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

JFK Federal Building. Government Center Room 2275 CENTERS for MEDICARE & MEDICAID SERVICES Boston. Massachusetts 02203

Division of Medicaid and Children's Health Operations / Boston Regional Office

June 22, 2011

Nicholas A. Toumpas, Commissioner Department of Health and Human Services 129 Pleasant Street

Concord, NH 03301-3857

Dear Mr. Toumpas:

We are pleased to enclose a copy of approved State plan amendment (SPA) No. 11-001 with an effective date of March 1. 2011, as requested by your Agency.

This SPA transmitted a proposed amendment to New Hampshire" s approved Title XIX State plan to increase the Federal poverty guidelines (FPGs) for various poverty level groups to reflect the increase in the FPGs as published in the Federal Register (FR) on “January 20, 2011.

Beginning with this SPA, we changed how we process the annual Federal Poverty Level (FPL) updates. States are no longer required to include tables with the actual dollar amounts in the plan pages. State plan pages that only include the applicable percentages of the FPL for each eligibility group is sufficient. There will be no need to submit SPAs every year thereafter unless the FPL percentage changes for an eligibility group. Although we will not be requiring States to submit SPAs every year after 2011, we will continue to review the FPL amounts that have been calculated by each State. We will ask the States to verify these amounts shortly after the guidelines are published by the U.S. Department of Health and Human Services. We also took this opportunity to delete State plan pages for poverty level groups that are no longer applicable. All the changes to this SPA that were agreed upon by CMS and your Department are noted in Section 23 (Remarks) on the Form 179.

If there are questions, please contact Robert Cruz. He can be reached at (617) 565-1257.

Sincerely. /s/

Richard R. McGreal

Associate Regional Administrator Enclosure

ce:

Kathleen Dunn, Medicaid Director Dawn Landry, State Plan Coordinator Diane Peterson

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED

HEALTH CARE FINANCING ADMINISTRATION OMB NO. 0938-0193 TRANSMITTAL AND NOTICE OF APPROVAL OF | !. TRANSMITTAL NUMBER: 2, STATE STATE PLAN MATERIAL {l-col NH

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

TO: REGIONAL ADMINISTRATOR 4. PROPOSED EFFECTIVE DATE HEALTH CARE FINANCING ADMINISTRATION 3/1/2011 DEPARTMENT OF HEALTH AND HUMAN SERVICES

5. TYPE OF PLAN MATERIAL (Check One):

FOR: HEALTH CARE FINANCING ADMINISTRATION

(J NEW STATE PLAN (1) 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: § 1902(a)(10)(A)(ii)(XV), §1902 (a)(10)A(i(IV), a. FFY 2011 $0 §1902(a)(10)(a)(i)(VI), 1902(a)(10)(A)()CVID, §1902(a)(10)(E)(i); b. FFY 2012 $0

§1902 (a)(10)(A)(ii)(TX) and §§ 1902(1)(1)(A) and (1)(1) 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: | 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION

Supplement | to Attachment 2.6-A, pages I- 6, 8 OR ATTACHMENT (if Applicable): Attachment 2.6-A, page 12d Supplement | to Attachment 2.6-A, pages I- 6, 8 Attachment 2.2-A, page 21 Attachment 2.6-A, page 12d

Attachment 2.2-A, page 21

10. SUBJECT OF AMENDMENT:

Mandatory Income Eligibility Limit Increases for Various Programs . 11. GOVERNOR’S REVIEW (Check One): [1 GOVERNOR'S OFFICE REPORTED NO COMMENT {J OTHER, AS SPECIFIED: comments, if any, will follow

(1 COMMENTS OF GOVERNOR’S OFFICE ENCLOSED (NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL

12, SIGNATURE OF STATE AGENCY OFFICIAL: 16. RETURN TO: Dawn I. Landry 13. TYPED HAE: ~~ u Brown Building/ DHHS, Program Support Nicp6las A. Toumpas 129 Pleasant Street 14. TITLES Concord, NH 03301 Commissioner 15. DATE SUBMITTED: March 25, 2011

17. DATE RECEIVED: 3725/11

19. EFFECTIVE D

Associate Regional Administrator, Division of Medicaid and Children’s lealth Operations, Boston Regional Office

21. TYPED NAME; Richard MeGreal

23. REMARKS; Per agreement with State staff, the following changes were made: (1) Removed FPL tables with dollar amounts in Supplement I to Attachment 2.6-A, pages 1- 3 (2) Amended the language in Attachment 2.6-A, page 12d (3) Removed Supplement 8b to Attachment 2.6-A, page 2 from this SPA since this page is not being updated. (4) Deleted the text in Supplement | to Attachment 2.6-A, pages 4 and 5 from State Plan since these pages are no longer applicable. (5) Deleted the text in Supplement 1 to Attachment 2.6-A, page 8 from State Plan since the QMB figures are already specified in the State Plan in Attachment 2.2-A, page 9b. (6) Deleted the text in Supplement | to Attachment 2.6-A, page 6 from State Plan since this QMB page is not applicable. (7) Deleted the text in Attachment 2.2-A, page 21 from State Plan since this page is no longer applicable. This page was submitted as "Supplement I" to Attachment 2.2-A, page 21. That was a mistake; this page is just Attachment 2.2-A, page 21 (8) Corrected regulation citation in Supplement | to Attachment 2.6-A, page 3 to say 1902(a) (lOMAXiiIX) instead of 1902(aX 5 KAXIMIX). (9) Form 179: Added FFY values in Box 7; Boxes 8 and 9 above were updated to reflect all of the changes described in Remarks 1-8.

FORM HCFA-179 (07-92)

Revision: HCFA-PM-91-4 (BPD) Supplement | to ATTACHMENT 2.6-A August 1991 Page | OMB No.: 0938-

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State:_New Hampshire

INCOME ELIGIBILITY LEVELS A. MANDATORY CATEGORICALLY NEEDY

1. AFDC-Related Groups Other Than Poverty Level Pregnant Women and Infants: Maximum Payment Family Size Need Standard Payment Standard Amounts 1 $1241 $414 $414 2 1632 481 481 3 2034 550 550 4 2402 613 613 5 2752 673 673 6 3224 754 754 7 3592 817 817 8 4134 910 _. 910 9 4438 962 962 10 4887 1039 1039 ui 5395 1126 1126 12 5815* 1198** 1198**

* For family sizes over 12, subtract $268 from the payment standard for 12. Add to the result, $67 for each additional member and divide that by 0.1835. Then add to that number, $268.

** For each additional person, add $67

2. Pregnant Women and Infants Under Section 1902(a)(10)(A)(i)(IV) of the Act:

Based on the following percent of the official Federal income poverty level --

® 133 percent oO 185_ percent (no more than 185 percent) (specify) TN No. 11-001 Approval Date __ 6/22/11 Effective Date _03/01/11

Supersedes TN No._08-016 HCFA ID: 7985E

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

August 1991 Page 2 OMB No.: 0938-

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State:_New Hampshire INCOME ELIGIBILITY LEVELS

A. MANDATORY CATEGORICALLY NEEDY (Continued)

3. For children under Section 1902(a)(10)(A)(i)(VI) of the Act (children who have attained age 1 but have not attained age 6), the income eligibility level is 133 percent of the Federal poverty level (as revised annually in the Federal Register) for the size family involved.

o

4. For children under Section 1902(a)(10)(A)(i)(VII) of the Act (children who were born after September 30, 1983 and have attained age 6 but have not attained age 19), the income eligibility level is 100 percent of the Federal poverty level (as revised annually in the Federal

Register) for the size family involved.

TN No. 11-001 Supersedes Approval Date 6/22/11

TN No. .08-016 HCFA ID: 7985E

Effective Date 03/01/11

Revision: HCFA-PM-91-4 (BPD) Supplement 1 to ATTACHMENT 2.6-A AUGUST 1991 Page 3 OMB No.: 0938- STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

STATE: NEW HAMPSHIRE

INCOME ELIGIBILITY LEVELS (Continued)

B. OPTIONAL CATEGORICALLY NEEDY GROUPS WITH INCOMES RELATED TO FEDERAL POVERTY LEVEL

1. Pregnant Women and Infants

The levels for determining income eligibility for optional groups of pregnant women and infants under the provisions of sections 1902(a)(10)(A)(ii)(IX) and 1902(1)(2) of the Act are as follows:

Based on 185 percent of the official Federal income poverty level (no less than 133 percent and no more than 185 percent).

TN No. 11-001 Supersedes Approval Date 6/22/11 Effective Date 03/01/11 TN No. 08-016

HCFA ID: 7985E

Revision: HCFA-PM-91-4 (BPD) Supplement 1 to ATTACHMENT 2.6-A AUGUST 1991 Page 4 OMB No.: 0938- STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

STATE: NEW HAMPSHIRE

INCOME ELIGIBILITY LEVELS (Continued)

This page is reserved for future use.

TN No. 11-001 Supersedes Approval Date: 6/22/\1 Effective Date: 03/01/11 TN No. 08-016 HCFA ID: 7985E

Revision: HCFA-PM-91-4 (BPD) Supplement 1 to ATTACHMENT 2.6-A AUGUST 1991 Page 5 OMB No.: 0938- STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE: NEW HAMPSHIRE

INCOME ELIGIBILITY LEVELS (Continued)

This page is reserved for future use.

TN No. 11-001 Supersedes Approval Date: _ 6/22/11 Effective Date: 03/01/11 TN No. 08-016 HCFA ID: 7985E

Revision: HCFA-PM-91-4 (BPD) SUPPLEMENT | TO ATTACHMENT 2.6-A AUGUST 1991 Page 6 OMB No.: 0938- STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

STATE: NEW HAMPSHIRE INCOME ELIGIBILITY LEVELS (Continued)

hi: is rese: ture use.

11-001

TN No.

Supersedes 5 Approval Date9/22/1 I TN No, 02-00.

Effective Date 3/1/2011

HCFA ID: 798SE

Revision: HCFA-PM-91-4 (BPD) SUPPLEMENT | TO ATTACHMENT 2.6-A AUGUST 1991 Page 8 OMB No.: 0938- STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE: NEW HAMPSHIRE

INCOME ELIGIBILITY LEVELS (Continued)

This page is reserved for future use.

TN No. 11-001 Supersedes Approval Date 6/22/11 Effective Date 03/01/11

TN No. 08-016 HCFA ID: 7985E

Revision:

ATTACHMENT 2.6-A Page 12d OMB No.:

State/Territory:_New Hampshire

Citation

Condition or Requirement

1902(a)(10)(A) (ii)(XV) of the Act

(ii)

Working Individuals with Disabilities — Basic Coverage Group — TWWIA

In determining the countable income and resources for working individuals with disabilities under this provision, the following standards and methodologies are applied:

The agency does not apply any income or resource standard.

NOTE: If the above option is chosen, no further eligibility-related options should be elected.

The agency applies the following income and/or resource standard(s): Net monthly income using the State’s methodology as specified in Supplement 6 to Attachment 2.6-A may not exceed 450% of the federal poverty guidelines.

Effective 3/1/2011, the countable resources for an individual may not exceed $25,391 and the countable resources for a married couple may not exceed $38,087. These standards are updated annually by the percentage change in the Consumer Price Index for All Urban Consumers (CPI-U).

TN No. _11-001 Supersedes TN No. 08-016

Approval Date ___ 6/22/11 Effective Date 03/01/11 HCFA ID:

Revision: _HCFA-PM-91-4 (BPD) ATTACHMENT 2.2-A August 1991 Page 21 OMB No.: 0938-

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State: New Hampshire

Agency* Citation(s) Groups Covered

B. Optional Groups Other Than the Medically Needy

15. 15a.

This page is reserved for future use.

TNNo. 11-001 Supersedes Approval Date: 6/22/11 Effective Date: 03/01/11 TNNo 08-016 HCFA ID: 7985E

Table of Contents State/Territory Name: New Hampshire State Plan Amendment (SPA) #: 11-009 This file contains the following documents in the order listed:

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

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

JFK Federal Building, Government Center

Room 2275 CENTERS for MEDICARE & MEDICAID SERVICES

Boston, Massachusetts 02203

Division of Medicaid & Children’s Health Operations / Region |

March 20, 2012

Nicholas Toumpas, Commissioner Department of Health and Human Services 129 Pleasant Street

Concord, New Hampshire 03301

Dear Mr. Toumpas:

We are pleased to enclose a copy of approved New Hampshire State Plan Amendment (SPA) No. 11-009 submitted to my office on December 30, 2011. This SPA transmitted a proposed revision to New Hampshire’s approved Title XIX State Plan in order to remove the 18 visit service limit on physician and advanced registered nurse practitioners (ARNP), to change the psychotherapy service limit from 12 to 18 visits for adults age 21 and over and from 12 to 24 the visits for children under age 21. In addition the state made minor updates on some of these older state plan pages.

This SPA has been approved effective November |. 2011 as requested by the State.

Changes are reflected in the following sections of your approved State Plan: Attachment 3.1A, page 2a and 2b

Attachment 3.1A, page 3b

Attachment 3.1B, page 2c

Attachment 3.1B, page 3a and 3b

Attachment 3.1E, page 1 and 2

Attachment 4.19B. page la, 2 and 2a

If you have any questions regarding this matter, you may contact Angel Miller at 617-565-1324 or by email at Angel.Miller@cms.hhs.vov.

Sincerely, Ss

Richard R. McGreal Associate Regional Administrator

Table of Contents State/Territory Name: New Hampshire State Plan Amendment (SPA) #: 11-009 This file contains the following documents in the order listed:

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

DEPARTMENT OF HEALTH & HUMAN SERVICES ‘Gi At Centers for Medicare & Medicaid Services

JFK Federal Building, Government Center

Room 2275 CENTERS for MEDICARE & MEDICAID SERVICES

Boston, Massachusetts 02203

Division of Medicaid & Children’s Health Operations / Region |

March 20, 2012

Nicholas Toumpas, Commissioner Department of Health and Human Services 129 Pleasant Street

Concord, New Hampshire 03301

Dear Mr. Toumpas:

We are pleased to enclose a copy of approved New Hampshire State Plan Amendment (SPA) No. 11-009 submitted to my office on December 30, 2011. This SPA transmitted a proposed revision to New Hampshire’s approved Title XIX State Plan in order to remove the 18 visit service limit on physician and advanced registered nurse practitioners (ARNP), to change the psychotherapy service limit from 12 to 18 visits for adults age 21 and over and from 12 to 24 the visits for children under age 21. In addition the state made minor updates on some of these older state plan pages.

This SPA has been approved effective November |, 2011 as requested by the State.

Changes are reflected in the following sections of your approved State Plan: e Attachment 3.1A, page 2a and 2b

Attachment 3.1A, page 3b

Attachment 3.1B, page 2c

Attachment 3.1B, page 3a and 3b

Attachment 3.1E, page 1 and 2

Attachment 4.19B, page la, 2 and 2a

eeeoee

If you have any questions regarding this matter. you may contact Angel Miller at 617-565-1324 or by email at Angel.Miller@cms.hhs.vov.

Sincerely, Ss

Richard R. McGreal Associate Regional Administrator

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

1. TRANSMITTAL NUMBER: 11-009

2. STATE NH

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

November 1, 2011

5. TYPE OF PLAN MATERIAL (Check One):

oO NEW STATE PLAN

(1 AMENDMENT TO BE CONSIDERED AS NEW PLAN

AMENDMENT

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

6. FEDERAL STATUTE/REGULATION CITATION: 42 CFR 440.50; 42 CFR 440.60, 42 CFR 440.230(d)

7. FEDERAL BUDGET IMPACT: $346,657 ~FFY 2012 ($166,770 phys; $179,887 psych)

§. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: Attachment 3.1A, page 2a and 2b

Attachment 3.1A, page 3b

Attachment 3.1B, page 2c

Attachment 3.1B, page 3a and 3b

Attachment 3.1-E, page | and 2

Attachment 4.19-B, page la, 2,2a

(note: no reimbursement changes; submitting pages only for CMS review of corresponding reimbursement methodology)

9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable): Attachment 3.1A, page 2a, TN 97-09; pg 2b, TN 10-008 Attachment 3.1A, page 3b, TN 10-003 Attachment 3.1B, page 2c, TN 11-009 Attachment 3.1B, page 3a, TN 10-008, pg 3b, TN 11-009 Attachment 3.1-E, page 1, TN 95-10, pg 2, TN 92-04 Attachment 4.19-B, pg la, TN 10-008, pg 2, TN 11-002, pg 2a, TN 11-002

10. SUBJECT OF AMENDMENT: Changes to Physician and Psychotherapy Service Limits

11, GOVERNOR'S REVIEW (Check One): (J GOVERNOR'S OFFICE REPORTED NO COMMENT

(J) COMMENTS OF GOVERNOR'S OFFICE ENCLOSED a NO REPLY RECEIVED WITHIN 45. DAYS OF SUBMITTAL

& OTHER, AS SPECIFIED: comments, if any, will follow

12. SIGNAT

‘13. TYPED NAME:

16. RETURN TO:

Dawn Landry Division of Family Assistance/Brown Building

‘14. TITLE: Commissioner

“75. DATE SUBMITTED: _ 12/30/2011

Department of Health and Human Services 129 Pleasant Street Concord, NH 03301

FOR REGIONAL OFFICE USE ONLY

17. DATE RECEIVED: 12/30/2011

18. DATE APPROVED: 03)27./2012

PLAN APPROVED ~ ONE COPY ATTACHED

“19. EFFECTIVE DATE OF APPROVED MATERIAL:

; 11/01/2011 21. TYPED NAME:

Richard R

McGreal

| 22. TITLE:

20.

Adan-i-ni.

23. REMARKS:

Associate—Regional

FORM HCFA-179 (07-92)

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

4a.

4b.

Title XIX —NH Attachment 3.1-A Page 2-a

Payment for nursing facility care is available to both categorically and medically needy recipients in need of such care. Payment is made for a non-private room. Determination of need for nursing facility care and authorization of payment for nursing facility care is made by the Bureau of Elderly and Adult Services.

Early and Periodi ing, Diagnosi. it

Limited to federal requirements for the categorically needy. Any limits to services provided in Attachment 3.1- A do not apply to individuals under EPSDT as long as medical necessity criteria as determined by the Office of Medicaid Business and Policy have been met.

4c. Family Planning Services

Family planning services provided by agencies under contract obligation with the Division of Public Health Services shall include education and counseling services.

5a. Physician Services

TN No:

Coverage for physician services is unlimited except for those physician services affiliated with outpatient hospital visits, which are limited to 12 per recipient per state fiscal year. Laboratory tests and diagnostic x-rays are not counted against the outpatient physician visit limit.

Except for kidney and tissue transplants, to include corneas, bone grafts, and skin transplants, which are covered without prior authorization, prior authorization is required for the coverage of physician services for organ transplants which include bone marrow, liver, heart, lung, heart-lung, pancreas, and pancreas-kidney. (See Attachment 3.1-E for specific details.) Certain surgical procedures to include bariatric surgery, breast reduction, blepharoplasty, panniculectomy, septoplasty and rhinoplasty also require prior authorization.

Non-covered organ transplantation and procurement services include physician services for the surgery, inpatient hospital services for the surgical admission(s), and organ procurement related to the following types of transplants: any type of organ or tissue transplant not specified above (including hairplasty) or more than two transplants of the same type of organ per recipient per lifetime.

In accordance with federal law, coverage for induced abortions is provided when the physician certifies that the pregnancy was the result of rape or incest or the woman suffers from a physical disorder, physical injury, or physical illness including a life-endangering physical condition caused by, or arising from, the pregnancy itself that would place the woman in danger of death unless an abortion is performed.

-009 Supersedes Approval Date_3/27:/2012 Effective Date: 11/01/2011 TNNo: 97-09

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

Title XIX - NH Attachment 3.1-A Page 2-b

Physician laboratory and diagnostic radiology services are subject to the limit described under the Other Laboratory and X-ray service heading.

Services provided by licensed psychiatrists and ophthalmologists are included in the physician limits. Payment for refraction is limited to one (1) per recipient per state fiscal year, whether the provider is an optometrist or ophthalmologist.

5b. Medical and Dental_ Services

Services provided by a doctor of dental surgery or dental medicine which would otherwise be physician services are treated in the same manner as physicians in accordance with Sa.

6a. Podiatrists’ Services

Payment for the services of licensed podiatrists is limited to four (4) visits per recipient per state fiscal year.

Podiatrist services shall be covered for medical and surgical treatments of the foot and lower leg for pathological conditions of the foot due to localized illness, injury, or symptoms involving the foot. Prevention and reduction of corns, calluses, and warts are covered if by cutting or surgical means only. Other licensed podiatrist services include routine foot care and trimming and burring of nails, including mycotic nails, performed by a podiatrist provided that:

The recipient's primary health care provider has documented in the recipient's medical record the the recipient's current medical condition justifies the need for such foot care to be performed by a podiatrist; and

The primary health care provider has written a referral to a podiatrist for such care, and the referral is maintained in the recipient's record.

Supersedes Approval Date _3/27/2012 Effective Date: 11/01/2011

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

Title XIX —NH Attachment 3.1-A Page 3-b

6b. Optometrist Services

6c.

Payment to state licensed optometrists or ophthalmologists for refraction is limited to one (1) per recipient per state fiscal year whether the provider is a licensed optometrist or ophthalmologist.

Chiropractor Services Not covered

. Clinical Psychologist

Treatment provided by a licensed clinical psychologist, who is not on the staff of a community mental health center, is limited to 18 visits per recipient per state fiscal year for adults (age 21 and over) and 24 visits per recipient per state fiscal year for children (under age 21). Such visits are to be counted toward the 18 visit adult/24 visit child psychotherapy cap for all non-physician practitioners.

Advanced Registered Nurse Practitioners

Section 6405 of P.L. 101-239 (OBRA 1989) is met by ARNP. Treatment provided by advanced registered nurse practitioners (known as advanced practice registered nurses-APRN's-in NH) who meet state licensure requirements is unlimited except for psychotherapy treatment. Psychotherapy is limited to 18 visits per recipient per state fiscal year for adults (age 21 and over) and 24 visits per recipient per state fiscal year for children (under age 21). Such visits are to be counted toward the 18 visit adult/24 visit child psychotherapy cap for all non-physician practitioners.

Certified Midwives

Midwife services comprised of the necessary supervision, care, and advice provided to women during the pregnancy, labor and postpartum period, and including care of the newborn, shall be provided pursuant to RSA 326-D and by individuals certified to practice midwifery in New Hampshire pursuant to RSA 326-D:6. For purposes of this Title XIX state plan service, certified midwives shall be considered the equivalent of licensed practitioners per CMS.

Pastoral Counselors

Psychotherapy services provided by a licensed pastoral counselor, who is not on the staff of a community mental health center, are limited to 18 visits per recipient per state fiscal year for adults (age 21 and over) and 24 visits per recipient per state fiscal year for children (under age 21). Such visits are to be counted toward the 18 visit adult/24 visit child psychotherapy cap for all non-physician practitioners.

Home Health Services

Home health services are provided in accordance with 42 CFR 440.70 and include the services specified in 7a-7d. Home health services are provided to a recipient on his or her physician's orders as part of a written plan of care that the physician reviews every 60 days, except as specified in 42 CFR 440.70(b)(3). Medical supplies, equipment and appliances suitable for use in the home are provided in accordance with physician review as specified in 42 CFR 440.70(b)(3).

Home health agencies must meet the Medicare conditions of participation in 42 CFR Part 484.

a. & b. Nursing and Home Health Aide

Services can only be provided in the patient's place of residence, not in a hospital, nursing facility, or ICF-MR, except as allowed at 42 CFR 470.70(c).

TNNo: 11-009 Supersedes Approval Date_3/27/2012 Effective Date: 11/01/2011 TNNo: 10-003

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

Title XIX - NH Attachment 3.1-B Page 2-c

Sa. Physician Services

5b.

TN No:

Coverage for physician services is unlimited except for those physician services affiliated with outpatient hospital visits, which are limited to 12 per recipient per state fiscal year. Laboratory tests and diagnostic x- rays are not counted against the outpatient physician visit limit.

