsforco-dependency; employeeassistance; probation; prevention; educational orself-help; programswhichtreatobesity, gambling, ornicotineaddiction; CustodialCareforMental Illnessand/orSubstanceDependenceandAbuse; halfwayhouseorSubstanceDependenceandAbuse maintenanceprograms; programsorderedbytheCourtdeterminedtobenotMedicallyNecessary. BaseBenchmarkBenefitthatwasSubstituted: Source: Remove SubstanceAbuseDisorderOutpatientServices BaseBenchmark TN: NE19-0014 EffectiveDate: 10/01/2020 Superseding: NewApproval Date: Page27of4

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AlternativeBenefitPlan Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: Duplication: CoveredunderNebraska's1915(b)(3) waiverservicesasOutpatientHospitalServices: MH/ SUD, Physician'sServices: MH/SUD, ClinicServices: MH/SUD, OtherPractitioner'sServices: MH/SUD, HomeHealthServices: MH/SUDinEHB5: MentalHealthandSubstanceUseDisorderServices. BaseBenchmarkBenefitthatwasSubstituted: Source: Remove SubstanceAbuseDisorderInpatientServices BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: Duplication: CoveredunderNebraska's1915(b)(3) waiverservicesasInpatientHospitalServices: MH/ SUD, Physician'sServices: MH/SUD, ClinicServices: MH/SUD, OtherPractitioner'sServices: MH/SUD inEHB5: MentalHealthandSubstanceUseDisorderServices. BaseBenchmarkBenefitthatwasSubstituted: Source: Remove DurableMedicalEquipment BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: Duplication: CoveredunderNebraskaMedicaidStatePlanasHomeHealthServices: MedicalSupplies, Equipment, andAppliancesinEHB7: RehabilitativeandHabilitativeServices. BaseBenchmarkBenefitthatwasSubstituted: Source: Remove Chemotherapy BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: Duplication: CoveredunderNebraskaMedicaidStatePlanasPhysician'sServicesinEHB1: Ambulatory PatientServices. BaseBenchmarkBenefitthatwasSubstituted: Source: Remove ProstheticDevices BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: Duplication: CoveredunderNebraskaMedicaidStatePlanasHomeHealthServices: ProstheticDevices andHomeHealthServices:MedicalSupplies, Equipment, andAppliancesinEHB7: Rehabilitativeand HabilitativeServices. BaseBenchmarkBenefitthatwasSubstituted: Source: Remove Transplant BaseBenchmark TN: NE19-0014 EffectiveDate: 10/01/2020 Superseding: NewApproval Date: Page28of4

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AlternativeBenefitPlan Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: Duplication: CoveredunderNebraskaMedicaidStatePlanasInpatientHospitalServicesinEHB3: Hospitalization. BaseBenchmarkBenefitthatwasSubstituted: Source: Remove OtherPractitionerOfficeVisit (RN, PA) BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: Duplication: CoveredunderNebraskaMedicaidStatePlanasPhysician'sServicesandOtherPractitioner ServicesinEHB1: AmbulatoryPatientServices. BaseBenchmarkBenefitthatwasSubstituted: Source: Remove utritionalCounseling N BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: Duplication: CoveredunderNebraskaMedicaidStatePlanasNutritionServicesinEHB9: Preventative andWellnessServicesandChronicDiseaseManagement. BaseBenchmarkPlan: Onlyfordiabetesmanagement. BaseBenchmarkBenefitthatwasSubstituted: Source: Remove RehabilitativeOTandRehabilitativePT BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: Duplication: CoveredunderNebraskaMedicaidStatePlanasHomeHealthServices: PT, OT, ST, & Audiology, PhysicalTherapyandrelatedservices: PT, and PhysicalTherapyandrelatedservices: OT, and ServicesforIndividualswithspeech, hearing, andlanguagedisordersinEHB7: Rehabilitativeand HabilitativeServices. BaseBenchmarkPlan: Limit: 45visit(s) peryear Explanation: Limitstorehabandhabcombined: Physical, occupationalorspeechtherapyservices, chiropracticorosteopathicphysiotherapy (combinedlimitto45sessionspercalendaryear). BaseBenchmarkBenefitthatwasSubstituted: Source: Remove RehabilitativeSpeechTherapy BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: Duplication: CoveredunderNebraskaMedicaidStatePlanasHomeHealthServices: PT, OT, ST, & Audiology, PhysicalTherapyandrelatedservices: ST, servicesforindividualswithspeech, hearing, and languagedisordersinEHB7: RehabilitativeandHabilitativeServices. BaseBenchmarkPlan: Limit: 45visit(s) peryear TN: NE19-0014 EffectiveDate: 10/01/2020 Superseding: NewApproval Date: Page29of4

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AlternativeBenefitPlan Explanation: Limitstorehabandhabcombined: Physical, occupationalorspeechtherapyservices, chiropracticorosteopathicphysiotherapy (combinedlimitto45sessionspercalendaryear). BaseBenchmarkBenefitthatwasSubstituted: Source: Remove OutpatientRehabilitationServices BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: Duplication: CoveredunderNebraskaMedicaidStatePlanasHomeHealthServices: PT, OT, ST, & Audiology, PhysicalTherapyandrelatedservices: PT, PhysicalTherapyandrelatedservices: OT, Physical Therapyandrelatedservices: ST, andinEHB7: RehabilitativeandHabilitativeServices. BaseBenchmarkPlan: 45treatment(s) peryear Limitsapplytorehabandhabcombined: physical, occupationalorspeechtherapyservices, chiropracticor osteopathicphysiotherapy (combinedlimitto45sessionspercalendaryear). BaseBenchmarkBenefitthatwasSubstituted: Source: Remove HabilitationServices BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: Duplication: CoveredunderNebraskaMedicaidStatePlanasHomeHealthServices: PT, OT, ST, & Audiology, PhysicalTherapyandrelatedservices: PT, PhysicalTherapyandrelatedservices: ST, Physical Therapyandrelatedservices:OTinEHB7: RehabilitativeandHabilitativeServices. BaseBenchmarkPlan: Limit: 45treatment(s) peryear Autismexclusions: Servicesfortreatmentofaustismspectrumdisorders, including, butnotlimitedto appliedbehavioralanaylsisandearlyintensivebehavioralintervention. Servicesforautismspectrmdisordersorpervasivedevelopmentalconditions, developmentaldelaysor sensoryintegrationdisorders...unlessotherwiserequiredbylaworspecificallycoveredelsewhereinthis contract. Explanations: NebraskasupplementedthisEHBcategoryforHabilitativeServices: "Healthcareservices thathelpapersonkeep, learn, orimproveskillsandfunctioningfordailyliving. Theseservicesmay includephysicalandoccupationaltherapy, speechlanguage pathologyandotherservicesforpeoplewith disabilitiesinavarietyofinpatientand/oroutpatientsettings." Quantitativelimitsonservicesapplyto outpatient, only. BaseBenchmarkBenefitthatwasSubstituted: Source: Remove ChiropracticCare BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: Duplication: CoveredunderNebraskaMedicaidStatePlanasChiropracticServicesinEHB1: Ambulatory PatientServices. BaseBenchmarkPlan: Limit: 20visit(s) peryear. Chiropracticphysiotherapyhasacombinedlimitwith TN: NE19-0014 EffectiveDate: 10/01/2020 Superseding: NewApproval Date: Page30of4

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AlternativeBenefitPlan PT, OTandspeechtherapiesof45sessionspercalendaryear. Chiropracticmanipulativeadjustmentshave acombinedlimitwithosteopathicphysiotherapyof20sessionspercalendaryear. BaseBenchmarkBenefitthatwasSubstituted: Source: Remove Dialysis BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: Duplication: CoveredunderNebraskaMedicaidStatePlanasClinicServices, OutpatientHospitalServices, andPhysicianServicesinEHB1: AmbulatoryPatientServicesandInpatientHospitalServicesinEHB3: Hospitalization. BaseBenchmarkBenefitthatwasSubstituted: Source: Remove AccidentalDental BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: Duplication: CoveredunderNebraskaMedicaidStatePlanasClinicServices, OutpatientHospitalServices, andPhysicianServicesinEHB1: AmbulatoryPatientServicesandInpatientHospitalServicesinEHB3: Hospitalization. BaseBenchmarkPlan: Benefitsarelimitedtotreatmentprovidedwithin12monthsoftheinjury. Benefits arenotavailablefororthodonticsordentalimplants. Benefitsshallnotbeprovidedforsuchserviceswhen theinjuryoccursastheresultofeating, biting, orchewing. BaseBenchmarkBenefitthatwasSubstituted: Source: Remove Radiation BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: Duplication: CoveredunderNebraskaMedicaidStatePlanasPhysicianServicesinEHB1: Ambulatory PatientServicesandInpatientHospitalServicesinEHB3: Hospitalization. BaseBenchmarkBenefitthatwasSubstituted: Source: Remove InfusionTherapy BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: Duplication: CoveredunderNebraskaMedicaidStatePlanasPhysicianServicesinEHB1: Ambulatory PatientServicesandInpatientHospitalServicesinEHB3: Hospitalization. BaseBenchmarkBenefitthatwasSubstituted: Source: Remove ReconstructiveSurgery BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: Duplication: CoveredunderNebraskaMedicaidStatePlanasPhysicianServicesinEHB1: Ambulatory TN: NE19-0014 EffectiveDate: 10/01/2020 Superseding: NewApproval Date: Page31of4

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AlternativeBenefitPlan OMBControlNumber: 09381148 StateName:ebraska N Attachment3.1-L- TransmittalNumber:NE-19-0014 BenefitsAssurancesABP7 EPSDTAssurances Ifthetargetpopulationincludespersonsunder21, pleasecompletethefollowingassurancesregardingEPSDT. Otherwise, skiptothe PrescriptionDrugCoverageAssurancesbelow. Thealternativebenefitplanincludesbeneficiariesunder21yearsofage. No PrescriptionDrugCoverageAssurances Thestate/territoryassuresthatitmeetstheminimumrequirementsforprescriptiondrugcoverageinsection1937oftheActand implementingregulationsat42CFR440.347. CoverageisatleastthegreaterofonedrugineachUnitedStatesPharmacopeia (USP) categoryandclassorthesamenumberofprescriptiondrugsineachcategoryandclassasthebasebenchmark. Thestate/territoryassuresthatproceduresareinplacetoallowabeneficiarytorequestandgainaccesstoclinicallyappropriate prescriptiondrugswhennotcovered. Thestate/territoryassuresthatwhenitpaysforoutpatientprescriptiondrugscoveredunderanAlternativeBenefitPlan, itmeetsthe requirementsofsection1927oftheActandimplementingregulationsat42CFR440.345, exceptforthoserequirementsthatare directlycontrarytoamount, durationandscopeofcoveragepermittedundersection1937oftheAct. Thestate/territoryassuresthatwhenconductingpriorauthorizationofprescriptiondrugsunderanAlternativeBenefitPlan, it complieswithpriorauthorizationprogramrequirementsinsection1927(d)(5) oftheAct. OtherBenefitAssurances Thestate/territoryassuresthatsubstitutedbenefitsareactuariallyequivalenttothebenefitstheyreplacedfromthebasebenchmark plan, andthatthestate/territoryhasactuarialcertificationforsubstitutedbenefitsavailableforCMSinspectionifrequestedbyCMS. Thestate/territoryassuresthatindividualswillhaveaccesstoservicesinRuralHealthClinics (RHC) andFederallyQualifiedHealth Centers (FQHC) asdefinedinsubparagraphs (B) and (C) ofsection1905(a)(2) oftheSocialSecurityAct. Thestate/territoryassuresthatpaymentforRHCandFQHCservicesismadeinaccordancewiththerequirementsofsection 1902(bb) oftheSocialSecurityAct. Thestate/territoryassuresthatitwillcomplywiththerequirementofsection1937(b)(5) oftheActbyproviding, effectiveJanuary1, 2014, toallAlternativeBenefitPlanparticipantsatleastEssentialHealthBenefitsasdescribedinsection1302(b) ofthePatient ProtectionandAffordableCareAct. Thestate/territoryassuresthatitwillcomplywiththementalhealthandsubstanceusedisorderparityrequirementsofsection 1937(b)(6) oftheActbyensuringthatthefinancialrequirementsandtreatmentlimitationsapplicabletomentalhealthorsubstance usedisorderbenefitscomplywiththerequirementsofsection2705(a) ofthePublicHealthServiceActinthesamemannerassuch requirementsapplytoagrouphealthplan. Thestate/territoryassuresthatitwillcomplywithsection1937(b)(7) oftheActbyensuringthatbenefitsprovidedtoAlternative BenefitPlanparticipantsinclude, foranyindividualdescribedinsection1905(a)(4)(C), medicalassistanceforfamilyplanning servicesandsuppliesinaccordancewithsuchsection. Page1of2 TN: NE19-0014 EffectiveDate: 10/01/2020 Superseding: NewApproval Date:

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AlternativeBenefitPlan OMBControlNumber: 09381148 StateName:ebraska N Attachment3.1-L- TransmittalNumber:NE-19-0014 ServiceDeliverySystemsABP8 Providedetailonthetypeofdeliverysystem(s) thestate/territorywillusefortheAlternativeBenefitPlan'sbenchmarkbenefitpackageor benchmark-equivalentbenefitpackage, includinganyvariationbytheparticipants' geographicarea. Typeofservicedeliverysystem(s) thestate/territorywilluseforthisAlternativeBenefitPlan(s). Selectoneormoreservicedeliverysystems: Managedcare. ManagedCareOrganizations (MCO). PrepaidInpatientHealthPlans (PIHP). PrepaidAmbulatoryHealthPlans (PAHP). PrimaryCareCaseManagement (PCCM). Fee-for-service. Otherservicedeliverysystem. ManagedCareOptions ManagedCareAssurance Thestate/territorycertifiesthatitwillcomplywithallapplicableMedicaidlawsandregulations, includingbutnotlimitedtosections 1903(m), 1905(t), and1932oftheActand42CFRPart438, inprovidingmanagedcareservicesthroughthisAlternativeBenefit Plan. ThisincludestherequirementforCMSapprovalofcontractsandratespursuantto42CFR438.6. ManagedCareImplementation PleasedescribetheimplementationplanfortheAlternativeBenefitPlanundermanagedcareincludingmember, stakeholder, and provideroutreachefforts. ewmembersareauto-enrolledinoneofthethreeMCOsaftereligibilitydeterminationbasedonapre-determinedalgorithm. All N memberswillhave90daysfrominitialMCOassignmenttoselectadifferentMCO, andchoicecounselinginselectingthePlanthat bestfitsthemember'sneedsisavailablethroughtheEnrollmentBrokerandwebsitewww.neheritagehealth.com. MemberswhoarebeingtransitionedfromMedicallyNeedywithaShareofCostintoHeritageHealthAdultwillbeauto-assignedtoan MCObytheState'sconflict-freeEnrollmentBrokerifnotalreadyenrolledinanMCO. Memberswillhave90daysfrominitialMCO assignmenttoselectadifferentMCO, andchoicecounselinginselectingthePlanthatbestfitsthemember'sneedsisavailablethrough theEnrollmentBrokerandwebsitewww.neheritagehealth.com. Parentcaretakerswitha5% disregardandmemberswhoarebeingtransitionedintoHeritageHealthAdultwillmaintainenrollmentin theircurrentMCO. NebraskacurrentlyhasarobustpopulationofproviderswhoparticipateinMedicaidandarecontractedwithHeritageHealthplans. All NebraskaManagedCareOrganizationshaveprovidedtheStatewithdetailedplansonensuringadequateaccesstoservicesfortheAdult Group. AllMCOswillalsohavetoattesttonetworkadequacypriortotheadditionoftheMedicaidAdultGrouppopulation. MCO: ManagedCareOrganization Themanagedcaredeliverysystemisthesameasanalreadyapprovedmanagedcareprogram. Yes TN: NE19-0014 EffectiveDate: 10/01/2020 Superseding: NewApproval Date: Page1of2

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AlternativeBenefitPlan Themanagedcareprogramisoperatingunder (selectone): Section1915(a) voluntarymanagedcareprogram. Section1915(b) managedcarewaiver. Section1932(a) mandatorymanagedcarestateplanamendment. Section1115demonstration. Section1937Alternative (Benchmark) BenefitPlanstateplanamendment. IdentifythedatethemanagedcareprogramwasapprovedbyCMS: Jun23, 2017 Describeprogrambelow: ebraskaMedicaid'smanagedcareprogram, calledHeritageHealth, iscomprisedofthreemanagedcareorganizationswhoare N responsibleforoverseeingthedeliveryofcomprehensive, integratedphysical, pharmacy, andbehavioralhealthservices statewideforMedicaidenrolleesutilizingariskbearingmodel. AdditionalInformation: MCO (Optional) Provideanyadditionaldetailsregardingthisservicedeliverysystem (optional): Fee-For-ServiceOptions Indicatewhetherthestate/territoryofferstraditionalfee-for-serviceand/orservicesmanagedunderanadministrativeservices organization: Traditionalstate-managedfee-for-service Servicesmanagedunderanadministrativeservicesorganization (ASO) arrangement Pleasedescribethisfee-for-servicedeliverysystem, includinganybundledpaymentarrangements, payforperformance, fee-for- servicecaremanagementmodels/non-risk, contractualincentivesaswellasthepopulationservedviathisdeliverysystem. ebraskaMedicaidStatePlanServicesthatareexcludedfromMCObenefitswillcontinuetobedeliveredastraditionalstate N managedfee-for-service, whichincludesLong-termcustodialcareservices, personalassistanceservices, andHCBS1915(c) services. Whenaclientbecomeseligibleduringaninpatienthospitalstay, theserviceswillbedeliveredastraditionalstatemanaged fee-for-services. AdditionalInformation: Fee-For-Service (Optional) Provideanyadditionaldetailsregardingthisservicedeliverysystem (optional): PRADisclosureStatement AccordingtothePaperworkReductionActof1995, nopersonsarerequiredtorespondtoacollectionofinformationunlessitdisplaysa validOMBcontrolnumber. ThevalidOMBcontrolnumberforthisinformationcollectionis0938-1148. Thetimerequiredtocomplete thisinformationcollectionisestimatedtoaverage5hoursperresponse, includingthetimetoreviewinstructions, searchexistingdata resources, gatherthedataneeded, andcompleteandreviewtheinformationcollection. Ifyouhavecommentsconcerningtheaccuracyof thetimeestimate(s) orsuggestionsforimprovingthisform, pleasewriteto: CMS, 7500SecurityBoulevard, Attn: PRAReportsClearance Officer, MailStopC4-26-05, Baltimore, Maryland21244-1850. V.20181119 TN: NE19-0014 EffectiveDate: 10/01/2020 Superseding: NewApproval Date: Page2of2

