us-nj/policy/cms/medicaid-state-plan/spa

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

(nj-09-03-m)(form-cms-179)(page-1)Page 1#

fEF` ti i" P f_= N T IF N:Ei-,. E`-I Alj !1Itv1f J .' i.( i1i: E i; Eit ii' R:'; 3= 0 rf ts1Et? iC'r. E Mtt) iC:itl, SER.3 ES TRAriSIU! lTTAL 13it) TiE F PPRQ1lAL UF STAT P'LAN M7E 1. . fld CtUT FS 7R MEl71GAR & MEUlCAlL1 ERf ES Ft• r1f+ PPE t) t f: i:) h1B tJt,) (x93- f1; i Th'r' dS'tl{ TTi- NUh16E L =:`t:. TE_ 0-i 3- Nll Iel Jersey PF20GRa 3ENT11 i0l. TiT;.E X : Ti~IE SCiAL SEC..1RiTY tCT 'iPy'IEC7 Ci3C31 Tt" REGINHL iCftll lISTRIT R _ , p,P, rP(? SFf CFFECTIVE C7,7E GNTE fi F{? R Eal,t RE MEGIC.1D SEd/ ICES Pv1ly 1, 2{0 IF; ( ItE'1° i" C7 #- IEiLTki qNi F-il M SERL' lCES iYE = 'L;; tV TEiiF lult r? e) • fiS;ELV siT' E F=_=; 3 , , iLl' IUC3JIEI T T E :C?tlal3t RED ;S Iv;'' F= L ati ' 1 IIE.NC:+ PIENT C) MPLE7: rt; S THf;I '; If TNIS IS rN 1d1EN ifIEANT Sp3r at Tt, ti aFrttal fcr' er' arnex, intj __ f EDEP. L STlTUTCfF EGULA Ii7N ITTIO I. ;; FERAL BI;G u? iMT,.C1T G}- IlPRA ,OC ction Q; Sacial curity Act ; a. =F' OJ . lth; ov+n t this time Set cn_'! 02_ ( 13 ._--. _._... ____ __.. _ _ _.._ _ b___ u tJr#r vr t iis tir 3 AG NUtr1 E? t= s-? E L1R EG'iION {7F'. ? GE 111B f Cf Tl- SUE.. F? SED= D '' 1_? N TT.Ctit+ lEhl7 ' SEC1 3({ . , T7t 1-l EiJT (i> >';`,.` bb! ej Stfi Pln Sctit r 2. }ac ` 11 . 1 , 1 1 i I: vy SEE REMARKS 0 5u,+r Ett j. i 7. Express Lane HgiJity Ot Un 1 ;'/ ERN(R S ftV Evhl r' hec# c t7}. _ i__. 1 01 h3V?R` S +' JFiCE EPORTE JG CIvIMEN° l" ': C'N r. fS S' ClFIED. tUN1 iEtlTS F £ VNC P'S = FIE Ehd LSED t. tu rer LrsU nt i ; ? 4 ^f the 'Ir RP Y ? Er'iVEG I4'3'' HiN CzYS FiUf3PJ11 TA,L S;v; 1- l;{? F= nr Tt.E , r- _ . _ __ ._ _ _ _ _ ENC'Y O-t ICl1L - r RE : a JUh,I G:ai' DiruGiO,' T E Ct I, J nnf'' Vle ___ ti, ; a ._ r __._. _ _--- . _... _._---- ivisn ci if1 ii rss stric ,rcit Srvi. r, s 14 t.. E r ssii er, __ _ _ (' ; ox ?'I f:ii .31e #2 Lt rt?` l It unlat 'irviees _ , Trprtton fl 8 ;- i71,r 5 C, t 7Si11` r1 v: F'3R REGIC3A. { 3FFiCE t. 15 {}Y ___._. 17 iTC R'.. E"/ E 3 C)Aiv .FjF:t`. t( . e Pi.AN APPRVEt — NE GC3F'Y Aa' 1 F= ECTiVF_ Cn f" E ? F ,PPRC'ED MftTA iL 1. 2YW 2C S1Gi " i ;: E tLtiC9/ 1L. e • rn 2 . TYPD N1ME: - _.._ _ .. _.... 3 G_ TIT ociate egionai A _ inistor ___ _ .._ of 14ledicaid and 23. RERIARi: Note Pen & Ink change to HCFA 179 to reflect the following in box 7: FFY 09 -$1, 000, 884 and FFY 10 -$4, 160, 402 FtI i G11s1-? s9 ;tJi-;}"') trstr cticr s tsr ack

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DFFICIAL

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: New Jersey

Page lif

SECTION 2 —- COVERAGE AND ELIGIBILITY

Citation(s)

2.1 Application, Determination of Eligibility and Furnishing Medicaid (Continued)

(4) The following component/components of Medicaid eligibility are determined under the Express Lane option. Also, specify any differences in budget unit, deeming, income exclusions, income disregards, or other methodology between Medicaid eligibility determinations for such children and the determination under the Express Lane option.

The components of Medicaid eligibility under this Express Lane option are income and residency.

Under this Express Lane option, income is determined by individual eligibility for Free lunch within the School Lunch Program (SLP), which has an income threshold of 130% FPL. The SLP determines income using adjusted gross income. This is different because without the Express Lane option, earned income disregards, the child support disregard and child care deductions would have been used when calculating financial eligibility for Medicaid.

Residency is accepted based on the child’s status as a student in the school district, as determined by the Express Lane Agency. This is different because without the Express Lane option,

families must provide proof of residency by submitting documentation such as school records or utility bills.

Full eligibility is then determined by: -verifying citizenship and identity using available electronic data bases -determining family size using our subsequent application.

(5) Check off which option is used to satisfy the Screen and Enroll requirement before a child may be enrolled under title XXI.

C] (a)Screening threshold established by the Medicaid agency as:

(| (i)___ percentage of the Federal poverty level (exceeds the highest Medicaid income threshold applicable to a child by a minimum of 30 percentage points); or

11-06-MA TN No.: 11-06 Approval DateFFR 0.8 2012Fffective Date APR-0- 1 208.

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EPARTMENT OF HEALTH ANO HUMAN SERVICES FORM APPROVED ENTERS FOR MEDICARE & MEDICIAD SERVICES conndMB NO, 0938-0193 TRANSMITTAL AND NOTICE OF APPROVAL OF | 7. TRANSMITTAL NUMBER: 2, STATE STATE PLAN MATERIAL 11-06-MA New Jersey

FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES

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

TO: REGIONAL ADMINISTRATOR CENTERS FOR MEDICARE & MEDICAID SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES

4. PROPOSED EFFECTIVE DATE April 1, 2011

5. TYPE OF PLAN MATERIAL (Check One):

(1 NEW STATE PLAN

(J 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: CHIPRA 2009 Section 203; Social Security Act Section 1902 (e) (13)

7. FEDERAL BUDGET IMPACT. a. FFY 2011 $0 b. FFY 2012 $6,366,239 (cost) See attachment

8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:

State Plan Section 2.1 pages 11e, 11f, 11g

** SEE REMARKS

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

New

10. SUBJECT OF AMENDMENT:

Express Lane Eligibility Option

11, GOVERNOR'S REVIEW (Check One): [] GOVERNOR'S OFFICE REPORTED NO COMMENT (] COMMENTS OF GOVERNOR'S OFFICE ENCLOSED

[-] NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL

%] OTHER, AS SPECIFIED: Not required, pursuant to 7.4 of the Plan

12 wi AGENCY OFFICIAL:

43. TYPED Nap “Pennie t Velez

44. TITLE: f~ rey uman Services

45, DATE ee

16. RETURN TO

Valerie Harr, Director

Division of Medical Assistance and Health Services P.O. Box 712, Mail Code #26

Trenton, NJ 08625-0712

FOR REGIONAL OFFICE USE ONLY

17. DATE RECEIVED:

18. DATE BEbFuary 8, 2012

PLAN APPROVED — ONE COPY ATTACHED

19. EFFECTIVE DATE OF APR MATERIAL:

20. SIGNATURE OF REGIONAL OFFICIAL:

21. TYPED NAME: Michael Melendez

Associate Regional Administrator Division of Medicaid and State Operations

22. TITLE:

23. REMARKS:

** By means of this SPA, the State of New Jersey is electing the option to rely on a finding from an Express Lane agency (NJ Free Lunch Program) when determining whether a child satisfies one or more components of Medicaid eligibility. (CHIPRA 2009 Section 203, Section 1902(e)(13) of the Social Security Act).

ORM CMS-179 (07-92)

instructions on Back

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

STATE PLAN MATERIAL

FORM APPROVED : OMB NO. 0938-0193 2. STATE

— : i i

13-06 MA NJ New Jersey

FOR: CENTERS FOR MEDICARE AND MEDICAID SERVICES

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

TO. REGIONAL ADMINISTRATOR CENTERS FOR MEDICARE AND MEDICAID SERVICES

DEPARTMENT OF HEALTH AND HUMAN SERVICES

4. PROPOSED EFFECTIVE DATE

April 1, 2013

8. TYPE OF PLAN MATERIAL (Check One):

(J AMENDMENT TO BE CONSIDERED AS NEW PLAN

{ AMENDMENT

HRU 10 1F THIS

s AN AMENDMENT (Separate Transmitt:

for each amendment)

6. FEDERAL STATUT! TATION: 1908(b) and 1905(y) of the Sacial Security Act

7. FEDERAL BUDGET IMPACT a. FFY 2013: $223k b. FFY 2014: $446k

8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:

Addendum to Attachment 3.1A page 13(c)1

Addendum to Attachment 3.1B page 13(c)1 **Please see remarks

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

New page

10. SUBJECT OF AMENDMENT: ACA Section 4106 Preventive Services 1% FMAP increase

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

(OTHER, AS SPECIFIED: Not required, pursuant to 7.4 of the Plan

. 12. SIGNATURE OF STATE AGENCY OFFICIAL:

i THLE:

15. DATE SUBMITTED: Gf OL 4

16. RETURN TO:

Valerie Harr, Director

Division of Medical Assistance and Health Services P.O. Box 712, #26

Trenton, NJ 08625-0712

FOR REGIONAL OFFICE USE ONLY

17, DATE RECEIVED;

18. DATE APEREN BD: eptember 12, 2013

PLAN APPROVED ~ ONE COPY ATTACHED Qh j

. 19. EFFECTIVE DATE OF APPROVED MATERIAL: April 01, 2013

AS [eed vas FFICT Velno 4

21. TYPED NAME: Michael Melendez

22. TITLE: Associate Regional Administrator

“33. REMARKS:

Division of Medicaid and State Operations.

**This SPA proposed to reflect that New Jersey Medicaid covers and reimburses all United Stated Preventive Services Task

Force(USPSTF) grade A and B preventative services, approved vaccines and their administration recommended by the -

Advisory Committee on Immunization Practices (ACIP) in the standard Medicaid benefit package without cost-sharing. This

amendment is in accordance with section 4106(b) of the Affordable Care Act (ACA) which establishes a one percentage

point increase in the Federal Medical Assistance Percentage (FMAP) applied to expenditures for adult vaccines and clinical __ preventive services to states that cover, without cost sharing, a full list of specified preventive services.and.adult vaccines

FORM CMS-179

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Medicaid Eligibility

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

42 CFR 435.226 1902(a)(10)(A)(Gi)(XVIT)

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

@ Yes (C No The state attests that it operates this eligibility group in accordance with the following provisions: Pp Individuals qualifying under this eligibility group must meet the following criteria: q [M] Are under the following age @ Under age 21 C Under age 20 C Under age 19 [] Were in foster care under the responsibility of a state on their 18th birthday. [m] Are not eligible and enrolled for mandatory coverage under the Medicaid state plan. [@] Have household income at or below a standard established by the state.

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

The state covered this eligibility group under its Medicaid state plan as of December 31, 2013, or under a Medicaid 1115 demonstration as of March 23, 2010 or December 31, 2013. @ Yes (© No

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

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

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

@ All children under the age selected C A reasonable classification of children under the age selected: [ml] Income standard used for this eligibility group

[®] Minimum income standard

The minimum income standard for this classification of children is the AFDC payment standard in effect as of July 16, 1996, not converted to MAGI-equivalent. This standard is described in $14 AFDC Income Standards.

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Medicaid Eligibility

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

42 CFR 435.227 1902(a)(10)(A)(ii)(VIIT)

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

[BM] Individuals qualifying under this eligibility group must meet the following criteria:

i 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): @ Under age 21 C Under age 20 C Under age 19 C Under age 18

i 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 C No

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

i 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.