Except for kidney and tissue transplants, to include comeas, bone grafts, and skin transplants, which are covered without prior authorization, prior authorization is required for the coverage of physician services for organ transplants which include bone marrow, liver, heart, lung, heart-lung, pancreas, and pancreas- kidney. (See Attachment 3.1-E for specific details.) Certain surgical procedures to include bariatric surgery, breast reduction, blepharoplasty, panniculectomy, septoplasty and rhinoplasty also require prior authorization.

Non-covered organ transplantation and procurement services include physician services for the surgery, inpatient hospital services for the surgical admission(s), and organ procurement related to the following types of transplants: any type of organ or tissue transplant not specified above (including hairplasty) or more than two transplants of the same type of organ per recipient per lifetime.

In accordance with federal law, coverage for induced abortions is provided when the physician certifies that the pregnancy was the result of rape or incest or the woman suffers from a physical disorder, physical injury, or physical illness including a life-endangering physical condition caused by, or arising from, the pregnancy itself that would place the woman in danger of death unless an abortion is performed.

Physician laboratory and diagnostic radiology services are subject to the limit described under the Other Laboratory and X-ray service heading.

Services provided by licensed psychiatrists and ophthalmologists are included in the physician limits. Payment for refraction is limited to one (1) per recipient per state fiscal year, whether the provider is an optometrist or ophthalmologist.

ledi ni i

Services provided by a doctor of dental surgery or dental medicine which would otherwise be physician services are treated in the same manner as physicians in accordance with Sa.

11-009

Supersedes Approval Date _3/27:/2012 Effective Date: 11/01/2011

TN No:

95-10

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

Title XLX - NH Attachment 3.1-B Page 3-a

6a. Podiatrists' Services

Payment for the services of licensed podiatrists is limited to four (4) visits per recipient per state fiscal year.

Podiatrist services shall be covered for medical and surgical treatments of the foot and lower leg for pathological conditions of the foot due to localized illness, injury, or symptoms involving the foot. Prevention and reduction of corns, calluses, and warts are covered if by cutting or surgical means only. Other licensed podiatrist services include routine foot care and trimming and burring of nails, including mycotic nails, performed by a podiatrist provided that:

The recipient's primary health care provider has documented in the recipient's medical record the the recipient's current medical condition justifies the need for such foot care to be performed by a podiatrist; and

The primary health care provider has written a referral to a podiatrist for such care, and the referral is maintained in the recipient's record.

6b. Optometrists’ Services

Payment to state licensed optometrists or ophthalmologists for refraction is limited to one (1) per recipient per state fiscal year whether the provider is a licensed optometrist or ophthalmologist.

6c. Chiropractors! Services Not provided

6d. Other Practitioners’ Services Clinical Psychologist

Treatment provided by a licensed clinical psychologist, who is not on the staff of a community mental health center, is limited to 18 visits per recipient per state fiscal year for adults (age 21 and over) and 24 visits per recipient per state fiscal year for children (under age 21). Such visits are to be counted toward the 18 visit adult/24 visit child psychotherapy cap for all non- physician practitioners.

TNNo: 11-00! Supersedes Approval Date 3/27/2012 Effective Date: 11/01/2011 TNNo: 10-00:

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

Title XIX —NH Attachment 3.1-B Page 3-b

6d. Other Practitioner's Services (cont)

Te.

74.

Advanced Registered Nurse Practitioners

Section 6405 of P.L. 101-239 (OBRA 1989) is met by ARNP. Treatment provided by advanced registered nurse practitioners (known as advanced practice registered nurses-APRN's-in NH) who meet state licensure requirements is unlimited except for psychotherapy treatment. Psychotherapy is limited to 18 visits per recipient per state fiscal year for adults (age 21 and over) and 24 visits per recipient per state fiscal year for children (under age 21). Such visits are to be counted toward the 18 visit adult/24 visit child psychotherapy cap for all non-physician practitioners.

Certified Midwives

Midwife services comprised of the necessary supervision, care, and advice provided to women during the pregnancy, labor and postpartum period, and including care of the newborn, shall be provided pursuant to RSA 326-D and by individuals certified to practice midwifery in New Hampshire pursuant to RSA 326-D:6. For purposes of this Title XIX state plan service, certified midwives shall be considered the equivalent of licensed practitioners per CMS.

Pastoral Counselors

Psychotherapy services provided by a licensed pastoral counselor, who is not on the staff of a community mental health center, are limited to 18 visits per recipient per state fiscal year for adults (age 21 and over) and 24 visits per recipient per state fiscal year for children (under age 21). Such visits are to be counted toward the 18 visit adult/24 visit child psychotherapy cap for all non-physician practitioners.

Home Health Services

Home health services are provided in accordance with 42 CFR 440.70 and include the services specified in 7a-7d. Home health services are provided to a recipient on his or her physician's orders as part of a written plan of care that the physician reviews every 60 days, except as specified in 42 CFR 440.70(b)(3). Medical supplies, equipment and appliances suitable for use in the home are provided in accordance with physician review as specified in 42 CFR 440.70(b)(3).

Home health agencies must meet the Medicare conditions of participation in 42 CFR Part 484.

a. & b. Nursin; e Health Aide Services can only be provided in the patient's place of residence, not in a hospital, nursing facility, or |CF-MR, except as allowed at 42 CFR 440.70(c).

ical Suppli ui i Prior authorization is required for the purchase of most (prosthetics and orthotics which fall under DME in the department's rules, but under item #12 in the state plan, do not require prior authorization) durable medical equipment as detailed in the department's rules at He-W 571, as well as for modifications to manual or power wheelchairs. Repairs to power wheelchairs require prior authorization if the repairs total $800 or more.

Prior authorization is required for disposable diapers and related incontinence supplies for recipients 21 years of age and older. Other medical supplies do not require prior authorization.

Physical and Occupational Therapy, Speech Pathology and Audiology Services

When provided by a home health agency, visiting nurse association or independent therapist, these services are limited to eighty (80), fifteen minute units per recipient per state fiscal year. The eighty (80) units may be used for one type of therapy or in any combination of therapies

Physical, Occupational and Speech Pathology/Audiology Services are provided in accordance with the service and practitioner requirements of 42 CFR 440.110 and 42 CFR 440.70(b)(4).

TNNo: 11-009 Supersedes Approval Date 3/27/2012 Effective Date: 11/01/2011 TNNo: 07-010

Revision: HCFA-PM-87-4 (BERC) ATTACHMENT 3.1-E

MARCH 1987 Page | QMB No. 0938-0193

State/Territory: New Hampshire STANDARDS FOR THE COVERAGE OF ORGAN TRANSPLANT SERVICES

Covered O: ‘rans 4 Organ transplants from human donor to human recipient are a covered service subject to the following conditions and limitations:

Covered transplants include kidney, bone marrow, heart, heart-lung, lung, liver, pancreas, and pancreas-kidney, as well as tissue transplants to include cornea, bone grafts and skin transplants with the exception of hairplasty.

Except for kidney and tissue transplants which are covered without prior authorization, prior authorization for organ transplants in item #1 above must be requested of and obtained from the Office of Medicaid Business and Policy (OMBP) prior to the service being rendered. Evaluation of prior authorization requests will include (a) a review of other treatment options explored, and (b) application of the most current, evidence-based clinical criteria as specified by OMBP in its rules at He-W 531 in order to determine the recipient’s suitability as a candidate for the specified organ transplant(s).

The organ transplant procedure and organ procurements must be performed by a NH Title XIX enrolled provider, at a NH Title XIX enrolled provider facility.

Non-Covered Organ Transplants:

Non-covered organ transplantation and procurement services include physician services for the surgery, inpatient hospital services for the surgical admission(s), and organ procurement related to the following types of transplants: any other organ transplant not specified in item #1 above, more than two transplants of the same type of organ per recipient per lifetime, and organ transplants that require prior authorization but which are not prior authorized.

TN No:

11-009

Supersedes Approval Date_3/ 27/2012 _ Effective Date: 11/01/2011

TN No:

95-10

Revision: HCFA-PM-87-4 (BERC) ATTACHMENT 3.1-E MARCH 1987 - Page2 QMB No. 0938-0193

State/Territory: New Hampshire STANDARDS FOR THE COVERAGE OF ORGAN TRANSPLANT SERVICES (Reserved)

TNNo: 11-00!

Supersedes Approval Date 3/27 /2012 Effective Date: 11/01/2011 TNNo: 92-04

Title XIX — NH Attachment 4.19-B Page l-a

PAYMENT RATES FOR ALL TYPES OF CARE OTHER THAN INPATIENT

HOSPITAL, SKILLED NURSING, OR INTERMEDIATE NURSING CARE SERVICES

4. Family Planning Services — Payment for these services is provided in accordance with the same principles of reimbursement developed for the specific types of practitioners and/or services described elsewhere in the state plan which are considered to qualify as family planning services. For example, those types of individual practitioner's services which qualify as family planning services are paid in accordance with #5 and #6 below. All fee schedules are accessible at

www.nhmedicaid.com/Downloads/procedurecodes.htm] and are applicable to all public and private

providers.

5. Physician Services — Payment is made in accordance with a fee schedule established by the department pursuant to NH RSA 161:4, VI. The department's rates are reviewed biennially in accordance with RSA 126-A:18-b. Rates were set as of April 1, 2010, and are effective for services provided on or after that date. In accordance with NH RSA 126-A;3, III, no provider shall bill or charge the department more than the provider's usual and customary charge. All fee schedules are accessible at icaid.co wniloa cedurecodes.htm!] and are applicable to all public and private providers.

6. Services of Other Licensed Practitioners — Payment for all types of other licensed practitioners is made in accordance with a fee schedule established by the department pursuant to NH RSA 161:4,

VI. The department's rates are reviewed biennially in accordance with RSA 126-A:18-b. Rates were set as of April 1, 2010, and are effective for services provided on or after that date. In accordance with NH RSA 126-A:3, IIT, no provider shall bill or charge the department more than the provider's usual and customary charge. All fee schedules are accessible at

www.nhmedicaid.com/Downloads/procedurecodes.html and are applicable to all public and private providers.

Note: When it is stated that "rates were set as of," this indicates the most recent date rates were changed on one or more codes for the type of service/practitioner in question. It is not meant to imply that all of the codes pertaining to the type of service/practitioner in question were changed or reviewed.

TN No: 1-009 Supersedes Approval Date _3/ 27/2012 Effective Date: 11/01/2011 TNNo: 10-008

Title XIX —- NH Attachment 4.19-B

7.

TN No:

Page 2

PAYMENT RATES FOR ALL TYPES OF CARE OTHER THAN INPATIENT

OSPITAI LED NURS ER ATE SING SERVICES

Home Health Care Services —- Payment rates for nursing and home health aide services are established in accordance with state statute at RSA 161:4, VI(a), RSA 161:4, VI(b), and RSA 126-A:18-a. The reimbursement methodology is detailed in the department's rules at He-W 553. A unit means a 15 minute unit. Skilled nursing services are reimbursed a flat rate per visit. Home health aide visits composed of fewer than 8 units of direct care time are reimbursed a flat rate per visit. Home health aide visits composed of eight or more units of direct care time are reimbursed a flat rate per unit of direct care time. The agency’s rates were set on April 1, 2010 in accordance with DHHS rules at He-W 553, and are effective for services provided on or after that date. Physical, occupational, and speech therapy/audiology services are reimbursed a per unit rate set by the department pursuant to NH RSA 161:4, VI and in accordance with # 11 below. Medical supplies, equipment and appliances are reimbursed at rates set by the department pursuant to NH RSA 161:4, VI. Additionally, in accordance with NH RSA 126-A:3, II], no provider shall bill or charge the department more than the provider's usual and customary charge. The fee schedule, which is applicable to all public and private providers of home health care services, can be accessed at www. icaid.co wnloads/procedurecedes, html. For equipment which is prior authorized, the approved reimbursement amount, which is based upon the provider's acquisition and retail costs and other individualized circumstances of the request such as rental/trial periods, accessories, etc., is provided on the prior authorization approval notice which is sent to the provider. For those supplies, equipment and appliances which are not individually priced based on the above circumstances, rates were set on April 1, 2010 and are effective for services provided on or after that date.

Private Duty Nursing Services ~ Payment is made at a fee per hour in accordance with a fee schedule established by the department pursuant to NH RSA 161:4, VI. The department's rates are reviewed biennially in accordance with RSA 126-A:18-b. Rates were set as of October 1, 2008 and are effective for services provided on or after that date. In accordance with NH RSA 126-A:3, III, no provider shall bill or charge the department more than the provider's usual and customary charge. All fee schedules are accessible at

icai jowntoads/ and are applicable to all public and private providers.

Clinic Services — The individual practitioners who practice in the clinics are reimbursed according to the methodologies described in various entries in the state plan for the various types of practitioners providing the

service. All fee schedules are accessible at www.nhmedicaid.com/Downlogds/procedurecodes.html and are

applicable to all public and private providers.

11-00

Supersedes Approval Date _3/ 27/2012 Effective Date: 11/01/2011

TN No:

11-002

Title XIX - NH Attachment 4.19-B

10.

Page 2a

PAYMENT RATES FOR ALL TYPES OF CARE OTHER THAN INPATIENT

OSPITAL, SKILLED NURSING, OR INTERMEDIATE NURSING CARE SERVICES

Dental Services -- Payment is made in accordance with a fee schedule established by the department pursuant to NH RSA 161:4, VI. The department's rates are reviewed biennially in accordance with RSA 126-A:18-b. Rates were set as of June 1, 2011, and are effective for services provided on or after that date. In accordance with NH RSA 126-A:3, ITI, no provider shall bill or charge the d ent more than the provider's usual and customary charge. All fee schedules are accessible at .nhmedicaid.co oads/p codes.

applicable to all public and private providers.

Effective June 1, 2011, interceptive orthodontia will be paid in one payment, inclusive of records. Also effective June 1, 2011, comprehensive orthodontia will be paid in three payments, inclusive of records: at banding, no sooner than 12 months after banding, and when evidence confirms that the case is completed. "Inclusive of records" means inclusive of the casts/models and various types of xrays such as panorex and cephalometric xrays that are required as part of the orthodontic consultation.

ical The: d Relat ices ional and -- Payment for physical, occupational and speech therapy services is based upon a 15 minute unit of service, unless the CPT code is defined otherwise, and made in accordance with a fee schedule established by the department pursuant to NH RSA 161:4, VI. The department's rates are reviewed biennially in accordance with RSA 126-A:18-b. Rates were set as of October 1, 2008, and are effective for services provided on or after that date. In accordance with NH RSA 126-A:3, IIT, no provider shall bill or charge the department more than the provider's usual and customary charge. All fee

schedules are accessible at www.nhmedicaid.com/Downloads/procedurecodes.html and are applicable to all public and private providers.

TNNo: 11-009

Supersedes Approval Date _3/27 /2012 Effective Date: 11/01/2011

TNNo: 11-002

_____________________________________________________________________________

Table of Contents State/Territory Name: New Hampshire State Plan Amendment (SPA) #: 13-0017-MM1 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form 3) Superseding Pages Notice 4) Approved SPA Pages

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

JFK Federal Building, Government Center

Room 2275

Boston, Massachusetts 02203

CMS

CENTERS FOR MEDICARE & MEDICAID SERVICES

Division of Medicaid and Children’s Health Operations / Boston Regional Office

June 2, 2014

Nicholas A. Toumpas, Commissioner Department of Health and Human Services State of New Hampshire

129 Pleasant Street

Concord, NH 03301

Re: New Hampshire SPA TN 13-0017-MM1 Dear Commissioner Toumpas,

Enclosed is an approved copy of New Hampshire’s (NH) State Plan Amendment (SPA) 13-0017-MM1, which was submitted to CMS on December 31, 2013. Based on the initial SPA submission review, CMS determined that additional information was needed before a final decision could be made. A formal request for additional information (RAI) was sent to the state on March 28, 2014, and on May 30, 2014, the State submitted a response to the RAI. SPA 13-0017-MMI, approved on June 2, 2014, incorporates the Modified Adjusted Gross Income (MAGI)-based methodologies into NH’s Medicaid State Plan in accordance with the Affordable Care Act. The effective date of this SPA is January |, 2014.

Transmittal # 13-0017-MM1 --MAGI-Based Income Methodologies --Effective January 1, 2014

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

S25, Pages $25-1 to S25-5 S28, Pages S28-1 to S28-4 S30, Pages S30-1 to S30-8 $32, Page S32-1

S33, Page S$33-1

S50, Page S50-1

S51, Page S51-1

S52, Pages S52-1 to $52-3 $53, Pages S53-1 to S53-2 S54, Pages S54-1 to $54-2 S55, Page S55-1

S57, Page S57-1

S59, Page S59-1 to S59-3

Page 2 —Nicholas A. Toumpas, Commissioner

In addition, enclosed is a summary of State Plan pages that are superseded by NH 13-0017-MM1]; this document should be incorporated into a separate section in the front of the State Plan.

Notwithstanding any other provisions of the New Hampshire Medicaid State Plan, the financial eligibility methodologies described in State Plan Amendment NH-13-017-MMI will apply to all MAGI-based eligibility groups covered under New Hampshire’s Medicaid State Plan. The MAGI financial methodologies set forth in 42 CFR § 435.603 apply to everyone except those individuals described at 42 CFR § 435.603(j) for whom MAGI-based methods do not apply. This State Plan Amendment supersedes the current financial eligibility provisions of the Medicaid State Plan only with respect to the MAGI- based eligibility groups.

CMS appreciates the significant amount of work your staff dedicated to preparing this State Plan Amendment. If there are questions, please contact Joyce Butterworth at (617) 565-1220 or by e-mail at

Jovce.Butterworth@cms.hhs.gov.

Sincerely, /s/

Richard R. McGreal Associate Regional Administrator Enclosure/s

ce: Kathleen Dunn, State Medicaid Director Diane Peterson, Medicaid Business and Policy Dawn Landry, Division of Family Assistance

/s/

OFFFICIAL

SUPERSEDING PAGES OF STATE PLAN MATERIAL

TRANSMITTAL NUMBER:

13-0017

STATE:

New Hampshire

Pages or sections of pages being superseded by S25, S28, S54, S59, and S14 and related pages or sections of pages

$30, S51, $52, $53, being deleted as

obsolete State Plan Section Complete Pages Removed Partial Pages Removed Page 1 Page 2, A.2.b Page 3 Page 2, A.2.c Page 3a Page 2a, A.3 Page 4 Page 5, A.10. Page 4a Page 9c, B.1 for Page 12 caretaker relatives Page 13 & pregnant women Page 13a Page 20, B.14 Page 14 Page 23b(continued), Attachment 2.2-A Page l4a B.19(d) and B.21 Page 23 Page 25, C.4. Page 23b Page 23e Page 1 Supplement 1 to Attachment Page 2 2.2-A Page 3 Page 3b Page 1, A.2.a.(i) & Page lla (iii) Page 19 Page 6 related to Page 19a AFDC recipients, Page 19b pregnant women, Attachment 2.6-A Page 21 infants, and children Page 7, l.a(1) & (2) Page 12, C.l.e. (2) Page 18, 5.e Page 25, 1l.a. (3) TN 13-0017-MM1 Approved 06/02/2014 Effective 01/01/2014

New Hampshire

OFFFICIAL

Page 6a.2, for

Supplement 1 to Attachment Pages 1-3 categorically needy 2.6-A Supplement 2 to Attachment Pages 1-5 2.6-A Supplement 5b to Attachment Page l, a. 2.6-A Page la.a Page 3 Page 1, (1), (2), (3), and (4) Page 2, for AFDC- Supplement 8a to Attachment related 2.6-A categorically needy Supplement 8b to Attachment Page 1, (1) 2.6-A Supplement 12 to Attachment Pages 2-4 2.6-A Addendum TN 13-0017-MM1 Approved 06/02/2014 Effective 01/01/2014

New Hampshire

OFFICIAL

Medicaid Eligibility

OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 AFDC Income Standards $14

Enter the AFDC Standards below. All states must enter:

MAGI-equivalent AFDC Payment Standard in Effect As of May 1, 1988 and AFDC Payment Standard in Effect As of July 16, 1996

Entry of other standards is optional.

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

Income Standard Entry - Dollar Amount - Automatic Increase Option Si3a

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

C Standard varies in some other way

Enter the statewide standard Additional incremental amount Household size | Standard ($) C Yes @No +]! 447 xX Increment amount $ +} 2 536 x #13 626 xX 4 710 xX FI 5 791 x +6 891 x 7 976 xX +/s 1,086 x

The dollar amounts increase automatically each year

C Yes @ No

AFDC Payment Standard in Effect As of July 16, 1996

Page | of 5 TN 13-0017-MM1 Approval Date: 06/02/2014 Effective Date: 01/01/2014

New Hampshire

OFFICIAL

Medicaid Eligibility

Income Standard Entry - Dollar Amount - Automatic Increase Option Si3a The standard is as follows: @ Statewide standard C Standard varies by region C Standard varies by living arrangement C Standard varies in some other way Enter the statewide standard H hold si Additional incremental amount ousehold size | Standard ($) @ Yes CNo +) 1 414 x Increment amount $ |67 +|2 481 x +3 550 x 4 613 x is 673 x +) 6 754 x +7 817 x +/s 910 xX io 962 x +} 10 1,039 x li 1,126 x | 12 1,198 x The dollar amounts increase automatically each year C Yes @ No MAGT-equivalent AFDC Payment Standard in Effect As of July 16, 1996 Income Standard Entry - Dollar Amount - Automatic Increase Option Si3a The standard is as follows: C Statewide standard

TN 13-0017-MM1 Approval Date: 06/02/2014 New Hampshire

Page Effective Date: 01/01/2014

2 of 5

OFFICIAL

CcCmMs Medicaid Eligibility

COTES FO MEDC a eC ECTS

C Standard varies by region C Standard varies by living arrangement

C Standard varies in some other way

The dollar amounts increase automatically each year C Yes C No

AFDC Need Standard in Effect As of July 16, 1996

Income Standard Entry - Dollar Amount - Automatic Increase Option

The standard is as follows:

Si3a

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

C Standard varies in some other way

The dollar amounts increase automatically each year C Yes CNo

AFDC Payment Standard in Effect As of July 16, 1996, increased by no more than the percentage increase in the Consumer Price Index for urban consumers (CPI-U) since such date.

Income Standard Entry - Dollar Amount - Automatic Increase Option Si3a

The standard is as follows:

C Statewide standard

C Standard varies by region

C Standard varies by living arrangement

C Standard varies in some other way

The dollar amounts increase automatically each year C Yes © No

MAGI-equivalent AFDC Payment Standard in Effect As of July 16, 1996, increased by no more

than the percentage increase in the Consumer Price Index for urban consumers (CPI-U) since such date

Page 3 of 5 TN 13-0017-MM1 Approval Date: 06/02/2014 Effective Date: 01/01/2014 New Hampshire

OFFICIAL

CCMS Medicaid Eligibility

Income Standard Entry - Dollar Amount - Automatic Increase Option

Si3a

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

C Standard varies in some other way

The dollar amounts increase automatically each year

C Yes (C No

TANF payment standard

Income Standard Entry - Dollar Amount - Automatic Increase Option

Si3a

The standard is as follows:

C Statewide standard

C Standard varies by region

C Standard varies by living arrangement

C Standard varies in some other way

The dollar amounts increase automatically each year

C Yes C No

MAGI-equivalent TANF payment standard

Income Standard Entry - Dollar Amount - Automatic Increase Option

Si3a

The standard is as follows:

@ Statewide standard

C Standard varies by region

C Standard varies by living arrangement

C Standard varies in some other way

[Enter the statewide standard

TN 13-0017-MM1 Approval Date: 06/02/2014 New Hampshire

Page 4 of 5 Effective Date: 01/01/2014

OFFICIAL

eS Peis oe SS Ee Medicaid Eligibility

CONES FOE MEORCRAE A MANE SEMICON

Household size

Standard ($)

Additional incremental amount C Yes (@ No

Increment amount $

+} 1 670 x +/2 816 x +5 965 x +4 1,108 x +Is 1,247 x +} 6 1,408 x +\7 1,551 x +] 8 1,723 x +) 1,855 x | 10 2,012 xX yi 2,178 xX #12 2.330 x

C Yes @ No

The dollar amounts increase automatically each year

PRA Disclosure Statement

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

TN 13-0017-MM1 New Hampshire

Page 5 of 5 Approval Date: 06/02/2014 Effective Date: 01/01/2014

OFFICIAL

Medicaid Eligibility

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

Eligibility Groups - Mandatory Coverage 525 ‘Parents and Other Caretaker Relatives

42 CFR 435.110 1902(a)(10)(A)(i)D) 1931(b) and (d)

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

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

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

The state elects the following options:

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

Options relating to the definition of caretaker relative (select any that apply):

oO The definition of caretaker relative includes the domestic partner of the parent or other caretaker relative, even after the partnership is terminated.