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AlternativeBenefitPlan OMBControlNumber: 09381148 StateName:ebraska N Attachment3.1-L- TransmittalNumber:NE-19-0014 EmployerSponsoredInsuranceandPaymentofPremiumsABP9 Thestate/territoryprovidestheAlternativeBenefitPlanthroughthepaymentofemployersponsoredinsurancefor participants withsuchcoverage, withadditionalbenefitsandservicesprovidedthroughaBenchmarkorBenchmark-EquivalentBenefit No Package. Thestate/territoryotherwiseprovidesforpaymentofpremiums. Yes Provideadescriptionincludingthepopulationcovered, theamountofpremiumassistancebypopulation, requiredcontributions, cost-effectivenesstestrequirements, andbenefitsinformation. ParticipationinNebraska'sHealthInsurancePremiumPayment (HIPP) Programisvoluntary. IndividualsenrolledintheHIPP programareaffordedthesamebeneficiaryprotectionsprovidedtoallotherMedicaidenrollees. Inadditiontothebenefitswrap, whichisprovidedtoensurethatindividualsenrolledintheHIPPprogramreceiveallservicesandbenefitsavailableunderthe MedicaidStateplan, theNebraskaMedicaidalsoprovidesawraptoanycost-sharingthatexceedsthecost-sharingdescribedinthe StateplanuptotheMedicaidallowabletakingintoaccounttheamountpaidbytheprimaryinsurance. Nebraskawillbefollowing thecost-effectivenessmethodologyasfoundintheapprovedStatePlan, Attachment4.22-C, pages1-3. OtherInformationRegardingEmployerSponsoredInsuranceorPaymentofPremiums: PRADisclosureStatement AccordingtothePaperworkReductionActof1995, nopersonsarerequiredtorespondtoacollectionofinformationunlessitdisplaysa validOMBcontrolnumber. ThevalidOMBcontrolnumberforthisinformationcollectionis0938-1148. Thetimerequiredtocomplete thisinformationcollectionisestimatedtoaverage5hoursperresponse, includingthetimetoreviewinstructions, searchexistingdata resources, gatherthedataneeded, andcompleteandreviewtheinformationcollection. Ifyouhavecommentsconcerningtheaccuracyof thetimeestimate(s) orsuggestionsforimprovingthisform, pleasewriteto: CMS, 7500SecurityBoulevard, Attn: PRAReportsClearance Officer, MailStopC4-26-05, Baltimore, Maryland21244-1850. V.20160722 Page1of1 TN: NE19-0014 EffectiveDate: 10/01/2020 Superseding: NewApproval Date:

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(ne-20-0010)(approval-document)(page-4)Page 4#

DEPARTMENT OF HEALTH AND HUMAN SERVICES HEALTH CARE FINANCING ADMINISTRATION

FORM APPROVED OMB NO. 0938-0193

TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL

2. STATE Nebraska

1. TRANSMITTAL NUMBER: NE 20-0010

FOR: HEALTH CARE FINANCING ADMINISTRATION

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

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

4. PROPOSED EFFECTIVE DATE _ March 1, 2020

5. TYPE OF PLAN MATERIAL (Check One):

(-] NEW STATE PLAN

(.] AMENDMENT TO BE CONSIDERED AS NEW PLAN

] AMEN DMENT

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

6, FEDERAL STATUTE/REGULATION CITATION: p. 135 of the SSA Title XIX of the Social Security Act

7, FEDERAL BUDGET IMPACT: a.FFY 2020 $52,541,288 b. FFY 2021 $489,029,234

8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:

Section 7, 7.4, Pages 90-101 (new)

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

10. SUBJECT OF AMENDMENT: Medicaid Disaster Relief for the COVID-19 National Emergency

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

OFFICIAL: 13.7" AME:

Jeremy Brunssen

14, TITLE: Interim Director, Division of Medicaid and Long-Term Care

15. DATE SUBMITTED: April 21, 2020

{] OTHER, AS SPECIFIED: Governor has waived review

16. RETURN TO:

Dawn Kastens

Division of Medicaid & Long-Term Care Nebraska Department of Health & Human Services 301 Centennial Mall South

Lincoln, NE 68509

FOR REGIONAL OFFICE USE ONLY

17. DATE RECEIVED: April 2, 2020

18. DATE APPROVED: April 24, 2020

PLAN APPROVED — ONE COPY ATTACHED

19. EFFECTIVE DATE OF APPROVED MATERIAL: March 1, 2020

20. SIGNATURE OF REGIONAL OFFICIAL: Anne M. Costello -S

‘signed by Anne M. Costetio-S "2020.04.26 14.40 16-0400"

21. TYPED NAME:

Anne Marie Costello

22. TITLE: Deputy Director, CMCS

23. REMARKS:

* pen and ink change made per state email dated 4.23.20.

FORM HCFA-179 (07-92)

(ne-20-0010)(approval-document)(page-5)Page 5#

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ĨĨĞĐƚŝǀĞ ĂƚĞ͗ ͺͺͺͺͺͺͺͺͺͺ ^ĞĐƚŝŽŶ ϳ ʹ 'ĞŶĞƌĂů WƌŽǀŝƐŝŽŶƐ ϳ͘ϰ͘ DĞĚŝĐĂŝĚ ŝƐĂƐƚĞƌ ZĞůŝĞĨ ĨŽƌ ƚŚĞ Ks/Ͳϭϵ EĂƚŝŽŶĂů ŵĞƌŐĞŶĐǇ KŶ DĂƌĐŚ ϭϯ͕ ϮϬϮϬ͕ ƚŚĞ WƌĞƐŝĚĞŶƚ ŽĨ ƚŚĞ hŶŝƚĞĚ ^ƚĂƚĞƐ ŝƐƐƵĞĚ Ă ƉƌŽĐůĂŵĂƚŝŽŶ ƚŚĂƚ ƚŚĞ Ks/Ͳϭϵ ŽƵƚďƌĞĂŬ ŝŶ ƚŚĞ hŶŝƚĞĚ ^ƚĂƚĞƐ ĐŽŶƐƚŝƚƵƚĞƐ Ă ŶĂƚŝŽŶĂů ĞŵĞƌŐĞŶĐǇ ďǇ ƚŚĞ ĂƵƚŚŽƌŝƚŝĞƐ ǀĞƐƚĞĚ ŝŶ Śŝŵ ďǇ ƚŚĞ ŽŶƐƚŝƚƵƚŝŽŶ ĂŶĚ ƚŚĞ ůĂǁƐ ŽĨ ƚŚĞ hŶŝƚĞĚ ^ƚĂƚĞƐ͕ ŝŶĐůƵĚŝŶŐ ƐĞĐƚŝŽŶƐ ϮϬϭ ĂŶĚ ϯϬϭ ŽĨ ƚŚĞ EĂƚŝŽŶĂů

ŵĞƌŐĞŶĐŝĞƐ Đƚ ;ϱϬ h͘^͘͘ ϭϲϬϭ Ğƚ ƐĞƋ͘Ϳ͕ ĂŶĚ ĐŽŶƐŝƐƚĞŶƚ ǁŝƚŚ ƐĞĐƚŝŽŶ ϭϭϯϱ ŽĨ ƚŚĞ ^ŽĐŝĂů ^ĞĐƵƌŝƚǇ Đƚ ;ĐƚͿ͘ KŶ DĂƌĐŚ ϭϯ͕ ϮϬϮϬ͕ ƉƵƌƐƵĂŶƚ ƚŽ ƐĞĐƚŝŽŶ ϭϭϯϱ;ďͿ ŽĨ ƚŚĞ Đƚ͕ ƚŚĞ ^ĞĐƌĞƚĂƌǇ ŽĨ ƚŚĞ hŶŝƚĞĚ ^ƚĂƚĞƐ ĞƉĂƌƚŵĞŶƚ ŽĨ ,ĞĂůƚŚ ĂŶĚ ,ƵŵĂŶ ^ĞƌǀŝĐĞƐ ŝŶǀŽŬĞĚ ŚŝƐ ĂƵƚŚŽƌŝƚǇ ƚŽ ǁĂŝǀĞ Žƌ ŵŽĚŝĨǇ ĐĞƌƚĂŝŶ ƌĞƋƵŝƌĞŵĞŶƚƐ ŽĨ ƚŝƚůĞƐ ys///͕ y/y͕ ĂŶĚ yy/ ŽĨ ƚŚĞ Đƚ ĂƐ Ă ƌĞƐƵůƚ ŽĨ ƚŚĞ ĐŽŶƐĞƋƵĞŶĐĞƐ Ks/Ͳϭϵ ƉĂŶĚĞŵŝĐ͕ ƚŽ ƚŚĞ ĞǆƚĞŶƚ ŶĞĐĞƐƐĂƌǇ͕ ĂƐ ĚĞƚĞƌŵŝŶĞĚ ďǇ ƚŚĞ ĞŶƚĞƌƐ ĨŽƌ DĞĚŝĐĂƌĞ Θ DĞĚŝĐĂŝĚ ^ĞƌǀŝĐĞƐ ;D^Ϳ͕ ƚŽ ĞŶƐƵƌĞ ƚŚĂƚ ƐƵĨĨŝĐŝĞŶƚ ŚĞĂůƚŚ ĐĂƌĞ ŝƚĞŵƐ ĂŶĚ ƐĞƌǀŝĐĞƐ ĂƌĞ ĂǀĂŝůĂďůĞ ƚŽ ŵĞĞƚ ƚŚĞ ŶĞĞĚƐ ŽĨ ŝŶĚŝǀŝĚƵĂůƐ ĞŶƌŽůůĞĚ ŝŶ ƚŚĞ ƌĞƐƉĞĐƚŝǀĞ ƉƌŽŐƌĂŵƐ ĂŶĚ ƚŽ ĞŶƐƵƌĞ ƚŚĂƚ ŚĞĂůƚŚ ĐĂƌĞ ƉƌŽǀŝĚĞƌƐ ƚŚĂƚ ĨƵƌŶŝƐŚ ƐƵĐŚ ŝƚĞŵƐ ĂŶĚ ƐĞƌǀŝĐĞƐ ŝŶ ŐŽŽĚ ĨĂŝƚŚ͕ ďƵƚ ĂƌĞ ƵŶĂďůĞ ƚŽ ĐŽŵƉůǇ ǁŝƚŚ ŽŶĞ Žƌ ŵŽƌĞ ŽĨ ƐƵĐŚ ƌĞƋƵŝƌĞŵĞŶƚƐ ĂƐ Ă ƌĞƐƵůƚ ŽĨ ƚŚĞ Ks/Ͳϭϵ ƉĂŶĚĞŵŝĐ͕ ŵĂǇ ďĞ ƌĞŝŵďƵƌƐĞĚ ĨŽƌ ƐƵĐŚ ŝƚĞŵƐ ĂŶĚ ƐĞƌǀŝĐĞƐ ĂŶĚ ĞǆĞŵƉƚĞĚ ĨƌŽŵ ƐĂŶĐƚŝŽŶƐ ĨŽƌ ƐƵĐŚ ŶŽŶĐŽŵƉůŝĂŶĐĞ͕ ĂďƐĞŶƚ ĂŶǇ ĚĞƚĞƌŵŝŶĂƚŝŽŶ ŽĨ ĨƌĂƵĚ Žƌ ĂďƵƐĞ͘ dŚŝƐ ĂƵƚŚŽƌŝƚǇ ƚŽŽŬ ĞĨĨĞĐƚ ĂƐ ŽĨ ϲWD

ĂƐƚĞƌŶ ^ƚĂŶĚĂƌĚ dŝŵĞ ŽŶ DĂƌĐŚ ϭϱ͕ ϮϬϮϬ͕ ǁŝƚŚ Ă ƌĞƚƌŽĂĐƚŝǀĞ ĞĨĨĞĐƚŝǀĞ ĚĂƚĞ ŽĨ DĂƌĐŚ ϭ͕ ϮϬϮϬ͘ dŚĞ ĞŵĞƌŐĞŶĐǇ ƉĞƌŝŽĚ ǁŝůů ƚĞƌŵŝŶĂƚĞ͕ ĂŶĚ ǁĂŝǀĞƌƐ ǁŝůů ŶŽ ůŽŶŐĞƌ ďĞ ĂǀĂŝůĂďůĞ͕ ƵƉŽŶ ƚĞƌŵŝŶĂƚŝŽŶ ŽĨ ƚŚĞ ƉƵďůŝĐ ŚĞĂůƚŚ ĞŵĞƌŐĞŶĐǇ͕ ŝŶĐůƵĚŝŶŐ ĂŶǇ ĞǆƚĞŶƐŝŽŶƐ͘ dŚĞ ^ƚĂƚĞ DĞĚŝĐĂŝĚ ĂŐĞŶĐǇ ;ĂŐĞŶĐǇͿ ƐĞĞŬƐ ƚŽ ŝŵƉůĞŵĞŶƚ ƚŚĞ ƉŽůŝĐŝĞƐ ĂŶĚ ƉƌŽĐĞĚƵƌĞƐ ĚĞƐĐƌŝďĞĚ ďĞůŽǁ͕ ǁŚŝĐŚ ĂƌĞ ĚŝĨĨĞƌĞŶƚ ƚŚĂŶ ƚŚĞ ƉŽůŝĐŝĞƐ ĂŶĚ ƉƌŽĐĞĚƵƌĞƐ ŽƚŚĞƌǁŝƐĞ ĂƉƉůŝĞĚ ƵŶĚĞƌ ƚŚĞ DĞĚŝĐĂŝĚ ƐƚĂƚĞ ƉůĂŶ͕ ĚƵƌŝŶŐ ƚŚĞ ƉĞƌŝŽĚ ŽĨ ƚŚĞ WƌĞƐŝĚĞŶƚŝĂů ĂŶĚ ^ĞĐƌĞƚĂƌŝĂů ĞŵĞƌŐĞŶĐǇ ĚĞĐůĂƌĂƚŝŽŶƐ ƌĞůĂƚĞĚ ƚŽ ƚŚĞ Ks/Ͳϭϵ ŽƵƚďƌĞĂŬ ;Žƌ ĂŶǇ ƌĞŶĞǁĂůƐ ƚŚĞƌĞŽĨͿ͕ Žƌ ĨŽƌ ĂŶǇ ƐŚŽƌƚĞƌ ƉĞƌŝŽĚ ĚĞƐĐƌŝďĞĚ ďĞůŽǁ͗ ĞƐĐƌŝďĞ ƐŚŽƌƚĞƌ ƉĞƌŝŽĚ ŚĞƌĞ͘ EKd ͗ ^ƚĂƚĞƐ ŵĂǇ ŶŽƚ ĞůĞĐƚ Ă ƉĞƌŝŽĚ ůŽŶŐĞƌ ƚŚĂŶ ƚŚĞ WƌĞƐŝĚĞŶƚŝĂů Žƌ ^ĞĐƌĞƚĂƌŝĂů ĞŵĞƌŐĞŶĐǇ ĚĞĐůĂƌĂƚŝŽŶ ;Žƌ ĂŶǇ ƌĞŶĞǁĂů ƚŚĞƌĞŽĨͿ͘ ^ƚĂƚĞƐ ŵĂǇ ŶŽƚ ƉƌŽƉŽƐĞ ĐŚĂŶŐĞƐ ŽŶ ƚŚŝƐ ƚĞŵƉůĂƚĞ ƚŚĂƚ ƌĞƐƚƌŝĐƚ Žƌ ůŝŵŝƚ ƉĂǇŵĞŶƚ͕ ƐĞƌǀŝĐĞƐ͕ Žƌ ĞůŝŐŝďŝůŝƚǇ͕ Žƌ ŽƚŚĞƌǁŝƐĞ ďƵƌĚĞŶ ďĞŶĞĨŝĐŝĂƌŝĞƐ ĂŶĚ ƉƌŽǀŝĚĞƌƐ͘ ZĞƋƵĞƐƚ ĨŽƌ tĂŝǀĞƌƐ ƵŶĚĞƌ ^ĞĐƚŝŽŶ ϭϭϯϱ ͺyͺͺͺͺ dŚĞ ĂŐĞŶĐǇ ƐĞĞŬƐ ƚŚĞ ĨŽůůŽǁŝŶŐ ƵŶĚĞƌ ƐĞĐƚŝŽŶ ϭϭϯϱ;ďͿ;ϭͿ;Ϳ ĂŶĚͬŽƌ ƐĞĐƚŝŽŶ ϭϭϯϱ;ďͿ;ϱͿ ŽĨ ƚŚĞ Đƚ͗ Ă͘ ͺͺyͺͺͺ ^W ƐƵďŵŝƐƐŝŽŶ ƌĞƋƵŝƌĞŵĞŶƚƐ ʹ ƚŚĞ ĂŐĞŶĐǇ ƌĞƋƵĞƐƚƐ ŵŽĚŝĨŝĐĂƚŝŽŶ ŽĨ ƚŚĞ ƌĞƋƵŝƌĞŵĞŶƚ ƚŽ ƐƵďŵŝƚ ƚŚĞ ^W ďǇ DĂƌĐŚ ϯϭ͕ ϮϬϮϬ͕ ƚŽ ŽďƚĂŝŶ Ă ^W ĞĨĨĞĐƚŝǀĞ ĚĂƚĞ ĚƵƌŝŶŐ ƚŚĞ ĨŝƌƐƚ ĐĂůĞŶĚĂƌ ƋƵĂƌƚĞƌ ŽĨ ϮϬϮϬ͕ ƉƵƌƐƵĂŶƚ ƚŽ ϰϮ &Z ϰϯϬ͘ϮϬ͘ ď͘ ͺͺyͺͺ WƵďůŝĐ ŶŽƚŝĐĞ ƌĞƋƵŝƌĞŵĞŶƚƐ ʹ ƚŚĞ ĂŐĞŶĐǇ ƌĞƋƵĞƐƚƐ ǁĂŝǀĞƌ ŽĨ ƉƵďůŝĐ ŶŽƚŝĐĞ ƌĞƋƵŝƌĞŵĞŶƚƐ ƚŚĂƚ ǁŽƵůĚ ŽƚŚĞƌǁŝƐĞ ďĞ ĂƉƉůŝĐĂďůĞ ƚŽ ƚŚŝƐ ^W ƐƵďŵŝƐƐŝŽŶ͘ dŚĞƐĞ ƌĞƋƵŝƌĞŵĞŶƚƐ ŵĂǇ ŝŶĐůƵĚĞ ƚŚŽƐĞ ƐƉĞĐŝĨŝĞĚ ŝŶ ϰϮ &Z ϰϰϬ͘ϯϴϲ ;ůƚĞƌŶĂƚŝǀĞ ĞŶĞĨŝƚ WůĂŶƐͿ͕ ϰϮ &Z ϰϰϳ͘ϱϳ;ĐͿ ;ƉƌĞŵŝƵŵƐ ĂŶĚ ĐŽƐƚ ƐŚĂƌŝŶŐͿ͕ ĂŶĚ ϰϮ &Z ϰϰϳ͘ϮϬϱ ;ƉƵďůŝĐ ŶŽƚŝĐĞ ŽĨ ĐŚĂŶŐĞƐ ŝŶ ƐƚĂƚĞǁŝĚĞ ŵĞƚŚŽĚƐ ĂŶĚ ƐƚĂŶĚĂƌĚƐ ĨŽƌ ƐĞƚƚŝŶŐ ƉĂǇŵĞŶƚ ƌĂƚĞƐͿ͘ E t ϰͬϮϰͬϮϬ ϯͬϭͬϮϬ

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^ƚĂƚĞͬdĞƌƌŝƚŽƌǇ͗ EĞďƌĂƐŬĂ ^ĞĐƚŝŽŶ ϳ͘ϰ ƉĂŐĞ ϵϭ dE͗ E ϮϬͲϬϬϭϬ ƉƉƌŽǀĂů ĂƚĞ͗ ͺͺͺͺͺͺͺͺͺͺ ^ƵƉĞƌƐĞĚĞƐ dE͗ ͺͺͺͺͺͺͺͺͺͺ