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 i StoR C4- eK Kae. Baltimore, Maryland 21244-18

Approval Date: 02/28/2014 Effective Date: 01/01/2014 Now Jersey $53

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Medicaid Eligibility

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

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

iw 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:

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

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

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

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

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

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

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See

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

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

The state covers the Adult Group as described at 42 CFR 435.119. @ Yes (CNo

[m] Adult Group - Non-pregnant individuals age 19 through 64, not otherwise mandatorily eligible, with income at or below 133% FPL. The state attests that it operates this eligibility group in accordance with the following provisions: [@ Individuals qualifying under this eligibility group must meet the following criteria: [Ml Have attained age 19 but not age 65. [@) Are not pregnant.

[Are not entitled to or enrolled for Part A or B Medicare benefits.

aw Are not otherwise eligible for and enrolled for mandatory coverage under the state plan in accordance with 42 CFR 435, subpart B.

Note: In 209(b) states, individuals receiving SSI or deemed to be receiving SSI who do not qualify for mandatory Medicaid eligibility due to more restrictive requirements may qualify for this eligibility group if otherwise eligible.

[@] Have household income at or below 133% FPL.

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.

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

Parents or other caretaker relatives living with a child under the age specified below are not covered unless the child is

[m] receiving benefits under Medicaid, CHIP or through the Exchange, or otherwise enrolled in minimum essential coverage, as defined in 42 CFR 435.4.

C Under age 19, or

@ A higher age of children, if any, covered under 42 CFR 435.222 on March 23, 2010: C Under age 20 @ Under age 21

[| Presumptive Eligibility

@ Yes C No

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Medicaid Eligibility

[M) The presumptive period begins on the date the determination is made.

[Mi] 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.

[Ml Periods of presumptive eligibility are limited as follows: C 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. @yYes CNo @ The state uses a single application form for Medicaid and presumptive eligibility, approved by CMS.

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

[m) The presumptive eligibility determination is based on the following factors: [B) The individual must meet the categorical requirements of 42 CFR 435.119. [] Household income must not exceed the applicable income standard described at 42 CFR 435.119. J] State residency.

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

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

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

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

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

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Medicaid Eligibility

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

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

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

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

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

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

O 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

LJ 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.

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Ss Medicaid Eligibility

Creme roe were ane & we Der AD LNCS

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

42 CFR 435.118 1902(a)(10)(A)(i\(IMD), (IV), (VI) and (VII) 1902(a)(10)(A)(ii)(IV) and (IX)

1931(b) and (d)

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

The state attests that it operates this eligibility group in accordance with the following provisions: [) Children qualifying under this eligibility group must meet the following criteria: [mM] Are under age 19

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

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

[m] Income standard used for infants under age one

[&) Minimum income standard

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

C Yes @ No

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

[®) Maximum income standard

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

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

The state's highest effective income level for coverage of infants under age one under sections 1931 (low-income families), 1902(a)(10)(A)(i)(I1) (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 March 23, 2010, converted to a MAGI- equivalent percent of FPL.

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Medicaid Eligibility

The state's highest effective income level for coverage of infants under age one under sections 1931 (low-income families), 1902(a)(10)(A)(i)(II1) (qualified children), 1902(a)(10)(A)(i)(IV) (mandatory poverty level-related

C 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: |194 % FPL

[B) 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)(IIT) (qualified children), 1902(a)(10)

C (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 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)(IIT) (qualified children), 1902(a)(10) (A)(i)(IV) (mandatory poverty level-related infants), 1902(a)(10)(A)(ii)(1X) (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.

Cc 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 one through age five, inclusive

{®] Minimum income standard

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Ss Medicaid Eligibility

(Cremean rom wate Ane @ asec aun RC

The minimum income standard used for this age group is 133% FPL. [=] Maximum income standard The state certifies that it has submitted and received approval for its converted income standard(s) for children

age one through five to MAGI-equivalent standards and the determination of the maximum income standard to be used for children age one through five.

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

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

@ income families), 1902(a)(10)(A)(i)CII) (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-

Cc income families), 1902(a)(10)(A)(i)(I1) (qualified children), 1902(a)(10)(A)(i)(VI) (mandatory poverty level- related children age one through five), and 1902(a)(10)(A)(iiIV) (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 MAGIT-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 to a MAGI-equivalent percent of FPL.

Enter the amount of the maximum income standard: |142 % 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)(II) (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.

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 December 31, 2013, converted to a MAGI-equivalent percent of FPL.

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Medicaid Eligibility

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

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

Cc 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.

fm] Maximum income standard

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

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

The state's highest effective income level for coverage of children age six through eighteen under sections 1931

Cc (low-income families), 1902(a)(10)(A)(i)(IIT) (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 e (low-income families), 1902(a)(10)(A)(i)(III) (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.

Cc 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.

Cc 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.

C 133% FPL

Enter the amount of the maximum income standard: |142 % FPL

[) Income standard chosen

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CMS Medicaid Eligibility

(Cone poe water ane @ operas EVE

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)(III) (qualified children),

C 1902(a)(10)(A)(i)(VI) (mandatory poverty level-related children age six through eighteen) and 1902(a)(10)(A) (ii)(TV) (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)(I1) (qualified children), 1902(a)(10)(A)(i)(VIT) (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, 201 3, converted to a MAGI-equivalent percent of FPL.

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

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

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

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

@ Yes C No

1902(a)(47) 1920A

42 CFR 435.1101 42 CFR 435.1102

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

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Ss Medicaid Eligibility

(CENTOI PON META ARS 4 seer AUD RRVICR

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.

[m] Children under the following age may be determined presumptively eligible:

Under age |19

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

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

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

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

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

Im] Household income must not exceed the applicable income standard described above, for the child's age.

[X] State residency

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

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

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MSs Medicaid Eligibility

Cnr rhe Mert Ane 4 ue ORCAI EVE

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

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

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

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

id 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)

(7 Is an elementary or secondary school operated or supported by the Bureau of Indian Affairs (7 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.

PRA Disclosure Statement

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s Medicaid Eligibility

(Cone roe eeoec ann a weperasD BCH

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

1 tote 9 sm cs ahh cb BS

42 CFR 435.116

1902(a)(10)(A)(i)(HII) 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: [Ml Individuals qualifying under this eligibility group must be pregnant or post-partum, as defined in 42 CFR 435.4. Pregnant women in the last trimester of their pregnancy without dependent children are eligible for full benefits under this group in accordance with section 1931 of the Act, if they meet the income standard for state plan Parents and Other

Caretaker Relatives at 42 CFR 435.110.

@ Yes C No

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

[@] Income standard used for this group

[®) Minimum income standard (Once entered and approved by CMS, the minimum income standard cannot be changed.)

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

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

[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.

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

The state's highest effective income level for coverage of pregnant women under sections 1931 (low-income

families), 1902(a)(10)(A)(i)(III) (qualified pregnant women), 1902(a)(10)(A)(i)(IV) (mandatory poverty level-

related pregnant women), 1902(a)(10)(A)(ii)(IX) (optional poverty level-related pregnant women), 1902(a)(10) ° (A)(ii)() (pregnant women who meet AFDC financial eligibility criteria) and 1902(a)(10)(A)(ii)(TV)

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

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Ss Medicaid Eligibility

Ceremran erie aaroer ans 4 ener AUD REECE

The state's highest effective income level for coverage of pregnant women under sections 1931 (low-income families), 1902(a)(10)(A)(i)(IIT) (qualified pregnant women), 1902(a)(10)(A)(i)(IV) (mandatory poverty level- related pregnant women), 1902(a)( 10)(A)(ii)(TX) (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)(IV) (institutionalized pregnant women) 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 pregnant women under a Medicaid 11 15 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL.

The state's effective income level for any population of pregnant women under a Medicaid 11 15 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:]194 % FPL

[mg] 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. [lM] There is no resource test for this eligibility group. [i] 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.

[ml] Presumptive Eligibility

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

@ Yes CNo [@] The presumptive period begins on the date the determination is made.

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

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

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

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cms Medicaid Eligibility

(AE pre MeeDAC ARE A aes DerAIG SEENON

@ Yes C 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.

peta eabmte:

[M) The presumptive eligibility determination is based on the following factors:

{m] The woman must be pregnant [m] Household income must not exceed the applicable income standard at 42 CFR 435.116. EX] State residency

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

ry The state uses qualified entities, as defined in section 1920A of the Act, to determine eligibility presumptively 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

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

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

= Is authorized to determine a child's eligibility 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)

(7 Is an elementary or secondary school operated or supported by the Bureau of Indian Affairs C1 Isa state or Tribal child support enforcement agency under title IV-D of the Act

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

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ROM fe mene ass & wscerD MCT

42 CFR 435.110

1902(a)(10)(A)(i)(1) 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: [™] Individuals qualifying under this eligibility group must meet the following criteria:

aw Are parents or other caretaker relatives (defi

ined at 42 CFR 435.4), including pregnant women, of dependent children (defined at 42 CFR 435.4) under age 18. Sp

ouses 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,

IX] provided the children are full-time students in a secondary school or the equivalent level of vocational or technical training.

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

oO The definition of caretaker relative includes the domesti

ic partner of the parent or other caretaker relative, even after the partnership is terminated.

Definition of domestic partner:

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

Description of other relatives:

® 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.

] Options relating to the definition of dependent child (select the one that applies): The state elects to eliminate the requirement that

@ care by reason of the death, physical or mental in least one parent.

a dependent child must be deprived of parental support or capacity, or absence from the home or unemployment of at

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

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0 DEIEESy—F = ee

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s Medicaid Eligibility

(Crm poe water ant 6 aepersD ICR

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

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

[m) Income standard used for this group

[®) Minimum income standard

The minimum income standard used for this group is the state's AFDC payment standard in effect as of May 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.

I] 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.

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

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

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

The state's effective income level for any population of parents/caretaker relatives under a Medicaid 1115 C demonstration as of March 23, 2010, converted to a MAGIT-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:

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Ss Medicaid Eligibility

Crom roe weecans 4 ener ECE

CA percentage of the federal poverty level: %

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

C Other dollar amount

[M] 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

@ Yes CNo

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

[| The end date of the presumptive period is the earlier of:

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: C 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.

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rts

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Ss Medicaid Eligibility

EAE Foe Mec AR & operas NRVC

C Other reasonable limitation:

The state requires that a written application be signed by the applicant or representative.

@ Yes CNo

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

application form is included.

[m) The presumptive eligibility determination is based on the following factors: [lM] 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 435.1 10.

IX] State residency

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

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

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

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

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

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

Is authorized to determine a child's eligibility to receive assistance under the Special Supplemental

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

® 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)

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

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

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DEPARTMENT OF HEALTH & HUMAN SERVICES

Centers for Medicare & Medicaid Services mn“

New York Regional Office :

26 Federal Plaza, Room 37-100 ‘

New York, NY 10278 CENTERS FOR MEDICARE & MEDICAID SERVICES

DIVISION OF MEDICAID AND CHILDREN’S HEALTH OPERATIONS

December 3, 2013

Valerie Harr, Director

State of New Jersey

Department of Human Services

Division of Medical Assistance and Health Services P.O. Box 712

Trenton, New Jersey 08625

Dear Ms. Harr:

Enclosed is an approved copy of New Jersey’s state plan amendment (SPA) 13-0016-MM3, which was submitted to CMS on November 6, 2013. SPA 13-0016-MM3 incorporates the MAGI-Based Income Methodologies into New Jersey’s state plan in accordance with the Affordable Care Act. This SPA was approved on December 3, 2013. The effective date of the SPA is January 1, 2014.

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

e $10, Pages $10-1 and S10-2

In addition, enclosed is a summary of state plan pages which are superseded by SPA 13-0016-MM3, which should also be incorporated into a separate section in the front of the state plan:

e Superseding Pages of State Plan Material, 13-0016-MM3

Notwithstanding any other provisions of the New Jersey Medicaid state plan, the financial eligibility methodologies described in SPA 13-0016-MM3 will apply to all MAGI-based eligibility groups covered under New Jersey’s Medicaid state plan. The MAGI financial methodologies set forth in 422 CFR §435.603 apply to everyone except those individuals described at 42 CFR §435.603(j) for whom MAGI-based methods do not apply. This SPA supersedes the current financial eligibility provisions of the Medicaid state plan only with respect to the MAGI-based eligibility groups.

Congratulations to you and your staff for your hard work and strong collaboration. If you have any questions, please contact Patricia Ryan at 212-616-2436 or Patricia.Ryan@cms.hhs.gov.