Definition of domestic partner:

& The definition of caretaker relative includes other relatives of the child based on blood (including those of half-blood), adoption or marriage.

means a grandfather, grandmother, brother, sister, stepfather, stepmother, stepbrother, stepsister, uncle, aunt, first cousin, nephew, or niece (including eon relatives of half-blood, relatives of preceding generations as denoted by the Description of other . ‘ i

A prefixes of grand, great, or great-great, adoptive parents and their relatives to relatives: 3 : the same degree as blood relatives, and spouses of the above relatives even after the marriage is terminated by death or divorce) who provides care and parental control to a dependent child

oO The definition of caretaker relative includes any adult with whom the child is living and who assumes primary responsibility for the dependent child's care.

[J Options relating to the definition of dependent child (select the one that applies):

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

Page | of 5 TN 13-0017-MM1 Approval Date: 06/02/2014 Effective Date: 01/01/2014 New Hampshire

OFFICIAL anne ier ees e a SC a ee Re ee eS

Medicaid Eligibility

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

[@] Income standard used for this group [B] Minimum income standard

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

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

An attachment is submitted.

[—] Maximum income standard

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

An attachment is submitted.

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

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

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

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

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

Enter the amount of the maximum income standard:

C A percentage of the federal poverty level: %

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

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

C Other dollar amount

Page 2 of 5 TN 13-0017-MM1 Approval Date: 06/02/2014 Effective Date: 01/01/2014

New Hampshire

OFFICIAL

Medicaid Eligibility

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

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

C Another income standard in-between the minimum and maximum standards allowed [&) There is no resource test for this eligibility group. {m] Presumptive Eligibility

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

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

[H] 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.

[m] Periods of presumptive eligibility are limited as follows: @ No more than one period within a calendar year. C No more than one period within two calendar years.

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

C Other reasonable limitation: The state requires that a written application be signed by the applicant or representative. @ Yes (No C The state uses a single application form for Medicaid and presumptive eligibility, approved by CMS.

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

An attachment is submitted.

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

Page 3 of 5 TN 13-0017-MM1 Approval Date: 06/02/2014 Effective Date: 01/01/2014 New Hampshire

OFFICIAL

Medicaid Eligibility

[@] The individual must be a caretaker relative, as described at 42 CFR 435.110.

[@] Household income must not exceed the applicable income standard described at 42 CFR 435.110. State residency

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

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

List of Qualified Entities S17

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

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

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

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

Food Program for Women, Infants and Children (WIC) under section 17 of the Child Nutrition Act of 1966

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

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

(J Is an elementary or secondary school operated or supported by the Bureau of Indian Affairs

(J Isa state or Tribal child support enforcement agency under title IV-D of the Act

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

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

Is an organization that determines eligibility for any assistance or benefits provided under any program of public or assisted housing that receives Federal funds, including the program under section 8 or any

oO other section of the United States Housing Act of 1937 (42 U.S.C. 1437) or under the Native American Housing Assistance and Self Determination Act of 1996 (25 U.S.C. 4101 et seq.)

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

Oo

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

Page 4 of 5 TN 13-0017-MM1 Approval Date: 06/02/2014 Effective Date: 01/01/2014

New Hampshire

OFFICIAL Dee re a RO eT ae

Medicaid Eligibility

The state assures that it has communicated the requirements for qualified entities, at 1920A(b)(3) of the Act, and

has provided adequate training to the entities and organizations involved. A copy of the training materials has been included.

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.

Page 5 of 5 TN 13-0017-MM1 Approval Date: 06/02/2014 Effective Date: 01/01/2014

New Hampshire

OFFICIAL

Medicaid Eligibility

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

Eligibility Groups - Mandatory Coverage 528 Pregnant Women

42 CFR 435.116 1902(a)(10)(A)(i)(IID and (IV) 1902(a)(10)(A)(ii)(1), (IV) and (IX) 1931(b) and (d)

1920

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

Pregnant women in the last trimester of their pregnancy without dependent children are eligible for full benefits under this

group in accordance with section 1931 of the Act, if they meet the income standard for state plan Parents and Other Caretaker Relatives at 42 CFR 435.110.

C Yes @ No

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

[B] Income standard used for this group [8] Minimum income standard (Once entered and approved by CMS, the minimum income standard cannot be changed.)

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

C Yes @ No The minimum income standard for this eligibility group is 133% FPL. [B] Maximum income standard The state certifies that it has submitted and received approval for its converted income standard(s) for pregnant

women to MAGI-equivalent standards and the determination of the maximum income standard to be used for pregnant women under this eligibility group.

An attachment is submitted.

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

The state's highest effective income level for coverage of pregnant women under sections 1931 (low-income families), 1902(a)(10)(A)(i)(IID) (qualified pregnant women), 1902(a)(10)(A)(i)(IV) (mandatory poverty level- related pregnant women), 1902(a)(10)(A)(ii)(IX) (optional poverty level-related pregnant women), 1902(a)(10) (A)(ii)(D (pregnant women who meet AFDC financial eligibility criteria) and 1902(a)(10)(A)(ii)UIV) (institutionalized pregnant women) in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL.

Page | of 4 TN 13-0017-MM1 Approval Date: 06/02/2014 Effective Date: 01/01/2014

New Hampshire

OFFICIAL

Medicaid Eligibility

The state's highest effective income level for coverage of pregnant women under sections 1931 (low-income families), 1902(a)(10)(A)(i)(II]) (qualified pregnant women), 1902(a)(10)(A)(i)(IV) (mandatory poverty level- related pregnant women), 1902(a)(10)(A)(ii)(IX) (optional poverty level-related pregnant women), 1902(a)(10) (A)(i)(D (pregnant women who meet AFDC financial eligibility criteria) and 1902(a)(10)(A)(ii)(IV) (institutionalized pregnant women) in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL.

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

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

C 185% FPL

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

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

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

[m] Presumptive Eligibility

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

@ Yes (© No

[] The presumptive period begins on the date the determination is made. [B] 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.

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

A written application must be signed by the applicant or representative.

Page 2 of 4 TN 13-0017-MM1 Approval Date: 06/02/2014 Effective Date: 01/01/2014

New Hampshire

OFFICIAL

Medicaid Eligibility

@ Yes € No C The state uses a single application form for Medicaid and presumptive eligibility, approved by CMS.

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

An attachment is submitted.

[@] The presumptive eligibility determination is based on the following factors: [@] The woman must be pregnant [B] Household income must not exceed the applicable income standard at 42 CFR 435.116. State residency Citizenship, status as a national. or satisfactory immigration status

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

List of Qualified Entities S17

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

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

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

NZ] Head Start Act

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

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

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

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

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

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

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

Page 3 of 4 TN 13-0017-MM1 Approval Date: 06/02/2014 Effective Date: 01/01/2014 New Hampshire

OFFICIAL

Medicaid Eligibility

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

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

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

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

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

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.

Page 4 of 4 TN 13-0017-MM1 Approval Date: 06/02/2014 Effective Date: 01/01/2014

New Hampshire

OFFICIAL

Medicaid Eligibility

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

Eligibility Groups - Mandatory Coverage Infants and Children under Age 19 S30

42 CFR 435.118

1902(a)(10)(A)(i)(ID, (IV), (VI) and (VID) 1902(a)(10)(A)(ii)(IV) and (IX)

1931(b) and (d)

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

The state attests that it operates this eligibility group in accordance with the following provisions: [@] Children qualifying under this eligibility group must meet the following criteria: [B] Are under age 19 [@] Have household income at or below the standard established by the state.

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

[@] Income standard used for infants under age one {] Minimum income standard

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

C Yes @ No

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

{B] Maximum income standard

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

An attachment is submitted.

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

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

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

Page | of 8 TN 13-0017-MM1 Approval Date: 06/02/2014 Effective Date: 01/01/2014

New Hampshire

OFFICIAL Pies oie a OL Ee

Medicaid Eligibility

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

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

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

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

C 185% FPL

Enter the amount of the maximum income standard: |196 % FPL

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

(@ The maximum income standard

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

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

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

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

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

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

Cc

{m] Income standard for children age one through age five, inclusive

[=] Minimum income standard

Page 2 of 8 TN 13-0017-MM1 Approval Date: 06/02/2014 Effective Date: 01/01/2014

New Hampshire

OFFICIAL

Medicaid Eligibility

The minimum income standard used for this age group is 133% FPL.

(=) Maximum income standard

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

An attachment is submitted.

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

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

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

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

Ce income families), 1902(a)(10)(A)(i)(IIL) (qualified children), 1902(a)(10)(A)(i)(VD) (mandatory poverty level- related children age one through five), and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL.

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

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

Enter the amount of the maximum income standard: |196 % FPL

[@) Income standard chosen The state's income standard used for children age one through five is: @ The maximum income standard

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

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

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

Page 3 of 8 TN 13-0017-MM1 Approval Date: 06/02/2014 Effective Date: 01/01/2014

New Hampshire

OFFICIAL

Medicaid Eligibility

If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and

Cc if not chosen as the maximum income standard, the state's effective income level for any population of children age one through five under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI- equivalent percent of FPL.

If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and

Cc if not chosen as the maximum income standard, the state's effective income level for any population of children age one through five under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI- equivalent percent of FPL.

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

[] Maximum income standard

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

An attachment is submitted.

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

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

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

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

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

C

C 133% FPL

Enter the amount of the maximum income standard: | 196 % FPL

[@] Income standard chosen

Page 4 of 8 TN 13-0017-MM1 Approval Date: 06/02/2014 Effective Date: 01/01/2014

New Hampshire

OFFICIAL

Medicaid Eligibility

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

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

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

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

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

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

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

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

@ Yes (No

Presumptive Eligibility for Children S16

1902(a)(47) 1920A

42 CFR 435.1101 42 CFR 435.1102

The state provides Medicaid coverage to children when determined presumptively eligible by a qualified entity under the following provisions:

Cy

Page 5 of 8 TN 13-0017-MM1 Approval Date: 06/02/2014 Effective Date: 01/01/2014

New Hampshire

OFFICIAL

REE pe ee ee eee Ss Medicaid Eligibility

If the state has elected to cover Optional Targeted Low-Income Children (42 CFR 435.229), the income standard for presumptive eligibility is the higher of the standard used for Optional Targeted Low-Income Children or the standard used for Infants and Children under 19 (42 CFR 435.118), for that child’s age.

If the state has not elected to cover Optional Targeted Low Income Children (42 CFR 435.229), the income standard for presumptive eligibility is the standard used under the Infants and Children under Age 19 eligibility group (42 CFR 435.118), for that child’s age.

{@) Children under the following age may be determined presumptively eligible:

Under age |19

[i] The presumptive period begins on the date the determination is made.

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

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

The last day of the month following the month in which the determination of presumptive eligibility is made, ifno application for Medicaid is filed by that date.

[m] Periods of presumptive eligibility are limited as follows: @ No more than one period within a calendar year.

C No more than one period within two calendar years.

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

C Other reasonable limitation:

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

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

An attachment is submitted.

[HB] The presumptive eligibility determination is based on the following factors: [®] Household income must not exceed the applicable income standard described above, for the child's age.

State residency

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

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

fl

Page 6 of 8 TN 13-0017-MM1 Approval Date: 06/02/2014 Effective Date: 01/01/2014

New Hampshire

OFFICIAL

ae aes a ET, ae Ss Medicaid Eligibility

List of Qualified Entities S17

A qualified entity is an entity that is determined by the agency to be capable of making presumptive

eligibility determinations based on an individual’s household income and other requirements, and that

meets at least one of the following requirements. Select one or more of the following types of entities

used to determine presumptive eligibility for this eligibility group:

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

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

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

[X] Food Program for Women, Infants and Children (WIC) under section 17 of the Child Nutrition Act of 1966

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

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

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

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

oO Is a state or Tribal office or entity involved in enrollment in the program under Medicaid, CHIP, or title IV-A of the Act Is an organization that determines eligibility for any assistance or benefits provided under any program

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

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

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

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

An attachment is submitted.

PRA Disclosure Statement

Page 7 of 8 TN 13-0017-MM1 Approval Date: 06/02/2014 Effective Date: 01/01/2014

New Hampshire

OFFICIAL

ans eT Sa a a ee Es

Medicaid Eligibility

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 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.

Page 8 of 8 TN 13-0017-MM1 Approval Date: 06/02/2014 Effective Date: 01/01/2014

New Hampshire

OFFICIAL

Medicaid Eligibility

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

Eligibility Groups - Mandatory Coverage Adult Group see

1902(a)(10)(A)(i)(VII1) 42 CFR 435.119

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

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

Page | of | TN 13-0017-MM1 Approval Date: 06/02/2014 Effective Date: 01/01/2014

New Hampshire

OFFICIAL

Medicaid Eligibility

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

Eligibility Groups - Mandatory Coverage Former Foster Care Children eee

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

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

The state attests that it operates this eligibility group under the following provisions:

[Ml] Individuals qualifying under this eligibility group must meet the following criteria: [B) Are under age 26. i Are not otherwise eligible for and enrolled for mandatory coverage under the state plan, except that eligibility under this group takes precedence over eligibility under the Adult Group.

Were in foster care under the responsibility of the state or Tribe and were enrolled in Medicaid under the state's state [mB] plan or 1115 demonstration when they turned 18 or at the time of aging out of that state's or Tribe's foster care program.

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

C Yes (@No

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

C Yes @No

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

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

Page 1 of 1 TN 13-0017-MM1 Approval Date: 06/02/2014 Effective Date: 01/01/2014

New Hampshire

OFFICIAL

Medicaid Eligibility

C 4

COS OE MERCK A AME NCNM ERIC

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

Eligibility Groups - Options for Coverage Individuals above 133% FPL eae 1902(a)(10)(A)(ii)(XX)

1902(hh) 42 CFR 435.218

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

C Yes @ No

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

Page | of 1 TN 13-0017-MM1 Approval Date: 06/02/2014 Effective Date: 01/01/2014

New Hampshire

OFFICIAL

Medicaid Eligibility

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

S51

Eligibility Groups - Options for Coverage Optional Coverage of Parents and Other Caretaker Relatives

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

Optional Coverage of Parents and Other Caretaker Relatives - The state elects to cover individuals qualifying as parents or other caretaker relatives who are not mandatorily eligible and who have income at or below a standard established by the state and in accordance with provisions described at 42 CFR 435.220.

C Yes @ No

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

Page | of 1 TN 13-0017-MM1 Approval Date: 06/02/2014 Effective Date: 01/01/2014

New Hampshire

OFFICIAL

Medicaid Eligibility

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

Eligibility Groups - Options for Coverage Reasonable Classification of Individuals under Age 21 mee 42 CFR 435.222

1902(a)(10)(A)(ii)(D) 1902(a)(10)(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.

@ Yes (© No

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

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

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

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

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

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

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

@ Yes (C 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.

C Yes @ No

Reasonable Classifications Previously Covered

The state elects the option to include in this eligibility group reasonable classifications that were covered under the Medicaid state plan as of December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013.

@ Yes ( No

The state covers all children under a specified age limit, no higher than any age limit and/or income standard covered in the state plan as of December 31, 2013 or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013, provided the income standard is higher than the current mandatory income standard for the individual's age. Higher income standards may include the disregard of all income.

C Yes @ No

Page | of 3 TN 13-0017-MM1 Approval Date: 06/02/2014 Effective Date: 01/01/2014

New Hampshire

OFFICIAL

Medicaid Eligibility

The state covers reasonable classifications of children that were covered under the Medicaid state plan as of December 31, 2013 or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013 with an income standard higher than the current mandatory income standard for the age group.

@ Yes © No

The previously covered reasonable classifications to be included are:

Previously Covered Reasonable Classifications Included

Reasonable Classifications of Children Sil

(J Individuals for whom public agencies are assuming full or partial financial responsibility. (J Individuals in adoptions subsidized in full or part by a public agency (J Individuals in nursing facilities, if nursing facility services are provided under this plan

oO Individuals receiving active treatment as inpatients in psychiatric facilities or programs, if such services are provided under this plan

Other reasonable classifications

Name of classification Description Age Limit

Children who were enrolled in Medicaid on 12/31/13 and would otherwise become ineligible for Medicaid at their first redetermination + | 2101(f)-like children using MAGI methodologies solely due ||Under age 19 xX to the loss of income disregards will remain Medicaid eligible until their next redetermination using MAGI methodologies.

Enter the income standard used for these classifications (which may be no higher than the highest standard used in the Medicaid state plan as of December 31, 2013 or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013).

| Click here once S11 form above is complete to view the income standards form.

2101 (f)-like children

[B] Income standard used [=] Minimum income standard

The minimum income standard for this classification of children must exceed the lowest income standard chosen for children under this age under the Infants and Children under Age 19 eligibility group.

[=] Maximum income standard

Page 2 of 3 TN 13-0017-MM1 Approval Date: 06/02/2014 Effective Date: 01/01/2014

New Hampshire

OFFICIAL BPs a a) EE EE]

Medicaid Eligibility

No income test was used (all income was disregarded) for this classification either in the Medicaid state plan as of December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013.

@ Yes ( No

The state's maximum standard for this classification of children is no income test (all income is disregarded).

[M) Income standard chosen Individuals qualify under this classification under the following income standard: @ This classification does not use an income test (all income is disregarded).

C Another income standard higher than the minimum income standard.

New reasonable classifications covered

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

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

C Yes @ No

{@] There is no resource test for this eligibility group.

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

Page 3 of 3 TN 13-0017-MM1 Approval Date: 06/02/2014 Effective Date: 01/01/2014 New Hampshire

OFFICIAL

Medicaid Eligibility

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

Eligibility Groups - Options for Coverage s Children with Non IV-E Adoption Assistance ss

42 CFR 435.227 1902(a)(10)(A)Gi)(VIID)

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

@ Yes (No The state attests that it operates this eligibility group in accordance with the following provisions:

[B) Individuals qualifying under this eligibility group must meet the following criteria:

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

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

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

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

@ Yes ( No

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

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

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

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

@ Yes (© No [@] Income standard used for this eligibility group

{[@] Minimum income standard

The minimum income standard for this eligibility group must exceed the lowest income standard chosen for children under this age under the Infants and Children under Age 19 eligibility group.

[=] Maximum income standard

Page | of 2 TN 13-0017-MM1 Approval Date: 06/02/2014 Effective Date: 01/01/2014

New Hampshire

OFFICIAL RTE ere a an a

—¥ Medicaid Eligibility

No income test was used (all income was disregarded) for this eligibility group either in the Medicaid state plan as of March 23, 2010 or December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013.

@ Yes (© No

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

(J The Medicaid state plan as of March 23, 2010. IX] The Medicaid state plan as of December 31, 2013. (J A Medicaid 1115 Demonstration as of March 23, 2010. (J A Medicaid 1115 Demonstration as of December 31, 2013. The state's maximum standard for this eligibility group is no income test (all income is disregarded). {@] Income standard chosen

Individuals qualify under this eligibility group under the following income standard, which must be higher than the minimum for this child's age:

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

Another income standard higher than both the minimum income standard and the effective income level for this eligibility group in the state plan as of March 23, 2010, converted to a MAGI-equivalent.

{@] There is no resource test for this eligibility group.

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

Page 2 of 2 TN 13-0017-MM1 Approval Date: 06/02/2014 Effective Date: 01/01/2014

New Hampshire

OFFICIAL

Medicaid Eligibility

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

Eligibility Groups - Options for Coverage Optional Targeted Low Income Children = 1902(a)(10)(A)(ii)(XTV) 42 CFR 435.229 and 435.4 1905(u)(2)(B)

Optional Targeted Low Income Children - The state elects to cover uninsured children who meet the definition of optional targeted

low income children at 42 CFR 435.4, who have household income at or below a standard established by the state and in accordance with provisions described at 42 CFR 435.229.

@ Yes C No The state attests that it operates this eligibility group in accordance with the following provisions: Individuals qualifying under this eligibility group must not be eligible for Medicaid under any mandatory eligibility group. y ry eligibility group.

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

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

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

@ Yes (© No

a Until October 1, 2019, states must include at least those individuals covered as of March 23, 2010, but may cover additional individuals. Effective October 1, 2019, states may reduce or eliminate coverage for this group.

[@] Individuals are covered under this eligibility group, as follows: @ All children under age 18 or 19 are covered: @ Under age 19

C Under age 18

C The reasonable classification of children covered is: [i] Income standard used for this classification [8] Minimum income standard The income standard for this classification of children must exceed the lowest income standard chosen for

children in the age group selected above, under the mandatory Infants and Children under Age 19 eligibility group.

[B] Maximum income standard

Page 1 of 3 TN 13-0017-MM1 Approval Date: 06/02/2014 Effective Date: 01/01/2014

New Hampshire

OFFICIAL DPhil, ee

Medicaid Eligibility

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

An attachment is submitted.

The state's maximum income standard for this classification of children (which must exceed the minimum for the classification) is:

The state's effective income level for this classification of children under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL.

The state's effective income level for this classification of children under the Medicaid State Plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL.

The state's effective income level for this classification of children under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL.

The state's effective income level for this classification of children under a Medicaid 1115 demonstration as of December 31, 2013, converted toa MAGI-equivalent percent of FPL.

C 200% FPL.

Cc A percentage of the FPL which may exceed the Medicaid Applicable Income Level, defined in section 2110(b)(4) of the Act, but by no more than 50 percentage points.

a The state's maximum income standard for this classification of children (which must exceed the minimum for the classification) is:

318 % FPL

[] Income standard chosen, which must exceed the minimum income standard Individuals qualify under the following income standard: @ The maximum income standard.

Cc The state's effective income level for this eligibility group under the Medicaid state plan as of March 23, 2010, converted toa MAGI-equivalent percent of FPL.

If higher than the effective income level used under the state plan as of March 23, 2010, the state's effective C income level for this eligibility group under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL.

If higher than the effective income level used under the state plan as of March 23, 2010, the state's effective C income level for this eligibility group under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL.

If higher than the effective income level used under the state plan as of March 23, 2010, the state's effective C income level for this eligibility group under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL.

C If higher than the effective income level used under the state plan as of March 23, 2010, 200% FPL.

Page 2 of 3 TN 13-0017-MM1 Approval Date: 06/02/2014 Effective Date: 01/01/2014 New Hampshire

. OFFICIAL ieee ae Oe SE a a ee] Medicaid Eligibility

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

Eligibility Groups - Options for Coverage Individuals with Tuberculosis =

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

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

C Yes @ No

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

Page | of | TN 13-0017-MM1 Approval Date: 06/02/2014 Effective Date: 01/01/2014

New Hampshire

OFFICIAL

Medicaid Eligibility

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

S57

Eligibility Groups - Options for Coverage Independent Foster Care Adolescents

42 CFR 435.226 1902(a)(10)(A)(ii)(X VID)

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

C Yes @ No

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

Page | of 1 TN 13-0017-MM1 Approval Date: 06/02/2014 Effective Date: 01/01/2014

New Hampshire

OFFICIAL

Medicaid Eligibility

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

Eligibility Groups - Options for Coverage Individuals Eligible for Family Planning Services nee

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

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

@ Yes © No The state attests that it operates this eligibility group in accordance with the following provisions: [B] The individual may be a male or a female. {m] Income standard used for this group

[B] Maximum income standard

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

An attachment is submitted.