ĨĨĞĐƚŝǀĞ ĂƚĞ͗ ͺͺͺͺͺͺͺͺͺͺ Đ͘ ͺͺyͺͺͺ dƌŝďĂů ĐŽŶƐƵůƚĂƚŝŽŶ ƌĞƋƵŝƌĞŵĞŶƚƐ ʹ ƚŚĞ ĂŐĞŶĐǇ ƌĞƋƵĞƐƚƐ ŵŽĚŝĨŝĐĂƚŝŽŶ ŽĨ ƚƌŝďĂů ĐŽŶƐƵůƚĂƚŝŽŶ ƚŝŵĞůŝŶĞƐ ƐƉĞĐŝĨŝĞĚ ŝŶ EĞďƌĂƐŬĂ DĞĚŝĐĂŝĚ ƐƚĂƚĞ ƉůĂŶ͕ ĂƐ ĚĞƐĐƌŝďĞĚ ďĞůŽǁ͗ EĞďƌĂƐŬĂ ǁŝůů ďĞŐŝŶ ƚŚĞ ƚƌŝďĂů ĐŽŶƐƵůƚĂƚŝŽŶ ƉĞƌŝŽĚ ĐŽŶĐƵƌƌĞŶƚůǇ ǁŝƚŚ ƐƵďŵŝƐƐŝŽŶ ŽĨ ƚŚŝƐ ^W ƚŽ D^͘ EĞďƌĂƐŬĂ ƚƌŝďĞƐ ǁŝůů ŚĂǀĞ ϭϱ ĐĂůĞŶĚĂƌ ĚĂǇƐ ƚŽ ŝŶŝƚŝĂƚĞ Ă ƚƌŝďĂů ĐŽŶƐƵůƚĂƚŝŽŶ ŝŶ ǁŚŝĐŚ EĞďƌĂƐŬĂ ǁŝůů ŝŵŵĞĚŝĂƚĞůǇ ĂĚĚƌĞƐƐ ĂŶǇ ƋƵĞƐƚŝŽŶƐ͘ ^ĞĐƚŝŽŶ ʹ ůŝŐŝďŝůŝƚǇ ϭ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐǇ ĨƵƌŶŝƐŚĞƐ ŵĞĚŝĐĂů ĂƐƐŝƐƚĂŶĐĞ ƚŽ ƚŚĞ ĨŽůůŽǁŝŶŐ ŽƉƚŝŽŶĂů ŐƌŽƵƉƐ ŽĨ ŝŶĚŝǀŝĚƵĂůƐ ĚĞƐĐƌŝďĞĚ ŝŶ ƐĞĐƚŝŽŶ ϭϵϬϮ;ĂͿ;ϭϬͿ;Ϳ;ŝŝͿ Žƌ ϭϵϬϮ;ĂͿ;ϭϬͿ;ĐͿ ŽĨ ƚŚĞ Đƚ͘ dŚŝƐ ŵĂǇ ŝŶĐůƵĚĞ ƚŚĞ ŶĞǁ ŽƉƚŝŽŶĂů ŐƌŽƵƉ ĚĞƐĐƌŝďĞĚ Ăƚ ƐĞĐƚŝŽŶ ϭϵϬϮ;ĂͿ;ϭϬͿ;Ϳ;ŝŝͿ;yy///Ϳ ĂŶĚ ϭϵϬϮ;ƐƐͿ ŽĨ ƚŚĞ Đƚ ƉƌŽǀŝĚŝŶŐ ĐŽǀĞƌĂŐĞ ĨŽƌ ƵŶŝŶƐƵƌĞĚ ŝŶĚŝǀŝĚƵĂůƐ͘ /ŶĐůƵĚĞ ŶĂŵĞ ŽĨ ƚŚĞ ŽƉƚŝŽŶĂů ĞůŝŐŝďŝůŝƚǇ ŐƌŽƵƉ ĂŶĚ ĂƉƉůŝĐĂďůĞ ŝŶĐŽŵĞ ĂŶĚ ƌĞƐŽƵƌĐĞ ƐƚĂŶĚĂƌĚ͘ Ϯ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐǇ ĨƵƌŶŝƐŚĞƐ ŵĞĚŝĐĂů ĂƐƐŝƐƚĂŶĐĞ ƚŽ ƚŚĞ ĨŽůůŽǁŝŶŐ ƉŽƉƵůĂƚŝŽŶƐ ŽĨ ŝŶĚŝǀŝĚƵĂůƐ ĚĞƐĐƌŝďĞĚ ŝŶ ƐĞĐƚŝŽŶ ϭϵϬϮ;ĂͿ;ϭϬͿ;Ϳ;ŝŝͿ;yyͿ ŽĨ ƚŚĞ Đƚ ĂŶĚ ϰϮ &Z ϰϯϱ͘Ϯϭϴ͗ Ă͘ ͺͺͺͺͺ ůů ŝŶĚŝǀŝĚƵĂůƐ ǁŚŽ ĂƌĞ ĚĞƐĐƌŝďĞĚ ŝŶ ƐĞĐƚŝŽŶ ϭϵϬϱ;ĂͿ;ϭϬͿ;Ϳ;ŝŝͿ;yyͿ /ŶĐŽŵĞ ƐƚĂŶĚĂƌĚ͗ ͺͺͺͺͺͺͺͺͺͺͺͺͺ ͲŽƌͲ ď͘ ͺͺͺͺͺ /ŶĚŝǀŝĚƵĂůƐ ĚĞƐĐƌŝďĞĚ ŝŶ ƚŚĞ ĨŽůůŽǁŝŶŐ ĐĂƚĞŐŽƌŝĐĂů ƉŽƉƵůĂƚŝŽŶƐ ŝŶ ƐĞĐƚŝŽŶ ϭϵϬϱ;ĂͿ ŽĨ ƚŚĞ Đƚ͗ /ŶĐŽŵĞ ƐƚĂŶĚĂƌĚ͗ ͺͺͺͺͺͺͺͺͺͺͺͺͺ ϯ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐǇ ĂƉƉůŝĞƐ ůĞƐƐ ƌĞƐƚƌŝĐƚŝǀĞ ĨŝŶĂŶĐŝĂů ŵĞƚŚŽĚŽůŽŐŝĞƐ ƚŽ ŝŶĚŝǀŝĚƵĂůƐ ĞǆĐĞƉƚĞĚ ĨƌŽŵ ĨŝŶĂŶĐŝĂů ŵĞƚŚŽĚŽůŽŐŝĞƐ ďĂƐĞĚ ŽŶ ŵŽĚŝĨŝĞĚ ĂĚũƵƐƚĞĚ ŐƌŽƐƐ ŝŶĐŽŵĞ ;D'/Ϳ ĂƐ ĨŽůůŽǁƐ͘ >ĞƐƐ ƌĞƐƚƌŝĐƚŝǀĞ ŝŶĐŽŵĞ ŵĞƚŚŽĚŽůŽŐŝĞƐ͗ E t ϰͬϮϰͬϮϬ ϯͬϭͬϮϬ

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^ƚĂƚĞͬdĞƌƌŝƚŽƌǇ͗ EĞďƌĂƐŬĂ ^ĞĐƚŝŽŶ ϳ͘ϰ ƉĂŐĞ ϵϮ dE͗ E ϮϬͲϬϬϭϬ ƉƉƌŽǀĂů ĂƚĞ͗ ͺͺͺͺͺͺͺͺͺͺ ^ƵƉĞƌƐĞĚĞƐ dE͗ ͺͺͺͺͺͺͺͺͺͺ

ĨĨĞĐƚŝǀĞ ĂƚĞ͗ ͺͺͺͺͺͺͺͺͺͺ >ĞƐƐ ƌĞƐƚƌŝĐƚŝǀĞ ƌĞƐŽƵƌĐĞ ŵĞƚŚŽĚŽůŽŐŝĞƐ͗ ϰ͘ ͺͺyͺͺͺ dŚĞ ĂŐĞŶĐǇ ĐŽŶƐŝĚĞƌƐ ŝŶĚŝǀŝĚƵĂůƐ ǁŚŽ ĂƌĞ ĞǀĂĐƵĂƚĞĚ ĨƌŽŵ ƚŚĞ ƐƚĂƚĞ͕ ǁŚŽ ůĞĂǀĞ ƚŚĞ ƐƚĂƚĞ ĨŽƌ ŵĞĚŝĐĂů ƌĞĂƐŽŶƐ ƌĞůĂƚĞĚ ƚŽ ƚŚĞ ĚŝƐĂƐƚĞƌ Žƌ ƉƵďůŝĐ ŚĞĂůƚŚ ĞŵĞƌŐĞŶĐǇ͕ Žƌ ǁŚŽ ĂƌĞ ŽƚŚĞƌǁŝƐĞ ĂďƐĞŶƚ ĨƌŽŵ ƚŚĞ ƐƚĂƚĞ ĚƵĞ ƚŽ ƚŚĞ ĚŝƐĂƐƚĞƌ Žƌ ƉƵďůŝĐ ŚĞĂůƚŚ ĞŵĞƌŐĞŶĐǇ ĂŶĚ ǁŚŽ ŝŶƚĞŶĚ ƚŽ ƌĞƚƵƌŶ ƚŽ ƚŚĞ ƐƚĂƚĞ͕ ƚŽ ĐŽŶƚŝŶƵĞ ƚŽ ďĞ ƌĞƐŝĚĞŶƚƐ ŽĨ ƚŚĞ ƐƚĂƚĞ ƵŶĚĞƌ ϰϮ &Z ϰϯϱ͘ϰϬϯ;ũͿ;ϯͿ͘ ϱ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐǇ ƉƌŽǀŝĚĞƐ DĞĚŝĐĂŝĚ ĐŽǀĞƌĂŐĞ ƚŽ ƚŚĞ ĨŽůůŽǁŝŶŐ ŝŶĚŝǀŝĚƵĂůƐ ůŝǀŝŶŐ ŝŶ ƚŚĞ ƐƚĂƚĞ͕ ǁŚŽ ĂƌĞ ŶŽŶͲƌĞƐŝĚĞŶƚƐ͗ ϲ͘ ͺͺyͺͺͺ dŚĞ ĂŐĞŶĐǇ ƉƌŽǀŝĚĞƐ ĨŽƌ ĂŶ ĞǆƚĞŶƐŝŽŶ ŽĨ ƚŚĞ ƌĞĂƐŽŶĂďůĞ ŽƉƉŽƌƚƵŶŝƚǇ ƉĞƌŝŽĚ ĨŽƌ ŶŽŶͲ ĐŝƚŝǌĞŶƐ ĚĞĐůĂƌŝŶŐ ƚŽ ďĞ ŝŶ Ă ƐĂƚŝƐĨĂĐƚŽƌǇ ŝŵŵŝŐƌĂƚŝŽŶ ƐƚĂƚƵƐ͕ ŝĨ ƚŚĞ ŶŽŶͲĐŝƚŝǌĞŶ ŝƐ ŵĂŬŝŶŐ Ă ŐŽŽĚ ĨĂŝƚŚ ĞĨĨŽƌƚ ƚŽ ƌĞƐŽůǀĞ ĂŶǇ ŝŶĐŽŶƐŝƐƚĞŶĐĞƐ Žƌ ŽďƚĂŝŶ ĂŶǇ ŶĞĐĞƐƐĂƌǇ ĚŽĐƵŵĞŶƚĂƚŝŽŶ͕ Žƌ ƚŚĞ ĂŐĞŶĐǇ ŝƐ ƵŶĂďůĞ ƚŽ ĐŽŵƉůĞƚĞ ƚŚĞ ǀĞƌŝĨŝĐĂƚŝŽŶ ƉƌŽĐĞƐƐ ǁŝƚŚŝŶ ƚŚĞ ϵϬͲĚĂǇ ƌĞĂƐŽŶĂďůĞ ŽƉƉŽƌƚƵŶŝƚǇ ƉĞƌŝŽĚ ĚƵĞ ƚŽ ƚŚĞ ĚŝƐĂƐƚĞƌ Žƌ ƉƵďůŝĐ ŚĞĂůƚŚ ĞŵĞƌŐĞŶĐǇ͘ ^ĞĐƚŝŽŶ ʹ ŶƌŽůůŵĞŶƚ ϭ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐǇ ĞůĞĐƚƐ ƚŽ ĂůůŽǁ ŚŽƐƉŝƚĂůƐ ƚŽ ŵĂŬĞ ƉƌĞƐƵŵƉƚŝǀĞ ĞůŝŐŝďŝůŝƚǇ ĚĞƚĞƌŵŝŶĂƚŝŽŶƐ ĨŽƌ ƚŚĞ ĨŽůůŽǁŝŶŐ ĂĚĚŝƚŝŽŶĂů ƐƚĂƚĞ ƉůĂŶ ƉŽƉƵůĂƚŝŽŶƐ͕ Žƌ ĨŽƌ ƉŽƉƵůĂƚŝŽŶƐ ŝŶ ĂŶ ĂƉƉƌŽǀĞĚ ƐĞĐƚŝŽŶ ϭϭϭϱ ĚĞŵŽŶƐƚƌĂƚŝŽŶ͕ ŝŶ ĂĐĐŽƌĚĂŶĐĞ ǁŝƚŚ ƐĞĐƚŝŽŶ ϭϵϬϮ;ĂͿ;ϰϳͿ;Ϳ ŽĨ ƚŚĞ Đƚ ĂŶĚ ϰϮ &Z ϰϯϱ͘ϭϭϭϬ͕ ƉƌŽǀŝĚĞĚ ƚŚĂƚ ƚŚĞ ĂŐĞŶĐǇ ŚĂƐ ĚĞƚĞƌŵŝŶĞĚ ƚŚĂƚ ƚŚĞ ŚŽƐƉŝƚĂů ŝƐ ĐĂƉĂďůĞ ŽĨ ŵĂŬŝŶŐ ƐƵĐŚ ĚĞƚĞƌŵŝŶĂƚŝŽŶƐ͘ WůĞĂƐĞ ĚĞƐĐƌŝďĞ ƚŚĞ ĂƉƉůŝĐĂďůĞ ĞůŝŐŝďŝůŝƚǇ ŐƌŽƵƉƐͬƉŽƉƵůĂƚŝŽŶƐ ĂŶĚ ĂŶǇ ĐŚĂŶŐĞƐ ƚŽ ƌĞĂƐŽŶĂďůĞ ůŝŵŝƚĂƚŝŽŶƐ͕ ƉĞƌĨŽƌŵĂŶĐĞ ƐƚĂŶĚĂƌĚƐ Žƌ ŽƚŚĞƌ ĨĂĐƚŽƌƐ͘ Ϯ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐǇ ĚĞƐŝŐŶĂƚĞƐ ŝƚƐĞůĨ ĂƐ Ă ƋƵĂůŝĨŝĞĚ ĞŶƚŝƚǇ ĨŽƌ ƉƵƌƉŽƐĞƐ ŽĨ ŵĂŬŝŶŐ ƉƌĞƐƵŵƉƚŝǀĞ ĞůŝŐŝďŝůŝƚǇ ĚĞƚĞƌŵŝŶĂƚŝŽŶƐ ĚĞƐĐƌŝďĞĚ ďĞůŽǁ ŝŶ ĂĐĐŽƌĚĂŶĐĞ ǁŝƚŚ ƐĞĐƚŝŽŶƐ ϭϵϮϬ͕ ϭϵϮϬ͕ ϭϵϮϬ͕ ĂŶĚ ϭϵϮϬ ŽĨ ƚŚĞ Đƚ ĂŶĚ ϰϮ &Z WĂƌƚ ϰϯϱ ^ƵďƉĂƌƚ >͘ WůĞĂƐĞ ĚĞƐĐƌŝďĞ ĂŶǇ ůŝŵŝƚĂƚŝŽŶƐ ƌĞůĂƚĞĚ ƚŽ ƚŚĞ ƉŽƉƵůĂƚŝŽŶƐ ŝŶĐůƵĚĞĚ Žƌ ƚŚĞ ŶƵŵďĞƌ ŽĨ ĂůůŽǁĂďůĞ W

ƉĞƌŝŽĚƐ͘ E t ϰͬϮϰͬϮϬ ϯͬϭͬϮϬ

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^ƚĂƚĞͬdĞƌƌŝƚŽƌǇ͗ EĞďƌĂƐŬĂ ^ĞĐƚŝŽŶ ϳ͘ϰ ƉĂŐĞ ϵϯ dE͗ E ϮϬͲϬϬϭϬ ƉƉƌŽǀĂů ĂƚĞ͗ ͺͺͺͺͺͺͺͺͺͺ ^ƵƉĞƌƐĞĚĞƐ dE͗ ͺͺͺͺͺͺͺͺͺͺ