Sincerely, /s/

Michael Melendez

Associate Regional Administrator

Division of Medicaid and Children’s Services New York Regional Office

Enclosure

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Medicaid Eligibility

OMB Control Number 0938-1148

2014

OMB Expiration date: 10/3

1902(e)(14) 42 CFR 435.603

42 CFR 435.603.

In the case of determining ongoing eligibility for beneficiaries determined eligible for Medicaid on or before December 31, 2013, MAGI-based income methodologies will not be applied until March 31, 2014, or the next regularly-scheduled renewal of eligibility, whichever is later, if application of such methods results in a determination of ineligibility prior to such date.

In determining family size for the eligibility determination of a pregnant woman, she is counted as herself plus each of the children she is expected to deliver.

In determining family size for the eligibility determination of the other individuals in a household that includes a pregnant woman:

C The pregnant woman is counted just as herself. C The pregnant woman is counted as herself, plus one.

@ The pregnant woman is counted as herself, plus the number of children she is expected to deliver. Financial eligibility is determined consistent with the following provisions:

When determining eligibility for new applicants, financial eligibility is based on current monthly income and family size.

When determining eligibility for current beneficiaries, financial eligibility is based on:

@ Current monthly household income and family size

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

In determining current monthly or projected annual household income, the state will use reasonable methods to:

[X] Include a prorated portion of a reasonably predictable increase in future income and/or family size.

{] Account for a reasonably predictable decrease in future income and/or family size.

Except as provided at 42 CFR 435.603(d)(2) through (d)(4), household income is the sum of the MAGI-based income of every individual included in the individual's household.

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

Household income includes actually available cash support, exceeding nominal amounts, provided by the person claiming an individual described at §435.603(f)(2)(i) as a tax dependent.

ia The state will apply Modified Adjusted Gross Income (MAGI)-based methodologies as described below, and consistent with

@ Yes (No TN: 13-0016 MM APPROVAL DATE: 12/03/2013 EFFECTIVE DATE: 01/01/2014 NEW JERSEY $10

Paae 1 nf?

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(CMS Medicaid Eligibility

OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 3 sp

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

42 CFR 435.4

42 CFR 435.406

42 CFR 435.956

Citizenship and Non-Citizen Eligibility

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

The state provides Medicaid eligibility to otherwise eligible individuals: 8) [HM] Who are citizens or nationals of the United States; and

Who are qualified non-citizens as defined in section 431 of the Personal Responsibility and Work Opportunity [Reconciliation Act (PRWORA) (8 U.S.C. $1641), or whose eligibility is required by section 402(b) of PRWORA (8 U.S.C. §1612(b)) and is not prohibited by section 403 of PRWORA (8 U.S.C. §1613); and

Who have declared themselves to be citizens or nationals of the United States, or an individual having satisfactory immigration status, during a reasonable opportunity period pending verification of their citizenship, nationality or C satisfactory immigration status consistent with requirements of 1903(x), 1137(d), 1902(ee) of the SSA and 42 CFR 435.406,

and 956.

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

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

@ Yes CNo

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

@ Yes (No The date benefits are furnished is: @ 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:

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Medicaid Eligibility

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

@ Yes CNo

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

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

a 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.

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

2. Is a non-citizen in a valid nonimmigrant status, as defined in 8 U.S.C. 1101(a)(15) or otherwise under the immigration laws (as defined in 8 U.S.C. 1101(a)(17));

3. Is a non-citizen who has been paroled into the United States in accordance with 8 U.S.C. 1 182(d)(5) for less than 1 year, except for an individual paroled for prosecution, for deferred inspection or pending removal proceedings;

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

Granted Temporary Protected Status (TPS) in accordance with 8 U.S.C. §1254a, and individuals with pending applications for TPS who have been granted employment authorization;

Granted employment authorization under 8 CFR 274a.12(c);

Family Unity beneficiaries in accordance with section 301 of Pub. L. 101-649, as amended;

aon

Under Deferred Enforced Departure (DED) in accordance with a decision made by the President; [| Granted Deferred Action status;

[@] Granted an administrative stay of removal under 8 CFR 241;

[lM] Beneficiary of approved visa petition who has a pending application for adjustment of status;

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

[M] Has been granted employment authorization; or

[Ml] Is under the age of 14 and has had an application pending for at least 180 days; TN: 13-0017-MIvi6 Approvat Date> 62/65/2644 New Jersey S89 Page 2 of 3

te: 91/01/2014

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Medicaid Eligibility

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

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

10. Exception: An individual with deferred action under the Department of Homeland Security's deferred action for the childhood arrivals process, as described in the Secretary of Homeland Security's June 15, 2012 memorandum, shall not be considered to be lawfully present with respect to any of the above categories in paragraphs (1) through (9) of this definition.

( Other

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

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

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

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

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-MM6 Approval Date: 02/05/2014 Effective Date: 01/01/2014 New Jersey $89 Page 3 of 3

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DEPARTMENT OF HEALTH & HUMAN SERVICES

Centers for Medicare & Medicaid Services Cc RA &&

7500 Security Boulevard, Mail Stop: S2-26-12 sae” Baltimore, Maryland 21244-1850 CENTER FOR MEDICAID & CHIP SERVICES

Children and Adults Health Programs Group

FEB 19 2014

Ms. Valerie Harr, Director

Division of Medical Assistance and Health Services New Jersey Department of Human Services

7 Quakerbridge Plaza

P.O. Box 712

Trenton, NJ 08625-0712

Dear Ms. Harr:

Iam pleased to inform you that your title XXI Children’s Health Insurance Program (CHIP) state plan amendment (SPA) numbers NJ-13-0018 and NJ-13-0020, submitted on November 21, 2013, and related to Modified Adjusted Gross Income (MAGI) Eligibility, have been approved with an effective date of January 1, 2014.

MAGI Eligibility & Methods:

SPA number NJ-13-0018 provides assurance on page CS15 that the state will apply methodologies based on MAGI for all separate CHIP covered groups, using the approved MAGI conversion plan income thresholds. The state indicates on page CS7 that it will cover targeted low-income children, and indicates on page CS8 that it will cover targeted low-income pregnant women. On page CS13 the state elects to cover as deemed newborns children born to mothers enrolled as targeted low-income children in CHIP. A copy of the approved CS15 is attached and should be incorporated within a separate subsection under Section 4.3 of the state’s approved CHIP state plan. A copy of the approved CS7 is attached and supersedes the current Geographic Area, Age and Income Sections 4.1.1, 4.1.2 and 4.1.3 of the current CHIP state plan. A copy of the approved CS8 is attached and supersedes the current Geographic Area, Age and Income Sections 4.1.1-P, 4.1.2- P and 4.1.3-P of the current CHIP state plan. A copy of the approved CS13 is attached and should be incorporated under Section 4.3 of the state’s approved CHIP state plan.

Establish 2101(f) Group:

SPA number NJ-13-0020 describes the state’s plan to provide coverage in its separate CHIP, as specified in the state’s submission of CS14: Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards. A copy of the approved state plan page CS14 is attached, and should be incorporated within a separate subsection under Section 4.1 of New Jersey’s approved CHIP state plan.

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ccmMs CHIP Eligibility

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

2813

Separate Child Health Insurance Program Eligibility - Deemed Newborns

Section 2112(e) of the SSA and 42 CFR 457.360

Deemed Newborns - Children born to targeted low-income pregnant women are deemed to have applied for and be eligible for CIHP or Medicaid until the child turns one.

[ig] The child was born to an eligible targeted low-income pregnant woman under section 2112 of the SSA.

aw The child is deemed to have applied for and been found eligible for CHIP or Medicaid. as appropriate, as of the date of the child's birth, and remains eligible without regard to changes in circumstances until the child's first birthday.

The state elects the following option(s):

x The state elects to cover as a deemed newborn a child born to a mother who is covered as a targeted low-income child under the state's separate CHIP on the date of the newborn's birth.

oO The state elects to recognize a child's deemed newborn status from another state and provides benefits in accordance with the —~ requirements of section 2112(e) of the SSA.

Oo The state elects to cover as a deemed newborn a child born to a mother who is covered under Medicaid or CHIP through the ~~ authority of the state’s section 1115 demonstration on the date of the newborn's birth.

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 50 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.

SPA# NJ-13-0018 Approval Date: FEB { 9 2014

Effective Date: January 1, 2014

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ccms CHIP Eligibility

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

Child Health Insurance Program

Eligibility - Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards csi4

Section 2101(f) of the ACA and 42 CFR 457.3 10(d)

[i] Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards The CHIP agency provides coverage for this group of children as follows:

co The state has received approval from CMS to maintain Medicaid eligibility for children who would otherwise be subject to Section 2101(/) such that no child in the state will be subject to this provision.

The state assures that separate CHIP coverage will be provided for children ineligible for Medicaid due to the elimination of .. income disregards in accordance with 42 CFR 457.310(d). Coverage for this population will cease when the last child protected ** from loss of Medicaid coverage as a result of the elimination of income disregards has been afforded 12 months of coverage in a separate CHIP (expected to be no later than April 1. 2016 ).

Describe the methodology used by the state to identify and enroll children in a separate CHIP who are subject to the protection afforded by Section 2101() of the Affordable Care Act:

The state has demonstrated and CMS has agreed that all children qualifying for section 2101(f) protection will qualify for the state’s existing separate CHIP.

‘a The state will enroll all children in a separate CHIP who lose Medicaid eligibility because of an increase in family income at their first renewal applying MAGI methods.

The state will enroll children in a separate CHIP whose family income falls above the converted MAGI Medicaid FPL but at or below the following percentage of FPL. The state has demonstrated and CMS has agreed that all or almost all the children who would have maintained Medicaid eligibility if former disregards were applied will be within this income range and therelore covered in the separate CHIP.

% FPL

The state will enroll children in a separate CHIP who are found to be ineligible for Medicaid based on MAGI but whose family ‘income has not increased since the child's last determination of Medicaid eligibility or who would have remained eligible for Medicaid (based on the 2013 Medicaid income standard) if the value of their 2013 disregards had been applied to the family income as determined by MAGI methodology.

Other.

Describe the benefits provided to this population:

© This population will be provided the same benefits as are provided to children in the state’s Medicaid program. é@ This population will be provided the same benefits as are provided to children in the state's separate CHIP.

Describe premiums and cost sharing required of this population:

FEB TS 2014

SPA# NJ-13-0020 Approval Date: Effective Date: January 1, 2014

Page I of 2

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ccCmMsS CHIP Eligibility

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

Separate Child Health Insurance Program

MAGI-Based Income Methodologies SIS

2102( by 1)(B)(v) of the SSA and 42 CFR 457.315

The CHIP Agency will apply Modified Adjusted Gross Income methodologies for all separate CHIP covered groups. as described below, and consistent with 42 CER 457.315 and 435.603(b) through (i).

In the case of determining ongoing eligibility for enrollees determined eligible for CHIP on or before December 31, 2013. MAGI- based income methodologies will not be applied until March 31, 2014 or the next regularly-scheduled renewal of eligibility. whichever is later.

If the state covers pregnant women. in determining family size for the eligibility determination of a pregnant woman, she is counted as herself plus cach of the children she is expected to deliver.

In determining family size for the eligibility determination of the other individuals in a household that includes a pregnant woman: © The pregnant woman is counted just as herself. © The pregnant woman is counted just as herself. plus one. fe ‘The pregnant woman is counted as herself. plus the number of children she is expected to deliver. Financial eligibility is determined consistent with the following provisions: When determining eligibility for new applicants, financial eligibility is based on current monthly income and family size. When determining eligibility for current beneficiaries. financial eligibility is based on: @ Current monthly household income and family size. © Projected annual household income for the remaining months of the current calendar year and family size. In determining current monthly or projected annual household income. the state will use reasonable methods to: XJ Include a prorated portion of the reasonably predictable increase in future income and/or family size. X] Account fora reasonably predictable decrease in future income and/or family size.

Except as provided at 42 CFR 457.315 and 435.603(d)(2) through (d)(4), household income is the sum of the MAGI-based income of every individual included in the individual's household.

Houschold income includes actually available cash support. exceeding nominal amounts. provided

by the person claiming an individual described at §435.603(1)(2)(i) as a tax dependent. “s

The CHIP Agency certifies that it has submitted and received approval for the conversion for all separate CHIP covered group ~ income standards to MAGI-equivalent standards.

An attachment is submitted.