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

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

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

The amount of the maximum income standard is

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

C Another income standard less than the maximum standard allowed.

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

Page | of 3 TN 13-0017-MM1 Approval Date: 06/02/2014 Effective DateL 01/01/2014 New Hampshire

OFFICIAL

Medicaid Eligibility

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

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

@ The state considers only the income of the applicant. {&] Benefits for this eligibility group are limited to family planning and related services described in the Benefit section. [B] Presumptive Eligibility The state makes family planning services and supplies available to individuals covered under this group when determined presumptively eligible by a qualified entity. @ Yes (© No The state also covers medical diagnosis and treatment services that are provided in conjunction with a family planning service in a family planning setting during the presumptive eligibility period. @ Yes CC No [=] The presumptive period begins on the date the determination is made. [B] 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.

[B] Periods of presumptive eligibility are limited as follows: @ No more than one period within a calendar year. C No more than one period within two calendar years.

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

C Other reasonable limitation:

Page 2 of 3 TN 13-0017-MM1 Approval Date: 06/02/2014 Effective DateL 01/01/2014 New Hampshire

OFFICIAL

Medicaid Eligibility

The state requires that a written application be signed by the applicant or representative. @ Yes © No

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

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

An attachment is submitted.

[i] The presumptive eligibility determination is based on the following factors:

[B) The individual must not be pregnant. {B] Household income must not exceed the applicable income standard specified for this group. State residency

Citizenship, status as a national, or satisfactory immigration status

The state uses entities, as defined in section 1920C, to determine eligibility presumptively for this eligibility group. [B] These entities must be eligible to receive payment for services under the state's approved Medicaid state plan and determined by the state to be capable of determining presumptive eligibility for this group.

The types of entities used to determine presumptive eligibility for this eligibility group are:

Name of entity Description Planned Parenthood of New + England x *F | Family Planning Clinics x

The state assures that it has communicated the requirements for entities, at 1920C of the Act, and has provided adequate training to the entities and organizations involved. 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.

V.20131009

Page 3 of 3 TN 13-0017-MM1 Approval Date: 06/02/2014 Effective DateL 01/01/2014 New Hampshire

OFFICIAL

Medicaid Eligibility

If higher than the effective income level used under the state plan as of March 23, 2010, a percentage of the C FPL which may exceed the Medicaid Applicable Income Level, defined in section 2110(b)(4) of the Act, but by no more than 50 percentage points.

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

318 % FPL

The income standard for this eligibility group is:

[B] There is no resource test for this eligibility group. [Bi] Presumptive Eligibility

Presumptive eligibility for this group depends upon the selection of presumptive eligibility for the Infants and Children [m] under Age 19 eligibility group. If presumptive eligibility is done for that group, it is done for this group under the same provisions.

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.

Page 3 of 3 TN 13-0017-MM1 Approval Date: 06/02/2014 Effective Date: 01/01/2014

New Hampshire

_____________________________________________________________________________

Table of Contents State/Territory Name: New Hampshire State Plan Amendment (SPA) #:13-0018-MM2 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Superseding Pages Notice (delete if not applicable) 4) Approved SPA Pages 5) Additional Attachments that are part of the state plan

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

JFK Federal Building, Government Center

Room 2275

Boston, Massachusetts 02203,

CMS

CENTERS FOR MEDICARE & MEDICAID SERVICES

Division of Medicaid and Children’s Health Operations / Boston Regional Office

March 11, 2014

Nicholas A. Toumpas, Commissioner Department of Health and Human Services State of New Hampshire

129 Pleasant Street

Concord, NH 03301

Re: New Hampshire SPA TN 13-0018-MM2

Dear Commissioner Toumpas,

Enclosed is an approved copy of New Hampshire’s (NH) State Plan Amendment (SPA) 13-0018-MM2, which was submitted to CMS on December 31, 2013. SPA 13-0018-MM2 incorporates a single streamlined application into NH’s Medicaid State Plan in accordance with the Affordable Care Act. The effective date of this SPA is October 1, 2013.

Transmittal # 13-0018-MM2 --Eligibility Process

Enclosed is a copy of the new State Plan pages to be incorporated within a separate section at the back of NH’s approved State Plan: e $94, Pages S94-1 and S94-2

In addition, enclosed is a summary of State Plan pages that are superseded by NH 13-0018-MM2; this document should be incorporated into a separate section in the front of the State Plan.

e Superseding pages of state plan material, SPA 13-0018-MM2 CMS appreciates the significant amount of work your staff dedicated to preparing this state plan

amendment. If there are questions, please contact Joyce Butterworth at (617) 565-1220 or by e-mail at Joyce.Butterworth@cms.hhs.gov.

Sincerely, /s/

Richard R. McGreal Associate Regional Administrator Enclosure/s

ce: Kathleen Dunn, State Medicaid Director Diane Peterson, Medicaid Business and Policy

-s-

SUPERSEDING PAGES OF STATE PLAN MATERIAL

TRANSMITTAL NUMBER:

NH-13-0018-MM2 STATE:

New Hampshire

PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:

S94 – Eligibility Process

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

Section 2, Page 10, TN 91-23 Effective date: 11/01/91, approved: 11/27/92 Section 2, Page 11a, TN 91-25 Effective date: 12/01/91, approved: 03/88/92

OFFICIAL

Medicaid Eligibility

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

General Eligibility Requirements Eligibility Process ; | xe

42 CFR 435, Subpart J and Subpart M

Eligibility Process

The state meets all the requirements of 42 CFR 435. Subpart J for processing furnishing Medicaid.

applications, determining and verifying eligibility, and 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.

o 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 [Xi 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 ¢ applicable modified adjusted g1

ency uses for individuals applying for coverage who may be eligible on a basis other than the 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.

oO 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 ageney'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 CPR 435.1200(1). by telephone. via mail. and in person.

The agency also accepts applications by other electronic means:

@ Yes © No

Page | of 2 NH 13-0018MM2 Approval Date: 03/11/2014 Effective Date: 10/01/2013 New Hampshire S94-1

OFFICIAL Dc

cms Medicaid Eligibility

CONOR POE DACA A AOE IOEDS

Indicate the other electronic means below:

Name of Method Description

+ Fax Applications can also be submitted through facsimile x

The ageney 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 1V-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:

{m] 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 ageney cannot determine eligibility solely on the basis of the information available to it, or otherwise needs additional (W] information to complete the redetermination, it provides the individual with a pre-populated renewal form containing the information already available.

iw 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

[X] 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 change and with other agencies administering insurance affordability programs.

with the E

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 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.

Page 2 of 2 NH 13-0018MM2 Approval Date: 03/11/2014 Effective Date: 10/01/2013 New Hampshire S94-2

NH Department of Health and Human Services (DHHS) Division of Family Assistance (DFA)

OTPPAT OF AeAlgom 800MA ong

te ee ee

Application for Health Coverage & Help Paying Costs

THINGS TO KNOW

Use this application to see what coverage choices you qualify for

Who can use this application?

Apply faster online

What you may need to apply

Why do we ask for

this information?

What happens next?

Get help with this application.

You can apply for additional programs by completing a few more questions

Did you know that we offer other forms of assistance?

e e

Affordable private health insurance plans that offer comprehensive coverage to help you stay well.

A new tax credit that can immediately help pay your premiums for health coverage

Free or low-cost insurance from Medicaid or the Children’s Health Insurance Program (CHIP)

You may qualify for a free or low-cost program even if you earn as much as $94,000 a year (for a family of 4).

Use this application to apply for anyone in your family.

Apply even if you or your child already has health coverage. You could be eligible for lower-cost or free coverage.

If you're single, you may be able to use a short form. Visit HealthCare.gov.

Families that include immigrants can apply. You can apply for your child even if you aren't eligible for coverage. Applying won't affect your immigration status or chances of becoming a permanent resident or citizen.

If someone is helping you fill out this application, you may need to complete Appendix C.

, Go to HealthCare.gov or nheasy.nh.gov.

Social Security numbers (or document numbers for any legal immigrants who need insurance) Employer and income information for everyone in your family (for example, from paystubs, W-2 forms, or wage and tax statements)

Policy numbers for any current health insurance

Information about any job-related health insurance available to your family

We ask about income and other information to let you know what coverage you qualify for and if you can get any help paying for it. We'll keep all the information you provide private and secure, as required

by law.

Send your complete, signed application to the address on page 7.

If you don’t have all the information we ask for, sign and submit your application anyway. We'll follow-up with you within 1-2 weeks.

You'll get instructions on the next steps to complete your health coverage. If you don’t hear from us, visit HealthCare.gov or call 1-800- 852-3345 ext. 9700. Filling out this application doesn’t mean you

__have to buy health coverage.

You can apply for these additional programs by filling out DFA Form 800MA

Online: HealthCare.gov

Phone: Call Client Services at 1-800- 852-3345 ext. 9700.

In person: There may be counselors in your area who can help. Call 1-800- 852-3345 ext. 9700 for more information.

En Espanol: Llame a nuestro centro de ayuda gratis al 1-800- 852-3345 ext. 9700.

Insert, included with this

application. To apply for these programs, you must return all pages of this application, including the insert, to your local District Office.

State Supplement Program (SSP) Medical Assistance: Aid to the Needy Blind (ANB), Aid to the Permanently and Totally Disabled (APTD), and Old Age Assistance (OAA).

Long Term Care Services: {f you are living in a Nursing Facility, or you require Home Care services, we may be able to help pay for some of those costs.

Medicaid for Employed Adults with Disabilities, otherwise known as the MEAD program.

* Medicare Savings Programs (MSP) to help with your Medicare premiums.

‘You may be able to get the following help from us:

Food Stamps: The Food Stamp Program helps thousands of people buy healthy food.

Cash: If you are having trouble paying your bills, we offer cash assistance for qualifying adults and families.

Child Care: If you are having trouble paying for child care while you are working, looking for work, or going to school, we may be able to help pay for some of your child care costs.

YOU CANNOT USE THIS APPLICATION TO APPLY FOR THESE OTHER FORMS OF ASSISTANCE. If you want to apply for any of these other forms of assistance, go to www.nheasy.nh.gov to apply online, visit our website at www.dhhs.nh.gov/dfa/apply.htm to download an ___.. application, or call us at 1-800-852-3345 ext. 9700. ; . : — if you ONLY want to apply for Medicaid or federal payment assistance to help buy health coverage fill out all pages as best you can. Do not fill out any questions you do not understand. If you have questions, call Client Services at 1-800-852-3345 ext. 9700 OR ask the person helping you with this

application. “ NEED HELP WITH YOUR APPLICATION? Visit HealthCare.gov or call us at 1-800-345-3345 ext. 9700. Para obtener una copia de este ?. formulario en Espafiol, llame 1-800-852-3345 ext. 9700. If you need help in a language other than English, call 1-800-852-3345 ext. 9700 and tell the customer service representative the language you need. We'll get you help at no cost to you. TTY users should call 1-800-735-2964 or 711.

13-0018MM2 New Hampshire

Approval Date: 03/11/2014 Effective Date: 10/01/2013

NH Department of Health and Human Services (DHHS) DFA Form 800MA Division of Family Assistance (DFA) 01/14

OFFICIAL

13-0018MM2 Approval Date: 03/11/2014 Effective Date: 10/01/2013 New Hampshire

NH Department of Health and Human Services (DHHS) “yA i q } DFA Form 800MA Division of Family Assistance (DFA) ay ‘ i ICA 01/14

STEP.1 _ Tell us about yourself. (We need one adult in the family to be the contact person for your application.)

1. First name, Middle name, Last name, & Suffix:

2. Home address (Leave blank if you don’t have one.): 3. Apartment or suite number: 4. City: 5. State: 6. ZIP code: 7. County:

8. Mailing address (if different from home address. ): 9. Apartment or suite number: 10. City: 11. State: 12. ZIP code: 13. County:

14. Phone number: 15. Other phone number:

(_) - ( )-

16. Do you have an email address? [] Yes [J No

If so, what is your Email address: 17. Would you like to get your notices online instead of getting them in the mail? LJ Yes [] No

If you select “yes” above, a letter will be sent to you in the mail. This letter will contain the following:

e information about New Hampshire's online eligibility web portal, NH EASY;

e steps on how to establish a NH EASY account; and

e atime-sensitive PIN, which is needed to create a NH EASY account.

You must create a NH EASY account to receive your notices online. You can also check your application status and report changes through NH EASY!

18. Preferred spoken or written language (if not English).

STEP 2 Tell us about your family.

Who do you need to include on this application?

Tell us about all the family members who live with you. If you file taxes, we need to know about everyone on your tax return. (You don’t need to file taxes to get health coverage.)

DO include: You DON’T have to include:

¢ Yourself e Your unmarried partner who doesn’t need health

e Your spouse coverage if you have no children in common

e Your children under 21 who live with you e Your unmarried partner’s children

e Your unmarried partner if you have children in common or if e Your parents who live with you, but file their own he or she needs health coverage tax return (if you’re over 21)

e Anyone you include on your tax return, even if they don’t live e Other adult relatives who file their own tax return with you

e Anyone else under 21 who you take care of and lives with you

The amount of assistance or type of program you qualify for depends on the number of people in your family and their incomes. This information helps us make sure everyone gets the best coverage they can.

Complete Step 2 for each person in your family. Start with yourself, then add other adults and children. If you have more than 2 people in your family, you'll need to make a copy of the pages and attach them. You don’t need to provide immigration status or a Social Security Number (SSN) for family members who don't need health coverage. We'll keep all the information you provide private and secure as required by law. We'll use personal information only to check if you're eligible for health coverage.

"=" NEED HELP WITH YOUR APPLICATION? Visit HealthCare.gov or call us at 1-800-852-3345 ext. 9700 . Para obtener una copia de este

formulario en Espafiol, llame 1-800-852-3345 ext. 9700. If you need help in a language other than English, call 1-800-852-3345 ext. 9700 and tell ~ the customer service representative the language you need. We'll get you help at no cost to you. TTY users should call 1-800-735-2964 or 711.

Page 1 of 9

13-0018MM2 Approval Date: 03/11/2014 Effective Date: 10/01/2013 New Hampshire

NH Department of Health and Human Services (DHHS) NTC. : Division of Family Assistance (DFA) a x ig ICTAL OFA Form oom

STEP 2: PERSON 1 (Start with yourself) Complete Step 2 for yourself, your spouse/partner and children who live with you and/or anyone on i i

y | your same federal income tax return if you fil . See page 1 for more information about who to include. If you don't file a tax return, remember to still add family members who lve with you sone 1. First name, Middle name, Last name, & suffix: ‘2. Relationship to you? ; SELF 3. Date of birth (mm/dd/yyyy) 4. Sex: LJMale L]Female

5. Social Securitynumber (SSN); sosesennns

We need this if you want health coverage and have an SSN. Providing your SSN can be helpful if you don’t want health coverage too since it can

speed up the application process. We use SSNs to check income and other information to see who's eligible for help with health coverage costs. If

someone wants help getting an SSN, call 1-800-772-1213 or visit socialsecurity.gov. TTY users should call 1-800-325-0778.

6. Do you plan to file a federal income tax return NEXT YEAR? - .

(You can still apply for health insurance even if you don't file a federal income tax return.)

COYES. If yes, please answer questions a-e. LINO. If no, skip to question d. a. Will you file jointly with a spouse? L]Yes LINo If yes, name of spouse: b. Will you claim any dependents on your tax return? L]Yes LINo If yes, list name(s) of dependents: c. Do any of these dependents live with someone else? [Yes LJNo If yes, list name(s) of dependents: d. Are you required to file a federal income tax return next year? OYes CINo e. Will you be claimed as a dependent on someone's tax return? L]Yes [JNo

If yes, please list the name of the tax filer: How are you related to the tax filer?

7. Are you pregnant? L]Yes CINo If yes, a. how many babies are expected during this pregnancy? b. due date:

8. Do you need health coverage? (Even if you have insurance, there might be a program with better coverage or lower costs.) (yes. If yes, answer all the questions below il CINo. If no, skip to the income questions on page 3. oo ; _ Leave the rest of this page blank. ; => 7 9. Do you have a physical, mental, or emotional health condition that causes limitations in activities (like bathing, dressing, daily chores, etc) or live in a medical facility or nursing home? 0 Yes 1) No 10. Are you a U.S. citizen or U.S. national? [] Yes (J No 11. If you aren't a U.S. citizen or U.S. national, do you have eligible immigration status? Des. Fill in your document type and ID number below. a. Immigration document type b. Document ID number

c. Have you lived in the U.S. since 1996? OYes CINo d. Are you, or your spouse or parent a veteran or an active-duty member of the U.s. military? [JYes [CINo

12. Do you want help paying for medical bills from the last 3 months? (Yes CINo 13. Do you live with at least one child under the age of 19, and are you the main person taking care of this child? L]Yes CNo 14. Are you a full-time student? []Yes LJNo 15. Were you in foster care at age 18 or older? [Yes [No 16. If Hispanic/Latino, ethnicity (OPTIONAL—check all that apply.)

(Mexican CJMexican American [1Chicano/a [Puerto Rican []Cuban []Other

17. Race (OPTIONAL—check all that apply.)

Owhite OKorean [Japanese (Native Hawaiian (Guamanian or Chamorro Dvietnamese DaAsian Indian LFilipino Black or African American (Other Pacific Islander OChinese (Other Asian (Samoan (American Indian or Alaska native (Other

‘gg: NEED HELP WITH YOUR APPLICATION? Visit HealthCare.gov or call us at 1-800-852-3345 ext. 9700 . Para obtener una copia de este

? * formulario en Espafiol, llame 1-800-852-3345 ext. 9700. If you need help in a language other than English, call 1-800-852-3345 ext. 9700 and tell

© > the customer service representative the language you need. We'll get you help at no cost to you. TTY users should call 1-800-735-2964 or 711. Page 2 of 9

13-0018MM2 Approval Date: 03/11/2014 Effective Date: 10/01/2013 New Hampshire

NH Department of Health and Human Services (DHHS)

inf 7 a DFA F Division of Family Assistance (DFA) °m oon “STEP.2: PERSON ‘1° © (Continue with yourself) Current Job & Income Information (Employed CINot employed Self-employed If you’re currently employed, tell us about Skip to question 28. Skip to question 27. your income. Start with question 18. CURRENT JOB 1: 18. Employer name and address 19. Employer phone number ( ) = 20. Wages/tips (before taxes) []Hourly []Weekly [Every 2 weeks []Twice a month [JMonthly L1Yearly $ 21. Average hours worked each WEEK CURRENT JOB 2: (If you have more jobs and need more space, attach another sheet of paper.) 22. Employer name and address 23. Employer phone number (_) - 24. Wagesitips (before taxes) []Hourly []Weekly [JEvery 2 weeks []Twice a month [)Monthly L]Yearly $ 25. Average hours worked each WEEK 26. In the past year, did you: [JChange jobs [Stop working Cstart working fewer hours Clone of these 27. If self-employed, answer the following questions: ; ; a. Type of work b. How much net income (profits once business expenses are paid) will you get from this self-employment this month? $ 28. OTHER INCOME THIS MONTH: Check all that apply, and give the amount and how often you get it NOTE: You don't need to tell us about child support, veteran's payment, or supplemental security income (SSI). None [Unemployment $ How Often? [inet farmingffishing $s How Often? OPensions $ How Often? DiRental/royalty $s How Often? OSocial security $ How Often? DAnnuity/trust $ How Often? DRetirement $ “_How Often? (Other income $ How Often? DAlimony $ How Often? Type:

29. DEDUCTIONS: Check all that apply, and give the amount and how often you get it. If you pay for certain things that can be deducted on a federal income tax return, telling us about them could make the cost of health coverage a little lower. NOTE: You shouldn't include a cost that you already considered in your answer to net self-employment (question 27b). Alimony paid $ How Often? other deductions $ How Often? CStudent loan interest $ -__How Often? Type:

30. YEARLY Income: Complete only if your income changes from month to month. If you don't expect changes to your monthly income, skip to the next person. —> Your total income this year Your total income next year (if you think it will be different)

$ $ * THANKS! This is all we need to know about you.

NEED HELP WITH YOUR APPLICATION? Visit HealthCare.gov or call us at 1-800-852-3345 ext. 9700 . Para obtener una copia de este

* formulario en Espajiol, llame 1-800-852-3345 ext. 9700. If you need help in a language other than English, call 1-800-852-3345 ext. 9700 and tell

the customer service representative the language you need. We'll get you help at no cost to you. TTY users should call 1-800-735-2964 or 711. Page 3 of 9

13-0018MM2 Approval Date: 03/11/2014 Effective Date: 10/01/2013 New Hampshire

NH Department of Health and Human Services (DHHS) DFA Form 800MA Division of Family Assistance (DFA) 01/14

13-0018MM2 Approval Date: 03/11/2014 Effective Date: 10/01/2013 New Hampshire

NH Department of Health and Human Services (DHHS) : DFA Division of Family Assistance (DFA) pEetCTAL Form oa

STEP 2: PERSON 2. .

Complete Step 2 for yourself, your spouse/partner and children who live with you and/or anyone on your same federal income tax return if you file one. See _Page 1 for more information about who to include. If you don’ file a tax return, remember to stil add family members who live with you. 1. First name, Middle name, Last name, & suffix: | 2. Relationship to you?

3. Date of birth (mm/dd/yyyy) j 4. Sex: LJMale L]Female

\

5. Social Security number (SSN): ee cooeeeennns We need this if you want health coverage and have an SSN. 6. Does PERSON 2 live at the same address as you? L]Yes LINo

If no, list address:

7. Does PERSON 2 plan to file a federal income tax return NEXT YEAR? (You can still apply for health insurance even if you don't file a federal income tax return.)

LIYES. if yes, please answer questions a-e. CNO. If no, skip to question d. a. Will PERSON 2 file jointly with a spouse? (]Yes [No

If yes, name of spouse:

b. Will PERSON 2 claim any dependents on your tax return? L]Yes LJNo

If yes, list name(s) of dependents: c. Do any of these dependents live with someone else? []Yes CINo If yes, list name(s) of dependents: d. Are you required to file a federal income tax return next year? []Yes [No

e. Will PERSON 2 be claimed as a dependent on someone's tax return? L]Yes [No If yes, please list the name of the tax filer: How is PERSON 2 related to the tax filer?