ĨĨĞĐƚŝǀĞ ĂƚĞ͗ ͺͺͺͺͺͺͺͺͺͺ ϯ͘ ͺͺyͺͺͺ dŚĞ ĂŐĞŶĐǇ ĚĞƐŝŐŶĂƚĞƐ ƚŚĞ ĨŽůůŽǁŝŶŐ ĞŶƚŝƚŝĞƐ ĂƐ ƋƵĂůŝĨŝĞĚ ĞŶƚŝƚŝĞƐ ĨŽƌ ƉƵƌƉŽƐĞƐ ŽĨ ŵĂŬŝŶŐ ƉƌĞƐƵŵƉƚŝǀĞ ĞůŝŐŝďŝůŝƚǇ ĚĞƚĞƌŵŝŶĂƚŝŽŶƐ Žƌ ĂĚĚƐ ĂĚĚŝƚŝŽŶĂů ƉŽƉƵůĂƚŝŽŶƐ ĂƐ ĚĞƐĐƌŝďĞĚ ďĞůŽǁ ŝŶ ĂĐĐŽƌĚĂŶĐĞ ǁŝƚŚ ƐĞĐƚŝŽŶƐ ϭϵϮϬ͕ ϭϵϮϬ͕ ϭϵϮϬ͕ ĂŶĚ ϭϵϮϬ ŽĨ ƚŚĞ Đƚ ĂŶĚ ϰϮ &Z WĂƌƚ ϰϯϱ ^ƵďƉĂƌƚ >͘ /ŶĚŝĐĂƚĞ ŝĨ ĂŶǇ ĚĞƐŝŐŶĂƚĞĚ ĞŶƚŝƚŝĞƐ ĂƌĞ ƉĞƌŵŝƚƚĞĚ ƚŽ ŵĂŬĞ ƉƌĞƐƵŵƉƚŝǀĞ ĞůŝŐŝďŝůŝƚǇ ĚĞƚĞƌŵŝŶĂƚŝŽŶƐ ŽŶůǇ ĨŽƌ ƐƉĞĐŝĨŝĞĚ ƉŽƉƵůĂƚŝŽŶƐ͘ dŚĞ ĂŐĞŶĐǇ ĚĞƐŝŐŶĂƚĞƐ ĞŶƚŝƚŝĞƐ ƋƵĂůŝĨŝĞĚ ƚŽ ŵĂŬĞ ĚĞƚĞƌŵŝŶĂƚŝŽŶƐ ĨŽƌ ƉƌĞŐŶĂŶƚ ǁŽŵĞŶ ŽŶůǇ͕ ĂƐ ĚĞĨŝŶĞĚ ŝŶ E ϭϯͲϬϬϮϳ͕ ƚŽ ĞǆƉĂŶĚ ƚŽ ƉƌŽǀŝĚĞ ĚĞƚĞƌŵŝŶĂƚŝŽŶƐ ĨŽƌ WĂƌĞŶƚͬĂƌĞƚĂŬĞƌ ZĞůĂƚŝǀĞƐ͕ &ŽƌŵĞƌ &ŽƐƚĞƌ ĂƌĞ ŚŝůĚƌĞŶ͕ ĂŶĚ ŚŝůĚƌĞŶ ƵŶĚĞƌ ĂŐĞ ϭϵ͘ dŚĞ ƉŽůŝĐŝĞƐ ĂŶĚ ƉƌŽĐĞĚƵƌĞƐ ĨŽƌ ƋƵĂůŝĨŝĞĚ ĞŶƚŝƚŝĞƐ ĂƉƉůŝĞƐ ƚŽ ƚŚĞƐĞ ĚĞƚĞƌŵŝŶĂƚŝŽŶƐ͘ dŚĞƌĞ ŵĂǇ ďĞ ŶŽ ŵŽƌĞ ƚŚĂŶ ŽŶĞ ƉĞƌŝŽĚ ŽĨ ƉƌĞƐƵŵƉƚŝǀĞ ĞůŝŐŝďŝůŝƚǇ ƉĞƌ ƉƌĞŐŶĂŶĐǇ͘ WĞƌŝŽĚƐ ŽĨ ƉƌĞƐƵŵƉƚŝǀĞ ĞůŝŐŝďŝůŝƚǇ ĂƌĞ ůŝŵŝƚĞĚ ƚŽ ŶŽ ŵŽƌĞ ƚŚĂŶ ŽŶĞ ƉĞƌŝŽĚ ǁŝƚŚŝŶ ƚǁŽ ĐĂůĞŶĚĂƌ ǇĞĂƌƐ ĨŽƌ WĂƌĞŶƚͬĂƌĞƚĂŬĞƌ ZĞůĂƚŝǀĞƐ͕ &ŽƌŵĞƌ &ŽƐƚĞƌ ĂƌĞ ŚŝůĚƌĞŶ͕ ĂŶĚ ŚŝůĚƌĞŶ ƵŶĚĞƌ ĂŐĞ ϭϵ͘ ϰ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐǇ ĂĚŽƉƚƐ Ă ƚŽƚĂů ŽĨ ͺͺͺͺͺ ŵŽŶƚŚƐ ;ŶŽƚ ƚŽ ĞǆĐĞĞĚ ϭϮ ŵŽŶƚŚƐͿ ĐŽŶƚŝŶƵŽƵƐ ĞůŝŐŝďŝůŝƚǇ ĨŽƌ ĐŚŝůĚƌĞŶ ƵŶĚĞƌ ĂŐĞ ĞŶƚĞƌ ĂŐĞ ͺͺͺͺͺ ;ŶŽƚ ƚŽ ĞǆĐĞĞĚ ĂŐĞ ϭϵͿ ƌĞŐĂƌĚůĞƐƐ ŽĨ ĐŚĂŶŐĞƐ ŝŶ ĐŝƌĐƵŵƐƚĂŶĐĞƐ ŝŶ ĂĐĐŽƌĚĂŶĐĞ ǁŝƚŚ ƐĞĐƚŝŽŶ ϭϵϬϮ;ĞͿ;ϭϮͿ ŽĨ ƚŚĞ Đƚ ĂŶĚ ϰϮ &Z ϰϯϱ͘ϵϮϲ͘ ϱ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐǇ ĐŽŶĚƵĐƚƐ ƌĞĚĞƚĞƌŵŝŶĂƚŝŽŶƐ ŽĨ ĞůŝŐŝďŝůŝƚǇ ĨŽƌ ŝŶĚŝǀŝĚƵĂůƐ ĞǆĐĞƉƚĞĚ ĨƌŽŵ D'/Ͳ ďĂƐĞĚ ĨŝŶĂŶĐŝĂů ŵĞƚŚŽĚŽůŽŐŝĞƐ ƵŶĚĞƌ ϰϮ &Z ϰϯϱ͘ϲϬϯ;ũͿ ŽŶĐĞ ĞǀĞƌǇ ͺͺͺͺͺ ŵŽŶƚŚƐ ;ŶŽƚ ƚŽ ĞǆĐĞĞĚ ϭϮ ŵŽŶƚŚƐͿ ŝŶ ĂĐĐŽƌĚĂŶĐĞ ǁŝƚŚ ϰϮ &Z ϰϯϱ͘ϵϭϲ;ďͿ͘ ϲ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐǇ ƵƐĞƐ ƚŚĞ ĨŽůůŽǁŝŶŐ ƐŝŵƉůŝĨŝĞĚ ĂƉƉůŝĐĂƚŝŽŶ;ƐͿ ƚŽ ƐƵƉƉŽƌƚ ĞŶƌŽůůŵĞŶƚ ŝŶ ĂĨĨĞĐƚĞĚ ĂƌĞĂƐ Žƌ ĨŽƌ ĂĨĨĞĐƚĞĚ ŝŶĚŝǀŝĚƵĂůƐ ;Ă ĐŽƉǇ ŽĨ ƚŚĞ ƐŝŵƉůŝĨŝĞĚ ĂƉƉůŝĐĂƚŝŽŶ;ƐͿ ŚĂƐ ďĞĞŶ ƐƵďŵŝƚƚĞĚ ƚŽ D^Ϳ͘ Ă͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐǇ ƵƐĞƐ Ă ƐŝŵƉůŝĨŝĞĚ ƉĂƉĞƌ ĂƉƉůŝĐĂƚŝŽŶ͘ ď͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐǇ ƵƐĞƐ Ă ƐŝŵƉůŝĨŝĞĚ ŽŶůŝŶĞ ĂƉƉůŝĐĂƚŝŽŶ͘ Đ͘ ͺͺͺͺͺ dŚĞ ƐŝŵƉůŝĨŝĞĚ ƉĂƉĞƌ Žƌ ŽŶůŝŶĞ ĂƉƉůŝĐĂƚŝŽŶ ŝƐ ŵĂĚĞ ĂǀĂŝůĂďůĞ ĨŽƌ ƵƐĞ ŝŶ ĐĂůůͲĐĞŶƚĞƌƐ Žƌ ŽƚŚĞƌ ƚĞůĞƉŚŽŶĞ ĂƉƉůŝĐĂƚŝŽŶƐ ŝŶ ĂĨĨĞĐƚĞĚ ĂƌĞĂƐ͘ ^ĞĐƚŝŽŶ ʹ WƌĞŵŝƵŵƐ ĂŶĚ ŽƐƚ ^ŚĂƌŝŶŐ ϭ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐǇ ƐƵƐƉĞŶĚƐ ĚĞĚƵĐƚŝďůĞƐ͕ ĐŽƉĂǇŵĞŶƚƐ͕ ĐŽŝŶƐƵƌĂŶĐĞ͕ ĂŶĚ ŽƚŚĞƌ ĐŽƐƚ ƐŚĂƌŝŶŐ ĐŚĂƌŐĞƐ ĂƐ ĨŽůůŽǁƐ͗ WůĞĂƐĞ ĚĞƐĐƌŝďĞ ǁŚĞƚŚĞƌ ƚŚĞ ƐƚĂƚĞ ƐƵƐƉĞŶĚƐ Ăůů ĐŽƐƚ ƐŚĂƌŝŶŐ Žƌ ƐƵƐƉĞŶĚƐ ŽŶůǇ ƐƉĞĐŝĨŝĞĚ ĚĞĚƵĐƚŝďůĞƐ͕ ĐŽƉĂǇŵĞŶƚƐ͕ ĐŽŝŶƐƵƌĂŶĐĞ͕ Žƌ ŽƚŚĞƌ ĐŽƐƚ ƐŚĂƌŝŶŐ ĐŚĂƌŐĞƐ ĨŽƌ ƐƉĞĐŝĨŝĞĚ ŝƚĞŵƐ ĂŶĚ ƐĞƌǀŝĐĞƐ Žƌ ĨŽƌ ƐƉĞĐŝĨŝĞĚ ĞůŝŐŝďŝůŝƚǇ ŐƌŽƵƉƐ ĐŽŶƐŝƐƚĞŶƚ ǁŝƚŚ ϰϮ &Z ϰϰϳ͘ϱϮ;ĚͿ Žƌ ĨŽƌ ƐƉĞĐŝĨŝĞĚ ŝŶĐŽŵĞ ůĞǀĞůƐ ĐŽŶƐŝƐƚĞŶƚ ǁŝƚŚ ϰϮ &Z ϰϰϳ͘ϱϮ;ŐͿ͘ Ϯ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐǇ ƐƵƐƉĞŶĚƐ ĞŶƌŽůůŵĞŶƚ ĨĞĞƐ͕ ƉƌĞŵŝƵŵƐ ĂŶĚ ƐŝŵŝůĂƌ ĐŚĂƌŐĞƐ ĨŽƌ͗ Ă͘ ͺͺͺͺͺ ůů ďĞŶĞĨŝĐŝĂƌŝĞƐ E t ϰͬϮϰͬϮϬ ϯͬϭͬϮϬ

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^ƚĂƚĞͬdĞƌƌŝƚŽƌǇ͗ EĞďƌĂƐŬĂ ^ĞĐƚŝŽŶ ϳ͘ϰ ƉĂŐĞ ϵϰ dE͗ E ϮϬͲϬϬϭϬ ƉƉƌŽǀĂů ĂƚĞ͗ ͺͺͺͺͺͺͺͺͺͺ ^ƵƉĞƌƐĞĚĞƐ dE͗ ͺͺͺͺͺͺͺͺͺͺ

ĨĨĞĐƚŝǀĞ ĂƚĞ͗ ͺͺͺͺͺͺͺͺͺͺ ď͘ ͺͺͺͺͺ dŚĞ ĨŽůůŽǁŝŶŐ ĞůŝŐŝďŝůŝƚǇ ŐƌŽƵƉƐ Žƌ ĐĂƚĞŐŽƌŝĐĂů ƉŽƉƵůĂƚŝŽŶƐ͗ WůĞĂƐĞ ůŝƐƚ ƚŚĞ ĂƉƉůŝĐĂďůĞ ĞůŝŐŝďŝůŝƚǇ ŐƌŽƵƉƐ Žƌ ƉŽƉƵůĂƚŝŽŶƐ͘ ϯ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐǇ ĂůůŽǁƐ ǁĂŝǀĞƌ ŽĨ ƉĂǇŵĞŶƚ ŽĨ ƚŚĞ ĞŶƌŽůůŵĞŶƚ ĨĞĞ͕ ƉƌĞŵŝƵŵƐ ĂŶĚ ƐŝŵŝůĂƌ ĐŚĂƌŐĞƐ ĨŽƌ ƵŶĚƵĞ ŚĂƌĚƐŚŝƉ͘ WůĞĂƐĞ ƐƉĞĐŝĨǇ ƚŚĞ ƐƚĂŶĚĂƌĚ;ƐͿ ĂŶĚͬŽƌ ĐƌŝƚĞƌŝĂ ƚŚĂƚ ƚŚĞ ƐƚĂƚĞ ǁŝůů ƵƐĞ ƚŽ ĚĞƚĞƌŵŝŶĞ ƵŶĚƵĞ ŚĂƌĚƐŚŝƉ͘ ^ĞĐƚŝŽŶ ʹ ĞŶĞĨŝƚƐ ĞŶĞĨŝƚƐ͗ ϭ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐǇ ĂĚĚƐ ƚŚĞ ĨŽůůŽǁŝŶŐ ŽƉƚŝŽŶĂů ďĞŶĞĨŝƚƐ ŝŶ ŝƚƐ ƐƚĂƚĞ ƉůĂŶ ;ŝŶĐůƵĚĞ ƐĞƌǀŝĐĞ ĚĞƐĐƌŝƉƚŝŽŶƐ͕ ƉƌŽǀŝĚĞƌ ƋƵĂůŝĨŝĐĂƚŝŽŶƐ͕ ĂŶĚ ůŝŵŝƚĂƚŝŽŶƐ ŽŶ ĂŵŽƵŶƚ͕ ĚƵƌĂƚŝŽŶ Žƌ ƐĐŽƉĞ ŽĨ ƚŚĞ ďĞŶĞĨŝƚͿ͗ Ϯ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐǇ ŵĂŬĞƐ ƚŚĞ ĨŽůůŽǁŝŶŐ ĂĚũƵƐƚŵĞŶƚƐ ƚŽ ďĞŶĞĨŝƚƐ ĐƵƌƌĞŶƚůǇ ĐŽǀĞƌĞĚ ŝŶ ƚŚĞ ƐƚĂƚĞ ƉůĂŶ͗ ϯ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐǇ ĂƐƐƵƌĞƐ ƚŚĂƚ ŶĞǁůǇ ĂĚĚĞĚ ďĞŶĞĨŝƚƐ Žƌ ĂĚũƵƐƚŵĞŶƚƐ ƚŽ ďĞŶĞĨŝƚƐ ĐŽŵƉůǇ ǁŝƚŚ Ăůů ĂƉƉůŝĐĂďůĞ ƐƚĂƚƵƚŽƌǇ ƌĞƋƵŝƌĞŵĞŶƚƐ͕ ŝŶĐůƵĚŝŶŐ ƚŚĞ ƐƚĂƚĞǁŝĚĞŶĞƐƐ ƌĞƋƵŝƌĞŵĞŶƚƐ ĨŽƵŶĚ Ăƚ ϭϵϬϮ;ĂͿ;ϭͿ͕ ĐŽŵƉĂƌĂďŝůŝƚǇ ƌĞƋƵŝƌĞŵĞŶƚƐ ĨŽƵŶĚ Ăƚ ϭϵϬϮ;ĂͿ;ϭϬͿ;Ϳ͕ ĂŶĚ ĨƌĞĞ ĐŚŽŝĐĞ ŽĨ ƉƌŽǀŝĚĞƌ ƌĞƋƵŝƌĞŵĞŶƚƐ ĨŽƵŶĚ Ăƚ ϭϵϬϮ;ĂͿ;ϮϯͿ͘ ϰ͘ ͺͺͺͺͺ ƉƉůŝĐĂƚŝŽŶ ƚŽ ůƚĞƌŶĂƚŝǀĞ ĞŶĞĨŝƚ WůĂŶƐ ;WͿ͘ dŚĞ ƐƚĂƚĞ ĂĚŚĞƌĞƐ ƚŽ Ăůů W ƉƌŽǀŝƐŝŽŶƐ ŝŶ ϰϮ &Z WĂƌƚ ϰϰϬ͕ ^ƵďƉĂƌƚ ͘ dŚŝƐ ƐĞĐƚŝŽŶ ŽŶůǇ ĂƉƉůŝĞƐ ƚŽ ƐƚĂƚĞƐ ƚŚĂƚ ŚĂǀĞ ĂŶ ĂƉƉƌŽǀĞĚ W;ƐͿ͘ Ǥ ̴̴̴̴̴ Ȁ Ǥ Ǥ ̴̴̴̴̴ Ȁ ǡ ǣ WůĞĂƐĞ ĚĞƐĐƌŝďĞ͘ E t ϰͬϮϰͬϮϬ ϯͬϭͬϮϬ

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^ƚĂƚĞͬdĞƌƌŝƚŽƌǇ͗ EĞďƌĂƐŬĂ ^ĞĐƚŝŽŶ ϳ͘ϰ ƉĂŐĞ ϵϱ dE͗ E ϮϬͲϬϬϭϬ ƉƉƌŽǀĂů ĂƚĞ͗ ͺͺͺͺͺͺͺͺͺͺ ^ƵƉĞƌƐĞĚĞƐ dE͗ ͺͺͺͺͺͺͺͺͺͺ