PRA Disclosure Statement

FEB 19 2014

SPA# NJ-13-0018 Approval Date: Effective Date: January 1, 2014

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~·~ (( .!:;.!!f.ll_fi. Medicaid Eligibility OMB Control Number 0938-1148 OMB Ext>iraltion CFR 435, Subpart J and Subpart M Eligibility Process IZJ The state meets all the requirements of 42 CFR 435, Subpart J for processing applications, determining and verifying eligibility, and furnishing Medicaid. Application Processing Indicate which application the agency uses for individuals applying for coverage who may be eligible based on the applicable modified adjusted gross income standard. 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) ofthe 181 Affordable Care Act and approved by the Secretary, which may be no more burdensome than the streamlined application developed by the Secretary. An alternative application used to apply for multiple human service programs approved by the Secretary, provided that the 0 agency makes readily available the single or alternative application used only for insurance affordability programs to individuals seeking assistance only through such programs. Indicate which application the agency uses for individuals applying for coverage who may be eligible on a basis other than the applicable modified adjusted gross income standard: The single, streamlined application developed by the Secretary or one of the alternate forms developed by the state and 0 approved by the Secretary, and supplemental forms to collect additional information needed to determine eligibility on such other basis, submitted to the Secretary. l8l 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. The agency's procedures permit an individual, or authorized person acting on behalf of the individual, to submit an application via the internet website described in 42 CFR 435.1200(f), by telephone, via mail, and in person. The agency also accepts applications by other electronic means: (' Yes (i No TN: 13-0023-MM2 New Jersey 594 Approval Date: 03/18/2014 Effective Date: 10/1 /2013 Page 1 of2

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~ (( ~.!!f.ll_!i" Medicaid Eligibility The agency has procedures to take applications, assist applicants and perform initial processing of applications for the eligibility 1ZJ groups listed below at locations other than those used for the receipt and processing of applications for the title IV -A program, including Federally-qualified health centers and disproportionate share hospitals. Parents and Other Caretaker Relatives Pregnant Women Infants and Children under Age 19 Redetermination Processing IZJ Redeterminations of eligibility for individuals whose financial eligibility is based on the applicable modified adjusted gross income standard are performed as follows, consistent with 42 CFR 435.916: ~ Once every 12 months ~ Without requiring information from the individual if able to do so based on reliable information contained in the individual's • account or other more current information available to the agency If the agency cannot determine eligibility solely on the basis of the information available to it, or otherwise needs additional ~ information to complete the redetermination, it provides the individual with a pre-populated renewal form containing the information already available. ~ Redeterminations of eligibility for individuals whose financial eligibility is not based on the applicable modified adjusted gross • income standard are performed, consistent with 42 CFR 435.916 (check all that apply): ~ Once every 12 months D Once every 6 months D 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 IZJ Medicaid, CHIP, Exchanges and other insurance affordability programs. The single state agency has entered into agreements with the Exchange and with other agencies administering insurance affordability programs. PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN: 13-0023-MM2 New Jersey 594 Approval Date: 03/18/2014 Effective Date: 10/1 /2013 Pa11;e 2 of2

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Application for Health Coverage & Help Paying Costs J FAMCLYCl'lRE Affordable health coverage. Quality care. s 0 z ~ 0 1- l/) I..!J z I 1- • • • 0 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? c What happens next? Get help with this application • Free or low-cost insurance from Medicaid or the Children's Health Insurance Program (CHIP), known as NJ FamilyCare • Private health insurance plans that offer comprehensive coverage to help you stay well • A new tax credit that can help pay your premiums for health coverage • 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 njfamllycare.or:a. • 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. Apply faster online at njfamilycare.or& . • 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. To view the Privacy Act Statement, go to njfamilycare.or:a. 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 njfamllycare.or& or caii1-80G-701.0710. Filling out this application doesn't mean you have to buy health coverage. • Online: njfamilycare.or& • Phone: Call our Help Center at 1-800-701.0710. • In person: There may be counselors in your area who can help. Visit our website or call1-800-701.0710 for more information. • En Espaf'iol: llame a nuestro centro de ayuda gratis al 1-800-701.0710. NEED HELP WITH YOUR APPLICATION? Visit njfamilycare.or& or call us at 1-80G-701..()710. Para obtener una copia de este formulario en Espai'iol, llame 1-80G-701..()710. If you need help in a language other than English, caii1-80G-701..()710 and tell the customer service representative the language you need. We'll get you help at no cost to you. TIY users should call1-800-701..()720. .. I

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FAM~LYcrutE Affordable health coverage. Quality care. 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 8. Mailing address (if different from home address) 9. Apartment or suite number 10. City 12. ZIP code 14. Phone number 1 5. Other phone number ( ) ( ) 16. Do you want to get information about this application by email? 0 Yes 0 No Email address: ____________________________ _ 17. What is your preferred spoken or written language (if not English)? 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: • Yourself • Your spouse • Your children under 21 who live with you • Your unmarried partner who needs health coverage • Anyone you include on your tax return, even if they don't live with you • Anyone else under 21 who you take care of and lives with you You DON'T have to include: • Your unmarried partner who doesn't need health coverage • Your unmarried partner's children • Your parents who live with you, but file their own tax return (if you're over 21 ) • Other adult relatives who file their own tax return 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 paps 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 n.jfamilycare.or& or call us at 1-800.701..0710. Para obtener una copia de este formula rio en Espaflol, llame 1-800.701..0710. If you need help in a language other than English, caii1-80G-701-G710 and tell the customer service representative the language you need. We'll get you help at no cost to you. TTY users should caii1-80G-701-G720. Page 1 of7

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FAM~LY~ STEP 2: PERSON 1 (Start with yourself) Affordable health cowrage. Quality care. 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'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? SELF 3. Date of birth (mm/dd/yyyy) 4. Sex D Male D Female 5. Social Security number (SSN) ___ - __ - ___ _ 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.&ov. TTY users should call1-800-325-0778. 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.) D YES. If yes, please answer questions a-c. D NO. If no, skip to question c. a. Will you file jointly with a spouse? DYes D No lfyes,nameofspouse: __________________________________________________________________________ __ b. Will you claim any dependents on your tax return? DYes D No If yes, list name(s) of dependents:--------------------------------------------------------------- c. Will you be claimed as a dependent on someone's tax return? DYes D No If yes, please list the name of the tax filer:-------------------------------------------------------------- How are you related to the tax.filer? --------------------------------~------------------------------- 7. Are you pregnant? DYes D No a. If yes, how many babies are expected during this pregnancy? Due Date 8. Do you need health coverage? (Even if you have insurance, there might be a program with better coverage or lower costs.) D YES. If yes, answer all the questions below. 0 D NO. If no, SKIP to the income questions on page 3. C) Leave the rest of this page blank. 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? DYes D No 10. Are you a U.S. citizen or U.S. national? DYes D No 11. If you aren't a U.S. citizen or U.S. national, do you have eligible immigration status? DYes. Fill in your document type and ID number below. b. Document ID number--------------------- a. Immigration document type--------------------- c. Have you lived in the U.S. since 1996? DYes D No d. Are you, or your spouse or parent a veteran or an active-duty member of the U.S. military? DYes D No 12. Do you want help paying for medical bills from the last 3 months? DYes D No 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? DYes D No 14. Are you a full-time student? DYes D No 15. Were you in foster care at age 18 or older? DYes D No 16. If Hlspanlc/Latlno, ethnlcity (OPTIONAL-check all that apply.) D Mexican D Mexican American D Chicano/a D Puerto Rican D Cuban D Other 17. Race (OPTIONAL-check all that apply.) D White D Native American Indian D Black or African or Alaska Native American D Asian Indian D Chinese D Filipino D japanese D Korean D Vietnamese D Other Asian D Native Hawaiian D Guamanian or Chamorro D Samoan D Other Pacific Islander D Other NEED HELP WITH YOUR APPLICATION? Visit njfamilycare.or& or call us at 1-800-701..0710. Para obtener una copia de este formula rio en Espai'lol, llame 1-800-701..0710.1fyou need help in a language other than English, call1-800-701..0710 and tell the customer service representative the language you need. We'll get you help at no cost to you. TTY users should call1-800-701..0720. Page2of7

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FAMCLY~ STEP 2: PERSON 1 (Continue with yourself) Affordable health coverage. Quality care. Current job & Income Information 0 Employed If you're currently employed, tell us about your income. Start with question 18. CURRENT JOB 1: 0 Not employed Skip to question 28. 0 Self-employed Skip to question 27. 18. Employer name and address 19. Employer phone number ( ) 20. Wages/tips (before taxes) 0 Hourly . 0 Weekly 0 Every 2 weeks 0 Twice a month 0 Monthly 0 Yearly $ 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. Wages/tips (before taxes) 0 Hourly 0 Weekly 0 Every 2 weeks 0 Twice a month 0 Monthly 0 Yearly $ 25. Average hours worked each WEEK 26. In the past year, did you: 0 Change jobs 0 Stop working 0 Start working fewer hours 0 None 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). 0None 0 Unemployment $ How often? 0 Net farming/fishing $ 0 Pensions $ How often? 0 Net rental/royalty $ 0 Social Security $ How often? 0 Other income $ 0 Retirement accounts $ How often? Type: 0 Alimony received $ How often? 29. DEDUCTIONS: Check all that apply, and give the amount and how often you get it. How often? How often? How often? 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). 0 Alimony paid $ How often? 0 Other deductions $ How often? ____ _ 0 Student 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. C) 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 njfamilycare.or& or call us at 1-800.701..0710. Para obtener una copia de este formula rio en Espailol, llame 1-800.701..0710. If you need help in a language other than English, call1-800.701..0710 and tell the customer service representative the language you need. We'll get you help at no cost to you. TTY users should call1-800.701..0720. Page3of7

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NJFAMCLY~ STEP 2: PERSON 2 If you have more than two people to Include, make a copy of Step 2: Person 2 (pages 4 and 5) and complete. Affordable health coverage. Quality care. 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'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) 5. Social Security number (SSN) ___ - __ - ___ _ We need this if you want health coverage and have an SSN. 6. Does PERSON 2 live at the same address as you? DYes D No If no, list address: 4. Sex D Male D Female 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.) DYES. If yes, please answer questions a-c. D NO. If no, skip to question c. a. Will PERSON 2 file jointly with a spouse? DYes D No If yes, name of spouse:----------------------------------- b. Will PERSON 2 claim any dependents on his or her tax return? DYes D No If yes, list name(s) of dependents:------------------------------- c. Will PERSON 2 be claimed as a dependent on someone's tax return? DYes D No If yes, please list the name of the tax filer:---------------------------- How is PERSON 2 related to the tax filer? 8. Is PERSON 2 pregnant? DYes D No a. If yes, how many babies are expected during this pregnancy? 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.) D YES. If yes, answer all the questions below. O D NO. If no, SKIP to the income questions on page 5. A Leave the rest of this page blank. W 1 0. 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? DYes D No 11. Is PERSON 2 a U.S. citizen or U.S. national? DYes D No 12. If PERSON 2 Isn't a U.S. citizen or U.S. national, do they have eligible immigration status? D Yes. Fill in their document type and ID number below. a.Documenttype ____________ _ b. Document ID number------------- c. Has PERSON 2 lived in the U.S. since 1996? DYes D No d. Is PERSON 2, or their spouse or parent a veteran or an active- duty member in the U.S. military? DYes D No 13. Does PERSON 2 want help paying for medical bills from the last 3 months? DYes DNo 14. Does PERSON 2 live with at least one child under the age of 19, and are they the main person taking care of this child? DYes 0No 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? DYes D No a.lfyes, end date: b. Reason the insurance ended: 17. Is PERSON 2 a full-time student? DYes D No 18. If Hispanlc/Latino, ethnicity (OPTIONAL check all that apply.) 15. Was PERSON 2 in foster care at age 18 or older? DYes DNo D Mexican D Mexican American D Chicano/a D Puerto Rican D Cuban D Other ______ _ 19. Race (OPTIONAL-check all that apply.) D White D Native American Indian D Black or African or Alaska Native American D Asian Indian D Chinese D Filipino D japanese D Korean D Vietnamese D Other Asian D Native Hawaiian D Guamanian or Chamorro D Samoan D Other Pacific Islander D Other Now, tell us about any income from PERSON 2 C) NEED HELP WITH YOUR APPLICATION? Visit njfamilycare,ora or call us at 1-800-701-0710. Para obtener una copia de este formulario en Espai'lol, llame 1-800.701-0710. If you need help in a language other than English, caii1-80G-701-0710 and tell the customer service representative the language you need. We'll get you help at no cost to you. TTY users should call1-800-701-0720. Page4of7