8. ls PERSON 2 pregnant? (Yes LINo If yes, a. how many babies are expected during this pregnancy? __b. due date:

9. Does PERSON 2 need health coverage? (Even if they have insurance, there might be a program with better coverage or lower costs.) (Yes If yes, answer all the questions below (No If no, skip to the income questions on page 5. = en _— _.. _. Leave the rest of this page blank. _ 10. Does PERSON 2 have a physical, mental, or emotional health condition that causes limitations in activities (like bathing, dressing, daily chores, etc) or live in a medical facility or nursing home? OYes [No 11. ls PERSON 2 a U.S. citizen or U.S. national? T1Yes [INo 12. If PERSON 2 isn’t a U.S. citizen or U.S. national, do they have eligible immigration status? (Yes. Fill in their document type and ID number below. a. Document type b. Document ID number

c. Has PERSON 2 lived in the U.S. since 1996? LYes CJNo_ d. Is PERSON 2, or their spouse or parent a veteran or an active- duty member of the U.S. military? L]Yes [No

14. Does PERSON 2 live with at least one child under the age | 15. Were you in foster medical bills from the last 3 months? of 19, and are they the main person taking care of this child? care at age 18 or older? Des CINo L G¥esONo | Des FINO

Please answer the following questions if PERSON 2 is 22 or younger: 16. Did PERSON 2 have insurance through a job and lose it within the past 3 months? L]Yes CINo a. If yes, end date: b. Reason the insurance ended:

43. Does PERSON 2 want help paying for

17. is PERSON 2 a fulltime student? ClYes INO _ 18. If Hispanic/Latino, ethnicity (OPTIONAL—check all that apply.) (Mexican [Mexican American (1Chicano/a (Puerto Rican []Cuban [Other

19. Race (OPTIONAL—check all that apply.)

Owhite Okorean (Japanese (Native Hawaiian (OGuamanian or Chamorro OVietnamese ODAsian Indian (Filipino (Black or African American (Other Pacific Islander UChinese (Other Asian (Samoan American Indian or Alaska native Other

Now, tell us about any income from PERSON 2 on the back. -— : NEED HELP WITH YOUR APPLICATION? Visit HealthCare.gov or call us at 1-800-852-3345 ext. 9700 . Para obtener una copia de este 1 formulario en Espafiol, llame 1-800-852-3345 ext. 9700. If you need help in a language other than English, call 1-800-852-3345 ext. 9700 and tell : the customer service representative the language you need. We'll get you help at no cost to you. TTY users should call 1-800-735-2964 or 711. 13-0018MM2 Approval Date: 03/11/2014 Effective Date: 10/01/2013 New Hampshire

NH Department of Health and Human Services (DHHS) DFA Form 800MA Division of Family Assistance (DFA) 01/14

Page 4 of 9

OFFICIAL

13-0018MM2 Approval Date: 03/11/2014 Effective Date: 10/01/2013 New Hampshire

NH Department of Health and Human Services (DHHS) OLE TAL Division of Family Assistance (DFA) we te DFA Form son

&

01/14 Current Job & Income Information (Employed CINot employed OSelf-employed If you're currently employed, tell us about Skip to question 30. Skip to question 29. your income. Start with question 20. CURRENT JOB 1: 20. Employer name and address 21. Employer phone number ( ) = 2 Wagesttips (before taxes) []Hourly []Weekly [JEvery 2 weeks [JTwice a month L]Monthly LlYearly 23. Average hours worked each WEEK _CURRENT JOB 2: (If you have more jobs and need more space, attach another sheet of paper.) 24. Employer name and address 25. Employer phone number (_) - 26. Wagesitips (before taxes) []Hourly []Weekly [Every 2 weeks []Twice a month [Monthly []Yearly $ 27. Average hours worked each WEEK 28. In the past year, did PERSON 2: []Change jobs [Stop working [)Start working fewer hours ONone of these - 29. If self-employed, answer the following questions: re — / a. Type of work b. How much net income (profits once business expenses are paid) will you get from this self-employment this month? $

30. OTHER INCOME THIS MONTH: Check alll that apply, and give the amount and how often you get it. NOTE: You don’t need to tell us about child support, veteran’s payment, or supplemental security income (SSI). None

Unemployment $ How Often? Diet farmingfishing $ How Often? OPensions $ How Often? ORental/royalty $ How Often? OSocial security $ How Often? DAnnuity/Trust $ How Often? ORetirement $ How Often? (Other income $ How Often? DAlimony $ How Often? Type:

31. DEDUCTIONS: Check all that apply, and give the amount and how often you get it. If PERSON 2 pays for certain things that can be deducted on a federal income tax return, telling us about them could make the cost of health coverage a little lower. NOTE: You shouldn't include a cost that you already considered in your answer to net self-employment (question 27b).

DAlimony paid $ How Often? (Other deductions $ How Often?

Student loan interest $ How Often? Type:

32. YEARLY Income: Complete only if PERSON 2’s income changes from month to month. If you don’t expect changes to PERSON 2’s monthly income, skip to the next person. PERSON 2’s total income this year PERSON 2's total income next year (if you think it will be different) $ : $ THANKS! This is all we need to know about PERSON 2.

NEED HELP WITH YOUR APPLICATION? Visit HealthCare.gov or call us at 1-800-852-3345 ext. 9700 . Para obtener una copia de este

formulario en Espafiol, llame 1-800-852-3345 ext. 9700. If you need help in a language other than English, call 1-800-852-3345 ext. 9700 and tell

; the customer service representative the language you need. We'll get you help at no cost to you. TTY users should call 1-800-735-2964 or 711. Page 5 of 9

13-0018MM2 Approval Date: 03/11/2014 Effective Date: 10/01/2013

New Hampshire

NH Department of Health and Human Services (DHHS) DFA Form 800MA Division of Family Assistance (DFA) 01/14

oFICIAL

13-0018MM2 Approval Date: 03/11/2014 Effective Date: 10/01/2013 New Hampshire

NH Department of Health and Human Services (DHHS) OV GERT cCTAL DFA Form 800MA Division of Family Assistance (DFA) wea 01/4

p 2 for yourself, your spouse/partner and children who live with you and/or anyone on your same federal income tax return ifyou file one. See page 1 for more information about who to include. If you don't file a tax return, remember to still add family members who live with you. 1. First name, Middle name, Last name, & suffix: | 2. Relationship to you?

3. Date of birth (mm/dd/yyyy) 4. Sex: (JMale JFemale

5. Social Security number (SSN): We need this if you want health coverage and have an SSN.

6. Does PERSON 3 live at the same address as you? [JYes LJNo If no, list address:

7. Does PERSON 3 plan to file a federal income tax return NEXT YEAR? (You can still apply for health insurance even if you don't file a federal income tax return.)

LIYES. If yes, please answer questions a-e. LINO. If no, skip to question d. a. Will PERSON 3 file jointly with a spouse? (Yes [No

If yes, name of spouse:

b. Will PERSON 3 claim any dependents on your tax return? L]Yes LINo

c. Do any of these dependents live with someone else? Yes LJNo

If yes, list name(s) of dependents:

d. Are you required to file a federal income tax return next year? []Yes [No

If yes, list name(s) of dependents:

e. Will PERSON 3 be claimed as a dependent on someone's tax return? L]Yes LJNo If yes, please list the name of the tax filer:

How is PERSON 3 related to the tax filer?

8. Is PERSON 3 pregnant? [Yes [INo If yes, a. how many babies are expected during this pregnancy? __b. due date: 9. Does PERSON 3 need health coverage? (Even if they have insurance, there might be a program with better coverage or lower costs.) (Yes If yes, answer all the questions below [No If no, skip to the income questions on page 7. cote eats aint eta cee Leave the rest of this page blank. => fe 10. Does PERSON 3 have a physical, mental, or emotional health condition that causes limitations in activities (like bathing, dressing, daily chores, etc) or live in a medical facility or nursing home? L]Yes LJNo 11. Is PERSON 3 a U.S. citizen or U.S. national? (Yes CINo 12. If PERSON 3 isn't a U.S. citizen or U.S. national, do they have eligible immigration status? Des. Fill in their document type and ID number below. a. Document type b. Document ID number c. Has PERSON 3 lived in the U.S. since 1996? L]Yes LJNo_ d. Is PERSON 3, or their spouse or parent a veteran or an active- duty member of the U.S. military? L1Yes LINo 14. Does PERSON 3 live with at least one child under 15. Was PERSON 3 in foster medical bills from the last 3 months? the age of 19, and are they the main person taking care at age 18 or older? Oyes CINo care of this child? [Yes LJNo OYes CINo Please answer the following questions if PERSON 3 is 22 or younger: 16. Did PERSON 3 have insurance through a job and lose it within the past 3 months? L]Yes LJNo

a. If yes, end date: b. Reason the insurance ended:

13. Does PERSON 3 want help paying for

17. ls PERSON 3 a fulltime student? Yes LINO 18. If Hispanic/Latino, ethnicity (OPTIONAL—check all that apply.) (mexican (JMexican American []Chicano/a [Puerto Rican [JCuban [Other

19. Race (OPTIONAL—check all that apply.)

DWhite OKorean [LiJapanese [Native Hawaiian (1Guamanian or Chamorro Divietnamese DAsian Indian OFilipino Black or African American (Other Pacific Islander OChinese (Other Asian (Samoan [American Indian or Alaska native (Other

ee ~ "Now, tell us about any income from PERSON 3 on the back. NEED HELP WITH YOUR APPLICATION? Visit HealthCare.gov or call us at 1-800-852-3345 ext. 9700. Para obtener una copia de este formulario en Espafiol, llame 1-800-852-3345 ext. 9700. If you need help in a language other than English, call 1-800-852-3345 ext. 9700 and tell the customer service representative the language you need. We'll get you help at no cost to you. TTY users should call 1-800-735-2964 or 711.

13-0018MM2 Approval Date: 03/11/2014 Effective Date: 10/01/2013 New Hampshire

NH Department of Health and Human Services (DHHS) ntl fe” DFA Form 800MA Division of Family Assistance (DFA) eye He rAL O14 Morea Page 6 of 9 Current Job & Income Information (Employed CINot employed Self-employed If you're currently employed, tell us about Skip to question 30. Skip to question 29.

your income. Start with question 20. _CURRENT JOB 1:

20. Employer name and address 21. Employer phone number

( ) = 22. Wagesttips (before taxes) []Hourly [JWeekly [Every 2 weeks L]Twice a month []Monthly [Yearly $

23. Average hours worked each WEEK

CURRENT JOB 2: (If you have more jobs and need more space, attach another sheet of paper.) ee

24. Employer name and address 25. Employer phone number (_ ) -

26. Wages/tips (before taxes) [Hourly (]Weekly LJEvery 2 weeks []Twice a month [Monthly [Yearly

$

27. Average hours worked each WEEK

28. In the past year, did PERSON 3: [JChange jobs [Stop working [)Start working fewer hours []None of these , 29. if self-employed, answer the following questions: oe b. How much net income (profits once business expenses are paid) will you get from this self-employment this month?

$

a. Type of work

30. OTHER INCOME THIS MONTH: Check all that apply, and give the amount and how often you get it. NOTE: You don't need to tell us about child support, veteran’s payment, or supplemental security income (SSI). (None

(Unemployment $ How Often? CNet farmingffishing $ How Often? Pensions $ How Often? ORental/royalty $ How Often? OSocial security $ How Often? DaAnnuity/Trust $ How Often? ORetirement $ How Often? (other income $ How Often? DaAlimony $ How Often? Type:

31. DEDUCTIONS: Check all that apply, and give the amount and how often you get it. If PERSON 3 pays for certain things that can be deducted on a federal income tax return, telling us about them could make the cost of health coverage a little lower.

NOTE: You shouldn't include a cost that you already considered in your answer to net self-employment (question 27b).

DAlimony paid $ How Often? other deductions $ How Often?

OStudent loan interest $ How Often? Type:

32. YEARLY Income: Complete only if PERSON 3’s income changes from month to month. If you don't expect changes to PERSON 3’s monthly income, move to step 3. PERSON 3's total income this year PERSON 3’s total income next year (if you think it will be different) $ $ THANKS! This is all we need to know about PERSON 3. If you have more than three people to include, make a copy of Step 2: Person 3 (pages 6 and 7) and complete the questions for those people.

13-0018MM2 Approval Date: 03/11/2014 Effective Date: 10/01/2013

New Hampshire

NH Department of Health and Human Services (DHHS) - DFA Form 800MA

Division of Family Assistance (DFA) 01/14

NEED HELP WITH YOUR APPLICATION? Visit HealthCare.gov or call us at 1-800-852-3345 ext. 9700. Para obtener una copia de este formulario

? en Espajiol, llame 1-800-852-3345 ext. 9700. If you need help in a language other than English, call 1-800-852-3345 ext. 9700 and tell the customer “"- "service representative the language you need. We'll get you help at no cost to you. TTY users should call 1-800-735-2864 or 711.

Page 7 of 9

STEP 3 American indian or Alaska Native (AIAN) family member(s)

1. Are you or is anyone in your family American Indian or Alaska Native? Lif No, skip to Step 4.

Les. If yes, go to Appendix B.

: STEP. 4 Your Family’s Health Coverage

Answer these questions for anyone who needs health coverage. 1. Is anyone enrolled in health coverage now from the following? LIVES. If yes, check the type of coverage and write the person(s)’ name(s) next to the coverage they have. [JNO.

Medicaid [Employer insurance Ocuip Name of the health insurance: Medicare Policy number: CITRICARE (don't check if you have direct care of Line of Duty) Is this COBRA coverage? L]Yes [JNo Is this a retiree health plan? Yes [No [VA health care programs Other [Peace Corps Name of health insurance: Policy number:

Is this a limited-benefit plan (like a school accident policy)? OyYes CINo

2. Is anyone listed on this application offered health coverage from a job? Check yes even if the coverage is from someone else's job, such as a parent or spouse.

LIYES. If yes, you'll need to complete and include Appendix A. Is this a state employee benefit plan? L]Yes LJNo [INO. If no, continue to Step 5.

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-XXXX. The time required to complete this information collection is estimated to average [insert time (hours or minutes)] per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have 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.

13-0018MM2 Approval Date: 03/11/2014 Effective Date: 10/01/2013 New Hampshire

NH Department of Health and Human Services (DHHS) DFA Form 800MA Division of Family Assistance (DFA) 01/14 NEED HELP WITH YOUR APPLICATION? Visit HealthCare.gov or call us at 1-800-852-3345 ext. 9700 . Para obtener una copia de este ? formulario en Espajiol, llame 1-800-852-3345 ext. 9700. If you need help in a language other than English, call 1-800-852-3345 ext. 9700 and tell the customer service representative the language you need. We'll get you help at no cost to you. TTY users should call 1-800-735-2964 or 711.

Page 8 of 9

ee el

13-0018MM2 Approval Date: 03/11/2014 Effective Date: 10/01/2013 New Hampshire

NH Department of Health and Human Services (DHHS) tek ee DFA Form 800MA Division of Family Assistance (DFA) 01/14

STEP.5... Read & sign this application.

e I'm signing this application under penalty of perjury which means I've provided true answers to all the questions on this form to the best of my knowledge. | know that | may be subject to penalties under federal law if | provide false and or untrue information.

e ~=|know that! must tell the Health Insurance Marketplace or the Medicaid agency if anything changes (and is different than) what ! wrote on this application. | can visit HealthCare.qov or call 1-877-464-2447 to report any changes. | understand that a change in my information could affect the eligibility for member(s) of my household.

¢ | know that under federal law, discrimination isn't permitted on the basis of race, color, national origin, sex, age, sexual orientation, gender identity, or disability. | can file a complaint of discrimination by visiting www.hhs.gov/ocr/office/file.

. | confirm that no one applying for health insurance on this application is incarcerated (detained or jailed). If | have included an individual who is incarcerated, | understand this person will not be eligible for health benefits until they are released.

The following person is incarcerated and will be released

We need this information to check your eligibility for help paying for health coverage if you choose to apply. We'll check your answers using information in our electronic databases and databases from the Internal Revenue Service (IRS), Social Security, the Department of Homeland Security, and/or a consumer reporting agency. If the information doesn’t match, we may ask you to send us proof.

Renewal of coverage in future years

To make it easier to determine my eligibility for help paying for health coverage in future years, | agree to allow the Marketplace to use income data, including information from tax returns. The Marketplace will send me a notice, let me make any changes, and | can opt out at any time.

Yes, renew my eligibility automatically for the next

(5 years (the maximum number of years allowed), or for a shorter number of years:

(14 years (13 years [12 years (11 year (] Don't use information from tax returns to renew my coverage.

If anyone on this application is eligible for Medicaid

e lam giving to the Medicaid agency our rights to pursue and get any money from other health insurance, legal settlements, or other third parties. | am also giving to the Medicaid agency rights to pursue and get medical support from a spouse or parent.

¢ Does any child on this application have a parent living outside of the home? [Yes LJNo

e If yes, | know | will be asked to cooperate with the agency that collects medical support from an absent parent. If | think that cooperating to collect medical support will harm me or my children, | can tell Medicaid and | may not have to cooperate.

¢ | understand that, if | am in a nursing home, DHHS must be able to exchange eligibility information with the nursing home to best administer the program. My signature below authorizes that exchange and remains in effect for as long as | receive DHHS assistance for my nursing home care.

¢ | understand that for long-term care services (Nursing Facility or Home and Community-Based Care), | am required to disclose to DHHS any interest that my spouse or | have in any annuity.

e [understand that if either my spouse or | are requesting long-term care services, any annuity purchased or modified by my spouse or me on or after February 8, 2006 will be considered a transfer of assets for less than fair market value unless the State is named the beneficiary for at least the amount of Medicaid paid for long-term care services.

¢ | understand that the information | have provided will be verified by collateral contacts and/or Federal, State, and local officials and that if any information is found to be incorrect or false, or if | have deliberately withheld information related to my receipt of assistance, now or in the future, | may lose my benefits and may be prosecuted for fraud.

e | understand that my signature below and/or on the application authorizes DHHS to obtain verification that | or anyone in my assistance group (AG) meet the eligibility requirements for assistance, and authorizes release of such information to DHHS. My authorization to release information to DHHS remains in effect for as long as | or anyone in my AG receives any kind of DHHS assistance.

e | understand that my signature below and/or on the application permits DHHS and any contracted third party entity to verify my income, identity, and assets, and the income, identity, and assets of any other person whose income, identity, and assets are required to determine eligibility for the assistance | am requesting. Failure to give permission to conduct these verifications or revoking permission to conduct these verifications will result in denial or termination of assistance.

My right to appeal

If | think the Health Insurance Marketplace or DHHS has made a mistake, | can appeal its decision. To appeal means to tell someone at the Health Insurance Marketplace or DHHS that | think the action is wrong, and ask for an administrative appeal of the action. | know that ! can find out how to appeal by contacting the Marketplace at 1-800-318-2596 or DHHS at (603) 271-4292. | know that | can be represented in the process by someone other than myself. My eligibility and other important information will be explained to me.

Sign this application. The person who filled out Step 1 should sign this application. If you're an authorized representative you may sign here, as long as you have provided the information required in Appendix C. Your signature below certifies, under penalty of perjury, that you have reviewed the information on this application, including any information indicated on the appendixes and insert, and it is true and complete to the best of my knowledge.

Signature Date (mm/dd/yyyy)

Page 9 of 9

13-0018MM2 Approval Date: 03/11/2014 Effective Date: 10/01/2013 New Hampshire :

aks a NH Department of Health and Human Services (DHHS) CATR 7 ] y: JL DFA Form 800MA Division of Family Assistance (DFA) oo 01/4 SSTEP-6.- Mail completed application. Mail your signed application to CMU: Fax your signed application toCMU: Call in your application to Client Services:

Central Medicaid Unit (CMU) 429 Pleasant Street (603) 271-8604 (603) 271-9700 or toll free Concord NH 03301 1-800-852-3345 ext. 9700

If you would like to follow up on an application that has been mailed or faxed to If you are filling out DFA Form 800MA Insert, you must CMU, you can call them at (603) 271-9729 or toll free at 1-877-464-2447. send all pages of this application, including the insert, to

APPEN DIX A your local District Office.

Health Coverage from Jobs

You DON’T need to answer these questions unless someone in the household is eligible for health coverage from a job. Attach a copy of this page for each job that offers coverage.

Tell us about the job that offers coverage.

Take the Employer Coverage Tool on the next page to the employer who offers coverage to help you answer these questions. You only need to include this page when you send in your application, not the Employer Coverage Tool.

EMPLOYEE Information

1. Employee name (First, Middle, Last) 2. Employee Social Security number EMPLOYER Information

3. Employer name 4. Employer Identification Number (EIN)

5. Employer address : 6. Employer phone number 7. City: 8. State: ( SP code:

10. Who can we contact about employee health coverage at this job?

41. Phone number (if different from above) 12. Email address

(_) — “43. Are you currently eligible for coverage offered by this employer, or will you become eligible in the next 3 months? (Yes (Continue) 13a. If you're in a waiting or probationary period, when can you enroll in coverage? List the names of anyone else who is eligible for coverage from this job.

(mmidd/yyyy)

Name: Name: Name: [No (Stop here and go to Step 5 in the application) Tell us about the health plan offered by this employer. 14. Does the employer offer a health plan that meets the minimum value standard*?L] Yes LINo 15. For the lowest-cost plan that meets the minimum value standard‘ offered only to the employee (don’t include family plans):

If the employer has wellness programs, provide the premium that the employee would pay if he/ she received the maximum discount for any tobacco cessation programs, and did not receive any other discounts based on wellness programs.

a. How much would the employee have to pay in premiums for this plan? $ b. How often? []Weekly (Every 2 weeks []Twice a month CJQuarterly []Yearly

16. What change will the employer make for the new plan year (if known)?

(Employer won't offer health coverage

(Employer will start offering health coverage to employees or change the premium for the lowest-cost plan available only to the employee that meets the minimum value standard.* (Premium should reflect the discount for wellness programs. See question 15.)

a. How much will the employee have to pay in premiums for that plan? $ b. How often? LJWeekly [JEvery 2 weeks L]Twice a month C]Quarterly []Yearly Date of change (mm/dd/yyyy):

*An employer-sponsored health plan meets the “minimum value standard” if the plan's share of the total allowed benefit costs covered by the plan is no less than 60 percent of such costs (Section 36B(c)(2)(C)(ii) of the Intemal Revenue Code of 1986)

13-0018MM2 Approval Date: 03/11/2014 Effective Date: 10/01/2013 New Hampshire

NH Department of Health and Human Services (DHHS) ice nL DFA Form 800MA Division of Family Assistance (DFA) on rat ik tif & Le 01/14

EMPLOYER COVERAGE TOOL ve

a

Use this tool to help answer questions in Appendix A about any employer health c coverage that you's re 2 eligible for (even if it's from another person's job, like a parent or spouse). The information in the numbered boxes below match the boxes on Appendix A. For example, the answer to question 14 on this page should match question 14 on Appendix A.

Write your name and Social Security number in boxes 1 and 2 and ask the employer to fill out the rest of the form.

Complete one tool for each employer that offers health coverage.

EMPLOYEE Information

The employee needs to fill out this section.

1. Employee name (First, Middle, Last) 2. Employee Social Security number EMPLOYER Information

Ask the employer for this information.

3. Employer name 4. Employer Identification Number (EIN)

5. Employer address 6. Employer phone number

7. City: 8. State: 9. ZIP code:

10. Who can we contact about employee health coverage at this job?

11. Phone number (if different from above) 12. Email address

( ) =

: 13. Is the employee currently eligible for coverage offered by this employer, or will the employee become eligible in the next 3 months? D0 Yes (Continue) 13a. If the employee is not eligible today, including as a result of a waiting or probationary period, when is the employee eligible for coverage? ' (mmidd/yyyy) [1 No (Stop and return this form to employee) ; Tell us about the health plan offered by this employer. Does the employer offer a health plan that covers an employee's spouse or dependent? Lives. Which people? [JSpouse []Dependent(s) No (Go to question 14) 14. Does the employer offer a health plan that meets the minimum value standard*? DYes (Go to question 15) [No (STOP and return form to employee)

15. For the lowest-cost plan that meets the minimum value standard’ offered only to the employee (don't include family plans): If the employer has wellness programs, provide the premium that the employee would pay if he/ she received the maximum discount for any tobacco cessation programs, and did not receive any other discounts based on wellness programs.

a. How much would the employee have to pay in premiums for this plan? $ b. How often? []Weekly [JEvery 2 weeks [Twice a month [1Quarterly D1Yearly

If the plan year will end soon and you know that the health plans offered will change, go to question 16. If you don't know, STOP and return form to employee.

16. What change will the employer make for the new plan year? [Employer won't offer health coverage (Employer will start offering health coverage to employees or change the premium for the lowest-cost plan available only to the employee that meets the minimum value standard.* (Premium should reflect the discount for wellness programs. See question 15.) a. How much will the employee have to pay in premiums for that plan? $ b. How often? []Weekly [Every 2 weeks [Twice a month (]Quarterly L)Yearly Date of change (mm/dd/yyyy):

*An employer-sponsored health plan meets the “minimum value standard’ if the plan’s share of the total allowed benefit costs covered by the plan is no less than 60 percent of such costs (Section 36B(c)(2)(C)(ii) of the Intemal Revenue Code of 1986)

:.: NEED HELP WITH YOUR APPLICATION? Visit HealthCare.gov or call us at 1-800-852-3345 ext. 9700 . Para obtener una copia de este formulario en Espajiol, lame 1-800-852-3345 ext. 9700. If you need help in a language other than English, call 1-800-852-3345 ext. 9700 and tell . the customer service representative the language you need. We'll get you help at no cost to you. TTY users should call 1-800-735-2964 or 711.