ĨĨĞĐƚŝǀĞ ĂƚĞ͗ ͺͺͺͺͺͺͺͺͺͺ dĞůĞŚĞĂůƚŚ͗ ϱ͘ ͺͺyͺͺͺ dŚĞ ĂŐĞŶĐǇ ƵƚŝůŝǌĞƐ ƚĞůĞŚĞĂůƚŚ ŝŶ ƚŚĞ ĨŽůůŽǁŝŶŐ ŵĂŶŶĞƌ͕ ǁŚŝĐŚ ŵĂǇ ďĞ ĚŝĨĨĞƌĞŶƚ ƚŚĂŶ ŽƵƚůŝŶĞĚ ŝŶ ƚŚĞ ƐƚĂƚĞ͛Ɛ ĂƉƉƌŽǀĞĚ ƐƚĂƚĞ ƉůĂŶ͗ EĞďƌĂƐŬĂ DĞĚŝĐĂŝĚ ŝƐ ŽĨĨĞƌŝŶŐ ƌĞŝŵďƵƌƐĞŵĞŶƚ ĨŽƌ ƚĞůĞƉŚŽŶŝĐ ĞǀĂůƵĂƚŝŽŶ ĂŶĚ ŵĂŶĂŐĞŵĞŶƚ ĨŽƌ ƚŚĞ ĨŽůůŽǁŝŶŐ ďĞŶĞĨŝĐŝĂƌŝĞƐ ƐĞĞŬŝŶŐ ĐĂƌĞ ǁŚĞŶ ƚŚĞǇ ĂƌĞ ĂůƌĞĂĚǇ ĂŶ ĞƐƚĂďůŝƐŚĞĚ ƉĂƚŝĞŶƚ Žƌ ƚŚĞ ƉĂƌĞŶƚ Žƌ ůĞŐĂů ŐƵĂƌĚŝĂŶ ŽĨ ĂŶ ĞƐƚĂďůŝƐŚĞĚ ƉĂƚŝĞŶƚ͗ ͲĞŶĞĨŝĐŝĂƌŝĞƐ ǁŚŽ ĂƌĞ ĂĐƚŝǀĞůǇ ĞǆƉĞƌŝĞŶĐŝŶŐ ŵŝůĚ ƐǇŵƉƚŽŵƐ ŽĨ Ks/Ͳϭϵ ;ĨĞǀĞƌ͕ ĐŽƵŐŚ͕ ƐŚŽƌƚŶĞƐƐ ŽĨ ďƌĞĂƚŚͿ ƉƌŝŽƌ ƚŽ ŐŽŝŶŐ ƚŽ ƚŚĞ ĞŵĞƌŐĞŶĐǇ ĚĞƉĂƌƚŵĞŶƚ͕ ƵƌŐĞŶƚ ĐĂƌĞ͕ Žƌ ŽƚŚĞƌ ŚĞĂůƚŚ ĐĂƌĞ ĨĂĐŝůŝƚǇ͖ ͲĞŶĞĨŝĐŝĂƌŝĞƐ ǁŚŽ ŶĞĞĚ ƌŽƵƚŝŶĞ͕ ƵŶĐŽŵƉůŝĐĂƚĞĚ ĨŽůůŽǁ ƵƉ ĂŶĚ ǁŚŽ ĂƌĞ ŶŽƚ ĐƵƌƌĞŶƚůǇ ĞǆƉĞƌŝĞŶĐŝŶŐ ƐǇŵƉƚŽŵƐ ŽĨ Ks/Ͳϭϵ͖ ĂŶĚ͕ ͲĞŶĞĨŝĐŝĂƌŝĞƐ ƌĞƋƵŝƌŝŶŐ ďĞŚĂǀŝŽƌĂů ŚĞĂůƚŚ ĂƐƐĞƐƐŵĞŶƚ ĂŶĚ ŵĂŶĂŐĞŵĞŶƚ͘ dŚĞ ƚĞůĞƉŚŽŶŝĐ ĞǀĂůƵĂƚŝŽŶ ĂŶĚ ŵĂŶĂŐĞŵĞŶƚ ƐĞƌǀŝĐĞƐ ŵƵƐƚ ďĞ ƌĞŶĚĞƌĞĚ ďǇ Ă ƋƵĂůŝĨŝĞĚ ŚĞĂůƚŚ ĐĂƌĞ ƉƌŽĨĞƐƐŝŽŶĂů͕ ĚĞĨŝŶĞĚ ĂƐ Ă ƉŚǇƐŝĐŝĂŶ͕ ŶƵƌƐĞ ƉƌĂĐƚŝƚŝŽŶĞƌ͕ Žƌ ƉŚǇƐŝĐŝĂŶ ĂƐƐŝƐƚĂŶƚ ĂĐƚŝǀĞůǇ ĞŶƌŽůůĞĚ ŝŶ EĞďƌĂƐŬĂ DĞĚŝĐĂŝĚ Ăƚ ƚŚĞ ƚŝŵĞ ŽĨ ƐĞƌǀŝĐĞ͘ dĞůĞƉŚŽŶŝĐ ĞǀĂůƵĂƚŝŽŶ ĂŶĚ ŵĂŶĂŐĞŵĞŶƚ ďǇ ƐƚĂĨĨ ŽƚŚĞƌ ƚŚĂŶ ƚŚŽƐĞ ůŝƐƚĞĚ ƐŚŽƵůĚ ŶŽƚ ďĞ ƐƵďŵŝƚƚĞĚ ĨŽƌ ƌĞŝŵďƵƌƐĞŵĞŶƚ ĂŶĚ ǁŝůů ŶŽƚ ďĞ ƌĞŝŵďƵƌƐĞĚ͘ ^ĞƌǀŝĐĞƐ ĂƌĞ ƚŽ ďĞ ƌĞŶĚĞƌĞĚ ŽŶůǇ ƚŽ ĞƐƚĂďůŝƐŚĞĚ ƉĂƚŝĞŶƚƐ͕ ĂŶĚ ƉĂƌĞŶƚƐ Žƌ ůĞŐĂů ŐƵĂƌĚŝĂŶƐ ŽĨ ĞƐƚĂďůŝƐŚĞĚ ƉĂƚŝĞŶƚƐ͘ dĞůĞƉŚŽŶŝĐ ĞǀĂůƵĂƚŝŽŶ ĂŶĚ ŵĂŶĂŐĞŵĞŶƚ ŽĨ ƐĞƌǀŝĐĞƐ ŵĂǇ ďĞ ƵƚŝůŝǌĞĚ ďǇ ƚŚĞ ĨŽůůŽǁŝŶŐ ďĞŚĂǀŝŽƌĂů ŚĞĂůƚŚ ƉƌŽǀŝĚĞƌƐ͗ WƐǇĐŚŽůŽŐŝƐƚ ;WŚͬWƐǇͿ͕ ƉƌŽǀŝƐŝŽŶĂů ƉƐǇĐŚŽůŽŐŝƐƚ ;W, ƉƌŽǀŝƐŝŽŶĂůͿ͕ ůŝĐĞŶƐĞĚ ŝŶĚĞƉĞŶĚĞŶƚ ŵĞŶƚĂů ŚĞĂůƚŚ ǁŽƌŬĞƌ ;>/,DWͿ͕ ůŝĐĞŶƐĞĚ ŵĞŶƚĂů ŚĞĂůƚŚ ǁŽƌŬĞƌ ;>,DWͿ͕ ƉƌŽǀŝƐŝŽŶĂůůǇ ůŝĐĞŶƐĞĚ ŵĞŶƚĂů ŚĞĂůƚŚ ǁŽƌŬĞƌ ;W>D,WͿ͕ ůŝĐĞŶƐĞĚ ĂůĐŽŚŽů ĂŶĚ ĚƌƵŐ ĐŽƵŶƐĞůŽƌ ;>Ϳ͕ ĂŶĚ ƉƌŽǀŝƐŝŽŶĂůůǇ ůŝĐĞŶƐĞĚ ĂůĐŽŚŽů ĂŶĚ ĚƌƵŐ ĐŽƵŶƐĞůŽƌ ;W>Ϳ͘ ,ŽŵĞ ,ĞĂůƚŚ͗ /ŶŝƚŝĂů ĂƐƐĞƐƐŵĞŶƚƐ ĂŶĚ ƌĞĐĞƌƚŝĨŝĐĂƚŝŽŶ ĂƐƐĞƐƐŵĞŶƚƐ ŵĂǇ ďĞ ĐŽŵƉůĞƚĞĚ ďǇ ƵƐŝŶŐ ƚĞůĞŚĞĂůƚŚ ĨŽƌ ƉŚǇƐŝĐŝĂŶƐ ĂŶĚ ŶƵƌƐĞ ƉƌĂĐƚŝƚŝŽŶĞƌƐ͘ /ŶŝƚŝĂů ĂƐƐĞƐƐŵĞŶƚƐ͕ ƌĞĐĞƌƚŝĨŝĐĂƚŝŽŶƐ͕ ĂŶĚ ŽŶŐŽŝŶŐ ǀŝƐŝƚƐ ƉĞƌ ŝŶĚŝǀŝĚƵĂů ƉůĂŶ ŽĨ ĐĂƌĞ ŵĂǇ ďĞ ĐŽŵƉůĞƚĞĚ ďǇ ƵƐŝŶŐ ƚĞůĞŚĞĂůƚŚ ĨŽƌ ŶƵƌƐĞƐ͘ dĞůĞŚĞĂůƚŚ ŵĂǇ ďĞ ƵƐĞĚ ĨŽƌ ƐƵƉĞƌǀŝƐŽƌǇ ǀŝƐŝƚƐ ĨŽƌ ĂŝĚĞ ƐĞƌǀŝĐĞƐ͘ ,ŽƐƉŝĐĞ͗ /ŶŝƚŝĂů ĂƐƐĞƐƐŵĞŶƚƐ ĂŶĚ ƌĞĐĞƌƚŝĨŝĐĂƚŝŽŶ ĂƐƐĞƐƐŵĞŶƚƐ ŵĂǇ ďĞ ĐŽŵƉůĞƚĞĚ ďǇ ƵƐŝŶŐ ƚĞůĞŚĞĂůƚŚ ĨŽƌ ƚŚĞ ĂƉƉƌŽƉƌŝĂƚĞ ƉŚǇƐŝĐŝĂŶƐ ĂŶĚ ŶƵƌƐĞ ƉƌĂĐƚŝƚŝŽŶĞƌƐ͘ /ŶŝƚŝĂů ĂƐƐĞƐƐŵĞŶƚƐ͕ ƌĞĐĞƌƚŝĨŝĐĂƚŝŽŶƐ͕ ĂŶĚ ŽŶŐŽŝŶŐ ǀŝƐŝƚƐ ƉĞƌ ŝŶĚŝǀŝĚƵĂů ƉůĂŶ ŽĨ ĐĂƌĞ ŵĂǇ ďĞ ĐŽŵƉůĞƚĞĚ ďǇ ƵƐŝŶŐ ƚĞůĞŚĞĂůƚŚ ĨŽƌ ŶƵƌƐĞƐ͘ >ĂĐƚĂƚŝŽŶ ŽƵŶƐĞůŝŶŐ ^ĞƌǀŝĐĞƐ ƉƌŽǀŝĚĞĚ ƚŚƌŽƵŐŚ W^d͗ ŽŵƉƌĞŚĞŶƐŝǀĞ ůĂĐƚĂƚŝŽŶ ĐŽƵŶƐĞůŝŶŐ ƐĞƌǀŝĐĞƐ ŵĂǇ ďĞ ƉƌŽǀŝĚĞĚ ďǇ ƵƐŝŶŐ ƚĞůĞŚĞĂůƚŚ͘ dŽďĂĐĐŽ ĞƐƐĂƚŝŽŶ ŽƵŶƐĞůŝŶŐ͗ dŽďĂĐĐŽ ĞƐƐĂƚŝŽŶ ŽƵŶƐĞůŝŶŐ ƐĞƌǀŝĐĞƐ ŵĂǇ ďĞ ƉƌŽǀŝĚĞĚ ďǇ ƵƐŝŶŐ ƚĞůĞŚĞĂůƚŚ͘ WĞĚŝĂƚƌŝĐ &ĞĞĚŝŶŐ ŝƐŽƌĚĞƌ KƵƚƉĂƚŝĞŶƚ dŚĞƌĂƉǇ͗ WĞĚŝĂƚƌŝĐ &ĞĞĚŝŶŐ ŝƐŽƌĚĞƌ KƵƚƉĂƚŝĞŶƚ dŚĞƌĂƉǇ ƐĞƌǀŝĐĞƐ ŵĂǇ ďĞ ƉƌŽǀŝĚĞĚ ďǇ ƵƐŝŶŐ ƚĞůĞŚĞĂůƚŚ͘ E t ϰͬϮϰͬϮϬ ϯͬϭͬϮϬ

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^ƚĂƚĞͬdĞƌƌŝƚŽƌǇ͗ EĞďƌĂƐŬĂ ^ĞĐƚŝŽŶ ϳ͘ϰ ƉĂŐĞ ϵϲ dE͗ E ϮϬͲϬϬϭϬ ƉƉƌŽǀĂů ĂƚĞ͗ ͺͺͺͺͺͺͺͺͺͺ ^ƵƉĞƌƐĞĚĞƐ dE͗ ͺͺͺͺͺͺͺͺͺͺ

ĨĨĞĐƚŝǀĞ ĂƚĞ͗ ͺͺͺͺͺͺͺͺͺͺ ŽŵŵƵŶŝƚǇ ^ƵƉƉŽƌƚ͗ ŽŵŵƵŶŝƚǇ ^ƵƉƉŽƌƚ ^ĞƌǀŝĐĞƐ ŵĂǇ ďĞ ĚŽŶĞ ǀŝĂ ƚĞůĞŚĞĂůƚŚ͘ Ɛ ĐůŝŶŝĐĂůůǇ ĂƉƉƌŽƉƌŝĂƚĞ͕ ,/WW ĐŽŵƉůŝĂŶƚ ƚǁŽͲǁĂǇ ƌĞĂůͲƚŝŵĞ ŝŶƚĞƌĂĐƚŝǀĞ ĂƵĚŝŽ ĂŶĚ ǀŝĚĞŽ ƚĞůĞŚĞĂůƚŚ ŵĂǇ ďĞ ŽĨĨĞƌĞĚ ƚŽ ƉƌŽĐĞĞĚ ǁŝƚŚ ďĞŚĂǀŝŽƌĂů ŚĞĂůƚŚ ŝŶƚĞƌǀĞŶƚŝŽŶƐ͘ ůů ǀŝƐŝƚƐ͕ ƌĞŐĂƌĚůĞƐƐ ŽĨ ŵŽĚĂůŝƚǇ ŽĨ ĐŽŵŵƵŶŝĐĂƚŝŽŶ͕ ŵƵƐƚ ďĞ ĐůŝŶŝĐĂůůǇ ŶĞĐĞƐƐĂƌǇ ƚŽ ǁŽƌŬ ŽŶ ƚƌĞĂƚŵĞŶƚ ŐŽĂůƐ ĂƐ ŽƵƚůŝŶĞĚ ŝŶ ƚŚĞ ďĞŶĞĨŝĐŝĂƌŝĞƐ ƉůĂŶ ŽĨ ĐĂƌĞ͘ sŝƐŝƚ ĚŽĐƵŵĞŶƚĂƚŝŽŶ ŵƵƐƚ ŝŶĐůƵĚĞ ƚŚĞ ŵŽĚĂůŝƚǇ ŽĨ ĐŽŵŵƵŶŝĐĂƚŝŽŶ͕ ƚŚĞ ƌĂƚŝŽŶĂůĞ ĨŽƌ ƚŚĂƚ ŵŽĚĂůŝƚǇ ĂŶĚ ƚŚĞ ĚƵƌĂƚŝŽŶ ŽĨ ƚŚĞ ŝŶƚĞƌǀĞŶƚŝŽŶ͘ ƌƵŐ ĞŶĞĨŝƚ͗ ϲ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐǇ ŵĂŬĞƐ ƚŚĞ ĨŽůůŽǁŝŶŐ ĂĚũƵƐƚŵĞŶƚƐ ƚŽ ƚŚĞ ĚĂǇ ƐƵƉƉůǇ Žƌ ƋƵĂŶƚŝƚǇ ůŝŵŝƚ ĨŽƌ ĐŽǀĞƌĞĚ ŽƵƚƉĂƚŝĞŶƚ ĚƌƵŐƐ͘ dŚĞ ĂŐĞŶĐǇ ƐŚŽƵůĚ ŽŶůǇ ŵĂŬĞ ƚŚŝƐ ŵŽĚŝĨŝĐĂƚŝŽŶ ŝĨ ŝƚƐ ĐƵƌƌĞŶƚ ƐƚĂƚĞ ƉůĂŶ ƉĂŐĞƐ ŚĂǀĞ ůŝŵŝƚƐ ŽŶ ƚŚĞ ĂŵŽƵŶƚ ŽĨ ŵĞĚŝĐĂƚŝŽŶ ĚŝƐƉĞŶƐĞĚ͘ WůĞĂƐĞ ĚĞƐĐƌŝďĞ ƚŚĞ ĐŚĂŶŐĞ ŝŶ ĚĂǇƐ Žƌ ƋƵĂŶƚŝƚŝĞƐ ƚŚĂƚ ĂƌĞ ĂůůŽǁĞĚ ĨŽƌ ƚŚĞ ĞŵĞƌŐĞŶĐǇ ƉĞƌŝŽĚ ĂŶĚ ĨŽƌ ǁŚŝĐŚ ĚƌƵŐƐ͘ ϳ͘ ͺͺͺͺͺ WƌŝŽƌ ĂƵƚŚŽƌŝǌĂƚŝŽŶ ĨŽƌ ŵĞĚŝĐĂƚŝŽŶƐ ŝƐ ĞǆƉĂŶĚĞĚ ďǇ ĂƵƚŽŵĂƚŝĐ ƌĞŶĞǁĂů ǁŝƚŚŽƵƚ ĐůŝŶŝĐĂů ƌĞǀŝĞǁ͕ Žƌ ƚŝŵĞͬƋƵĂŶƚŝƚǇ ĞǆƚĞŶƐŝŽŶƐ͘ ϴ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐǇ ŵĂŬĞƐ ƚŚĞ ĨŽůůŽǁŝŶŐ ƉĂǇŵĞŶƚ ĂĚũƵƐƚŵĞŶƚ ƚŽ ƚŚĞ ƉƌŽĨĞƐƐŝŽŶĂů ĚŝƐƉĞŶƐŝŶŐ ĨĞĞ ǁŚĞŶ ĂĚĚŝƚŝŽŶĂů ĐŽƐƚƐ ĂƌĞ ŝŶĐƵƌƌĞĚ ďǇ ƚŚĞ ƉƌŽǀŝĚĞƌƐ ĨŽƌ ĚĞůŝǀĞƌǇ͘ ^ƚĂƚĞƐ ǁŝůů ŶĞĞĚ ƚŽ ƐƵƉƉůǇ ĚŽĐƵŵĞŶƚĂƚŝŽŶ ƚŽ ũƵƐƚŝĨǇ ƚŚĞ ĂĚĚŝƚŝŽŶĂů ĨĞĞƐ͘ WůĞĂƐĞ ĚĞƐĐƌŝďĞ ƚŚĞ ŵĂŶŶĞƌ ŝŶ ǁŚŝĐŚ ƉƌŽĨĞƐƐŝŽŶĂů ĚŝƐƉĞŶƐŝŶŐ ĨĞĞƐ ĂƌĞ ĂĚũƵƐƚĞĚ͘ ϵ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐǇ ŵĂŬĞƐ ĞǆĐĞƉƚŝŽŶƐ ƚŽ ƚŚĞŝƌ ƉƵďůŝƐŚĞĚ WƌĞĨĞƌƌĞĚ ƌƵŐ >ŝƐƚ ŝĨ ĚƌƵŐ ƐŚŽƌƚĂŐĞƐ ŽĐĐƵƌ͘ dŚŝƐ ǁŽƵůĚ ŝŶĐůƵĚĞ ŽƉƚŝŽŶƐ ĨŽƌ ĐŽǀĞƌŝŶŐ Ă ďƌĂŶĚ ŶĂŵĞ ĚƌƵŐ ƉƌŽĚƵĐƚ ƚŚĂƚ ŝƐ Ă ŵƵůƚŝͲƐŽƵƌĐĞ ĚƌƵŐ ŝĨ Ă ŐĞŶĞƌŝĐ ĚƌƵŐ ŽƉƚŝŽŶ ŝƐ ŶŽƚ ĂǀĂŝůĂďůĞ͘ ^ĞĐƚŝŽŶ ʹ WĂǇŵĞŶƚƐ KƉƚŝŽŶĂů ďĞŶĞĨŝƚƐ ĚĞƐĐƌŝďĞĚ ŝŶ ^ĞĐƚŝŽŶ ͗ ϭ͘ ͺͺͺͺͺ EĞǁůǇ ĂĚĚĞĚ ďĞŶĞĨŝƚƐ ĚĞƐĐƌŝďĞĚ ŝŶ ^ĞĐƚŝŽŶ ĂƌĞ ƉĂŝĚ ƵƐŝŶŐ ƚŚĞ ĨŽůůŽǁŝŶŐ ŵĞƚŚŽĚŽůŽŐǇ͗ Ǥ ̴̴̴̴̴ Ȃ

ĨĨĞĐƚŝǀĞ ĚĂƚĞ ;ĞŶƚĞƌ ĚĂƚĞ ŽĨ ĐŚĂŶŐĞͿ͗ ͺͺͺͺͺͺͺͺͺͺͺͺͺ >ŽĐĂƚŝŽŶ ;ůŝƐƚ ƉƵďůŝƐŚĞĚ ůŽĐĂƚŝŽŶͿ͗ ͺͺͺͺͺͺͺͺͺͺͺͺͺ E t ϰͬϮϰͬϮϬ ϯͬϭͬϮϬ

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^ƚĂƚĞͬdĞƌƌŝƚŽƌǇ͗ EĞďƌĂƐŬĂ ^ĞĐƚŝŽŶ ϳ͘ϰ ƉĂŐĞ ϵϴ dE͗ E ϮϬͲϬϬϭϬ ƉƉƌŽǀĂů ĂƚĞ͗ ͺͺͺͺͺͺͺͺͺͺ ^ƵƉĞƌƐĞĚĞƐ dE͗ ͺͺͺͺͺͺͺͺͺͺ

ĨĨĞĐƚŝǀĞ ĂƚĞ͗ ͺͺͺͺͺͺͺͺͺͺ WĂǇŵĞŶƚ ĨŽƌ ƐĞƌǀŝĐĞƐ ĚĞůŝǀĞƌĞĚ ǀŝĂ ƚĞůĞŚĞĂůƚŚ͗ ϯ͘ ͺͺyͺͺͺ &Žƌ ƚŚĞ ĚƵƌĂƚŝŽŶ ŽĨ ƚŚĞ ĞŵĞƌŐĞŶĐǇ͕ ƚŚĞ ƐƚĂƚĞ ĂƵƚŚŽƌŝǌĞƐ ƉĂǇŵĞŶƚƐ ĨŽƌ ƚĞůĞŚĞĂůƚŚ ƐĞƌǀŝĐĞƐ ƚŚĂƚ͗ Ǥ ̴̴̴̴̴ Ǣ Ǥ ̴̴̴̴̴ Ǣ