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l'lJFAM~LYCME Affordabk! health coverage. Quality core. Current job & Income Information D Employed If you're currently employed, tell us about your income. Start with question 20. CURRENT JOB 1: D Not employed Skip to question 30. D Self-employed Skip to question 29. 20. Employer name and address 21. Employer phone number ( ) 22. Wages/tips (before taxes) D Hourly D Weekly D Every 2 weeks D Twice a month D Monthly D Yearly $ 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. Wages/tips (before taxes) D Hourly D Weekly D Every 2 weeks D Twice a month D Monthly D Yearly $ 27. Average hours worked each WEEK 28. In the past year, did PERSON 2: D Change jobs D Stop working D Start working fewer hours D None of these 29. 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? $ ______ _ 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). 0None D Unemployment $ How often? D Net farming/fishing $ D Pensions $ How often? D Net rental/royalty $ D Social Security $ How often? D Other income $ D Retirement accounts $ How often? Type: D Alimony received $ How often? 31. DEDUCTIONS: Check all that apply, and give the amount and how often you get it. How often? How often? How often? 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 29b). D Alimony paid $ How often? D Other deductions $ How often? ____ _ D 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, add another person or skip to the next section. 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 njfamilycare.org or call us at 1-800-701-0710. Para obtener una copia de este formulario en Espaf'iol, llame 1-800-701-0710. If you need help in a language other than English, call1-800-701-0710 and tell the customer service representative the language you need. We'll get you help at no cost to you. TTY users should call1-800-701-0720. Page 5 of7

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FAMCLYcrutE Affordable health coverage. Quality care. Native American Indian or Alaska Native (AI/AN) family member(s) 1. Are you or is anyone in your family Native American Indian or Alaska Native? D If No, skip to Step 4. DYes. If yes, go to Appendix B. lji:IIJ 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? D YES. If yes, check the type of coverage and write the person(s)' name(s) next to the coverage they have. D NO. D Medicaid ________________ _ D Employer insurance _____________ _ D NJ FamilyCare _______________ _ D Medicare _________________ _ D TRICARE (Don't check if you have direct care or Line of Duty) D VA health care programs ___________ _ D Peace Corps----------------- Name of health insurance: ___________ _ Policy number:---------------- Is this COBRA coverage? DYes D No Is this a retiree health plan? 0 Yes D No D Other Name of health insurance:------------ Policy number:---------------- Is this a limited-benefit plan (like a school accident policy)? DYes 0No 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. DYES. If yes, you'll need to have your employer complete Appendix A and return to address provided. D NO. If no, continue to Step 5. Select your Health Plan Choose a Health Plan from the list below. If you do not choose now, you will have an opportunity to select a Health Plan before enrollment occurs. You must be enrolled in a Health Plan to receive all of the services offered through NJ FamilyCare. The Health Plan selected only applies if you are eligible for NJ FamilyCare. If you need assistance selecting your Health Plan, contact a Health Benefits Coordinator at 1-800-701-0710, TTY 1-800-701-0720. D Amerigroup New jersey, Inc. (Available in ALL counties; except Salem County) D Healthfirst Health Plan of New jersey (Available in Atlantic, Bergen, Essex, Hudson, Mercer, Middlesex, Morris, Passaic, Somerset, Sussex, Union & Warren counties ONLY) D Horizon Nj Health (Available in ALL Counties) D UnitedHealthcare Community Plan (Available in ALL Counties) D WeiiCare Health Plans of New jersey (Available in Essex, Hudson, Middlesex, Passaic, & Union counties ONLY) I understand that if I'm found eligible and because I have joined a Health Plan, I must follow the rules for obtaining health care from the Health Plan. I understand that I must let my Health Plan and NJ FamilyCare know if there is any change in the number of people in my family and that any newborn children will be enrolled in my Health Plan. I understand that, unless I, or a family member, have a true medical emergency, I must call my personal doctor for medical advice, medical care or for a referral to a specialist. I understand that if I, or a family member, have a true medical emergency, I must call my personal doctor or the Health Plan as soon as possible after I, or the family member, go to the hospital. I understand that I must keep any medical appointment I have scheduled with a doctor and, if I cannot, I must call the doctor's office to cancel the appointment. I understand that if I go to a doctor other than my personal doctor I have selected, without a referral from my doctor or approval from the Health Plan, I may have to pay for that doctor's services because NJ FamilyCare will not pay for the unapproved service or visit. I understand that I may change to another Health Plan and that I can call the Health Benefits Coordinator to help me do that. I give permission for the release of my medical history and health care records and those of my family members who will be enrolled to any person(s) in the Health Plan and its providers who shall provide or coordinate health care to me and my family as long as I am a member of the Health Plan. NEED HELP WITH YOUR APPLICATION? Visit njfamilycare.or& or call us at 1-800-701-0710. Para obtener una copia de este formulario en Espaiiol,llame 1-800-701-0710. If you need help in a language other than English, call1-800-701-0710 and tell the customer service representative the language you need. We'll get you help at no cost to you. TTY users should call1-800-701-0720. Page6of7

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FAMCLYcrulE Affordable health coverage. Quality core. Ill jill Read & sign this application. 1 understand that the NJ FamilyCare program may use or disclose protected health information about me or my children if Federal privacy law requires or allows it, or if State law requires it. 1 authorize my employer to release health benefits information to the NJ FamilyCare Office of Premium Support. 1 know that I must promptly tell NJ FamilyCare if anything changes or becomes different from what I wrote on this application including changes in income, address or household size. I can visit njfamilycare.ors or call1-800-701-0710 to report any changes. I understand that a change in my information could affect the eligibility for member(s) of my household. I 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. I can file a complaint of discrimination by visiting www.hhs.sov/ocr/office/file. 1 authorize the NJ Division of Taxation to release my tax return information to NJ FamilyCare. I also authorize any educational institution or school district to release my medical records or those of my child(ren) to the NJ FamilyCare program for the purpose of determining eligibility and billing the Program. I confirm that no one applying for health insurance on this application is incarcerated (detained or jailed). If not, --------:----::-----:-------is incarcerated. (name of person) 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, NJ Division of Taxation, 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, I agree to allow NJ FamilyCare to use income data, including information from tax returns. NJ FamilyCare will send me a notice, let me make any changes, and I can opt out at any time. If anyone on this application is eligible for NJ FamilyCare I am giving to the NJ FamilyCare agency our rights to pursue and get any money from other health insurance, legal settlements, or other third parties. I am also giving to the NJ FamilyCare 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? DYes D No If yes, I know I will be asked to cooperate with the agency that collects medical support from an absent parent. If I think that cooperating to collect medical support will harm me or my children, I can tell NJ FamilyCare and I may not have to cooperate. My right to appeal If I think NJ FamilyCare has made a mistake, I can appeal its decision. To appeal means to tell someone at NJ FamilyCare that I think the action is wrong, and ask for a fair review of the action. I know that I can find out how to appeal by contacting NJ FamilyCare at 1-800-701-0710. I know that I can be represented in the process by someone other than myself. My eligibility and other important information will be explained to me. Estate Recovery NJ FamilyCare Medicaid benefits received after the age of 55 may be reimbursable to the State of New jersey from the member's estate. The recovery may include premium payments made on behalf of the beneficiary. For more information about Estate Recovery, visit http://www.state.nj.us/humanservices/dmahs/clients/The_NJ_Medicaid_Program_and_Estate_Recovery_What_ You_Should_Know.pdf 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. Signature I Date (mm/ddlyyyy) Jill ill Mail completed application. Mail your signed application to: NJ FamilyCare PO BOX8367 TRENTON. NJ 08650-9802 If you are not registered to vote where you live now. would you like to apply to register to vote? Applying to register or declining to register to vote will not affect the amount of assistance you will be provided by this Agency. For more information on the Notice of Your Opportunity To Vote Ri~hts visit the link below: http://www.state.nj.us/state/electlons/nvra-forms/nvra-opportunlty-form-081810.pdf For more information on the Voter Re~jstratjon Application visit the link below: http://www.state.nj.us/state/electionslvotlng-lnformatlon-voter-reglstration-forms.html (Fill in the required information, print as a two-sided document. and fold to mail). If you would like a Voter Registration Application mailed to you. please check this box D. NEED HELP WITH YOUR APPLICATION? Visit njfamilycare.or& or call us at 1-800-701-0710. Para obtener una copia de este formulario en Espaiiol,llame 1-800-701-0710.1fyou need help in a language other than English, call1-800-701-0710 and tell the customer service representative the language you need. We'll get you help at no cost to you. TTY users should call1-800-701-0720. Page7of7

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APPENDIX A NJFAM~LYCJ.!dll Affordable health coverage. Quality care. 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. You need to include this page when you send In your application. EMPLOYEE Information 1. Employee name (First, Middle, Last) 2. Employee Social Security number ----------- _____________ ., _________________________ L.__ _______________ _ EMPLOYER Information 9.ZIPcode 13. Are you currently eligible for coverage offered by this employer, or will you become eligible In the next 3 months? DYes (Continue) 13a. If you're in a waiting or probationary period, when can you enroll in coverage?------:-----;-::-:-;-----,---- (mm/dd/yyyy) List the names of anyone else who is eligible for coverage from this job. Name: ___________ __ Name: ___________ __ Name: ____________ _ D No (Stop here and go to Step 5 in the application) Tell us about the health plan offered by this employer. ,..i·~theemploYeroftw ahealth~'tiat·~~~:~~~Yt$ 0 No ts~;:;~~~~:~~- _·_ ....• --~-- >·~:,C:~"~~~t:"~~~~~: · . ~fpr anytclbacco.cessat~Qn~JIIhcf.Qil:Jflt)t~:. ·--~-on wellness programs . . :.;:::::.'Q::~~'!~~;~- [)Veady 16. What change will the employer make for the new plan year (if known)? 0 Employer won't offer health coverage 0 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 well ness programs. See question 15.) a. How much will the employee have to pay in premiums for that plan? $ ____ _ b. How often? 0 Weekly 0 Every 2 weeks 0 Twice a month 0 Quarterly 0 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 Internal Revenue Code of 1986) ft NEED HELP WITH YOUR APPLICATION? Visit nifamilycare.org or call us at 1·800·701·0710. Para obtener una copia de este V formula rio en Espaiiol, llame 1·800·701·0710. If you need help in a language other than English, call 1·800·701·0710 and tell the customer service representative the language you need. We'll get you help at no cost to you. TTY users should call1·800·701·0720.

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FAMCLY~ APPENDIX B Affordable health coverage. Quality core. Native American Indian or Alaska Native Family Member (AI/AN) Complete this appendix if you or a family member are Native American Indian or Alaska Native. Submit this with your NJ FamilyCare Application for Health Coverage & Help Paying Costs. Tell us about your Native American Indian or Alaska Native family member(s). Native 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. AI/AN PERSON 1 I AI/AN PERSON 2 I 1. Name First Middle First Middle (First name, Middle name, Last name) Last Last 2. Member of a federally recognized tribe? DYes DYes If yes, tribe name If yes, tribe name DNo DNo 3. Has this person ever gotten a service from DYes DYes the Indian Health Service, a tribal health program, or urban Indian health program, DNo DNo or through a referral from one of these If no, is this person eligible to get If no, is this person eligible to get 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? DYes DNo DYes DNo 4. Certain money received may not be $ $ counted for NJ FamilyCare. List any income (amount and how often) reported on your application that includes money How often? How often? from these sources: . Per capita payments from a tribe that come from natural resources, usage rights, leases, or royalties . 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) . Money from selling things that have cultural significance A NEED HELP WITH YOUR APPLICATION? Visit njfamilycare.org or call us at 1·800·701·0710. Para obtener una copia de este V formulario en Espaflol, llame 1·800·701·0710. If you need help in a language other than English, call 1·800·701·0710 and tell the customer service representative the language you need. We'll get you help at no cost to you. TTY users should call 1·800·701·0720.

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Medicaid Eligibility

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

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:

im 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:

[m] Intends to reside in the state, including without a fixed address, or

[| Entered the state with a job commitment or seeking employment, whether or not currently employed.

aw 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: [lM] Residing in the state, with or without a fixed address, or

im The state of residency of the parent or caretaker, in accordance with 42 CFR 435.403(h)(1), with whom the individual resides.

ml 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:

i Regardless of which state the individual resides, if the parent or guardian applying for Medicaid on the individual's behalf resides in the state, or

Regardless of which state the individual resides, if the parent or guardian resides in the state at the time of the individual's = placement, or

If the individual applying for Medicaid on the individual's behalf resides in the state and the parental rights of the [] institutionalized individual's parent(s) were terminated and no guardian has been appointed and the individual is

institutionalized in the state.