13-0018MM2 Approval Date: 03/11/2014 Effective Date: 10/01/2013 New Hampshire

NH Department of Health and Human Services (DHHS)

Division of Family Assistance (DFA)

APPENDIX B

DFA Form 800MA 01/14

American Indian or Alaska Native Family Member (Al/AN)

Complete this appendix if you or a family member are American Indian or Alaska Native. Submit this with your Application for Health

Coverage & Help Paying Costs.

Tell us about your American Indian or Alaska Native family member(s).

American Indians and Alaska Natives can get services from the Indian Health Services, tribal health programs, or urban Indian health programs. They also may not have to pay cost sharing and may get special monthly enrollment periods. Answer the following questions to make sure your family gets the most help possible.

NOTE: If you have more people to include, make a copy of this page and attach.

1. Name First Middle First Middle (First name, Middle name, Last name) : Last Last 2. Member of a federally recognized tribe? | L]Yes | Dyes — 7

If yes, tribe name

If yes, tribe name

LINo | LINo

3. Has this person ever gotten a service LYes LYes

from the Indian Health Service, a tribal

health program, or urban Indian health LINo , ; -_ | LINo . ; 3

program, or through a referral from one of If no, is this person eligible to get If no, is this person eligible to get

these programs? services from the Indian Health services from the Indian Health Service, tribal health programs, or Service, tribal health programs, or urban Indian health programs, or urban Indian health programs, or through a referral from one of these through a referral from one of these programs? | programs? LYes LINo | OYes LINo

4. Certain money received may not be |

counted for Medicaid or the Children’s $ $

Health Insurance Program (CHIP). List any oO ~ - —_

income (amount and how often) reported How often? __ How often?

on your application that includes money

from these sources:

e Per capita payments from a tribe that come from natural resources, usage rights, leases, or royalties

e Payments from natural resources, farming, ranching, fishing, leases, or royalties from land designated as Indian trust land by the Department of Interior (including reservations and former reservations)

e Money from selling things that have cultural significance

NEED HELP WITH YOUR APPLICATION? Visit HealthCare.gov or or call us at 1-800-852-3345 ext. 9700 . Para obtener una copia de este ? formulario en Espafiol, llame 1-800-852-3345 ext. 9700. If you need help in a language other than English, call 1-800-852-3345 ext. 9700 and tell the customer service representative the language you need. We'll get you help at no cost to you. TTY users should call 1-800-735-2964 or 711.

13-0018MM2 New Hampshire

Approval Date: 03/11/2014

Effective Date: 10/01/2013

NH Department of Health and Human Services (DHHS) Division of Family Assistance (DFA)

APPENDIX C

Authorized Representative Declaration

You may choose an authorized representative to help you with some or all of the requirements of applying for or getting Medical Assistance. An authorized representative is a friend, relative or other person who has a concern for your well-being. An authorized representative is a person you choose. We will not choose one for you. The person you choose must agree to help you. An agency cannot act as an authorized representative, but an individual at an agency can. An authorized representative must be an individual person.

DFA Form 800MA 01/14

An authorized representative may fill out an application form and other paperwork for you. They may also report changes in your income, resources, and other changes for you. They may receive your medical assistance ID card, and other mail from us. You get to choose what you would like them to do for you or on your behalf by checking the boxes below.

AUTHORIZED REPRESENTATIVE DUTIES Check off the things that you want the authorized representative to do for you: C1 Get my application, forms and other Department paperwork, and fill these forms out for me.

CO Provide the Department with proof of my income, resources, and other case information, and report and verify changes in my case circumstances to the Department for me.

CJ Receive my notices from the Department.

C1 Receive my medical assistance ID card for me. U1 Go to my eligibility interviews for me.

0 Other:

CLIENT’S SIGNATURE

Please read the following statements carefully. Your signature below means you have read and understand these statements.

e | certify that | have read and understand the information on this form.

e understand that | am responsible for any errors, omissions, or inaccurate information that my authorized representative reports to the District Office.

e understand that if my authorized representative uses my benefits without my permission, these benefits will not be replaced or reissued by the Department of Health and Human Services.

e understand that the person | named as my authorized representative will continue to act for me unless | tell the Department in writing of a change.

Client's Signature Date

Client’s Printed Name

NEED HELP WITH YOUR APPLICATION? Visit HealthCare.gov or call us at 1-800-852-3345 ext. 9700. Para obtener una copia de este formulario en Espafiol, llame 1-800-852-3345 ext. 9700. If you need help in a language other than English, call 1-800-852-3345 ext. 9700 and tell the customer service representative the language you need. We'll get you help at no cost to you. TTY users should call 1-800-735-2964 or 711.

13-0018MM2 Approval Date: 03/11/2014 Effective Date: 10/01/2013 New Hampshire

a © DFA Form 800MA ad ul 01/14

NH Department of Health and Human Services (DHHS) me tpn

Division of Family Assistance (DFA) A byt yt bk

AUTHORIZED REPRESENTATIVE INFORMATION

Tell us your authorized representative's name, address, and telephone number. Please print clearly. 1. Name of authorized representative (First name, Middle name, Last name)

2. Address 3. Apartment or suite number

4. City: §. State: 6. ZIP code:

7. Phone number ( )o- 8. Describe your relationship to the authorized representative. 9. Date of Birth (Optional)

10. Agency name (if applicable)

AUTHORIZED REPRESENTATIVE’S SIGNATURE

| certify that | have read and understand the information on this form. | agree to accept the duties noted on this form and understand the following:

e understand that | must give proof of my identity to act as an Authorized Representative.

e [understand that if | have been disqualified for a program violation, | cannot act as an Authorized Representative unless there is no one else suitable to represent this individual.

e {understand that the Department has the authority to discontinue my ability to act as an Authorized Representative if it is determined that | am not acting in the best interest of the household | am assisting.

Authorized Representative's Signature Date

Authorized Representative's Printed Name

FOR CERTIFIED APPLICATION COUNSELORS, NAVIGATORS, AGENTS, AND BROKERS ONLY.

Complete this section if you're a certified application counselor, navigator, agent, or broker filling out this application for somebody else.

1. Application start date (mm/dd/yyyy)

2. First name, Middle name, Last name, & Suffix

3. Organization name 4. ID number (if applicable)

13-0018MM2 Approval Date: 03/11/2014 Effective Date: 10/01/2013 New Hampshire

NH Department of Health and Human Services (DHHS) Division of Family Assistance (DFA)

DFA Form 800

01/14

APPLICATION FOR ASSISTANCE

Welcome to the Department of Health & Human Services (DHHS), Division of Family Assistance (DFA)

To apply for the programs and services we offer, you must fill out this Application for Assistance, have an interview, and give us proof of your household circumstances. Please read all of the information given to you, and answer all of the questions as best as you can. Do not answer anything that you do not understand. lf you need help in filling out this Application, tell us. We will accept your Application even if you only fill in your name, address, and signature. However, we will be able to figure out if you can get benefits much quicker if you complete the entire Application. DFA assistance is based on your income. Some DFA programs may also look at the cash value of things that you own, your “assets,” when figuring out if you qualify for a

program DFA offers.

Food Stamp (FS) Benefits

The Food Stamp Program helps low-income people buy the food they need for good health. You will need to have an interview with a DHHS worker to see if you are eligible for this program. Your FS benefits are based on the date of application. With identification, you may get emergency FS benefits within 7 calendar days if:

» you have less than $150 in monthly gross income and no more than $100 in liquid resources;

= you have shelter costs that are higher than your gross income and liquid resources; or

= you are a migrant or seasonal farm worker who is destitute as defined in 7 CFR 273.10(e)(3).

Social Security Numbers (SSN)

The Federal Privacy Act of 1974 as amended, requires that we tell you the laws that allow us to ask for the SSN of each person requesting assistance, whether you are required to give them to us, and what we will do with them. SSNs are required for the following programs. After each program is the law or regulation that requires us to ask for these SSNs, or why we need it:

= FANE: 42 USC 405(c)(2), 45 CFR 205.52, RSA 167:4-c, & RSA 167:79,iii(h).

= Food Stamps:,\ RSA 167:4-c, Food Stamp Act of 1977, as amended, 7 USC 2011-2036, 7 CFR 273.2(b)(4), & 7 CFR 273.6.

= Medical Assistance and other __ financial assistance: RSA 167:4-c, Section 2651 of PL 98-369, 42 CFR 435.910, 42 CFR 435.920, & 42 USC 1320b-7.

Each person who wants assistance from the above

programs must provide an SSN or apply for a

number at the Social Security Administration (SSA).

13-0018MM2 Approval Date: 03/11/2014 New Hampshire

If you are applying only for some members of your family, such as a parent applying for Medical Assistance just for a child, you only have to give us the child’s number or apply for one for your child. Your child’s eligibility for medical coverage will not be affected if you don’t give us your SSN.

If an SSN is not provided for each person who is applying for the listed programs, your application may be denied or you may get less benefits. If someone wants help getting an SSN, call 1-800- 772-1213 or visit socialsecurity.gov. TTY users should call 1-800-325-0778.

Applicants for NH Child Care Scholarship only do not have to provide an SSN but if SSNs are provided it may help shorten the eligibility verification process.

We ask for SSNs so we can verify identity, earned and unearned income, and resource information you give us. It will be shared with:

= federal, state, and local entities;

* various offices within DHHS as allowed by federal law;

employment and unemployment databases;

the Internal Revenue Service and SSA; financial entities; and

other computer matching programs.

The information will be used:

* to figure out if your household is eligible or continues to be eligible for the assistance you requested;

* to figure out the amount of your benefits or errors in your eligibility or benefits; and

= in an investigation of suspected abuse of program law or rules.

This information may be disclosed to other Federal

and State agencies for official examination, and to

law enforcement officials for the purpose of

apprehending persons fleeing to avoid the law. If a

Effective Date: 10/01/2013

Food Stamp claim arises against your household, the information on this application, including all SSNs, may be referred to Federal and State agencies, as well as private claims collection agencies, for claims collection action.

We do not give SSNs or any other information regarding non-applicants to the US Citizenship and Immigration Services (USCIS), formerly known as INS, or any other agency not directly connected with programs and/or services offered by DHHS.

received in error if we made a mistake in processing your case.

Financial or Medical Child Support

Emergency Medicaid for Non-Citizens

Emergency Medicaid may be available to certain non-citizens, regardless of their immigration status, to cover some emergency services, including labor and delivery. Social Security Numbers are not needed to apply for Emergency Medicaid.

Citizenship & Identity

You must declare and prove the citizenship or non- citizenship status of each household member applying for assistance. Non-citizens applying for assistance, except Emergency Medicaid, must provide USCIS documentation of qualified alien status. USCIS documentation will be verified.

Third Party Insurance or Medical Payments

If you are applying for Medical Assistance, receipt of such assistance is an assignment to DHHS of your rights to all third party insurance or medical payments without anyone having to sign any other form. All available parties must be billed and all resulting payments must be applied to the cost of medical care before DHHS will pay. Also, if you receive a settlement or an award from a liable third party, you must pay DHHS back for related medical services we paid. RSA 167:14-a

Benefits Received in Error

If you are applying for TANF cash payments, your receipt of such assistance is an assignment to DHHS of your rights to financial child support. Without signing any other form, you give DHHS the right to collect and keep financial child support payments made on behalf of your children who receive assistance. RSA 161-C:22

DHHS collects and keeps the support to partially offset the amount of cash assistance paid to you. If support payments are equal to or more than the amount we give you, your cash assistance case will be closed and the support payments sent to you.

Receipt of Children’s Medicaid is an assignment of medical child support rights. This means that you must cooperate with DHHS to establish and enforce medical child support for your children. Medical child support usually means health insurance provided by the absent parent, but can also be an ongoing dollar amount paid by the other parent to allow you to buy health insurance for your children.

If you receive money to purchase medical insurance, this money will be kept by the State if you receive Medicaid for your child and will be used to pay back the state and federal governments. If paternity is not established for any of your children who are getting Medicaid, you must also cooperate with DHHS to legally establish paternity.

The assignment of support rights is a requirement. Your rights and responsibilities and the penalty for refusal without a good reason, will be explained to you when you meet with your District Office worker.

You are required to pay back any benefits or services received in error, regardless of whether you made a mistake in the information you provided, or failed to provide, to us. If you get Food Stamps, you must also pay back any benefits you

Begin Date for Medicaid Eligibility

Your Medicaid eligibility generally begins on the day that you meet all the requirements for the program you applied for, including the resource limit.

This is your record of application and will be filled out by a Department of Health and Human Services worker and returned to you. DFA has received

a completed application for : from on

District Office Signature of Worker

NH Department of Health and Human Services (DHHS) Referred for XFS [] Yes [] No DFA Form 800

Division of Family Assistance (DFA) Initials: 01/14

APPLICATION FOR ASSISTANCE

A. Please tell us about who you are and where you live.

Name: Primary Language: Current Place of Residence: [] Ownhome [Nursing Facility [] Adult Family Home CL Assisted Living [1 Congregate Housing [JHomeless []Hospital [] Hotel/Motel (] Residential Care Facility [_] Other

Street Address: Mailing Address: (if different) City/State/Zip: Home Phone: Work Phone: Cell/Message: E-Mail Address: CJ Ido not have an E-Mail addres ; OFRTCLAL Does anyone in your family have Medicare Part AorB? L]Y LJN oe

a BR Why do you need our help?

Information Supplier: (if different from applicant) Name Address Phone #

B. Please tell us about the people you live with. Start with yourself and list ALL of the people living with you. You do not have to give the Social Security Number or citizenship status of any individual who is not applying for assistance.

Name SSN DOB | Relation to you | U.S. Citizen? | Student (Yes orNo. | RID (DFA Use Only)

If Yes, put grade too) SELF LIYCIN

LYCIN

OYOIN

LIYCIN

LCIYCIN

Pia |p |S |’ [=

LIYCIN

C. | want to apply for: (TYPES OF ASSISTANCE REQUESTED)

(J ALL PROGRAMS LJ Cash J Food Stamps CJ Child Care

LJ Home and Community-Based Care (HCBC) CJ Medicare Savings Programs (MSP) [QMB/QWDI/SLMB/SLMB135] CJ Nursing Facility (NF) Services - Facility Name:

(J Medical Assistance — if you need Medical Assistance for a child, pregnant women, or parent/caretaker relative of a child, you must also complete the insert entitled Medical Assistance for Children, Pregnant Women, and Parent/Caretaker Relatives Insert

D. The following information is collected to be sure that everyone is served fairly. Your answers are voluntary. The information provided will not affect your eligibility or benefit amount.

Are you Hispanic or Latino? [JYes []No

Areyou: White? (JY LIN Asian? (JY CIN __ Native Hawaiian or Other Pacific Islander? [] Y L]N Black or African American? [] Y [JN American Indian or Alaskan Native? (] Y LIN

AGENCY USE ONLY:

RFA# Case # Forms Given: 725 177 Cash. OPEN CLOSE DENY DATE: DO:

Food Stamps OPEN CLOSE DENY DATE: DO:

MA. OPEN CLOSE DENY DATE: Do:

CM/MCPW OPEN CLOSE DENY DATE: Do:

Child Care OPEN CLOSE DENY DATE: DO:

DFA SR 14-08 PLEASE SIGN YOUR APPLICATION ON THE BACK! (3YC)

| EBT Card Status: None Active Deactivated Cancelled

E. Please tell us about all income for everyone in your home. |G. Your Expenses:

Your Wages: $ CJ Weekly [J Bi-Weekly [J Monthly | Rent (monthly): $ OtherWages: $ (J Weekly C] Bi-Weekly [J Monthly | Mortgage (monthly): $ OtherWages $ C1 Weekly (1 Bi-Weekly CL] Monthly | Lot Rent/Condo Fee (monthly): $ Has anyone recently lostajob? JYes [JNo Taxes (yearly): $ If yes, who? When? i [ Dependent Care: $ SSA/SSDI: $ Spousal Support: $ Medical Expenses: $ SSsk $ Unemployment: $ VA: $ Child Support: $ | Pension: $ Other: $ Do: you pay for the following = utilities separate from your rent or F. Please tell us about all assets for everyone in yourhome. | mortgage? Checking/Savings: $ Other Chk/Save: $ Heat: []Yes []No Stocks/Bonds/CD’s: $ IRA: $ Phone: []Yes []No Spon ete sheralion $ Other Assets: $ Electric: []Yes []No Trusts: $ Life Insurance: $ Other: []Yes [JNo Vehicle (Yr/Mdl): Vehicle (Yr/Mdl): H. Potential Eligibility Questionnaire 1. Are you a migrant or seasonal farm worker? LC Yes [] No 2. Have you or anyone in your household received Food Stamp assistance for this month? (Yes (J No 3. Are you currently living in a shelter for battered individuals? LJ Yes [No 4. Is anyone in your household blind or disabled? (Yes [J No 5. Have you sold or transferred property in the last 5 years? 1 Yes (No 6. Is anyone in your household currently receiving assistance from another State? (Yes LJ) No If yes, which State? What kind of assistance? 7. Is anyone in your household pregnant or has anyone given birth in the last 3 months? CJ Yes (No

8. Do you have any unpaid medical bills from the past 3 months that you would like help paying? 1 Yes [J No

9. If you are applying for Financial Assistance to Needy Families (FANF), is the father’s name blank or CYes [No “not stated” on the birth certificate for any of your children?

10. If applying for FANF, how many absent parents?

11. Do you or any other household member have health insurance other than Medicaid? (Yes LJ No If yes, name of Insurer? Policy Number:

L. Signatures

| CERTIFY, UNDER PENALTY OF PERJURY, THAT | HAVE REVIEWED THIS INFORMATION ON THIS APPLICATION, INCLUDING ANY INFORMATION INDICATED ON THE INSERT; IT IS TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE, INCLUDING THE INFORMATION CONCERNING CITIZENSHIP AND ALIEN STATUS. | UNDERSTAND A FULL FINANCIAL AND MEDICAL ELIGIBILITY INTERVIEW MAY NEED TO BE CONDUCTED BEFORE MY ELIGIBILITY CAN BE DETERMINED.

Applicant Signature Date

Signature of Person Helping the Applicant Date Relationship to Applicant

| withdraw my application for: []Cash [] Medical Assistance []FoodStamps [ChildCare [JHCBC/NF [|] MSP

Signature Date

| certify that | have given the above individual(s) the opportunity to review this application. | also certify that | have provided a copy of this form, if one was requested.

Printed Name & Signature Title/Agency Date

OFKRIiCTIAL

NH Department of Health and Human Services (DHHS) Division of Family Assistance (DFA)

DFA Form 811R 01/14

APPLICATION: YOUR RIGHTS AND RESPONSIBILITIES

Time Limits

You can only receive Financial Assistance to Needy Families for 60-months in your lifetime. Months you received this assistance while you were a child do not count towards the lifetime limit. Your time limit begins when you receive benefits as an adult. There is no time limit on State Supplement Programs, Medical Assistance, Food Stamp benefits, or

child care assistance.

Nondiscrimination Notice

Reporting Changes

In accordance with Federal law and U.S. Department of Agriculture (USDA) and U.S. Department of Health and Human Services (HHS) policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, or disability. Under the Food Stamp Act and USDA policy, discrimination is also prohibited on the basis of religion or political beliefs.

To file a complaint of discrimination, contact USDA or HHS. Write USDA, Director, Office of Civil Rights, Room 326-W, Whitten Building, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410 or call (202) 720- 5964 (voice & TDD). Write HHS, Director, Office of Civil Rights, Room 506-F, 200 Independence Avenue, S.W., Washington, D.C. 20201 or call (202) 619-0403 (voice) or (202) 619-3257 (TTY). USDA and HHS are equal opportunity providers and employers. Or you may also write Ombudsman, NH DHHS, 129 Pleasant St., Concord, NH 03301-3857 or call (603) 271-6941 or 1- 800-852-3345 ext 6941. TDD Access: Relay NH 1-800- 735-2964 or 711.

Administrative Appeal

You or someone representing you may request an Administrative Appeal if you are not satisfied with any decision regarding eligibility made by DHHS. You may be represented by an attorney, yourself, or another person, such as a relative or friend, at an Administrative Appeal. DHHS will not pay for the cost of any legal services, but there are free and reduced cost legal services available in NH. An Administrative Appeal may be requested either verbally or in writing by contacting a District Office or DHHS, 105 Pleasant Street, Concord, NH 03301-6521. Telephone (603) 271-4292 or 1-800- 852-3345 ext 4292; TDD Access: Relay NH_ 1-800-735- 2964 or 711.

You will be required to periodically complete a review of

your circumstances. Your cash, child care, and Food

Stamp case could be closed, and/or your eligibility for

Medical Assistance may be affected, if you do not

completely fill out the form and return it by the due date

and participate in a personal interview, if required.

If you only get Food Stamp benefits and you have a 4, 5,

or 6-month eligibility period, you only need to report

those changes in household circumstances that would

place your household’s income above 130% of the

poverty level.

If you receive cash, child care, Medical Assistance, or if

your Food Stamp eligibility period is not 4, 5, or 6

months, then you must notify the Department within 10

calendar days after the change happens for changes in

factors that affect eligibility, such as:

source of income;

hours worked by a household member;

amount of income of any member in your household;

all household changes, such as marriage, divorce,

new baby, child leaves, etc.;

child care provider;

e resources (e.g., cash, stocks, bonds, or money in a bank or savings account);

e receipt of any lump sum payment or settlement;

e residence, or shelter costs; or

e dependent care costs, child support payments or medical deductions, or other changes that may affect the amount of your household’s benefits.

Protection of Medical Assistance for Social Security Beneficiaries

Quality Control

Your case may be selected for a quality control or other governmental review. Such a review entails an in-depth investigation into your household’s financial or medical situation, living arrangements and other circumstances. We may be contacting banks, employers, companies, merchants, child care providers, and other appropriate sources, concerning your household and statements you made to DHHS. Failure to cooperate in these reviews could result in the loss of your benefits.

If you are receiving cash assistance under the OAA, ANB, or APTD program, and a Social Security cost-of- living increase or this increase combined with an increase in other income makes you ineligible for financial assistance, you may still be entitled to Medical Assistance under the Pickle Amendment policy.

Once you begin receiving Medical Assistance under the Pickle Amendment, future Social Security cost-of-living increases will not affect your eligibility. However, other changes in your circumstances can still make you ineligible for Medical Assistance.

If you are eligible to receive money payments under one of the above programs, but choose not to receive a payment, you will NOT be entitled to this protection of your Medical Assistance under the Pickle Amendment.

DFA SR 14-05 (NA)

ATTENTION! Anything you tell or give to us will be verified: = at the federal, state and local levels; and also

" through collateral contacts and/or computer matching with other electronic verification tools such as, but not limited to, USCIS, IEVS, Vital Records, SSA, financial institutions, & employment databases.

We do this to confirm your eligibility for our programs and determine your benefits. If any information we get from using these sources doesn’t match the information you provided to us, you may be denied assistance, your benefits may change, and you may be subject to criminal prosecution for knowingly providing false information. Any member of your household who breaks any of these rules on purpose can be prohibited from participating in the cash assistance, child care assistance, and Food Stamp programs for periods ranging from one year to permanently. In the Food Stamp Program, you can also be fined up to $250,000, imprisoned up to 20 years, or both, and will be subject to prosecution under the applicable state and federal laws for violations of the Food Stamp Act.

Notice to Immigrant Families

If you get help with health care or Food Stamps, it will not affect your immigration status. If you or members of your family used or received Medicaid or Food Stamps, it will not affect your or your family members’ ability to become U.S. citizens.

However, if you get cash assistance such as TANF or help with the cost of nursing home care, it might create problems with becoming a U.S. citizen, especially if the benefits are your family’s only income. Before you apply, you may want to talk with an agency that helps immigrants with legal questions or contact the US Citizenship and Immigration Services

(USCIS).