Ǥ ̴̴̴̴̴ Ǣ /ŶĚŝĂŶ ,ĞĂůƚŚ ^ĞƌǀŝĐĞƐ͕ dƌŝďĂů ůŝŶŝĐƐ͕ ĂŶĚ hƌďĂŶ /ŶĚŝĂŶ ,ĞĂůƚŚ ĞŶƚĞƌƐ ;/dh͛ƐͿ ŵĂǇ ďŝůů ƚŚĞ ĞŶĐŽƵŶƚĞƌ ƌĂƚĞ ĨŽƌ ƚĞůĞŚĞĂůƚŚ ƐĞƌǀŝĐĞƐ ƚŚĂƚ ǁŽƵůĚ ƚǇƉŝĐĂůůǇ ŚĂǀĞ ďĞĞŶ ďŝůů ĨŽƌ Ă ŶŽŶͲ ƚĞůĞŚĞĂůƚŚ ĞŶĐŽƵŶƚĞƌ͘ /Ŷ ŽƌĚĞƌ ƚŽ ƌĞŵĂŝŶ ŝŶ ĂĐĐŽƌĚĂŶĐĞ ǁŝƚŚ ƚŚĞ ĨŽƵƌ ǁĂůůƐ ƌƵůĞ ŝŶ ĨĞĚĞƌĂů ƐƚĂƚƵƚĞ͕ /dh͛Ɛ ŵĂǇ ďŝůů ĞŶĐŽƵŶƚĞƌƐ ǀŝĂ ƚĞůĞŚĞĂůƚŚ ƚŚĞ ƐĂŵĞ ĂƐ ƚŚĞǇ ǁŽƵůĚ ƚǇƉŝĐĂůůǇ ďŝůů ĨŽƌ Ă ŶŽŶͲƚĞůĞŚĞĂůƚŚ ĞŶĐŽƵŶƚĞƌ͕ ǁŝƚŚ ƚŚĞ ĂĚĚŝƚŝŽŶ ŽĨ ƚŚĞ ƚĞůĞŚĞĂůƚŚ ŵŽĚŝĨŝĞƌ ƚŽ ďŽƚŚ ƚŚĞ ĞŶĐŽƵŶƚĞƌ ĂŶĚ ƚŚĞ ĐŽƌƌĞƐƉŽŶĚŝŶŐ ƉƌŽĐĞĚƵƌĞ ĐŽĚĞƐ͕ ĂƐ ůŽŶŐ ĂƐ ĞŝƚŚĞƌ ƚŚĞ ƉƌŽǀŝĚĞƌ Žƌ ƚŚĞ ĐůŝĞŶƚ ŝƐ ǁŝƚŚŝŶ ƚŚĞ ǁĂůůƐ ŽĨ ƚŚĞ ĨĂĐŝůŝƚǇ ĚƵƌŝŶŐ ƚŚĞ ƚŝŵĞ ŽĨ ƚŚĞ ǀŝƐŝƚ͘ &ĞĚĞƌĂůůǇ YƵĂůŝĨŝĞĚ ,ĞĂůƚŚ ĞŶƚĞƌƐ ĂŶĚ ZƵƌĂů ,ĞĂůƚŚ ĞŶƚĞƌƐ ŵĂǇ ďŝůů ƚŚĞ ĞŶĐŽƵŶƚĞƌ ƌĂƚĞ ĨŽƌ ĐŽƌĞ ƐĞƌǀŝĐĞƐ ƉƌŽǀŝĚĞĚ ǀŝĂ ƚĞůĞŚĞĂůƚŚ ĚƵƌŝŶŐ ƚŚĞ ĞŵĞƌŐĞŶĐǇ ƉĞƌŝŽĚ͘ dŚĞ ĐŚĂŶŐĞƐ ƚŽ ƚĞůĞŚĞĂůƚŚ ĚĞƐĐƌŝďĞĚ ŝŶ ƐĞĐƚŝŽŶ ͘ ϱ͘ ŵĂŬĞ ƵƐĞ ŽĨ ŶĞǁ ƌĂƚĞƐ ĂŶĚ ŶĞǁ ƐĞƉĂƌĂƚĞ ďŝůůŝŶŐ ĐŽĚĞƐ͘ ŽĚĞ 'ϮϬϭϮ ŝƐ ƵƐĞĚ ĨŽƌ Ă ďƌŝĞĨ ĐŽŵŵƵŶŝĐĂƚŝŽŶ ƚĞĐŚŶŽůŽŐǇͲďĂƐĞĚ ƐĞƌǀŝĐĞ͖ ĨŽƌ ĞǆĂŵƉůĞ͕ ǀŝƌƚƵĂů Žƌ ƚĞůĞƉŚŽŶĞ ĐŽŵŵƵŶŝĐĂƚŝŽŶ ďǇ Ă ƉŚǇƐŝĐŝĂŶ Žƌ ŽƚŚĞƌ ƋƵĂůŝĨŝĞĚ ŚĞĂůƚŚ ĐĂƌĞ ƉƌŽĨĞƐƐŝŽŶĂů ǁŚŽ ĐĂŶ ƌĞƉŽƌƚ ĞǀĂůƵĂƚŝŽŶ ĂŶĚ ŵĂŶĂŐĞŵĞŶƚ ƐĞƌǀŝĐĞƐ͕ ƉƌŽǀŝĚĞĚ ƚŽ ĂŶ ĞƐƚĂďůŝƐŚĞĚ ƉĂƚŝĞŶƚ͕ ŶŽƚ ŽƌŝŐŝŶĂƚŝŶŐ ĨƌŽŵ Ă ƌĞůĂƚĞĚ ͬD ƐĞƌǀŝĐĞ ƉƌŽǀŝĚĞĚ ǁŝƚŚŝŶ ƚŚĞ ƉƌĞǀŝŽƵƐ ϳ ĚĂǇƐ Žƌ ŶŽƚ ůĞĂĚŝŶŐ ƚŽ ĂŶ ͬD ƐĞƌǀŝĐĞ Žƌ ƉƌŽĐĞĚƵƌĞ ǁŝƚŚŝŶ ƚŚĞ ŶĞǆƚ Ϯϰ ŚŽƵƌƐ Žƌ ƐŽŽŶĞƐƚ ĂǀĂŝůĂďůĞ ĂƉƉŽŝŶƚŵĞŶƚ͖ ϱͲϭϬ ŵŝŶƵƚĞƐ ŽĨ ŵĞĚŝĐĂů ĚŝƐĐƵƐƐŝŽŶ͘ dŚĞ ƌĂƚĞ ĨŽƌ ƚŚŝƐ ĐŽĚĞ ŝƐ Ψϭϯ͘ϴϮ͘ ŽĚĞ ϵϵϰϰϭ ŝƐ ƵƐĞĚ ĨŽƌ ƚĞůĞƉŚŽŶĞ ĞǀĂůƵĂƚŝŽŶ ĂŶĚ ŵĂŶĂŐĞŵĞŶƚ ƐĞƌǀŝĐĞ ďǇ Ă ƉŚǇƐŝĐŝĂŶ͕ ŶƵƌƐĞ ƉƌĂĐƚŝƚŝŽŶĞƌ͕ Žƌ ƉŚǇƐŝĐŝĂŶ ĂƐƐŝƐƚĂŶƚ ǁŚŽ ŵĂǇ ƌĞƉŽƌƚ ĞǀĂůƵĂƚŝŽŶ ĂŶĚ ŵĂŶĂŐĞŵĞŶƚ ; ͬDͿ ƐĞƌǀŝĐĞƐ ƉƌŽǀŝĚĞĚ ƚŽ ĂŶ ĞƐƚĂďůŝƐŚĞĚ ƉĂƚŝĞŶƚ͕ ƉĂƌĞŶƚ͕ Žƌ ŐƵĂƌĚŝĂŶ ŶŽƚ ŽƌŝŐŝŶĂƚŝŶŐ ĨƌŽŵ Ă ƌĞůĂƚĞĚ ͬD ƐĞƌǀŝĐĞ ƉƌŽǀŝĚĞĚ ǁŝƚŚŝŶ ƚŚĞ ƉƌĞǀŝŽƵƐ ϳ ĚĂǇƐ Žƌ ůĞĂĚŝŶŐ ƚŽ ĂŶ ͬD ƐĞƌǀŝĐĞ Žƌ ƉƌŽĐĞĚƵƌĞ ǁŝƚŚŝŶ ƚŚĞ ŶĞǆƚ Ϯϰ ŚŽƵƌƐ Žƌ ƐŽŽŶĞƐƚ ĂǀĂŝůĂďůĞ ĂƉƉŽŝŶƚŵĞŶƚ͖ ϱͲϭϬ ŵŝŶƵƚĞƐ ŽĨ ŵĞĚŝĐĂů ĚŝƐĐƵƐƐŝŽŶ͘ dŚĞ ƌĂƚĞ ĨŽƌ ƚŚŝƐ ĐŽĚĞ ŝƐ Ψϭϰ͘ϰϳ͘ ŽĚĞ ϵϵϰϰϮ ŝƐ ƵƐĞĚ ĨŽƌ ƚĞůĞƉŚŽŶĞ ĞǀĂůƵĂƚŝŽŶ ĂŶĚ ŵĂŶĂŐĞŵĞŶƚ ƐĞƌǀŝĐĞ ďǇ Ă ƉŚǇƐŝĐŝĂŶ͕ ŶƵƌƐĞ ƉƌĂĐƚŝƚŝŽŶĞƌ͕ Žƌ ƉŚǇƐŝĐŝĂŶ ĂƐƐŝƐƚĂŶƚ ǁŚŽ ŵĂǇ ƌĞƉŽƌƚ ͬD ƐĞƌǀŝĐĞƐ ƉƌŽǀŝĚĞĚ ƚŽ ĂŶ ĞƐƚĂďůŝƐŚĞĚ ƉĂƚŝĞŶƚ͕ ƉĂƌĞŶƚ͕ Žƌ ŐƵĂƌĚŝĂŶ ŶŽƚ ŽƌŝŐŝŶĂƚŝŶŐ ĨƌŽŵ Ă ƌĞůĂƚĞĚ ͬD ƐĞƌǀŝĐĞ ƉƌŽǀŝĚĞĚ ǁŝƚŚŝŶ ƚŚĞ ƉƌĞǀŝŽƵƐ ϳ ĚĂǇƐ Žƌ ůĞĂĚŝŶŐ ƚŽ ĂŶ ͬD ƐĞƌǀŝĐĞ Žƌ ƉƌŽĐĞĚƵƌĞ ǁŝƚŚŝŶ ƚŚĞ ŶĞǆƚ Ϯϰ ŚŽƵƌƐ Žƌ ƐŽŽŶĞƐƚ ĂǀĂŝůĂďůĞ ĂƉƉŽŝŶƚŵĞŶƚ͖ ϭϭͲϮϬ ŵŝŶƵƚĞƐ ŽĨ ŵĞĚŝĐĂů ĚŝƐĐƵƐƐŝŽŶ͘ dŚĞ ƌĂƚĞ ĨŽƌ ƚŚŝƐ ĐŽĚĞ ŝƐ ΨϮϴ͘ϳϭ͘ E t ϰͬϮϰͬϮϬ ϯͬϭͬϮϬ

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^ƚĂƚĞͬdĞƌƌŝƚŽƌǇ͗ EĞďƌĂƐŬĂ ^ĞĐƚŝŽŶ ϳ͘ϰ ƉĂŐĞ ϵϵ dE͗ E ϮϬͲϬϬϭϬ ƉƉƌŽǀĂů ĂƚĞ͗ ͺͺͺͺͺͺͺͺͺͺ ^ƵƉĞƌƐĞĚĞƐ dE͗ ͺͺͺͺͺͺͺͺͺͺ

ĨĨĞĐƚŝǀĞ ĂƚĞ͗ ͺͺͺͺͺͺͺͺͺͺ ŽĚĞ ϵϵϰϰϯ ŝƐ ƵƐĞĚ ĨŽƌ ƚĞůĞƉŚŽŶĞ ĞǀĂůƵĂƚŝŽŶ ĂŶĚ ŵĂŶĂŐĞŵĞŶƚ ƐĞƌǀŝĐĞ ďǇ Ă ƉŚǇƐŝĐŝĂŶ͕ ŶƵƌƐĞ ƉƌĂĐƚŝƚŝŽŶĞƌ͕ Žƌ ƉŚǇƐŝĐŝĂŶ ĂƐƐŝƐƚĂŶƚ ǁŚŽ ŵĂǇ ƌĞƉŽƌƚ ͬD ƐĞƌǀŝĐĞƐ ƉƌŽǀŝĚĞĚ ƚŽ ĂŶ ĞƐƚĂďůŝƐŚĞĚ ƉĂƚŝĞŶƚ͕ ƉĂƌĞŶƚ͕ Žƌ ŐƵĂƌĚŝĂŶ ŶŽƚ ŽƌŝŐŝŶĂƚŝŶŐ ĨƌŽŵ Ă ƌĞůĂƚĞĚ ͬD ƐĞƌǀŝĐĞ ƉƌŽǀŝĚĞĚ ǁŝƚŚŝŶ ƚŚĞ ƉƌĞǀŝŽƵƐ ϳ ĚĂǇƐ Žƌ ůĞĂĚŝŶŐ ƚŽ ĂŶ ͬD ƐĞƌǀŝĐĞ Žƌ ƉƌŽĐĞĚƵƌĞ ǁŝƚŚŝŶ ƚŚĞ ŶĞǆƚ Ϯϰ ŚŽƵƌƐ Žƌ ƐŽŽŶĞƐƚ ĂǀĂŝůĂďůĞ ĂƉƉŽŝŶƚŵĞŶƚ͖ ϮϭͲϯϬ ŵŝŶƵƚĞƐ ŽĨ ŵĞĚŝĐĂů ĚŝƐĐƵƐƐŝŽŶ͘ dŚĞ ƌĂƚĞ ĨŽƌ ƚŚŝƐ ĐŽĚĞ ŝƐ Ψϰϲ͘ϲϬ͘ ŽĚĞ ϵϴϵϲϲ ŝƐ ƵƐĞĚ ĨŽƌ dĞůĞƉŚŽŶĞ ĂƐƐĞƐƐŵĞŶƚ ĂŶĚ ŵĂŶĂŐĞŵĞŶƚ ƐĞƌǀŝĐĞ ƉƌŽǀŝĚĞĚ ďǇ ĂŶ ĞŶƌŽůůĞĚ ďĞŚĂǀŝŽƌĂů ŚĞĂůƚŚ ƉƌŽǀŝĚĞƌ ƚŽ ĂŶ ĞƐƚĂďůŝƐŚĞĚ ƉĂƚŝĞŶƚ͕ ƉĂƌĞŶƚ͕ Žƌ ŐƵĂƌĚŝĂŶ ŶŽƚ ŽƌŝŐŝŶĂƚŝŶŐ ĨƌŽŵ Ă ƌĞůĂƚĞĚ ĂƐƐĞƐƐŵĞŶƚ ĂŶĚ ŵĂŶĂŐĞŵĞŶƚ ƐĞƌǀŝĐĞ ƉƌŽǀŝĚĞĚ ǁŝƚŚŝŶ ƚŚĞ ƉƌĞǀŝŽƵƐ ϳ ĚĂǇƐ ŶŽƚ ůĞĂĚŝŶŐ ƚŽ ĂŶ ĂƐƐĞƐƐŵĞŶƚ ĂŶĚ ŵĂŶĂŐĞŵĞŶƚ ƐĞƌǀŝĐĞ Žƌ ƉƌŽĐĞĚƵƌĞ ǁŝƚŚ ƚŚĞ ŶĞǆƚ Ϯϰ ŚŽƵƌƐ Žƌ ƐŽŽŶĞƐƚ ĂǀĂŝůĂďůĞ ĂƉƉŽŝŶƚŵĞŶƚ͖ ϱͲϭϬ ŵŝŶƵƚĞƐ ŽĨ ŵĞĚŝĐĂů ĚŝƐĐƵƐƐŝŽŶ͘ dŚĞ ƌĂƚĞ ĨŽƌ ƚŚŝƐ ĐŽĚĞ ŝƐ Ψϭϭ͘ϳϱ͘ ŽĚĞ ϵϴϵϲϳ ŝƐ ƵƐĞĚ ĨŽƌ ƚĞůĞƉŚŽŶĞ ĂƐƐĞƐƐŵĞŶƚ ĂŶĚ ŵĂŶĂŐĞŵĞŶƚ ƐĞƌǀŝĐĞ ƉƌŽǀŝĚĞĚ ďǇ ĂŶ ĞŶƌŽůůĞĚ ďĞŚĂǀŝŽƌĂů ŚĞĂůƚŚ ƉƌŽǀŝĚĞƌ ƚŽ ĂŶ ĞƐƚĂďůŝƐŚĞĚ ƉĂƚŝĞŶƚ͕ ƉĂƌĞŶƚ͕ Žƌ ŐƵĂƌĚŝĂŶ ŶŽƚ ŽƌŝŐŝŶĂƚŝŶŐ ĨƌŽŵ Ă ƌĞůĂƚĞĚ ĂƐƐĞƐƐŵĞŶƚ ĂŶĚ ŵĂŶĂŐĞŵĞŶƚ ƐĞƌǀŝĐĞ ƉƌŽǀŝĚĞĚ ǁŝƚŚŝŶ ƚŚĞ ƉƌĞǀŝŽƵƐ ϳ ĚĂǇƐ ŶŽƚ ůĞĂĚŝŶŐ ƚŽ ĂŶ ĂƐƐĞƐƐŵĞŶƚ ĂŶĚ ŵĂŶĂŐĞŵĞŶƚ ƐĞƌǀŝĐĞ Žƌ ƉƌŽĐĞĚƵƌĞ ǁŝƚŚ ƚŚĞ ŶĞǆƚ Ϯϰ ŚŽƵƌƐ Žƌ ƐŽŽŶĞƐƚ ĂǀĂŝůĂďůĞ ĂƉƉŽŝŶƚŵĞŶƚ͖ ϭϭͲϮϬ ŵŝŶƵƚĞƐ ŽĨ ŵĞĚŝĐĂů ĚŝƐĐƵƐƐŝŽŶ͘ dŚĞ ƌĂƚĞ ĨŽƌ ƚŚŝƐ ĐŽĚĞ ŝƐ ΨϮϬ͘ϲϳ͘ ŽĚĞ ϵϴϵϲϴ ŝƐ ƵƐĞĚ ĨŽƌ ƚĞůĞƉŚŽŶĞ ĂƐƐĞƐƐŵĞŶƚ ĂŶĚ ŵĂŶĂŐĞŵĞŶƚ ƐĞƌǀŝĐĞ ƉƌŽǀŝĚĞĚ ďǇ ĂŶ ĞŶƌŽůůĞĚ ďĞŚĂǀŝŽƌĂů ŚĞĂůƚŚ ƉƌŽǀŝĚĞƌ ƚŽ ĂŶ ĞƐƚĂďůŝƐŚĞĚ ƉĂƚŝĞŶƚ͕ ƉĂƌĞŶƚ͕ Žƌ ŐƵĂƌĚŝĂŶ ŶŽƚ ŽƌŝŐŝŶĂƚŝŶŐ ĨƌŽŵ Ă ƌĞůĂƚĞĚ ĂƐƐĞƐƐŵĞŶƚ ĂŶĚ ŵĂŶĂŐĞŵĞŶƚ ƐĞƌǀŝĐĞ ƉƌŽǀŝĚĞĚ ǁŝƚŚŝŶ ƚŚĞ ƉƌĞǀŝŽƵƐ ϳ ĚĂǇƐ ŶŽƚ ůĞĂĚŝŶŐ ƚŽ ĂŶ ĂƐƐĞƐƐŵĞŶƚ ĂŶĚ ŵĂŶĂŐĞŵĞŶƚ ƐĞƌǀŝĐĞ Žƌ ƉƌŽĐĞĚƵƌĞ ǁŝƚŚ ƚŚĞ ŶĞǆƚ Ϯϰ ŚŽƵƌƐ Žƌ ƐŽŽŶĞƐƚ ĂǀĂŝůĂďůĞ ĂƉƉŽŝŶƚŵĞŶƚ͖ ϮϭͲϯϬ ŵŝŶƵƚĞƐ ŽĨ ŵĞĚŝĐĂů ĚŝƐĐƵƐƐŝŽŶ͘ dŚĞ ƌĂƚĞ ĨŽƌ ƚŚŝƐ ĐŽĚĞ ŝƐ ΨϯϮ͘ϰϮ͘ ŽĚĞ 'ϬϬϳϭ ŝƐ ƵƐĞĚ ĨŽƌ WĂǇŵĞŶƚ ĨŽƌ ĐŽŵŵƵŶŝĐĂƚŝŽŶ ƚĞĐŚŶŽůŽŐǇͲďĂƐĞĚ ƐĞƌǀŝĐĞƐ ĨŽƌ ϱ ŵŝŶƵƚĞƐ Žƌ ŵŽƌĞ ŽĨ Ă ǀŝƌƚƵĂů ;ŶŽƚ ĨĂĐĞͲƚŽͲĨĂĐĞͿ ĐŽŵŵƵŶŝĐĂƚŝŽŶ ďĞƚǁĞĞŶ ĂŶ &Y, Žƌ Z, ƉƌĂĐƚŝƚŝŽŶĞƌ ĂŶĚ Ă &Y, Žƌ Z, ƉĂƚŝĞŶƚ͘ dŚĞ ƌĂƚĞ ĨŽƌ ƚŚŝƐ ĐŽĚĞ ŝƐ Ψϰϲ͘ϰϬ͘ Ǥ ̴̴̴̴̴ ǡ ȋ Ȍǡ ǣ Ǥ ̴̴̴̴̴ ǦǦ Ǥ Ǥ ̴̴̴̴̴ Ǥ KƚŚĞƌ͗ ϰ͘ ͺͺyͺͺ KƚŚĞƌ ƉĂǇŵĞŶƚ ĐŚĂŶŐĞƐ͗ EĞďƌĂƐŬĂ DĞĚŝĐĂŝĚ ŝƐ ĂůƐŽ ĂĚĚŝŶŐ ŶĞǁ ĐŽĚĞƐ ĂŶĚ ƌĂƚĞƐ ĂƐƐŽĐŝĂƚĞĚ ǁŝƚŚ Ks/Ͳϭϵ ƚŚĂƚ ĚŽ ŶŽƚ ĂƉƉĞĂƌ ĐƵƌƌĞŶƚůǇ ŽŶ ŽƵƌ ĨĞĞ ƐĐŚĞĚƵůĞ͘ dŚĞƐĞ ĐŽĚĞƐ ĂŶĚ ƌĂƚĞƐ ĂƌĞ͗ E t ϰͬϮϰͬϮϬ ϯͬϭͬϮϬ