Individuals living in institutions who became incapable of indicating intent at or after age 21, if physically present in the state,

fm) unless another state made the placement. [M] Individuals who have been placed in an out-of-state institution, including foster care homes, by an agency of the state. im 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. [Ml] IV-E eligible children living in the state, or TN: 13-0024-MM5 Approval Date: 03/18/2014 Effective Date: 01/01/2014 New Jersey S88

Page 1 of 4

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Medicaid Administration

The entity or entities that have responsibility for determinations of eligibility for families, adults, and for individuals under 21 are:

[KX] The Medicaid agency

oO Single state agency under Title IV-A (in the 50 states or the District of Columbia) or under Title I or XVI (AABD) in Guam, Puerto Rico, or the Virgin Islands

[X] An Exchange that is a government agency established under sections 1311(b)(1) or 1321(c)(1) of the Affordable Care Act The entity that has responsibility for determinations of eligibility for the aged, blind, and disabled are:

KX] The Medicaid agency

oO Single state agency under Title IV-A (in the 50 states or the District of Columbia) or under Title I or XVI (AABD) in Guam, Puerto Rico, or the Virgin Islands

[J An Exchange that is a government agency established under sections 1311(b)(1) or 1321(c)(1) of the Affordable Care Act [X] The Federal agency administering the SSI program Indicate which agency determines eligibility for any groups whose eligibility is not determined by the Federal agency: Medicaid agency (1 Title IV-A agency (J An Exchange

The entity or entities that have responsibility for conducting fair hearings with respect to denials of eligibility based on the applicable modified adjusted gross income standard are:

IX] Medicaid agency (7) An Exchange that is a government agency established under sections 1311(b)(1) or 1321(c)(1) of the Affordable Care Act

[X] An Exchange appeals entity, including an entity established under section 1411(f) of the Affordable Care Act

Name of entity: |Office of Marketplace Eligibility Appeals (OMEA)

The agency has established a review process whereby the agency reviews appeals decisions made by the Exchange or Exchange appeals entity or other state agency, but only with respect to conclusions of law, including interpretations of state or federal policies.

@ Yes C No

42 CFR 431.10 42 CFR 431.11

Organization and Administration

Provide a description of the organization and functions of the Medicaid agency.

The Department of Human Services administers most of the State's Social Services programs, institutions and agencies, including

the administration of federal funds appropriated to all of these services. Under its jurisdiction are the Division of Medical

Assistance and Health Services (DMAHS), Division of Aging Services (DoAS), Division of Family Development (DFD), Division TN: 13-0025-MM4 Approval Date: 08/25/2014 Effective Date: 10/01/2013 New Jersey A1-A2

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of Mental Health and Addiction Services (DMHAS), Division of Disability Services (DDS), the Commission for the Blind and Visually Impaired (CBV1), the Division of the Deaf and Hard Hearing (DDHH), and the Division of Developmental Disabilities (DDD).

DMAHS is responsible for the training, monitoring and oversight of AFDC-related Medicaid, NJ FamilyCare, Aged, Blind, Disabled programs, and institutional/waivered programs eligibility process for the 21 County Welfare Agencies (CWAs). This division is the focal point for development, interpretation and communication of Medicaid eligibility policy to CWAs, Division staff, and outside agencies and parties. This division is responsible for the analysis of existing and proposed Federal and State laws and regulations relating to eligibility to determine the impact on Medicaid programs, clients, and county operations. It provides technical assistance and administrative oversight for Medicaid programs and serves as a liaison to the Division of Family ‘Development for functions related to their programs. Also, this division works with the Division of Disability Services in administering the NJ Workability Program as well as the Division of Children’s Behavioral Health Services in processing Medicaid applications for out of home placements for their participants.

CWA means an agency of county government that is charged with the responsibility for determining eligibility for public assistance programs, including AFDC-Related Medicaid, Temporary Assistance to Needy Families (TANF), the Food Stamp program and Medicaid (Title XIX). Depending on the county, the CWA might be identified as the Board of Social Services, the Welfare Board, the Division of Welfare, or the Division of Social Services. CWAs are overseen by the office of Eligibility Policy within DMAHS and have Memoranda of Understandings (MOUs) with DMAHS. They conduct all Title XIX Medicaid eligibility determinations including all Modified Adjusted Gross Income (MAGI) related eligibility groups and those aged and disabled groups not determined eligible by the Social Security Administration (SSA), DMAHS' Institutional Support Services (ISS), and the Health Benefits Coordinator. ISS, a subdivision of DMAHS within the Office of Eligibility Policy, makes eligibility determinations for clients placed in State developmental centers, or county or State psychiatric hospitals, who are under age 21 or over 65, and for clients enrolled in the Division of Developmental Disabilities/Community Care Waiver program. Financial eligibility for the Waiver is determined by ISS and clinical eligibility is determined by DDD. The Health Benefits Coordinator is a State Vendor overseen by the Office of the Chief of Operations within DMAHS, and makes initial eligibility determinations for both Medicaid and CHIP. All initial Medicaid determinations made by the Health Benefits Coordinator are forwarded to appropriate State staff for review and final eligibility determination. The statutory authority for the delegation of eligibility determinations to the counties is found in N.J.S. 30:4D-7.r; 30:4D-3.i(8)(f); 30:4D-7a; 26:2H-18.32; and annually in language in the N.J. Appropriations Act. N.J.S. 30:4D-7 also authorizes the Commissioner to issue rules and regulations to administer the program which include: N.J.A.C. 10:49-14.4; 10:49-14.6; 10:71-1.1; 10:71-1.2; 10:71-1.5; 10:71-2.1; 10:71-3.13; 10:71-3.15.

DMAHS determines eligibility for the Community Care Waiver (CCW) program which is an 1115 waiver, reviews vendor Medicaid cases, and performs an independent review of someone seeking disability determination following SSA rules.

Major Units and Staff-

IDMAHS Director-

The Director's Office is responsible for the overall management, administration and development of the programs administered by the DMAHS. Areas of responsibility of this office involve interpretation of program policy and related program activity, study of federal and State legislation and federal regulations as they pertain to program functioning, policy formulation, issuance of Final Agency Decisions in contested cases, provider suspensions and debarments, and program planning and evaluation. The responsibilities of this office also include responding to legislative and constituent concerns, and serving as a link with provider organizations and client advocates. The Director’s Office is also responsible for review, analysis and preparation of comments for all aspects of State and Federal legislation that may impact DMAHS. The Office ensures that its duties are carried out in accordance with Departmental directives, policies and timelines. Additionally, the Office is involved in special studies and investigations, and oversight of special projects.

Medical Assistance Advisory Council-

The primary objective of the Advisory Council is to advise the Division about health care issues and to foster communication between the larger, pluralistic community. the establishment of the Council is in accordance with federal regulation. The Council's membership is comprised of providers, consumers, Division staff and staff from other State and federal agencies.

Chief of Staff-

The Chief of Staff is responsible for supporting the Director and for the overall management of the Office of Research, Office of TN: _13-0025-1IVIIMI4- Approvat Date: 08/25/2014 Effective Date: 1070172013 New Jersey A2

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Internal Affairs, Bureau of Quality Control and the Human Resources, General Services, Auditing and Communication Units.

Chief Financial Officer- This Office oversees the operations of the Office of Budget & Finance, the Divisions Reimbursement Offices, and the Hospital Services, In Patient Rate Setting and Data Analysis Units.

Chief of Operations-

This Chief of Operations has oversight and management responsibilities for the overall planning, organization, development and administration of all NJ FamilyCare/ Medicaid client units. Additionally the Chief of Operations evaluates program operations for improvements to increase the organization’s efficiency and effectiveness. This office also has oversight of the Office of Eligibility Policy, Premium Support, Policy, State Monitoring Unit, Waiver Operations, NJ FamilyCare Outreach, and Office of Customer Service.

Chief Information Officer-

The Chief Information Officer is responsible for all information technology and administrative support services. The Chief Information Officer plans, designs, recommends and implements major automated systems in order to fulfill the statistical, administrative, and general data processing needs of the Division. This office also oversees the Medicaid Management Information System (MMIS) Fiscal Agent contract.

Human Resources- This office is responsible for the personnel, payroll, and Public Employees Occupational Safety and Health (PEOSH) units for the Division of Medical Assistance and Health Services and the Division of Family Development.

Office of Eligibility Policy-

This office is responsible for the management of County Operations, Eligibility Policy, HMO Account Coordinators, Office of Eligibility Operations, Special Projects and the Buy-in unit. Supports the design, development and implementation of new policies, procedures and programs as determined by the Division Director.

Office of the Medical Director- This office oversees the operations of the Utilization Management, Preventive Health Care Services, Quality Assurance, Provider Relations and Dental Services Offices.

Office of Managed Health Care-

The Office of Managed Health Care (OMHC) is responsible for the overall administration of the Managed Care Program. It is the ongoing responsibility of the OMHC to interface with Managed Care Organizations (MCOs), and CMS on contractual issues, contract/policy interpretation, and the provision of contract technical assistance to MCOs, Division staff, providers, and other agencies. Within the Office of Managed Care is Managed Behavioral Health, Delivery System Innovation, and the Office of Quality Assurance.

Office of Legal and Regulatory Affairs-

The Office of Legal and Regulatory Affairs (OLRA) is the in-house legal and regulatory office within DMAHS, and performs the following functions: providing informal legal advice and assistance to. DMAHS and other State staff; drafting, reviewing and commenting on legislation and budget language; drafting and promulgating regulations; drafting state plan amendments, submitting them to CMS, and responding to CMS questions about those amendments, drafting and reviewing contracts and agreements; processing fair hearing requests and drafting final agency decisions for the Director; handling HIPAA issues and open public records requests; handling recovery cases involving torts, casualty insurance, estates, special needs trusts, and incorrect payments; and restricting to a single pharmacy or other provider beneficiaries who have engaged in overutilization or other abuse.

|The OLRA Fair Hearing Unit processes hearing requests from applicants who have been denied eligibility or whose application has not been acted upon with reasonable promptness as well any recipient whose services or eligibility have been terminated, suspended, or reduced. The Fair Hearing Unit also processes hearing requests from Medicaid providers seeking to appeal the denial of a request for prior authorization and denial of claims submitted for payment. Fair hearing requests are transmitted to the Office of Administrative Law (OAL) for a hearing before an Administrative Law Judge (ALJ). The OAL is an independent agency that conducts fair hearings for a number of agencies within the State of New Jersey, including DMAHS. The ALJ issues an Initial Decision (i.e. recommended decision) for de novo review by DMAHS’ Director. Thereafter DMAHS’ Director issues a Final

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CORTE toe MERC ASE & aaONrAID ERECT

Agency Decision, which is appealable to the Appellate Division of the New Jersey Superior Court.

Other divisions within the Department of Human Services the Division of Aging Services (DoAS), the Division of Family Development (DFD), the Division of Mental Health and Addiction Services (DMHAS), the Division of Disability Services (DDS), the Commission for the Blind and Visually Impaired (CBVI), the Division of the Deaf and Hard of Hearing (DDHH), and the Division of Developmental Disabilities (DDD).

Division of Family Development (DFD), also within the New Jersey Department of Human Services, administers programs of financial and administrative support for certain qualified individuals and families.

Division of Aging Services (DoAS), is a Division within the New Jersey Department of Human Services created through SFY2013 budget language that transferred senior supports and services from the Department of Health to the Department of Human Services. The DoAS administers federal and State-funded services and supports for the elderly and adult disabled population. The agency receives federal funds under the Older Americans Act whereby it serves over 500,000 individuals and is the focal point for planning services for the aging, developing comprehensive information about New Jersey’s older adult population and its needs, and maintaining information about services available to older adults throughout the state.

Division of Developmental Disabilities (DDD), a division within the New Jersey Department of Human Services, provides evaluation, functional and guardianship services to eligible persons. Services include residential services, family support, contracted day programs, work opportunities, social supervision, guardianship, and referral services.

Division of Disability Services (DDS), a division within the New Jersey Department of Human Services, promotes the maximum independence and participation of people with disabilities in community life.

Division of Mental Health and Addiction Services (DMHAS), is also a Division within the New Jersey Department of Human Services.

Upload an organizational chart of the Medicaid agency.

An attachment is submitted.

Provide a description of the structure of the state's executive branch which includes how the Medicaid agency fits in with other health, human service and public assistance agencies.

The Department of Human Services is part of the Executive Branch, led by the Commissioner of Human Services who is a cabinet official appointed by the Governor. The Department of Human Services is the single state agency which administers the Medicaid program through the Division of Medical Assistance and Health Services (DMAHS). DMAHS works with the divisions within Human Services and other departments in the Executive Branch to administer most of the State’s social services programs, institutions and agencies, including the administration of federal funds received for all of these services.