_ DO NOT

© Do not give false information or hide information to get or continue to get benefits.

e Do not trade or sell Food Stamp benefits to anyone who is not authorized to use them for your household.

e Do not use Food Stamp benefits to buy ineligible items, such as alcoholic drinks and tobacco.

e Do not use any benefits your household was not entitled to receive.

e Do not give your EBT Card PIN out to anyone.

e Do not use child care services paid for by DHHS, for employment-related activities not approved by DHHS.

e Do not use your EBT card or cash from your EBT card at

liquor stores, gaming establishments, or businesses which provide adult-oriented entertainment.

~ Medical Assistance Fraud

Identity & Residence

Anyone convicted of making a fraudulent statement or representation with respect to identity or residence in order to receive benefits in two locations at the same time will be ineligible for financial assistance and Food Stamp benefits for 10 years.

Section 1128B of the Social Security Act provides federal penalties for fraudulent acts and false reporting in connection with your application for or receipt of Medical Assistance benefits.

A person may be prosecuted in Federal Court for deliberate statements that are known to be false and which affect eligibility for any benefit or payment under the Medical Assistance program.

A person may also be prosecuted for concealing or failing to disclose any event that affects their right to any benefit or payment, or its conversion to a use other than intended. The law also provides a penalty for a kickback, bribe, or rebate in connection with the furnishing of Medical Assistance.

Conviction of an offense could result in loss of Medical Assistance benefits for a period not to exceed 1 year. Penalties are fines up to $25,000 or imprisonment for not more than 5 years, or both.

Intentional False Statements

Trafficking Food Stamp Benefits

Any person who is found guilty in a court of law for buying or selling illegal drugs or certain prescription drugs in exchange for Food Stamp benefits, will be prohibited from participating in the Food Stamp Program for 24 months for the first offense and permanently for the second offense. Any person who is found guilty in a court of law for buying or selling ammunition, firearms or explosives in exchange for Food Stamp benefits, or of any trafficking in Food Stamp benefits of more than $500, will become permanently ineligible for Food Stamp benefits.

Any person who intentionally makes a false statement or misrepresents his or her circumstances or intentionally fails to disclose the receipt of property, wages, income or resources or any change in circumstances that would affect his or her initial or continued eligibility for assistance may be found guilty of violating state law. The penalties are: a class A felony where the value of the monetary award or goods or services exceeds $1,000; a class B felony where the value exceeds $100; and a misdemeanor where the value does not exceed $100. RSA 167:17-b and 17-c.

NH Department of Health and Human Services (DHHS) ‘ , 2 : DFA Form 811S Division of Family Assistance (DFA) 01/14

APPLICATION: STATEMENTS OF UNDERSTANDING INITIALS | All Programs

| certify that | have read “Your Rights and Responsibilities,” and | understand them.

| understand that DHHS will keep my eligibility and case information confidential and only persons involved in administering DHHS’ programs or as otherwise permitted by Federal regulations or State law will review it.

| understand that despite other rules of confidentiality, names of children in Food Stamp and/or FANF households are required to be released to schools so that they may be determined automatically eligible for Free School Meals.

| understand that | must provide proof of: my household situation, what | have written on the application, and what | have told DHHS.

| understand that the information | have provided will be verified by collateral contacts and/or Federal, State, and local officials and that if any information is found to be incorrect or false, or if | have deliberately withheld information related to my receipt of assistance, now or in the future, | may lose my benefits and may be prosecuted for fraud.

| understand that my signature below and/or on the application authorizes DHHS to obtain verification that | or anyone in my assistance group (AG) meet the eligibility requirements for assistance, and authorizes release of such information to DHHS. My authorization to release information to DHHS remains in effect for as long as | or anyone in my AG receives any kind of DHHS assistance.

| understand that my signature below and/or on the application permits DHHS and any contracted third party entity to verify my income, identity, and assets, and the income, identity, and assets of any other person whose income, identity, and assets are required to determine eligibility for the assistance | am requesting. Failure to give permission to conduct these verifications or revoking permission to conduct these verifications will result in denial or termination of assistance.

| Cash & Food Stamp Programs

| certify that if | applied for FANF, the Domestic Violence Option has been explained to me, and | understand it.

| certify that if | applied for FANF, | got written information about the treatment of lump sum income.

| understand that my receipt of TANF cash assistance is an assignment to DHHS of each recipient's rights to child and spousal support.

| understand that if | get cash assistance from DHHS, the cash | get could cause my Food Stamp benefits to end or be reduced. | also understand that if this happens, | will not get advance notice of this change.

| understand that to get a cash payment from any DFA program, | must be eligible to get that cash every day of the entire payment period. If | am not eligible for cash at any time during that payment period, | understand that a cash payment will not be issued to me.

| understand that in NH, if anyone in my household is fleeing to avoid prosecution of a felony crime, or is violating conditions of probation or parole, that person will be ineligible to get cash or Food Stamp benefits until that individual has satisfied his/her legal obligations with respect to the felony crime or probation or parole violations. My signature below is my sworn statement that no one in my household at this time is fleeing felony prosecution or violating conditions of probation or parole.

| understand that the use of my Electronic Benefits Transfer (EBT) card for Food Stamp or cash benefits is controlled by my 4-digit Personal Identification Number (PIN), that | am responsible for the security of my EBT card and PIN, and that EBT benefits will not be replaced if someone else uses my card after | have activated it.

| understand that if | do not use my Food Stamp benefits on my EBT card for 365 days in a row, | will lose those benefits and not get them back. If | do not use my cash benefits for 90 days in a row, | will lose those benefits and not get them back. | understand that | will be disqualified from the Food Stamp Program and may be prosecuted if | use my EBT card for illegal purposes. These illegal activities include selling my card and my PIN for cash, drugs, or other items, or exchanging Food Stamp benefits for cash at a retailer.

DFA SR 14-05 PLEASE INITIAL AND SIGN THE BACK! (3YC)

Cash & Food Stamp Programs Con’t : INITIALS |

| understand that for Food Stamp benefits, to get a deduction for child care expenses, rent or mortgage payments, utility or other shelter expenses, child support paid to a non-household member, or medical expenses (only for the elderly or disabled), | must tell DHHS about these expenses and then provide proof of them. Failure to report or verify any of the above listed expenses, or of receipt of fuel assistance, could mean that | will get less Food Stamp benefits each month, and will be seen as my statement that my household does not want to get a deduction for the unreported or unverified expense.

| understand that my EBT card or cash from my EBT card cannot be used at liquor stores, gaming establishments, or businesses which provide adult-oriented entertainment, and that if | use my EBT card or cash from my EBT card at one of these places, | will be sanctioned with a cash penalty, per RSA 167:7-b.

Medical Assistance

| understand that my receipt of medical assistance is an assignment to DHHS of my rights to all third party medical insurance or payments, including medical child support.

| understand that my receipt of medical assistance means DHHS must be able to obtain medical records from medical providers. My signature below and/or on the application authorizes my family’s medical providers to release any records to DHHS.

| understand that, if | am in a nursing home, DHHS must be able to exchange eligibility information with the nursing home to best administer the program. My signature below and/or on the application authorizes that exchange and remains in effect for as long as | receive DHHS assistance for my nursing home care.

| understand that for long-term care services (Nursing Facility or Home and Community-Based Care), | am required to disclose to DHHS any interest that my spouse or | have in any annuity.

| understand that if either my spouse or | are requesting long-term care services, any annuity purchased or modified by my spouse or me on or after February 8, 2006 will be considered a transfer of assets for less than fair market value unless the State is named the beneficiary for at least the amount of Medicaid paid for long-term care services.

NH Child Care Scholarship

| understand that | must only use child care services paid for by DHHS for those employment-related activities approved by DHHS. | may have to reimburse DHHS for those payments made for times | was involved in other, non-approved activities.

Signatures

| certify, under penalty of perjury, that | have reviewed the above information and the information summarizing my interview, and it is true and complete to the best of my knowledge.

Applicant Signature Date

Signature of Person Helping the Applicant Date Relationship to Applicant

| certify that | have given the above signed individual(s) the opportunity to review this document, and that | have completely explained and given them a copy of the Rights and Responsibilities Notice. | also certify that | have given them a copy of this page, if it was requested.

Printed Name & Signature Title/Agency Date

Table of Contents

1 Introduction

Le Background 1.2 1.3 2 NHEASY Streamlined Application Changes ........cccccsscssscsssssssssseessseeesscsescscsssssessseseeneneeesseeeseaseneees 3 2.1 Start Module — Getting Started 2.2 Household Module — Household Information 2.3 People Module — People Details 2.4 People Module — People SUMMALY.........ccceccececeeeceeteeeneestensseenenssesneesessessseisneesesesenenenenerereeneeesegs 9 2.5 Income Module — Employment Details 2.6 Income Module — Self-Employment Details 2.7 Income Module — Other Income Details 2.8 Income Module — Yearly INCOME Details ............:cceceeeeeeteneteeieeseeeereeeessssssseseseseneneneneeeeeeenents 2.9 Income Module — Yearly Income Summary 2.10 Expense Module — Dependent Care Details 2.11. Expense Module — Child/Spousal Support Details 2.12 Expense Module — Other Expenses Details 2.13 Other Module — Other State Assistance Details.........ccccccccceeeneeeeeneeseieessisessseeessensseneesenenetenee 18 2.14 Other Module — Other State Assistance SUMMALY .........ccceceeeeteeeeneeteneeteneeteneeeneeseteeetiteees 19 ~ p 13-0018MM2 Approval Date: 03/11/201 Effective Date: 10/01/2013

New Hampshire

OFFICIAL

1 Introduction

1.1 Background

As part of the Affordable Care Act (ACA) implementation for New Hampshire EASY, the Centers for Medicare and Medicaid Services (CMS) mandate all applicants have a specialized, streamlined application when applying for medical coverage. New Hampshire has an integrated eligibility system for government benefits, medical coverage included. Becaus2.of this, there are questions that are asked — even when an applicant only requests medical coverage — that may not be required for medical benefit eligibility determination. In order to comply with the CMS requirement for a streamlined medical coverage application, there are certain questions that need to be made optional, or removed altogether.

1.2 Scope

This document will outline the following:

e Streamlined application field changes to NH EASY

1.3 References

The following references were leveraged to guide decision making regarding requirements and design for all items in the Scope section of this document.

Document Title Publishing Organization Guidance on State Alternative June 2013 | Centers for Medicare and - Applications for Health Coverage Medicaid Services (Federal CMS) Application for Health Coverage and Help | September | Centers for Medicare and 3.0 Paying Costs (Short Form) 2013 Medicaid Services (Federal CMS) Application for Health Coverage and Help | September | Centers for Medicare and 3.0 Paying Costs (Family Attachment) 2013 Medicaid Services (Federal CMS) Single Streamlined Application for the September | Centers for Medicare and 3.0 Health Insurance Marketplace (Online 2013 Medicaid Services (Federal CMS) Application)

Table 1-1: List of References

13-0018MM2 Approval Date: 03/11/201 Effective Date: 10/01/2013 New Hampshire

~ q at AT OFFICIAL 2 NHEASY Streamlined Application Changes The following details all field changes that will be implemented for NH EASY. Modifications that are made to

show/hide individual fields when certain programs are requested at the case level will require looping through all individuals in the case if programs requested subsequently change.

2.1 Start Module - Getting Started

Getting Started

*Select the <ssistance program(s) below for which at least one person in the household is applying:

Cash Assistance Medical Coverage @ Medical Coverage for Children, Pregnant Women and Non-Disabled Adults Age 18-64 (1 Food Stamps Child Care Assistance Medicare Beneficiary Assistance (QMB/SLMB)

Medical Coverage and Medicare Beneficiary Assistance for Past Months

If you are applying for Medical Coverage (including Children, Pregnant Women and Non-Disabled Adults Age 18-64) and/or Medicare Beneficiary Assistance, you can also apply for these benefits for the last 1,2, or 3 months. For example, if you are applying in March, you can also apply for December, January, and February.

You can apply for Medical Coverage for up to 3 months back. If you want this back ols] coverage, enter the number of months you want (1, 2, or 3):

Assisting Person Information Are you completing this application on behalf of someone else? (=)

ove cD

© Nd.gov | privacy policy | accessibility policy | non-discrimination policy | contact us

Figure 2-1: Getting Started The following field changes will be implemented:

e “Please select the reason why you are applying for assistance:”

o. This field will be removed from the front-end in all cases, regardless of what program is being requested. e “Are you completing this application on behalf of someone else?”

© This field will be changed from always required to always optional

o It will continue to default as blank per existing functionality

o Allconditionally dependent fields will remain required/optional as per existing functionality

13-0018MM2 Approval Date: 03/11/201 Effective Date: 10/01/2013 New Hampshire

2.2 Household Module - Household Information

Application =: 360273234

Applicant 2)

‘First Name: _ Suffix: 3 sash -

Primary Language

*What is the language most commonly spoken in the household? | English 7 [=] Address Where You Live

Do you consider yourself to be homeless? No. [¥]

Direction: * Street Name: Street Type: (Main st

dditional Address Information:

ee *State: Zip: [Concord ie] [New Hampshire |] (03301 4

Mailing Address Information *Do you have a mailing address that is different from the address where you live? [no [=]

Phone Contact Information Asi you provide a phone number (home or cell) we may be able to conduct your

Home: Cc j-—_ ]- ‘eligibility interview over the phone.

Cell: { -[ af

Work: - - Ext:

Email Contact Information

Do you have an email address? fl . ? 4

=) NH.gov | privacy policy | accessibility policy | non-discrimination policy | contact us Figure 2-2: Household Information The following field changes will be implemented: e “Do you have an email address?” o. This field will be changed from always required to always optional. o It will continue to default as blank per existing functionality.

13-0018MM2 Approval Date: 03/11/201 Effective Date: 10/01/2013 New Hampshire

2.3 People Module - People Details

N Hieasy Department of Health and Human Services

IDHHS | My Account | Change text size: A A A John Doe | Logout

Application =; 800122787 15% Complete @

People Detai

“First Name: cum, Mi *Last Name: Suffix: Jane _ Doe

Has Jane Doe ever applied for benefits in New Hampshire under any other (No [=] name (e.g., maiden name, nickname, etc.)? |

Programs Requested

*What is Jane Doe applying for: Wi medical Coverage for Children, Pregnant Women and Non-Disabled Adults Age 18-64

none Personal Details *Gender: (Female [+] * Date of Birth: for |/(05_ |//1995° , . , Att you oF , ws * > you give us an SSN right now, it will help us process your Does this person have a Social Security Number No [x] application quicker. Providing your SSN is protected by the Federal Privacy Act of 1974 as Amended.

* What is the reason for not having a Social Security Applied [x]

Number? * What is Jane Doe's marital status? Never Married [=] } *Which of these best describes where Jane Doe is living: it —_ [x] Hispanic Origin: i [=]

Race (select all that apply): © american Indian/Alaska Native © Black/African American

Asian Native Hawaiian/Pacific Islander

(4 white © other

| ct eNOS NOL SALES RILEY BITC ILE LAO SADE LAAN

Figure 2-3: People Details (pictured: 19 year old applicant)

13-0018MM2 Approval Date: 03/11/201 Effective Date: 10/01/2013 New Hampshire

nO TUR CeCe ON CO OT ~. NOR One ORT *Is Jane Doe a US Citizen? No [x Immigration Information *Does Jane Doe have an eligible immigration status? I 7) *Has Jane Doe lived in the US since 1996? Yes | es] Does Jane Doe have an Alien/USCIS Number? No [x] Does Jane Doe have an 1-94 Number? Yes [=] *1-94 Number [24344353452 i *Supporting Document: Other 3] *Document Description: [I-94 Machine Readable ee Pregnancy | Is Jane Doe pregnant or has she been pregnant recently? Education *What is Jane Doe's current enrollment status? Full-Time 3] | Disability Is Jane Doe permanently disabled or blind? isl ' Tax Filer Information *Is Jane Doe planning to file a federal income tax return next year? [No i] *Is Jane Doe a tax dependent claimed by a parent not living in the household? ‘no [x] Household Relati: *Jane Doe is the [0 [+] of John Doe. *Is Jane Doe a tax dependent of John Doe No [+] *Is John Doe a tax dependent of Jane Doe [No iy olicy | accessibility policy | non-discrimination policy | contact us

Figure 2-4: People Details (pictured: 19 year old applicant) The following field changes will be implemented:

e “Has <Name> ever applied for benefits in New Hampshire under any other name (e.g., maiden name, nickname, etc.)?”

o. This field will be changed from always required to always optional ©. It will continue to default as ‘No’ per existing functionality

e Anew orange header, “Programs Requested”, will be added above the “Personal Details” orange header and will include the Programs Requested question.

e “What is <Name> applying for:”

o The existing Programs Requested question will be moved below the “Programs Requested” orange header.

o The following text will be added below this field that will dynamically appear if the individual in context selects “None” for Programs Requested:

= “You have indicated you are not applying for benefits. You are only required to answer questions in this application that have an orange asterisk.”

e “Does <Name> have a Social Security Number?”

o Ifat least one program is requested for the individual in context, this field will be required. This includes dynamically changing the label to include a leading asterisk.

13-0018MM2 Approval Date: 03/11/201 Effective Date: 10/01/2013 New Hampshire

©. If the individual in context selects “None” for Programs Requested, this field will be optional and visible. This includes dynamically changing the label to omit a leading asterisk.

© It will continue to default as blank per existing functionality

© The current SSN text (“If you give us an SSN right now...”) below the SSN free form text box will be moved such that it will now only be displayed with the high level SSN question

e “Social Security Number:” © Asper existing functionality this is only shown when a user enters ‘Yes’ to the high level SSN question. © If displayed, this field will never be required for all individuals.

e “What is the reason for not having a Social Security Number?” o As per existing functionality this is only shown when a user enters ‘No’ to the high level SSN question.

o If displayed, this field will be required for individuals who have selected at least one program for Programs Requested. For non-applicants, it will be optional.

© If displayed, it will continue to default as blank per existing functionality. e “Is <Name> a US Citizen?” © It will always be mandatory for applicants (clients requesting a program). © This field will not be visible when the individual in context chooses “None” for the “What is <Name> applying for:” question. © It will continue to default as blank per existing functionality. The following immigration information fields will show when the field “Is <Name a US Citizen?” is populated as “No”. e “US Entry Date”

© If MAGI Only is requested at the case level, this field will not be visible. Else, this field will be visible and will always be required per existing functionality.

e “Immigration Status” ©. This field will be removed entirely from the front-end for all programs requested at the case level. ¢ “Does <Name> have an eligible immigration status?”

© This will be a new mandatory question that will be visible for all programs requested (when US Citizen is “No”). There will be a checkbox next to this field; if checked, the other immigration information fields will be revealed (see specific logic for each question below).

o. If the checkbox is not populated, no other alien fields will be visible.

o A blue question mark icon will appear next to this field and will include the policies for declaring an eligible immigration status, when selected by the user.

e “Has <Name> lived in the US since 1996?”

©. This will be a new Yes/No field, only visible when MAGI Only has been requested at the case level and the “Does <Name> have an eligible immigration status” checkbox is checked.

o If this field is visible, it will be required. t : ©. This field will default to blank. ; e “Alien Status” o If anything other than MAGI Only is requested at the case level, this field will be visible and required when a user populates “Does <Name> have an eligible immigration status?” as “Yes”. Else, this field will not be visible. e “Does <Name> have an Alien/USCIS Number?” © Ifthe “Does <Name> have an eligible immigration status?” checkbox is checked, this field will be visible.

o. If MAGI Only is requested at the case level, this field will always be optional if visible. Else, this field will remain required per existing functionality.

13-0018MM2 Approval Date: 03/11/201 Effective Date: 10/01/2013 New Hampshire

OFICIAL

e “Does <Name> have an I-94 Number?”

o Ifthe field “Does <Name> have an Alien/USCIS Number?” is populated as “No”, this field will be visible per existing functionality.

© If MAGI Only is requested at the case level, this field will always be optional if visible. Else, this field will remain required per existing functionality.

e Forall Alien fields: “US Entry Date”, “Does <Name> have an eligible immigration status”, “Has <Name> lived in the US since 19962”, “Alien Status”, “Does <Name> have an Alien Registration Number”, “Alien Registration Number”, “Does <Name have an 1-94 Number?”, “I-94 Number”, “Supporting Document” and “Document Description”

o For all application types, if the user does not fill out all possible Immigration Information questions and that individual is requesting at least one program, upon selecting the “Next” button for that individual a Yes/No popup will appear before validation errors occur as well as before calling the Hub, that will read: “We will be able to process your application more quickly if you provide your citizenship information. Would you like to input the information now?”

= If “Yes” is selected, the user will stay on the People Details page. If “No” is selected, validation errors will appear if applicable, otherwise the user will be brought to the People Summary page per existing driver functionality.

= This Popup will only show once while the user is on the People Details page. If the user does not fill in the applicable information and navigates back to the People Details page from a future page, the user will see the same popup if the applicable information is not populated and the “Next” button is selected. ‘ :

e “What is <Name>’s current enrollment status?” ©. This field will be moved up to be the first question in the “Education” section

© Ifat least one program is requested for the individual in context, and the individual is 19 — 20 years of age, this field will be required. Else, this field will not be visible.

©. This change will be implemented for applications where MAGI-Only is requested at the case level. e “What is <Name>’s highest level of education?”

© This field will not be visible for MAGI-Only applications. For all other applications where MAGI is not requested at the case level, this field will be visible and optional per existing functionality.

e “ls <Name> on active duty in the armed forces?”

© This field will not be visible for MAGI-Only applications. For all other applications where MAGI is not requested at the case level, this field will be visible and optional per existing functionality.

e “Is <Name>a veteran?”

© This field will not be visible for MAGI-Only applications. For all other applications where MAGI is not requested at the case level, this field will be visible and optional per existing functionality.

© “Is <Name> required to file a federal tax return next year?” ©. This field will be removed entirely from the front-end. e “Do <Name> and <Name> buy and prepare meals together?”

© This field will not be visible for MAGI-Only applications. For all other applications where MAGI is not requested at the case level, this field will be visible and required, per existing functionality.

ay

13-0018MM2 Approval Date: 03/11/201 Effective Date: 10/01/2013 New Hampshire

2.4 People Module - People Summary

itt

People.

People Detai

_ . Relationship = .

Name/SSN Date of Birth 5 Applicant Student Status Pregnant View/Edit Remove

™@ John Doe ~ 10/10/1980 Applicant Tw 00-00-0000 yank viagra es» * Jane Doe 01/05/1995 Daughl H1-Ti ® 6 000-00-0000 eee eushter se Ue wisn le * Are there any other people in your household that are applying for assistance or are a parent of a child [y]

under 18 that is applying for assistance? Note: If you are applying for medical coverage, also be sure to include any tax dependents living with you.

ert

3 NH.gov | privacy policy | accessibility policy | non-discrimination policy | contact us

2 Figure 2-5: People Summary The following changes will be implemented: e “Student Status” o For MAGI Only applications, the first line will be blank if the questiors “What is <Name>’s current enrollment status?” is not displayed for that particular individual during application entry. o For MAGI Only applications, the second line will always be left blank (i.e. the value for Highest Level Completed).

13-0018MM2 Approval Date: 03/11/201 Effective Date: 10/01/2013 New Hampshire

2.5 Income Module - Employment Details New Hampshire

Department of Health and Human Services

Application #: 360273234

| ie ™ Y

*Is anyone in your household currently working at a job or has anyone lost a job in the last 30 days? Yes [+]

*Who has or had the job? “John Doe = _-E

Employer Information *Employer name:

Employer Telephone Number: Employer Address Information

Would you like to add the Employer Address? ino [x]

Employment Details

*Date the job started: ao |/110_|/(2000

Job Title: { — ~~]

*Do you still have this job? Yes [=]

Wage/ Salary Information

*How often is John Doe paid? ¢ “Average pay before taxes, including tips? +", rage hours worked per pay period: [Bi-weekly (4 400 3u |

c=] NH.gov | privacy policy | accessibility policy | non-discrimination policy | contact us Figure 2-6: Employment Details The following field changes will be implemented:

e “Job Title” ©. This field will be changed from always required to always optional oO. It will continue to default as blank per existing functionality

13-0018MM2 Approval Date: 03/11/201 Effective Date: 10/01/2013 New Hampshire

2.6 Income Module - Self-Employment Details

Self-Employment

*Is anyone in your household self-employed? ‘yes [¥]

*Who is self-employed? gn OE

Self-Employment Information

* What kind of self-employment is this? [Child Care Provider _ 2] * What is the average monthly profit/loss after deducting expenses $/132 |

(do not include monthly depreciation here)?

w

What is the monthly depreciation?