(ne-20-0010)(approval-document)(page-15)Page 15#

^ƚĂƚĞͬdĞƌƌŝƚŽƌǇ͗ EĞďƌĂƐŬĂ ^ĞĐƚŝŽŶ ϳ͘ϰ ƉĂŐĞ ϭϬϬ dE͗ E ϮϬͲϬϬϭϬ ƉƉƌŽǀĂů ĂƚĞ͗ ͺͺͺͺͺͺͺͺͺͺ ^ƵƉĞƌƐĞĚĞƐ dE͗ ͺͺͺͺͺͺͺͺͺͺ

ĨĨĞĐƚŝǀĞ ĂƚĞ͗ ͺͺͺͺͺͺͺͺͺͺ hϬϬϬϭ dĞƐƚ WƌŝĐĞ Ͳ Ψϯϱ͘ϵϮ hϬϬϬϮ dĞƐƚ WƌŝĐĞ Ͳ Ψϱϭ͘ϯϭ ϴϳϲϯϱ Ͳ Ψϱϭ͘ϯϯ ^ĞĐƚŝŽŶ & ʹ WŽƐƚͲ ůŝŐŝďŝůŝƚǇ dƌĞĂƚŵĞŶƚ ŽĨ /ŶĐŽŵĞ ͳǤ ̴̴̴̴̴ Ǥ ǣ Ǥ ̴̴̴̴̴ ǯ Ǥ ̴̴̴̴̴ ͵ͲͲ

Ǥ ̴̴̴̴̴ ǣ ̴̴̴̴̴̴̴̴̴̴̴̴̴̴̴̴̴ ʹǤ ̴̴̴̴̴ Ǥ ȋǣ ǤͳǤ ǤȌ dŚĞ ƐƚĂƚĞ ƉƌŽƚĞĐƚƐ ĂŵŽƵŶƚƐ ĞǆĐĞĞĚŝŶŐ ƚŚĞ ďĂƐŝĐ ƉĞƌƐŽŶĂů ŶĞĞĚƐ ĂůůŽǁĂŶĐĞ ĨŽƌ ŝŶĚŝǀŝĚƵĂůƐ ǁŚŽ ŚĂǀĞ ƚŚĞ ĨŽůůŽǁŝŶŐ ŐƌĞĂƚĞƌ ƉĞƌƐŽŶĂů ŶĞĞĚƐ͗ WůĞĂƐĞ ĚĞƐĐƌŝďĞ ƚŚĞ ŐƌŽƵƉ Žƌ ŐƌŽƵƉƐ ŽĨ ŝŶĚŝǀŝĚƵĂůƐ ǁŝƚŚ ŐƌĞĂƚĞƌ ŶĞĞĚƐ ĂŶĚ ƚŚĞ ĂŵŽƵŶƚ;ƐͿ ƉƌŽƚĞĐƚĞĚ ĨŽƌ ĞĂĐŚ ŐƌŽƵƉ Žƌ ŐƌŽƵƉƐ͘ ^ĞĐƚŝŽŶ ' ʹ KƚŚĞƌ WŽůŝĐŝĞƐ ĂŶĚ WƌŽĐĞĚƵƌĞƐ ŝĨĨĞƌŝŶŐ ĨƌŽŵ ƉƉƌŽǀĞĚ DĞĚŝĐĂŝĚ ^ƚĂƚĞ WůĂŶ ͬĚĚŝƚŝŽŶĂů /ŶĨŽƌŵĂƚŝŽŶ WZ ŝƐĐůŽƐƵƌĞ ^ƚĂƚĞŵĞŶƚ ĐĐŽƌĚŝŶŐ ƚŽ ƚŚĞ WĂƉĞƌǁŽƌŬ ZĞĚƵĐƚŝŽŶ Đƚ ŽĨ ϭϵϵϱ͕ ŶŽ ƉĞƌƐŽŶƐ ĂƌĞ ƌĞƋƵŝƌĞĚ ƚŽ ƌĞƐƉŽŶĚ ƚŽ Ă ĐŽůůĞĐƚŝŽŶ ŽĨ ŝŶĨŽƌŵĂƚŝŽŶ ƵŶůĞƐƐ ŝƚ ĚŝƐƉůĂǇƐ Ă ǀĂůŝĚ KD ĐŽŶƚƌŽů ŶƵŵďĞƌ͘ dŚĞ ǀĂůŝĚ KD ĐŽŶƚƌŽů ŶƵŵďĞƌ ĨŽƌ ƚŚŝƐ ŝŶĨŽƌŵĂƚŝŽŶ ĐŽůůĞĐƚŝŽŶ ŝƐ ϬϵϯϴͲϭϭϰϴ ; ǆƉŝƌĞƐ ϬϯͬϯϭͬϮϬϮϭͿ͘ dŚĞ ƚŝŵĞ ƌĞƋƵŝƌĞĚ ƚŽ ĐŽŵƉůĞƚĞ ƚŚŝƐ ŝŶĨŽƌŵĂƚŝŽŶ ĐŽůůĞĐƚŝŽŶ ŝƐ ĞƐƚŝŵĂƚĞĚ ƚŽ ĂǀĞƌĂŐĞ ϭ ƚŽ Ϯ ŚŽƵƌƐ ƉĞƌ ƌĞƐƉŽŶƐĞ͕ ŝŶĐůƵĚŝŶŐ ƚŚĞ ƚŝŵĞ ƚŽ ƌĞǀŝĞǁ ŝŶƐƚƌƵĐƚŝŽŶƐ͕ ƐĞĂƌĐŚ ĞǆŝƐƚŝŶŐ ĚĂƚĂ ƌĞƐŽƵƌĐĞƐ͕ ŐĂƚŚĞƌ ƚŚĞ ĚĂƚĂ ŶĞĞĚĞĚ͕ ĂŶĚ ĐŽŵƉůĞƚĞ ĂŶĚ ƌĞǀŝĞǁ ƚŚĞ ŝŶĨŽƌŵĂƚŝŽŶ ĐŽůůĞĐƚŝŽŶ͘ zŽƵƌ ƌĞƐƉŽŶƐĞ ŝƐ ƌĞƋƵŝƌĞĚ ƚŽ ƌĞĐĞŝǀĞ Ă ǁĂŝǀĞƌ ƵŶĚĞƌ ^ĞĐƚŝŽŶ ϭϭϯϱ ŽĨ ƚŚĞ ^ŽĐŝĂů ^ĞĐƵƌŝƚǇ Đƚ͘ ůů ƌĞƐƉŽŶƐĞƐ ĂƌĞ ƉƵďůŝĐ ĂŶĚ ǁŝůů ďĞ ŵĂĚĞ ĂǀĂŝůĂďůĞ ŽŶ ƚŚĞ D^ ǁĞď ƐŝƚĞ͘ /Ĩ ǇŽƵ ŚĂǀĞ ĐŽŵŵĞŶƚƐ ĐŽŶĐĞƌŶŝŶŐ ƚŚĞ ĂĐĐƵƌĂĐǇ ŽĨ ƚŚĞ ƚŝŵĞ ĞƐƚŝŵĂƚĞ;ƐͿ Žƌ ƐƵŐŐĞƐƚŝŽŶƐ ĨŽƌ ŝŵƉƌŽǀŝŶŐ ƚŚŝƐ ĨŽƌŵ͕ ƉůĞĂƐĞ ǁƌŝƚĞ ƚŽ͗ D^͕ ϳϱϬϬ ^ĞĐƵƌŝƚǇ ŽƵůĞǀĂƌĚ͕ ƚƚŶ͗ WZ ZĞƉŽƌƚƐ ůĞĂƌĂŶĐĞ KĨĨŝĐĞƌ͕ DĂŝů ^ƚŽƉ ϰͲϮϲͲϬϱ͕ E t ϰͬϮϰͬϮϬ ϯͬϭͬϮϬ

(ne-20-0011)(approval-document)(page-2)Page 2#

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-26-12 Baltimore, Maryland 21244-1850 June 1, 2020 Jeremy Brunssen, Interim Director Division of Medicaid & Long-Term Care Nebraska Department of Health & Human Services 301 Centennial Mall South Lincoln, NE 68509 Re: Nebraska State Plan Amendment (SPA) NE-20-0011 Dear Mr. Brunssen: We have reviewed the proposed amendment to add section 7.4 Medicaid Disaster Relief, pages 102-111 for the COVID-19 National Emergency to your Medicaid state plan, as submitted under transmittal number (TN) NE-20-0011. 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.

(ne-20-0011)(approval-document)(page-3)Page 3#

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WKH63$GRHVQRWUHVWULFWRUOLPLWSD\PHQWRUVHUYLFHVRURWKHUZLVH EXUGHQEHQHILFLDULHVDQGSURYLGHUV DQG WKH63$LVWHPSRUDU\ZLWKDVSHFLILHGVXQVHWGDWH WKDWLVQRWODWHUWKDQWKHODVWGD\RIWKHGHFODUHG&29,' SXEOLFKHDOWKHPHUJHQF\ RUDQ\ H[WHQVLRQWKHUHRI :HQRQHWKHOHVVHQFRXUDJHVWDWHVWRPDNHDOOUHOHYDQWLQIRUPDWLRQDERXWWKH 63$DYDLODEOHWRWKHSXEOLFVRWKH\DUHDZDUHRIWKHFKDQJHV 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 Nebraska’s Medicaid SPA Transmittal Number NE-20-0011 is approved effective March 1, 2020. This SPA is in addition to the Disaster Relief SPA NE 20-0010, approved April 24, 2020, and does not supersede anything approved in that SPA. Enclosed is a copy of the CMS-179 summary form and the approved state plan pages.

(ne-20-0011)(approval-document)(page-5)Page 5#

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED HEALTH CARE FINANCING ADMINISTRATION OMB NO. 0938-0193 FORM HCFA-179 (07-92) TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL FOR: HEALTH CARE FINANCING ADMINISTRATION 1. TRANSMITTAL NUMBER: NE 20-0011 2. STATE Nebraska 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) TO: REGIONAL ADMINISTRATOR HEALTH CARE FINANCING ADMINISTRATION DEPARTMENT OF HEALTH AND HUMAN SERVICES 4. PROPOSED EFFECTIVE DATE March 1, 2020 5. TYPE OF PLAN MATERIAL (Check One): NEW STATE PLAN AMENDMENT TO BE CONSIDERED AS NEW PLAN AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate Transmittal for each amendment) 6. FEDERAL STATUTE/REGULATION CITATION: Title XIX of the Social Security Act 1135 of the Social Security Act 7. FEDERAL BUDGET IMPACT: a. FFY 2020 $851,327 b. FFY 2021 $1,415,132 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: Section 7, 7.4, Pages 102-111 (new) 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable): 10. SUBJECT OF AMENDMENT: Medicaid Disaster Relief for the COVID-19 National Emergency (2) 11. GOVERNOR’S REVIEW (Check One): GOVERNOR’S OFFICE REPORTED NO COMMENT OTHER, AS SPECIFIED: COMMENTS OF GOVERNOR’S OFFICE ENCLOSED Governor has waived review NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL 12. SIGNATURE OF STATE AGENCY OFFICIAL: 16. RETURN TO: Dawn Kastens Division of Medicaid & Long-Term Care Nebraska Department of Health & Human Services 301 Centennial Mall South Lincoln, NE 68509 13. TYPED NAME: Jeremy Brunssen 14. TITLE: Interim Director, Division of Medicaid and Long-Term Care 15. DATE SUBMITTED: 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: -XQH 0D\ 0DUFK -XQH 0D\

SHQ LQNFKDQJHUHTXHVWHGE\HPDLOGDWHG $QQH0DULH&RVWHOOR 'HSXW\'LUHFWRU&0&6 Anne M. Costello -S Digitally signed by Anne M. Costello -S Date: 2020.06.18 12:23:42 -04'00'

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State/Territory:Nebraska Section7.4page102 TN:NE20Ͳ0011 SupersedesTN:New ApprovalDate: EffectiveDate:March1,2020 Section7–GeneralProvisions 7.4.MedicaidDisasterRelieffortheCOVIDͲ19NationalEmergency OnMarch13,2020,thePresidentoftheUnitedStatesissuedaproclamationthattheCOVIDͲ19 outbreakintheUnitedStatesconstitutesanationalemergencybytheauthoritiesvestedinhimbythe ConstitutionandthelawsoftheUnitedStates,includingsections201and301oftheNational EmergenciesAct(50U.S.C.1601etseq.),andconsistentwithsection1135oftheSocialSecurityAct (Act).OnMarch13,2020,pursuanttosection1135(b)oftheAct,theSecretaryoftheUnitedStates DepartmentofHealthandHumanServicesinvokedhisauthoritytowaiveormodifycertain requirementsoftitlesXVIII,XIX,andXXIoftheActasaresultoftheconsequencesCOVIDͲ19pandemic, totheextentnecessary,asdeterminedbytheCentersforMedicare&MedicaidServices(CMS),to ensurethatsufficienthealthcareitemsandservicesareavailabletomeettheneedsofindividuals enrolledintherespectiveprogramsandtoensurethathealthcareprovidersthatfurnishsuchitemsand servicesingoodfaith,butareunabletocomplywithoneormoreofsuchrequirementsasaresultofthe COVIDͲ19pandemic,maybereimbursedforsuchitemsandservicesandexemptedfromsanctionsfor suchnoncompliance,absentanydeterminationoffraudorabuse.Thisauthoritytookeffectasof6PM EasternStandardTimeonMarch15,2020,witharetroactiveeffectivedateofMarch1,2020.The emergencyperiodwillterminate,andwaiverswillnolongerbeavailable,uponterminationofthepublic healthemergency,includinganyextensions. TheStateMedicaidagency(agency)seekstoimplementthepoliciesandproceduresdescribedbelow, whicharedifferentthanthepoliciesandproceduresotherwiseappliedundertheMedicaidstateplan, duringtheperiodofthePresidentialandSecretarialemergencydeclarationsrelatedtotheCOVIDͲ19 outbreak(oranyrenewalsthereof),orforanyshorterperioddescribedbelow: Describeshorterperiodhere. NOTE:StatesmaynotelectaperiodlongerthanthePresidentialorSecretarialemergencydeclaration (oranyrenewalthereof).Statesmaynotproposechangesonthistemplatethatrestrictorlimit payment,services,oreligibility,orotherwiseburdenbeneficiariesandproviders. RequestforWaiversunderSection1135 __X___Theagencyseeksthefollowingundersection1135(b)(1)(C)and/orsection1135(b)(5)oftheAct: a. __X___SPAsubmissionrequirements–theagencyrequestsmodificationofthe requirementtosubmittheSPAbyMarch31,2020,toobtainaSPAeffectivedateduring thefirstcalendarquarterof2020,pursuantto42CFR430.20. b. __X___Publicnoticerequirements–theagencyrequestswaiverofpublicnotice requirementsthatwouldotherwisebeapplicabletothisSPAsubmission.These requirementsmayincludethosespecifiedin42CFR440.386(AlternativeBenefitPlans), 42CFR447.57(c)(premiumsandcostsharing),and42CFR447.205(publicnoticeof changesinstatewidemethodsandstandardsforsettingpaymentrates). ______ :ƵŶĞϭϴ͕ϮϬϮϬ ____ dŚŝƐ^WŝƐŝŶĂĚĚŝƚŝŽŶƚŽƚŚĞŝƐĂƐƚĞƌZĞůŝĞĨ^WϮϬͲϬϬϭϬĂŶĚĚŽĞƐŶŽƚƐƵƉĞƌƐĞĚĞĂŶǇƚŚŝŶŐĂƉƉƌŽǀĞĚŝŶƚŚĂƚ^W͘

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State/Territory:Nebraska Section7.4page105 TN:NE20Ͳ0011 ApprovalDate: SupersedesTN:New EffectiveDate:March1,2020 3. _____Theagencydesignatesthefollowingentitiesasqualifiedentitiesforpurposesofmaking presumptiveeligibilitydeterminationsoraddsadditionalpopulationsasdescribedbelowin accordancewithsections1920,1920A,1920B,and1920CoftheActand42CFRPart435 SubpartL.Indicateifanydesignatedentitiesarepermittedtomakepresumptiveeligibility determinationsonlyforspecifiedpopulations. Pleasedescribethedesignatedentitiesoradditionalpopulationsandanylimitationsrelatedto thespecifiedpopulationsornumberofallowablePEperiods. 4. _____Theagencyadoptsatotalof_____months(nottoexceed12months)continuous eligibilityforchildrenunderageenterage_____(nottoexceedage19)regardlessofchangesin circumstancesinaccordancewithsection1902(e)(12)oftheActand42CFR435.926. 5. _____TheagencyconductsredeterminationsofeligibilityforindividualsexceptedfromMAGIͲ basedfinancialmethodologiesunder42CFR435.603(j)onceevery_____months(nottoexceed 12months)inaccordancewith42CFR435.916(b). 6. _____Theagencyusesthefollowingsimplifiedapplication(s)tosupportenrollmentinaffected areasorforaffectedindividuals(acopyofthesimplifiedapplication(s)hasbeensubmittedto CMS). a. _____Theagencyusesasimplifiedpaperapplication. b. _____Theagencyusesasimplifiedonlineapplication. c. _____ThesimplifiedpaperoronlineapplicationismadeavailableforuseincallͲcenters orothertelephoneapplicationsinaffectedareas. SectionC–PremiumsandCostSharing 1. __X___Theagencysuspendsdeductibles,copayments,coinsurance,andothercostsharing chargesasfollows: TheStatewaivescostͲsharingfortestingservices(includinginvitrodiagnosticproducts),testingͲ relatedservices,andtreatmentsforCOVIDͲ19,includingvaccines,specializedequipmentand therapies(includingdrugs),foranyquarterinwhichthetemporaryincreasedFMAPisclaimed. ThisstatewillimplementthispolicybeginningMarch1,2020throughApril30,2020. 2. __X___Theagencysuspendsenrollmentfees,premiumsandsimilarchargesfor: a. _____Allbeneficiaries b. __X___Thefollowingeligibilitygroupsorcategoricalpopulations: ______ :ƵŶĞϭϴ͕ϮϬϮϬ ____ dŚŝƐ^WŝƐŝŶĂĚĚŝƚŝŽŶƚŽƚŚĞŝƐĂƐƚĞƌZĞůŝĞĨ^WϮϬͲϬϬϭϬĂŶĚĚŽĞƐŶŽƚƐƵƉĞƌƐĞĚĞĂŶǇƚŚŝŶŐĂƉƉƌŽǀĞĚŝŶƚŚĂƚ^W͘

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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 June 1, 2020 Jeremy Brunssen, Interim Director Division of Medicaid & Long-Term Care Nebraska Department of Health & Human Services 301 Centennial Mall South Lincoln, NE 68509 Re: Nebraska State Plan Amendment (SPA) NE-20-0014 Dear Mr. Brunssen: We have reviewed the proposed amendment to add section 7.4 Medicaid Disaster Relief, pages 112-120, for the COVID-19 National Emergency to your Medicaid state plan, as submitted under transmittal number (TN) 20-0014. 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.