The Department of Health (DOH), which is in the Executive Branch of New Jersey State government is responsible for the oversight and licensure of certain medical providers, among other functions.

The Department of Children and Families (DCF), is in the Executive Branch of New Jersey State government. It includes the Division of Child Protection and Permanency (DCP&P), the Division of Children’s System of Care (CSOC), the Division of Prevention and Community Partnerships (DPCP), the Child Welfare Training Academy, Central Operations, the Office of Communications and Legislation, the Office of Education, and the Office of Licensing. DCP&P, formerly known as the Division of Youth and Family Services (DYFS), within the New Jersey Department of Children and Families, is responsible for ensuring the safety of children and providing social services to children and their families. DCP&P enrolls into Medicaid financially eligible children under its supervision who reside in DCP&P-supported substitute living arrangements, such as foster care and certain

dea

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KERR FOE MDAC ARE 8 can AID NORTE

| |

i | | i | | | | |

Type of entity that determines eligibility:

single state agency.

subsidized adoption placements.

The Department of Banking and Insurance (DOBI), also in the Executive Branch of New Jersey State government, is responsible for regulation of health insurers.

The Medicaid Fraud Division (MFD) is a Division of the Office of the State Comptroller, and was created by statute to preserve the integrity of the Medicaid and NJ FamilyCare programs by conducting and coordinating fraud, waste, and abuse control activities for all State agencies responsible for services funded by those programs.

“Remove

Type of entity that determines eligibility:

Single state agency under Title IV-A (in the 50 states or the District of Columbia) or under Title I or XVI (AABD) in Guam, | Puerto Rico, or the Virgin Islands

C An Exchange that is a government agency established under sections 1311(b)(1) or 1321(c)(1) of the Affordable Care Act @ The Federal agency administering the SSI program

Provide a description of the staff designated by the entity and the functions they perform in carrying out their responsibility.

Pursuant to a 1634 agreement, the Social Security Administration determines Medicaid eligibility for Supplemental Income

recipients. | Remove

Single state agency under Title IV-A (in the 50 states or the District of Columbia) or under Title I or XVI (AABD) in Guam, Puerto Rico, or the Virgin Islands

@ An Exchange that is a government agency established under sections 1311(b)(1) or 1321(c)(1) of the Affordable Care Act | C The Federal agency administering the SSI program

Provide a description of the staff designated by the entity and the functions they perform in carrying out their responsibility.

The Federally-Facilitated Marketplace (FFM) will be determining eligibility for Medicaid for groups of individuals whose income eligibility is determined based on MAGI income methodology and who apply through the FFM. The FFM will not be assigning an individual who is determined eligible for Medicaid whose income eligibility is determined using MAGI methodology to a specific eligibility group, determining cost-sharing (if applicable), or assigning a benefit package — functions that will be performed by the

Remove

Type of entity that conducts fair hearings: C An Exchange that is a government agency established under sections 1311(b)(1) or 1321(c)(1) of the Affordable Care Act @ An Exchange appeals entity, including an entity established under section 1411(f) of the Affordable Care Act

Provide a description of the staff designated by the entity and the functions they perform in carrying out their responsibility.

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|OMEA will conduct Medicaid fair hearings for individuals whose Medicaid eligibility has been denied by the Federally-facilitated Marketplace (FFM). These will be individuals whose income eligibility is determined based on MAGI income methodology and who applied for health coverage through the FFM.

Add

Supervision of state plan administration by local political subdivisions (if described under Designation and Authority)

Is the supervision of the administration done through a state-wide agency which uses local political subdivisions?

C Yes C No

42 CFR 431.10 42 CFR 431.12 42 CFR 431.50

Assurances The state plan is in operation on a statewide basis, in accordance with all the requirements of 42 CFR 431.50.

All requirements of 42 CFR 431.10 are met.

There is a Medical Care Advisory Committee to the agency director on health and medical services established in accordance with meeting all the requirements of 42 CFR 431.12.

The Medicaid agency does not delegate, to other than its own officials, the authority to supervise the plan or to develop or issue policies, rules, and regulations on program matters.

Assurance for states that have delegated authority to determine eligibility:

There is a written agreement between the Medicaid agency and the Exchange or any other state or local agency that has been delegated authority to determine eligibility for Medicaid eligibility in compliance with 42 CFR 431.10(d).

Assurances for states that have delegated authority to conduct fair hearings:

There is a written agreement between the Medicaid agency and the Exchange or Exchange appeals entity that has been delegated authority to conduct Medicaid fair hearings in compliance with 42 CFR 431.10(d).

When authority is delegated to the Exchange or an Exchange appeals entity, individuals who have requested a fair hearing are given the option to have their fair hearing conducted instead by the Medicaid agency.

Assurance for states that have delegated authority to determine eligibility and/or to conduct fair hearings:

The Medicaid agency does not delegate authority to make eligibility determinations or to conduct fair hearings to entities other than government agencies which maintain personnel standards on a merit basis.

PRA Disclosure Statement

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

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Medicaid Eligibility OMB Control Number 0938-1148 OMB date: 10/31/2014 Sll or more qualified hospitals are determining presumptive eligibility under 42 CFR 435.1110, and the state is providing Medicaid for individuals determined presumptively eligible under this provision. (i' Yes ('No [Z] 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. l-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 0 Other Family/ Adult groups: 0 Eligibility groups for individuals age 65 and over 0 Eligibility groups for individuals who are blind 0 Eligibility groups for individuals with disabilities 0 Other Medicaid state plan eligibility groups 0 Demonstration populations covered under section 1115 The state establishes standards for qualified hospitals making presumptive eligibility determinations. New Jersey 521 Page 1 of3

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Medicaid Eligibility (i' Yes ('No Select one or both: IZJ 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. Although not required for Presumptive Eligibility, 80 percent of the Presumptive Eligibility . . f d d applications must result in a full Medicaid application. Participating entities are required to do a Descnpt10n o stan ar s: d. .d 1. ·b·l· h k., 100o/ fP · El. ·b·1· 1· A PE., Me ICai e 1g1 1 Ity c ec .or /o o resumptlve 1g1 1 1ty app 1cants. ny .orms designed by the hospital must be approved by DMAHS. D 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 ofthe 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. (i' 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 (i' No ~ 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. IZJ State residency IZJ Citizenship, status as a national, or satisfactory immigration status [Z] 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. TN: 14-0002 New Jersey I Approval Date: 06/06/2014 521 I Effective Date: 01/01/2014 Page 2 of3

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DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services New York Regional Office 26 Federal Plaza, Room 37-100 New York, NY I 0278 DIVISION OF MEDICAID AND CHILDREN'S HEAL TH OPERATIONS DMCHO: JM May 12, 2016 Meghan Davey Director Department of Human Services Division of Medical Assistance and Health Services P.O. Box 712 Trenton, NJ 08625-0712 RE: NJ SPA #16-0002 Dear Director Davey: C"'1S CENTI:RS FOR MEDICARE & MEOICAIO SERVICES The Centers for Medicare & Medicaid Services (CMS), New York Regional Office, has completed its review of New Jersey State Plan Amendment (SPA) Transmittal Number 16-0002. This SPA implements Health Homes as authorized under Section 2703 of the Patient Protection and Affordable Care Act. Children with SEO (Serious Emotional Disturbance) will qualify for health home services whereas SEO will be defined to include serious emotional disturbance, co-occurring developmental disability and mental illness, co-occurring mental health and substance abuse, or DD (Developmental Disability) eligible (per NJ Statute I 0: 196) with symptomology of SEO. The SPA was submitted to add Behavioral Health Home Services to children (under the age of 21) in Atlantic, Cape May and Monmouth counties to the previously approved counties, Mercer and Bergen, by enhancing the current care management teams within the Care Management Organizations. This SP A is approved May 12, 2016, with an effective date of January I, 2016. Enclosed is a copy of the approved pages for incorporation into the New Jersey State plan. In accordance with the statutory provisions at Section 1945( c )(I) of the Social Security Act, for payments made to health home providers under this amendment, during the first eight fiscal quarters that the SPA is in effect, January I, 2016 through December 31, 2017, the federal medical assistance percentage (FMAP) rate applicable to such payments shall be equal to 90 percent. The FMAP rate for payments made to health home providers will return to the state's published FMAP rate on January I, 2018. The Form CMS-64 has a designated category of service Line 43 for States to report health home services expenditures for enrollees with chronic conditions. Please share with your staff my appreciation for their time and effort throughout this process. If you have any questions regarding this State Plan Amendment, please contact John Montalto at John.Montalto@cms.hhs.gov or (212) 616-2326. Sincerely, Michael J. Melendez Associate Regional Administrator Division of Medicaid and Children's Health Operations

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Application print HHS NJ.1480.R00.01 - Jan 01, 2016 file:///C/Users/Gbb9/Desktop/NJ-16-0002%205%203%2016%20(2).htm[05/16/2016 10:37:31 AM]

Name:

Title:

Telephone number:

Email: The secondary contact for this submission package.

Name:

Title:

Telephone number:

Email: The tertiary contact for this submission package.

Name:

Title:

Telephone number:

Email: Proposed Effective Date (mm/dd/yyyy) Executive Summary

Summary description including goals and objectives: Federal Budget Impact Federal Fiscal Year Amount First Year $ TN: 16-0002 NEW JERSEY APPROVAL DATE: MAY 12, 2016 EFFECTIVE DATE: JANUARY 01, 2016 Ruby Goyal-Carkeek Deputy Director, Department of Children and Families, Division of Childrens System of Care (609) 888-7227 Ruby.Goyal-Carkeek@dcf.state.nj.us Meghan Davey Director, DMAHS (609) 588-2601 meghan.davey@dhs.state.nj.us Vicki Fresolone Research Scientist, Division of Mental Health and Addiction Services (609) 777-0750 Vicki.Fresolone@dhs.state.nj.us 01/01/2016 NJ plans to provide behavioral health home(BHH)services to children (under the age of 21)in Atlantic,Bergen,Cape May,Mercer,or Monmouth Co,by enhancing the current care management teams within Care Management Organization(CMO),the designated BHH provider.CMOs are agencies that provide direct,face to face care coordination&wraparound care planning for children&their families with the most complex needs&are responsible for facilitating access to a range of treatment&support services.Children must meet defined medical necessity criteria for BHH eligibility.Children in CMO are either SED,co-occurringDD/MI,Co-Occurring MH/SA,or are determined DD eligible(per NJ Statute10:196)with symptomology of SED.In anticipation of Statewide rollout of BHH,the CMO agencies in the counties will be the designated BHH to provide services to eligible children.NJs Children’s System of Care(CSOC)services are managed by a Contracted System Administrator(CSA),the single point of access for screening,referral&prior authorization for services,which includes;behavioral health,substance use&services for individuals with intellectual/developmental disabilities.The CSA makes referrals directly to CMOs.The care management teams will be enhanced to include medical&wellness expertise for purpose of providing fully integrated &coordinated care for children who meet criteria A transitional plan is actively pursued between the ages of 18 to 21 CSOC works to identify any resources needed for post children’s system involvement If further involvement with public system is warranted then applicable eligibility/assessment is pursued 2016 1728000.00

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Application print HHS NJ.1480.R00.01 - Jan 01, 2016 file:///C/Users/Gbb9/Desktop/NJ-16-0002%205%203%2016%20(2).htm[05/16/2016 10:37:31 AM]

Mental Health Condition

Substance Abuse Disorder

Asthma

Diabetes

Heart Disease

BMI over 25 Other Chronic Conditions

One chronic condition and the risk of developing another

Specify the conditions included:

Mental Health Condition

Substance Abuse Disorder

Asthma

Diabetes

Heart Disease

BMI over 25 Other Chronic Conditions

Specify the criteria for at risk of developing another chronic condition:

One or more serious and persistent mental health condition

Specify the criteria for a serious and persistent mental health condition:

Geographic Limitations

Health Homes services will be available statewide

Describe statewide geographical phase in/expansion. This should include dates and corresponding geographical areas that bring the program statewide.

If no, specify the geographic limitations: By county TN: 16-0002 NEW JERSEY APPROVAL DATE: MAY 12, 2016 EFFECTIVE DATE: JANUARY 01, 2016 Certain developmental disorders (organic) Cystic Fibrosis Eating Disorder Hypertension Kidney Disease Obesity (BMI >= 85%) Seizure Disorder Sickle Cell Children with SED will qualify. For purposes of this SPA, SED will be defined to include serious emotional disturbance, co-occurring developmental disability and mental illness, co-occurring mental health and substance abuse, or DD eligible (per NJ Statute 10:196) with symptomology of SED.