=] NH.gov | privacy policy | accessibility policy | non-discrimination policy | contact us

Figure 2-7: Self-Employment Details The following field changes will be implemented: e “What is the monthly depreciation?” o. This field will be changed from always required to always optional o It will continue to default as blank per existing functionality e “What are the.average monthly hours worked?” o. This field will be removed from the page. ;

13-0018MM2 Approval Date: 03/11/201 Effective Date: 10/01/2013

New Hampshire

| QRFICIAL

2.7. Income Module - Other Income Details

DHHS | My Account | ‘Change text size: AA A

Application #: 360273234

*Does anyone in your household get any other money? Yes [=] *Who gets any other money? John Doe 7 3]

Other Income Details * Other income type:

*How often is he/she paid?

*How much does John Doe receive, Bi-Weekly?

SSI/SSA/VA/RR Information What is the Claim Number?

What is the Entitlement Date? mm |/\dd _|/ yyyy

Close

c=) NH.gov | privacy policy | accessibility policy | non-discrimination policy | contact us

Figure 2-8: Other Income Details The following field changes will be implemented: e “Other income type” ,

o If MAGI Only is requested at the case level, the reference table TAUI that populates this field will be restricted to display only MAGI countable income types.

o If auser proceeds past the screen, and then changes the Programs Requested at the case level, this field will still show the initial filtered/unfiltered reference table. For example, if a user requests MAGI Only, proceeds past this screen, and subsequently changes the Programs Requested at the case level, the initial values populated in this “Other income type” change will not change if the user returns to this screen.

e “What is the Claim Number?” o If displayed, this field will be changed from always required to always optional

o It will continue to default as blank per existing functionality

13-0018MM2 ~ Approval Date: 03/11/201 Effective Date: 10/01/2013 New Hampshire

2.8 Income Module - Yearly Income Details

John Doe | Logout

*Does anyone in your household have income that changes from month to month? { i]

co] NH.gov | privacy policy | accessibility policy | non-discrimination policy | contact us

Figure 2-9: Yearly Income Details (No

DHHS | My Account | Change text

Application #: 360273234 43% Complete [i

sae

* Does anyone in your household have income that changes from month to month? lves Ty]

Yearly Income Information

*Who has income that changes from month to month? John Doe {x} * What will be John Doe's total income this year? $/3458

What will be John Doe's total income next year (if it is expected to be different)? $C

r=] NH.gov | privacy pdlicy | accessibility policy | non-discrimination policy | contact us

Figure 2-10: Yearly income Details (Yes) A new details page “Yearly Income” will be added in the Income Module and will always be displayed as the last tab in the Income Module. If MA or MAGI-Only is requested at the case level, this tab will be scheduled in the driver. Else, this tab will not be scheduled or visible to the client.

13-0018MM2 Approval Date: 03/11/201 Effective Date: 10/01/2013 New Hampshire

The following headers and fields will be added: e Gateway Question ‘ o “Does anyone in your household have income that changes from month to month?” = This will be a mandatory, Yes/No question and will default to blank. » If Yes, the Yearly Income Information section will become visible.

= |farecord already exists and a user selects to add another record, this question will be hidden and all subsequent questions will be shown per NH EASY standard.

e Yearly Income Information o “Who has income that changes from month to month?” "This will be a mandatory dropdown that will include all household members on the application.

= Household members will not show in the dropdown if he/she has already been associated with a record in this screen.

o “What will be <Name>’s total income this year?” * This will be a mandatory freeform text field and will default to blank.

= This will use the standard NH EASY money field and validation(s), and will require a value greater than 0 to be entered.

o “What will be <Name>’s total income next year (if it is expected to be different)?” " — This will be an optional freeform text field and will default to blank. * This will use the standard NH EASY money field and validation(s).

2.9 Income Module - Yearly Income Summary

al New Hampshire government we

Department of Health and Human Services DHHS | My Account | Change text size: a A A

Application =: 360273234

Name Income This Year Income Next Year View / Edit Remove John Doe $3,458.00 $0.00 [ Remove} *Does anyone else earn income that changes month to month? [¥]

8 NH.gov | privacy policy | accessibility policy | non-discrimination policy | contact us

Figure 2-11: Yearly Income Summary Anew summary page “Yearly Income” will be added in the Income Module.

13-0018MM2 Approval Date: 03/11/201 Effective Date: 10/01/2013 New Hampshire

The following columns will be added and populated with values from the Yearly Income Details page: e Name 0. This field will be populated with the value of “Who has income that changes from month to month?” e Income This Year ©. This field will be populated with the value of “What will be <Name>’s total income this year?” e Income Next Year

o This field will be populated with the value of “What will be <Name>’s total income next year (if it is expected to be different)?”

e The trailing question will be “Does anyone else earn income that changes month to month?”

o If Yes, the user will be taken to the Details page upon selecting the Next button where he/she can add another person’s income.

o If No, the user will be taken to the Expense Module if applicable or the Finish Module upon selecting the Next button.

2.10 Expense Module - Dependent Care Details

DHHS | My Account | Change text size: A A A

Application +: 960237496

|

Oependent Care

*Does anyone in your household pay for child care or adult day care to be employed?

*Who pays for the care? [Dan 3 Lilly Sr

Dependent Care Information

*Who needs this care? Wife Q Lilly a _ [x] *who is providing the care? ‘Some Place

Expense Payment Information

*How often? Bi-Weekly [¥]

*How much does Dan J Lilly Sr pay? $ 213

2 NH.gov | privacy policy | accessibility policy | non-dis

crimin

y | contact us

Figure 2-12: Dependent Care Details The Dependent Care tab will be visible in the driver until December 31%, 2013 for all MAGI Only applications, in order to accommodate the Healthy Kids program and MAGI in the same switch. Starting January 1*, 2014, this tab will never show for MAGI Only applications.

13-0018MM2 Approval Date: 03/11/201 Effective Date: 10/01/2013 New Hampshire

2.11 Expense Module - Child/Spousal Support Details

Department of Health and Human Services John Doe | Logout

*Does anyone in your household make support payments? ‘Yes [+]

*Who makes support payments? {John Doe ix]

* What kind of support is being paid: (Spousal Support il Actual Payment Information

*How often? Bi-Weekly [+]

*How much does John Doe pay? * $324

* are the support payments court ordered? Yes Ts]

How often?

ny

How much is John Doe ordered to pay?

S NH.gov | privacy policy | accessibility policy | non-discrimination policy | contact us

Figure 2-13: Child/Spousal Support Details The following field changes will be implemented:

The tab label will be changed to “Support Payments”.

“What kind of support is being paid” o. If MAGI Only is being requested at the case level, the only value that will be displayed/selectable in this field will be “Spousal Support”. Else, both values will be selectable.

The field order will be changed to be as follows: Who makes support payments?

What kind of support is being paid:

How often?

How much does <Name> pay?

oo°0 0

Are the support payments court ordered? = How often? = How much is <Name> ordered to pay?

“How often?” (Court ordered value) o If displayed, this field will be changed from always required to always optional o If displayed, It will continue to default as blank per existing functionality e “How much is <Name> ordered to pay?” (Court ordered value) o If displayed, this field will be changed from always required to always optional o If displayed, It will continue to default as blank per existing functionality

13-0018MM2 Approval Date: 03/11/201 Effective Date: 10/01/2013 New Hampshire

e A new validation will be added such that if the court ordered amount is > 0, then the opposite field not populated will also be required.

2.12 Expense Module - Other Expenses Details

Expense Information

*who has the expense? Dan J Lilly Sr

* What kind of expense is it? Student Loan Interest _ [J Payment Information *How Often? [Monthly fw

*How much does this person pay?

Clo:

@ Ni.gov | privacy policy | accessibility policy | no

Figure 2-14: Other Expenses Details The following field changes will be implemented:

© “What kind of expense is it?” — For the dropdown option, “Student Loan Interest Pd,” change this value in the reference table TDDT to “Student Loan Interest”.

13-0018MM2 Approval Date: 03/11/201 Effective Date: 10/01/2013 New Hampshire

OFFICIAL

2.13 Other Module - Other State Assistance Details

60% Complete

*Has anyone in the household received benefits from another state? Yes [=] *Who received benefits while living in another state? John Doe _ : [=] *Which state? [Massachusetts _ _ __ _ iy) Medicaid Benefit Details *Did John Doe receive Medicaid in any other state? “yes [+]

*when did the assistance end? 10 (§/10 (/ 2000

© Ni.gov | privacy policy | accessibility policy | non-discrimination policy | contact us

Figure 2-15: Other State Assistance Details The following field changes will be implemented:

e “Did <Name> receive Cash benefits in any other state?”

o If MAGI Only is requested at the case level, this field (as well as its child fields) will not be visible. e “Did <Name> receive Food Stamps in any other state?”

o If MAGI Only is requested at the case level, this field (as well as its child fields) will not be visible. e “Did <Name> receive Child Care in any other state?”

© If MAGI Only is requested at the case level, this field (as well as its child fields) will not be visible.

e For this screen, the existing validation to have at least one of the above questions populated as “Yes” when the gateway question “Has anyone in the household received benefits from another state?” is “Yes” will be removed for MAGI Only applications.

13-0018MM2 Approval Date: 03/11/201 Effective Date: 10/01/2013 New Hampshire

2.14 Other Module - Other State Assistance Summary

Name State Medicaid View/Edit Remove

John Doe Massachusetts Yes [ Remove |

*Has anyone else in your household received assistance from another state? { i

S$ NH.gov | privacy policy | accessibility policy | non-discrimination policy | contact us

Figure 2-16: Other State Assistance Summary The following changes will be implemented:

e “Cash”, “Food Stamps”, “Child Care” o For MAGI Only applications, these columns will never be displayed.

13-0018MM2 Approval Date: 03/11/201 Effective Date: 10/01/2013 New Hampshire

_____________________________________________________________________________

Table of Contents State/Territory Name: New Hampshire State Plan Amendment (SPA) #:13-0021 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

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

JFK Federal Building, Government Center

Room 2275

Boston, Massachusetts 02203

CMS

CENTERS FOR MEDICARE & MEDICAID SERVICES

Division of Medicaid and Children’s Health Operations / Boston Regional Office

September 12, 2014

Nicholas A. Toumpas, Commissioner Department of Health and Human Services State of New Hampshire

129 Pleasant Street

Concord, NH 03301

Re: New Hampshire SPA TN 13-0021-MM5 Dear Commissioner Toumpas,

Enclosed is an approved copy of New Hampshire’s (NH) State Plan Amendment (SPA) 13-0021-MMS, which was submitted to CMS on December 31, 2013. SPA 13-0021-MM5, approved on September 12, 2014, describes specific requirements for what constitutes state residency in accordance with 42 CFR §435.403. The effective date of this SPA is January 1, 2014.

Transmittal # 13-0021-MM5 --Non-Financial Eligibility — State Residency --Effective January 1, 2014

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

© S88, Pages S88-1 to S88-3

In addition, enclosed is a summary of State Plan pages that are superseded by NH 13-0021- MMS; this document should be incorporated into a separate section in the front of the State Plan.

CMS appreciates the significant amount or work your staff dedicated to preparing this State Plan Amendment. If there are questions, please contact Joyce Butterworth at (617) 565-1220 or by e- mail at Joyce.Butterworth@cms.hhs.gov.

Page 2 —Nicholas A. Toumpas, Commissioner

Sincerely, /s/

Richard R. McGreal Associate Regional Administrator

cc: Kathleen Dunn, State Medicaid Director Diane Peterson, Medicaid Business and Policy Dawn Landry, Division of Family Assistance

/s/

OFFICIAL

SUPERSEDING PAGES OF STATE PLAN MATERIAL

TRANSMITTAL NUMBER: STATE: NH-13-0021 MM5 New Hampshire PAGE NUMBER OF THE PLAN SECTION OR PAGE NUMBER OF THE SUPERSEDED PLAN SECTION ATTACHMENT: OR ATTACHMENT (If Applicable): S88 Non-Financial Eligibility- State Residency Section 2, Item 2.3, Page 13, TN 87-5b Attachment 2.6-A, Page 3, TN 13-0022 MM6

NH 13-0021 MM5 Approval Date: 09/12/2014 Effective Date: 01/01/2014

OFFICIAL

Medicaid Eligibility

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

Non-Financial Eligibility State Residency Seb 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:

wl 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 (a) Entered the state with a job commitment or seeking employment, whether or not currently employed.

wl 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

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

i 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:

wl 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

wl 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

{H] 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,

a unless another state made the placement. [H] Individuals who have been placed in an out-of-state institution, including foster care homes, by an agency of the state. a 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 . Page | of 4 13-0021-MM5 Approval Date: 09/12/2014 Effective Date: 01/01/2014

New Hampshire S88-1

OFFICIAL (SRR ie Sepa ee I TT SE]

Medicaid Eligibility

{@) Otherwise meet the requirements of 42 CFR 435.403.

. Page 2 of 4 13-0021-MM5 Approval Date: 09/12/2014 Effective Date: 01/01/2014 New Hampshire $88-2

OFFICIAL

Medicaid Eligibility

Meet the criteria specified in an interstate agreement. @ Yes (© No

[H] The state has interstate agreements with the following selected states:

><] Alabama [X] Illinois KK} Montana (X] Rhode Island XX] Alaska {) Indiana Nebraska [Xx] South Carolina ] Arizona XX] lowa ><] Nevada >] South Dakota >] Arkansas >X] Kansas (J New Hampshire [>X] Tennessee XX] California Kentucky IX] New Jersey Texas

XX] Colorado &) Louisiana New Mexico XX] Utah

] Connecticut XX] Maine C New York [Xx] Vermont

XX] Delaware Maryland North Carolina Virginia

XX] District of Columbia Massachusetts [XX] North Dakota Washington XX] Florida ] Michigan XX] Ohio [X] West Virginia &] Georgia Minnesota Oklahoma Wisconsin —] Hawaii XX] Mississippi XX] Oregon (] Wyoming

Xx] Idaho XX] Missouri ) Pennsylvania

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

a Are IV-E eligible (D Are in the state only for the purpose of attending school (Are out of the state only for the purpose of attending school CJ Retain addresses in both states

(1) Other type of individual

The state has a policy related to individuals in the state only to attend school.

@ Yes (© No

Provide a description of the policy:

These individuals are considered as being in the state temporarily if neither parent or guardian lives in the state, are applying on their own, and is being claimed as a tax dependent, and therefore are not considered to be residents of the state.

[B) Otherwise meet the criteria of resident, but who may be temporarily absent from the state.

: Page 3 of 4 13-0021-MM5 Approval Date: 09/12/2014 Effective Date: 01/01/2014 New Hampshire S88-3

OFFICIAL

Medicaid Eligibility

The state has a definition of temporary absence, including treatment of individuals who attend school in another state.

@ Yes C No

Provide a description of the definition:

“Temporary Absence” as an absence from the state with the intent of retaining N.H. residency and returning to the state as soon as the purpose for the absence is accomplished, including, but not limited to travel, visiting, the onset of illness while out of state which prohibits return to New Hampshire, or hospitalization in a medical facility.

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.

| Page 4 of 4 13-0021-MM5 Approval Date: 09/12/2014 Effective Date: 01/01/2014 New Hampshire S88-4

_____________________________________________________________________________

Table of Contents State/Territory Name: New Hampshire State Plan Amendment (SPA) #:13-0022-MM6 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Superseding Pages Notice 4) Approved SPA Pages 5) Additional Attachments that are part of the state plan (delete if not applicable)

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

JFK Federal Building, Government Center

Room 2275

Boston, Massachusetts 02203

CMS

CENTERS FOR MEDICARE & MEDICAID SERVICES

Division of Medicaid and Children’s Health Operations / Boston Regional Office

March 19, 2014

Nicholas A. Toumpas, Commissioner Department of Health and Human Services State of New Hampshire

129 Pleasant Street

Concord, NH 03301

Re: New Hampshire SPA TN 13-0022-MM6

Dear Commissioner Toumpas,

Enclosed is an approved copy of New Hampshire’s (NH) State Plan Amendment (SPA) 13-0022-MM6, which was submitted to CMS on December 31, 2013. SPA 13-0022-MM6, approved on March 19, 2014, describes NH rules concerning Medicaid requirements related to United States citizenship and non-citizen eligibility in accordance with 42 CFR §435.406. The effective date of this SPA is January 1, 2014.

Transmittal # 13-0022-MM6 --Citizenship and Non-Citizenship Eligibility --Effective January 1, 2014

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

e S89, Pages S89-1 to S89-3

In addition, enclosed is a summary of State Plan pages that are superseded by NH 13-0022- MM6; this document should be incorporated into a separate section in the front of the State Plan.

e Superseding pages of state plan material, SPA 13-0022-MM6

CMS appreciates the significant amount or work your staff dedicated to preparing this State Plan Amendment. If there are questions, please contact Joyce Butterworth at (617) 565-1220 or by e- mail at Joyce.Butterworth@cms.hhs.gov.

/s/

/s/

SUPERSEDING PAGES OF STATE PLAN MATERIAL

TRANSMITTAL NUMBER:

13-0022 MM6 STATE:

New Hampshire

PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:

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

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

Attachment 2.6-A, Page 2, item 3 a., b. & c. TN 91-23 Effective date: 11/01/91, Approved date: 11/27/92 Attachment 2.6-A, Page 3, item 3 d. & e. TN 91-23 Effective date: 11/01/91, Approved date: 11/01/91

OFFICIAL

Medicaid Eligibility

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

$89

Non-Financial Eligibility Citizenship and Non-Citizen Eligibility

1902(a)(46)(B)

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

42 CFR 435 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 {H Reconciliation Act (PRWORA) (8 U.S.C. §1641), or whose eligi 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.

C Yes @No

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

@Yes (No The date benefits are furnished is: @ The date of application containing the declaration of citizenship or immigration status. C The date the reasonable opportunity notice is sent.

C Other date, as described:

Page | of 3

TN 13-0022-MM6 Approval Date: 03/19/2014 Effective Date: 01/01/2014 New Hampshire S89-1

OFFICIAL

Medicaid Eligibility

The s (8U.

e provides Medicaid coverage to all Qualified Non-Citizens whose eligibility is not prohibited by section 403 of PRWORA 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.

C Yes @No

wl 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.

C. 1641(b) and (¢):

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

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

4. Is a non-citizen who belongs to one 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(¢): 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;

ff ee @

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 -

[B} Has been granted employment authorization: or [i] 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)(I)s 8. Is lawfully present in American Samoa under the immigration laws of American Samoa: or

9. Is a victim of severe trafficking in persons 2000. Pub. L. 106-386. as amended (22 U.

in accordance with the Victims of Trafficking and Violence Protection Act of C.7105(b)):

Page 2 of 3

TN 13-0022-MM6 Approval Date: 03/19/2014 Effective Date: 01/01/2014 New Hampshire S89-2

OFFICIAL

Medicaid Eligibility

10. Exception: An individual with deferred action under the Department of Homeland Security's deferred action for the childhood arrivals process, as described in the Secretary of Homeland Security's June 15.2012 memorandum, shall not be considered to be lawfully present with respect to any of the above categories in paragraphs (1) through (9) of this definition.

p.J Otlier:

he state assures that it provides limited Medicaid services for treatment of an emergency medical condition. not related to an organ transplant procedure. as defined in 1903(v)(3) of the SSA and implemented at 42 CFR 440.255, to the following individuals who meet all Medicaid eligibility requirements. except documentation of citizenship or satisfactory immigration status and/or present an SSN:

i

. [@) Qualified non-citizens subject to the 5 year waiting period described in 8 U.S.C. 1613:

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

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

Page 3 of 3

TN 13-0022-MM6 Approval Date: 03/19/2014 Effective Date: 01/01/2014 New Hampshire $89-3

_____________________________________________________________________________

Table of Contents State/Territory Name: New Hampshire State Plan Amendment (SPA) #:13-0023 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

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

JFK Federal Building, Government Center

Room 2275

Boston, Massachusetts 02203

CMS

CENTERS FOR MEDICARE & MEDICAID SERVICES

Division of Medicaid and Children’s Health Operations / Boston Regional Office

July 9, 2014

Nicholas A. Toumpas, Commissioner Department of Health and Human Services State of New Hampshire

129 Pleasant Street

Concord, NH 03301

Re: New Hampshire SPA TN 13- 0023-MM7 Dear Commissioner Toumpas,

Enclosed is an approved copy of New Hampshire’s (NH) State Plan Amendment (SPA) 13-0023-MM7, which was submitted to CMS on December 31, 2013. Based on the initial

SPA submission review, CMS determined that additional information was needed before a final decision could be made. A formal request for additional information (RAI) was sent to the state on March 31, 2014, and on July 1, 2014, the State submitted a response to the RAI. SPA 13-0023-MM/7, approved on July 9, 2014, indicates that qualified hospitals in NH determine eligibility presumptively under the option at 42 CFR §435.1110. The effective date of this SPA is January 1, 2014.

Transmittal # 13-0023-MM7 --Presumptive Eligibility By Hospitals --Effective January 1, 2014

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

e §21, Pages $21-1 to $21-3 CMS appreciates the significant amount or work your staff dedicated to preparing this State Plan

Amendment. If there are questions. please contact Joyce Butterworth at (617) 565-1220 or by e- mail at Joyce.Butterworth@cms.hhs.goy.

Page 2 —Nicholas A. Toumpas, Commissioner

Sincerely, /s/

Richard R. McGreal Associate Regional Administrator Enclosure/s

cc: Kathleen Dunn, State Medicaid Director Diane Peterson, Medicaid Business and Policy Dawn Landry, Division of Family Assistance

State/Territory name: New Hampshire Submitted By: Dawn Landry Last Revision Date: Jul 7, 2014 Submit Date: Dec 31, 2013 Medicaid State Plan Eligibility: Summary Page (CMS 179) Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. NH-13-0023 Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation 1902(a)(47)(B; 42 CFR 435.1110 Federal Budget Impact Federal Fiscal Year Amount First Year 2014 $ 0.00 Second Year 2015 $ 0.00 Subject of Amendment This state plan page indicates that hospitals in New Hampshire determine eligibility presumptively under the option at 42 CFR 435.1110, and that New Hampshire provides Medicaid coverage for individuals determined presumptively eligible under this provision. Governor's Office Review Governor's office reported no comment Comments of Governor's office received Describe: No reply received within 45 days of submittal Other, as specified Describe: Comments, if any, will follow. Signature of State Agency Official Date Received: 12/31/2014 Effective Date of Approved Material: 01/01/2014 Typed Name: Richard R. McGreal Plan Approved - One Copy Attached Date Approved: 07/09/2014 Signature of Regional Official: Division of Medicaid & Children's Health Operations Boston Regional Office OFFICIAL /s/

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. TN No. 13-0023-MM7 New Hampshire Approval Date: 07/09/2014 S21-1 Effective Date: 01/01/2014 OFFICIAL

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: 75% of individuals who are determined presumptively eligible must submit a regular application prior to the end of the PE period. The state has standards that relate to the proportion of individuals who are determined eligible for Medicaid based on the submission of an application before the end of the presumptive eligibility period. The 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. 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. TN No. 13-0023-MM7 New Hampshire Approval Date: 07/09/2014 S21-2 Effective Date: 01/01/2014 OFFICIAL

Page 3 of 3 Medicaid Eligibility 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. TN No. 13-0023-MM7 New Hampshire Approval Date: 07/09/2014 S21-3 Effective Date: 01/01/2014 OFFICIAL