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7KH 6WDWH RI 1HEUDVND UHTXHVWHG D ZDLYHU RI SXEOLF QRWLFH UHTXLUHPHQWV DSSOLFDEOH WR WKH 63$ VXEPLVVLRQ SURFHVV 3XUVXDQW WR VHFWLRQ E

& RI WKH $FW &06 LV ZDLYLQJ SXEOLF QRWLFH UHTXLUHPHQWV DSSOLFDEOH WR WKH 63$ VXEPLVVLRQ SURFHVV 3XEOLF QRWLFH IRU 63$V LV UHTXLUHG XQGHU &)5 IRU FKDQJHV LQ VWDWHZLGH PHWKRGV DQG VWDQGDUGV IRU VHWWLQJ 0HGLFDLG SD\PHQW UDWHV &)5 IRU FKDQJHV WR SUHPLXPV DQG FRVW VKDULQJ DQG &)5 IRU FKDQJHV WR $OWHUQDWLYH %HQHILW 3ODQV $%3V 3XUVXDQW WR VHFWLRQ E

& RI WKH $FW &06 LV DSSURYLQJ WKH VWDWH¶V UHTXHVW WR ZDLYH WKLV QRWLFH UHTXLUHPHQW RWKHUZLVH DSSOLFDEOH WR 63$ VXEPLVVLRQV The State of Nebraska also requested a waiver to modify the tribal consultation timeline applicable to this SPA submission process. Pursuant to section 1135(b)(5) of the Act, CMS is also allowing states to modify the timeframes associated with tribal consultation required under section 1902(a)(73) of the Act, including shortening the number of days before submission or conducting consultation after submission of the SPA. These waivers of the requirements related to public notice and tribal consultation apply only with respect to SPAs that meet the following criteria: (1) the SPA provides or increases beneficiary access to items and services related to COVID-19 (such as by waiving or eliminating cost sharing, increasing payment rates or amending ABPs to add services or providers); (2) the SPA does not restrict or limit payment or services or otherwise burden beneficiaries and providers; and (3) the SPA is temporary, with a specified sunset date that is not later than the last day of the declared COVID-19 public health emergency (or any extension thereof). We nonetheless encourage states to make all relevant information about the SPA available to the public so they are aware of the changes. We conducted our review of your submittal according to the statutory requirements at section 1902(a) of the Act and implementing regulations. This letter is to inform you that Nebraska’s Medicaid SPA Transmittal Number 20-0014 is approved effective May 1, 2020. This SPA is in addition to the Disaster Relief SPAs NE 20-0010, approved RQ April 23, 2020, and NE 20-0011, approved RQ June 17, 2020, and does not supersede anything approved in those SPAs. Enclosed is a copy of the CMS-179 summary form and the approved state plan pages. Please contact Barbara Cotterman at 816-426-6426 or by email at Barbara.Cotterman@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 Nebraska and the health care community. Sincerely, Anne Marie Costello Deputy Director Center for Medicaid & CHIP Services (QFORVXUHV Anne M. Costello -S Digitally signed by Anne M. Costello -S Date: 2020.06.18 12:24:23 -04'00'

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DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED HEALTH CARE FINANCING ADMINISTRATION OMB NO. 0938-0193 TRANSMITTAL AND NOTICE OF APPROVAL OF 1. TRANSMITTAL NUMBER: 2. STATE STATE PLAN MATERIAL NE 20-0014 Nebraska

FOR: HEALTH CARE FINANCING ADMINISTRATION

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

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

4. PROPOSED EFFECTIVE DATE May 1, 2020

5. TYPE OF PLAN MATERIAL (Check One):

[_] NEW STATE PLAN

[_] AMENDMENT TO BE CONSIDERED AS NEW PLAN

[x] AMENDMENT

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

6. FEDERAL STATUTE/REGULATION CITATION: Title XIX of the Social Security Act 1135 of the Social Security Act

7. FEDERAL BUDGET IMPACT: a. FFY 2020 $ 47,702 b. FFY_ 2021 $114,486

8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:

Section 7, 7.4, Pages 112-120 (new) *

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

10. SUBJECT OF AMENDMENT: Medicaid Disaster Relief for the COVID-19 National Emergency (3)

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: Governor has waived review

12. a AGENCY OFFICIAL:

13. TYPED NAME: Jeremy Brunssen.

14. TITLE: Interim Director, Division of Medicaid and Long-Term Care

15. DATE SUBMITTED:

Rrne-$-2020 May 14, 2020**

16. RETURN TO:

Dawn Kastens

Division of Medicaid & Long-Term Care Nebraska Department of Health & Human Services 301 Centennial Mall South

Lincoln, NE 68509

FOR REGIONAL OFFICE USE ONLY

17. DATE RECEIVED:

18. DATE APPROVED:

May 14, 2020 June 18, 2020 PLAN APPROVED — ONE COPY ATTACHED 19. EFFECTIVE DATE OF APPROVED MATERIAL: 20. SIGNATURE OF REGIONAANOEFIMIAL: i costello -S May 1, 2020 Costello -S Date: 2020.06.18 = SC re el

21. TYPED NAME: a ine Marie Costello

22. TITLE: Deputy Director, CMCS

23. REMARKS:

* pen and ink change requested per e-mail dated June 8, 2020 to change footer on each page to reflect 20-0011 as the

TN#, "New" in the Supercedes blank:, and to add the requested effective date of May 1, 2020. ** pen and ink change requested per e-mail dated June 15, 2020

FORM HCFA-179 (07-92)

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State/Territory: Nebraska Section 7.4 page 112 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. _____ 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). Approval Date: Effective Date: TN: Supersedes TN: dŚŝƐ ^W ŝƐ ŝŶ ĂĚĚŝƚŝŽŶ ƚŽ ƚŚĞ ŝƐĂƐƚĞƌ ZĞůŝĞĨ ^WƐ ĂƉƉƌŽǀĞĚ ŽŶ Ɖƌŝů Ϯϯ͕ ϮϬϮϬ ĂŶĚ :ƵŶĞ ϭϳ͕ ϮϬϮϬ ĂŶĚ ĚŽĞƐ ŶŽƚ ƐƵƉĞƌƐĞĚĞ ĂŶǇƚŚŝŶŐ ĂƉƉƌŽǀĞĚ ŝŶ ƚŚŽƐĞ ^W;ƐͿ͘ EĞǁ E ͲϮϬͲϬϬϭϰ DĂǇ Ϭϭ͕ ϮϬϮϬ :ƵŶĞ ϭϴ͕ ϮϬϮϬ

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State/Territory: Nebraska Section 7.4 page 114 TN: Supersedes TN: Approval Date: Effective Date: 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. dŚŝƐ ^W ŝƐ ŝŶ ĂĚĚŝƚŝŽŶ ƚŽ ƚŚĞ ŝƐĂƐƚĞƌ ZĞůŝĞĨ ^WƐ Ɖƌŝů Ϯϯ͕ ϮϬϮϬ ĂŶĚ :ƵŶĞ ϭϳ͕ ϮϬϮϬ ĂŶĚ ĚŽĞƐ ŶŽƚ ƐƵƉĞƌƐĞĚĞ ĂŶǇƚŚŝŶŐ ĂƉƉƌŽǀĞĚ ŝŶ ƚŚŽƐĞ ^W;ƐͿ͘ E ϮϬͲϬϬϭϰ EĞǁ :ƵŶĞ ϭϴ͕ ϮϬϮϬ DĂǇ Ϭϭ͕ ϮϬϮϬ

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State/Territory: Nebraska Section 7.4 page 115 Approval Date: _ TN: E ϮϬͲϬϬϭϰ Supersedes TN: EĞǁ Effective Date: 3. _____ The agency designates the following entities as qualified entities for purposes of making presumptive eligibility determinations or adds additional populations as described below in accordance with sections 1920, 1920A, 1920B, and 1920C of the Act and 42 CFR Part 435 Subpart L. Indicate if any designated entities are permitted to make presumptive eligibility determinations only for specified populations. Please describe the designated entities or additional populations and any limitations related to the specified populations or number of allowable PE periods. 4. _____ The agency adopts a total of _____ months (not to exceed 12 months) continuous eligibility for children under age enter age _____ (not to exceed age 19) regardless of changes in circumstances in accordance with section 1902(e)(12) of the Act and 42 CFR 435.926. 5. _____ The agency conducts redeterminations of eligibility for individuals excepted from MAGI- based financial methodologies under 42 CFR 435.603(j) once every _____ months (not to exceed 12 months) in accordance with 42 CFR 435.916(b). 6. _____ The agency uses the following simplified application(s) to support enrollment in affected areas or for affected individuals (a copy of the simplified application(s) has been submitted to CMS). a. _____ The agency uses a simplified paper application. b. _____ The agency uses a simplified online application. c. _____ The simplified paper or online application is made available for use in call-centers or other telephone applications in affected areas. Section C – Premiums and Cost Sharing 1. __X___ The agency suspends deductibles, copayments, coinsurance, and other cost sharing charges as follows: Nebraska Medicaid will suspend all cost sharing for all eligibility groups effective May 1, 2020. 2. _____ The agency suspends enrollment fees, premiums and similar charges for: a. _____ All beneficiaries b. _____ The following eligibility groups or categorical populations: Please list the applicable eligibility groups or populations. dŚŝƐ ^W ŝƐ ŝŶ ĂĚĚŝƚŝŽŶ ƚŽ ƚŚĞ ŝƐĂƐƚĞƌ ZĞůŝĞĨ ^WƐ ĂƉƉƌŽǀĞĚ ŽŶ Ɖƌŝů Ϯϯ͕ ϮϬϮϬ ĂŶĚ :ƵŶĞ ϭϳ͕ ϮϬϮϬ ĂŶĚ ĚŽĞƐ ŶŽƚ ƐƵƉĞƌƐĞĚĞ ĂŶǇƚŚŝŶŐ ĂƉƉƌŽǀĞĚ ŝŶ ƚŚŽƐĞ ^W;ƐͿ͘ :ƵŶĞ ϭϴ͕ ϮϬϮϬ DĂǇ Ϭϭ͕ ϮϬϮϬ

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State/Territory: Nebraska Section 7.4 page 117 Approval Date: TN: E ͲϮϬͲϬϬϭϰ Supersedes TN: __________ Effective Date: 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. _____ 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. Please describe the change in days or quantities that are allowed for the emergency period and for which drugs. 7. _____ 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. _____ 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): _____________ dŚŝƐ ^W ŝƐ ŝŶ ĂĚĚŝƚŝŽŶ ƚŽ ƚŚĞ ŝƐĂƐƚĞƌ ZĞůŝĞĨ ^WƐ ĂƉƉƌŽǀĞĚ ŽŶ Ɖƌŝů Ϯϯ͕ ϮϬϮϬ ĂŶĚ :ƵŶĞ ϭϳ͕ ϮϬϮϬ ĂŶĚ ĚŽĞƐ ŶŽƚ ƐƵƉĞƌƐĞĚĞ ĂŶǇƚŚŝŶŐ ĂƉƉƌŽǀĞĚ ŝŶ ƚŚŽƐĞ ^W;ƐͿ͘ EĞǁ :ƵŶĞ ϭϴ͕ ϮϬϮϬ DĂǇ Ϭϭ͕ ϮϬϮϬ

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State/Territory: Nebraska Section 7.4 page 119 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.) The state protects amounts exceeding the basic personal needs allowance for individuals who have the following greater personal needs: TN: E ϮϬͲϬϬϭϰ Supersedes TN: _E___Ğǁ______ dŚŝƐ ^W ŝƐ ŝŶ ĂĚĚŝƚŝŽŶ ƚŽ ƚŚĞ ŝƐĂƐƚĞƌ ZĞůŝĞĨ ^WƐ ĂƉƉƌŽǀĞĚ ŽŶ Ɖƌŝů Ϯϯ͕ ϮϬϮϬ ĂŶĚ :ƵŶĞ ϭϳ͕ ϮϬϮϬ ĂŶĚ ĚŽĞƐ ŶŽƚ ƐƵƉĞƌƐĞĚĞ ĂŶǇƚŚŝŶŐ ĂƉƉƌŽǀĞĚ ŝŶ ƚŚŽƐĞ ^W;ƐͿ͘ Approval Date: Effective Date: :ƵŶĞ ϭϴ͕ ϮϬϮϬ DĂǇ Ϭϭ͕ ϮϬϮϬ

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State/Territory: Nebraska Section 7.4 page 120 Please describe the group or groups of individuals with greater needs and the amount(s) protected for each group or groups. Section G – Other Policies and Procedures Differing from Approved Medicaid State Plan /Additional Information PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148 (Expires 03/31/2021). The time required to complete this information collection is estimated to average 1 to 2 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. Your response is required to receive a waiver under Section 1135 of the Social Security Act. All responses are public and will be made available on the CMS web site. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. ***CMS Disclosure*** Please do not send applications, claims, payments, medical records or any documents containing sensitive information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information collection burden approved under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please contact the Centers for Medicaid & CHIP Services at 410-786-3870. dŚŝƐ ^W ŝƐ ŝŶ ĂĚĚŝƚŝŽŶ ƚŽ ƚŚĞ ŝƐĂƐƚĞƌ ZĞůŝĞĨ ^WƐ ĂƉƉƌŽǀĞĚ ŽŶ Ɖƌŝů Ϯϯ͕ ϮϬϮϬ ĂŶĚ :ƵŶĞ ϭϳ͕ ϮϬϮϬ ĂŶĚ ĚŽĞƐ ŶŽƚ ƐƵƉĞƌƐĞĚĞ ĂŶǇƚŚŝŶŐ ĂƉƉƌŽǀĞĚ ŝŶ ƚŚŽƐĞ ^W;ƐͿ͘ TN: E ϮϬͲϬϬϭϰ Supersedes TN: _EĞǁ______ Approval Date: Effective Date: :ƵŶĞ ϭϴ͕ ϮϬϮϬ DĂǇ Ϭϭ͕ ϮϬϮϬ

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(ne-09-06)(approval-document)Nebraska Medicaid SPA NE-09-06: Approval Document (approved October 20, 2009, effective September 1, 2009)#

(ne-09-06)(approval-document)Nebraska Medicaid SPA NE-09-06: Approval Document (approved October 20, 2009, effective September 1, 2009)#

(ne-09-06)(attachment)Nebraska Medicaid SPA NE-09-06: Attachment (approved October 20, 2009, effective September 1, 2009)#

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(ne-09-06)(form-cms-179)Nebraska Medicaid SPA NE-09-06: Form CMS-179 (approved October 20, 2009, effective September 1, 2009)#

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(ne-09-08)(approval-document)Nebraska Medicaid SPA NE-09-08: Approval Document (approved June 16, 2011, effective July 1, 2009)#

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(ne-09-08)(attachment)Nebraska Medicaid SPA NE-09-08: Attachment (approved June 16, 2011, effective July 1, 2009)#

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(ne-09-08)(form-cms-179)Nebraska Medicaid SPA NE-09-08: Form CMS-179 (approved June 16, 2011, effective July 1, 2009)#

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(ne-10-01)(approval-document)Nebraska Medicaid SPA NE-10-01: Approval Document (approved March 18, 2010, effective January 1, 2010)#

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(ne-10-012)(approval-document)Nebraska Medicaid SPA NE-10-012: Approval Document (approved August 18, 2010, effective July 1, 2010)#

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(ne-10-012)(attachment)Nebraska Medicaid SPA NE-10-012: Attachment (approved August 18, 2010, effective July 1, 2010)#

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(ne-10-012)(form-cms-179)Nebraska Medicaid SPA NE-10-012: Form CMS-179 (approved August 18, 2010, effective July 1, 2010)#

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(ne-10-20)(approval-document)Nebraska Medicaid SPA NE-10-20: Approval Document (approved September 27, 2011, effective July 1, 2010)#

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(ne-10-20)(attachment)Nebraska Medicaid SPA NE-10-20: Attachment (approved September 27, 2011, effective July 1, 2010)#

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(ne-10-20)(form-cms-179)Nebraska Medicaid SPA NE-10-20: Form CMS-179 (approved September 27, 2011, effective July 1, 2010)#

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(ne-11-08)(approval-document)Nebraska Medicaid SPA NE-11-08: Approval Document (approved August 16, 2011, effective June 1, 2011)#

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(ne-11-08)(attachment)Nebraska Medicaid SPA NE-11-08: Attachment (approved August 16, 2011, effective June 1, 2011)#

(ne-11-08)(attachment)(page-1)Page 1#

(ne-11-08)(form-cms-179)Nebraska Medicaid SPA NE-11-08: Form CMS-179 (approved August 16, 2011, effective June 1, 2011)#

(ne-11-08)(form-cms-179)(page-1)Page 1#

(ne-11-14)(approval-document)Nebraska Medicaid SPA NE-11-14: Approval Document (approved December 21, 2011, effective July 1, 2011)#

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(ne-11-14)(attachment)Nebraska Medicaid SPA NE-11-14: Attachment (approved December 21, 2011, effective July 1, 2011)#

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(ne-11-14)(form-cms-179)Nebraska Medicaid SPA NE-11-14: Form CMS-179 (approved December 21, 2011, effective July 1, 2011)#

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(ne-11-15)(approval-document)Nebraska Medicaid SPA NE-11-15: Approval Document (approved October 13, 2011, effective July 1, 2011)#

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(ne-11-15)(attachment)Nebraska Medicaid SPA NE-11-15: Attachment (approved October 13, 2011, effective July 1, 2011)#

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(ne-11-15)(form-cms-179)Nebraska Medicaid SPA NE-11-15: Form CMS-179 (approved October 13, 2011, effective July 1, 2011)#

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(ne-11-016)(approval-document)Nebraska Medicaid SPA NE-11-016: Approval Document (approved March 2, 2012, effective April 1, 2011)#

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(ne-11-016)(attachment)Nebraska Medicaid SPA NE-11-016: Attachment (approved March 2, 2012, effective April 1, 2011)#

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(ne-11-016)(form-cms-179)Nebraska Medicaid SPA NE-11-016: Form CMS-179 (approved March 2, 2012, effective April 1, 2011)#

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(ne-11-19-m)(approval-document)Nebraska Medicaid SPA NE-11-19 M: Approval Document (approved March 6, 2012, effective July 1, 2012)#

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(ne-11-19-m)(attachment)Nebraska Medicaid SPA NE-11-19 M: Attachment (approved March 6, 2012, effective July 1, 2012)#

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(ne-11-19-m)(form-cms-179)Nebraska Medicaid SPA NE-11-19 M: Form CMS-179 (approved March 6, 2012, effective July 1, 2012)#

(ne-11-19-m)(form-cms-179)(page-1)Page 1#

(ne-11-20)(approval-document)Nebraska Medicaid SPA NE-11-20: Approval Document (approved December 22, 2011, effective July 1, 2011)#

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(ne-11-20)(attachment)Nebraska Medicaid SPA NE-11-20: Attachment (approved December 22, 2011, effective July 1, 2011)#

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(ne-11-20)(form-cms-179)Nebraska Medicaid SPA NE-11-20: Form CMS-179 (approved December 22, 2011, effective July 1, 2011)#

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(ne-11-23-m)(approval-document)Nebraska Medicaid SPA NE-11-23 M: Approval Document (approved March 6, 2012, effective July 1, 2012)#

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(ne-11-23-m)(attachment)Nebraska Medicaid SPA NE-11-23 M: Attachment (approved March 6, 2012, effective July 1, 2012)#

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