Among children meeting the above criteria, NJ will target behavioral health home services to those individuals who could benefit from the enhanced model of integrated behavioral/medical coordination that the behavioral health home model provides. This targeting will be based on a set of defined medical necessity criteria which will enumerate eligible medical comorbidities that must be present alongside the targeted conditions listed above. Medical necessity criteria will be determined and reviewed on an ongoing basis by the state and consistently applied by its qualified behavioral health home providers.

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Specify which counties: By region

Specify which regions and the make-up of each region: By city/municipality

Specify which cities/municipalities: Other geographic area

Describe the area(s):

Enrollment of Participants

Participation in a Health Homes is voluntary. Indicate the method the State will use to enroll eligible Medicaid individuals into a Health Home: Opt-In to Health Homes provider

Describe the process used: Automatic Assignment with Opt-Out of Health Homes provider

Describe the process used:

The State provides assurance that it will clearly communicate the opt-out option to all individuals assigned to a Health Home under an opt-out process and submit to CMS a copy of any letter or other communication used to inform such individuals of their right to choose. Other

Describe:

The State provides assurance that eligible individuals will be given a free choice of Health Homes providers.

The State provides assurance that it will not prevent individuals who are dually eligible for Medicare and Medicaid from receiving Health Homes services.

The State provides assurance that hospitals participating under the State Plan or a waiver of such plan will be instructed to establish procedures for referring eligible individuals with chronic conditions who seek or need treatment in a hospital emergency department to designated Health Homes providers.

The State provides assurance that it will have the systems in place so that only one 8-quarter period of enhanced FMAP for each Health Homes enrollee will be claimed. Enhanced FMAP may only be claimed for the first eight quarters after the effective date TN: 16-0002 NEW JERSEY APPROVAL DATE: MAY 12, 2016 EFFECTIVE DATE: JANUARY 01, 2016 NJ BHH will be available in Bergen and Mercer County located in the northern and central region of NJ, respectively. As of 2011 US Census, Mercer's population was 367, 063. Children represent 22% of the population in Mercer County (82, 122) and 17% of those children live below poverty line. Mercer experienced a 24% increase in children receiving NJFamilyCare (Medicaid) from 2008 to 2012. Mercer's current census is 600 youth. Bergen County is the most populous county of the state of New Jersey. As of the 2011 US Census, its population was 911,004. Children represent 22% of the population (202,352). Bergen has 4.5% of NJ children living below poverty line and the unemployment rate in Bergen is 7.7%. Bergen experienced a 37% increase in children receiving NJFamilyCare/Medicaid from 2008 to 2012 (third highest among all counties). Bergen's average monthly census in 2013 has been 540. Recent estimates indicate one third of Medicaid enrolled children who use behavioral healthcare also have serious medical conditions (Pires, March 2013) New Jersey estimates up to 200 youth will be enrolled in each of the BHH per year New Jerseys CSOC services are managed by a CSA. The CSA is the single point of access for screening, referral and prior authorization for childrens service, which includes behavioral health, substance use and intellectual/developmental disabilities. Single access to care is through the DCF/CSOC’s Contracted System Administrator, who will provide the authorization to eligible children for BHH services. An authorization is made to the CMO, the designated BHH entity who obtains consent from the parent/guardian or from youth (ages 18-20) for enrollment and participation in BHH. The CSA will continue to screen and prior authorize Atlantic, Cape May, Bergen, Monmouth and Mercer County youth for CMO service eligibility. Children and youth who are referred to the CMO will then be screened for Health Home services at the CMO and if eligible, the CMO will request prior authorization for the Health Home service from the CSA. This allows the CMO staff to work directly with the children and their families to explain and discuss the BHH services. Enrollees can opt in or opt out of the Health Home services at the CMO. If an individual opts out of the BHH services they will continue to receive the CMO services that they need If they opt in to BHH service individual will receive all of the services of the CMO plus the additional BHH services In addition if the family indicates to the lead care manager that they no longer wish to be involved with the BHH the need for continuing authorization would not be pursued BHH

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Application print HHS NJ.1480.R00.01 - Jan 01, 2016 file:///C/Users/Gbb9/Desktop/NJ-16-0002%205%203%2016%20(2).htm[05/16/2016 10:37:31 AM] of a Health Homes State Plan Amendment that makes Health Home Services available to a new population, such as people in a particular geographic area or people with a particular chronic condition.

The State assures that there will be no duplication of services and payment for similar services provided under other Medicaid authorities.

Transmittal Number: NJ-16-0002 Supersedes Transmittal Number: NJ-14-0015 Proposed Effective Date: Jan 1, 2016 Approval Date:

Attachment 3.1-H Page Number: Health Homes Providers

Types of Health Homes Providers

Designated Providers Indicate the Health Homes Designated Providers the State includes in its program and the provider qualifications and standards:

Physicians Describe the Provider Qualifications and Standards:

Clinical Practices or Clinical Group Practices Describe the Provider Qualifications and Standards:

Rural Health Clinics Describe the Provider Qualifications and Standards:

Community Health Centers Describe the Provider Qualifications and Standards:

Community Mental Health Centers Describe the Provider Qualifications and Standards:

Home Health Agencies Describe the Provider Qualifications and Standards:

Other providers that have been determined by the State and approved by the Secretary to be qualified as a health home provider:

Case Management Agencies Describe the Provider Qualifications and Standards:

Community/Behavioral Health Agencies Describe the Provider Qualifications and Standards: TN: 16-0002 NEW JERSEY APPROVAL DATE: MAY 12, 2016 EFFECTIVE DATE: JANUARY 01, 2016 The BHH providers will be current CMOs. CMOs are agencies that provide care coordination and wraparound care planning for children and their families with the most complex needs and are responsible for facilitating access to a full range of treatment and support services. They facilitate and work through child-family teams to develop individualized plans of care. The CMOs goals are to keep children in their homes, their schools, and their communities. CMOs are designated by the NJ Department of Children and Families CSOC and regulated by the NJ Division of Medical Assistance and Health Services. Each BHH will be a designated CMO and will be initially certified by the State of NJ as a BHH and will be required to become accredited by a nationally accredited body within two years of certification. To become a certified behavioral health home in the State of NJ a provider must: 1) be a designated CMO provider, 2) complete approved Learning Community curriculum, 3) meet DCF’s certification requirements (inclusive of implementing a system of care approach, training on motivational interviewing, appropriate level of staffing assuring collaboration with pediatric and specialty providers is planned for policies have been developed) 4) be accredited by a national recognized accrediting organization CMO’s can provide behavioral health home services on a provisional basis if

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Social Workers Describe the Provider Qualifications and Standards:

Behavioral Health Specialists Describe the Provider Qualifications and Standards:

Doctors of Chiropractic Describe the Provider Qualifications and Standards:

Licensed Complementary and Alternative Medicine Practitioners Describe the Provider Qualifications and Standards:

Physicians' Assistants Describe the Provider Qualifications and Standards:

Supports for Health Homes Providers

Describe the methods by which the State will support providers of Health Homes services in addressing the following components: 1. Provide quality-driven, cost-effective, culturally appropriate, and person- and family-centered Health Homes services, 2. Coordinate and provide access to high-quality health care services informed by evidence-based clinical practice guidelines, 3. Coordinate and provide access to preventive and health promotion services, including prevention of mental illness and substance use disorders, 4. Coordinate and provide access to mental health and substance abuse services, 5. Coordinate and provide access to comprehensive care management, care coordination, and transitional care across settings. Transitional care includes appropriate follow-up from inpatient to other settings, such as participation in discharge planning and facilitating transfer from a pediatric to an adult system of health care, 6. Coordinate and provide access to chronic disease management, including self-management support to individuals and their families, 7. Coordinate and provide access to individual and family supports, including referral to community, social support, and recovery services, 8. Coordinate and provide access to long-term care supports and services, 9. Develop a person-centered care plan for each individual that coordinates and integrates all of his or her clinical and non-clinical health-care related needs and services: 10. Demonstrate a capacity to use health information technology to link services, facilitate communication among team members and between the health team and individual and family caregivers, and provide feedback to practices, as feasible and appropriate: 11. Establish a continuous quality improvement program, and collect and report on data that permits an evaluation of increased coordination of care and chronic disease management on individual-level clinical outcomes, experience of care outcomes, and quality of care outcomes at the population level. Description:

Provider Infrastructure Describe the infrastructure of provider arrangements for Health Homes Services.

Provider Standards The State's minimum requirements and expectations for Health Homes providers are as follows: TN: 16-0002 NEW JERSEY APPROVAL DATE: MAY 12, 2016 EFFECTIVE DATE: JANUARY 01, 2016 As described in NJs 1115 Comprehensive Medicaid Waiver, NJ has committed to providing quality driven and cost effective treatment throughout the service delivery system. NJ's CSOC will support the Behavioral Health Home (BHH) in these endeavors through a commitment to providing data, technical assistance, training and support. The CSA will have staff designated to monitor and assist the BHH in enrolling eligible children, coordinating with other systems, and providing any other real time assistance to the BHH provider to meet quality, cost and efficiency goals. NJ DMAHS will work with the NJ Managed Care Organizations to ensure that they coordinate with the BHH in the area of data, and the facilitation of patient referrals. All BHH providers must be designated as a CMO by the NJ CSOC and therefore be well versed in behavioral health issues. NJ has implemented the Behavioral Health Home Learning Community (LC) for potential BHH providers. The Learning Community assists providers in developing a full implementation and readiness plan. Through the LC, providers will have an opportunity to develop the capacity to implement the BHH services, and the opportunity to share problems and develop solutions for connecting with other systems with which they will be coordinating The work of the CMO is also supported by the CSA who authorizes tracks and coordinates care and service outcomes (reporting IT and coordination of QM function) Family Support Organizations (FSOs) are also an integral partner to a CMO involved child and their family The FSOs are All BHH providers must be designated CMOs. They provide enhanced care coordination (i.e. face-to-face care management and comprehensive service planning for youth and their families with complex needs). CMOs facilitate the development of the child and family team (CFT) and coordinate the CFT meetings and implement individual service plans (ISP). As part of care coordination they identify, and link children and their families to required services and supports that address the needs that are identified on the plan of care. The CMO is well positioned to serve as the bridge for coordinating comprehensive and holistic care for children who also have a chronic medical condition. CMOs work is supported through the CFT which is comprised of minimally the following individuals: 1. A CMO care manager; 2 The child youth or young adult and the parent or other caregiver;

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Transmittal Number: NJ-16-0002 Supersedes Transmittal Number: NJ-14-0015 Proposed Effective Date: Jan 1, 2016 Approval Date:

Attachment 3.1-H Page Number: Health Homes Service Delivery Systems

Identify the service delivery system(s) that will be used for individuals receiving Health Homes services:

Fee for Service

PCCM PCCMs will not be a designated provider or part of a team of health care professionals. The State provides assurance that it will not duplicate payment between its Health Homes payments and PCCM payments. The PCCMs will be a designated provider or part of a team of health care professionals.

The PCCM/Health Homes providers will be paid based on the following payment methodology outlined in the payment methods section:

Fee for Service

Alternative Model of Payment (describe in Payment Methodology section)

Other

Description:

Requirements for the PCCM participating in a Health Homes as a designated provider or part of a team of health care professionals will be different from those of a regular PCCM.

If yes, describe how requirements will be different:

Risk Based Managed Care The Health Plans will not be a Designated Provider or part of a Team of Health Care Professionals. Indicate how duplication of payment for care coordination in the Health Plans' current capitation rate will be affected:

The current capitation rate will be reduced.

The State will impose additional contract requirements on the plans for Health Homes enrollees.

Provide a summary of the contract language for the additional requirements:

Other TN: 16-0002 NEW JERSEY APPROVAL DATE: MAY 12, 2016 EFFECTIVE DATE: JANUARY 01, 2016 An eligible BHH provider must meet the following:

1.Designated CMO 2.Medicaid approved provider 3.Certified as a BHH by the NJ CSOC. 4.Accredited as a specialty Behavioral Health Home by a nationally recognized and state approved accrediting body within two years of receiving state certification 5.Participation in a BHH Learning Community or other learning activity approved by the state

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Describe: The Health Plans will be a Designated Provider or part of a Team of Health Care Professionals.

Provide a summary of the contract language that you intend to impose on the Health Plans in order to deliver the Health Homes services.

The State provides assurance that any contract requirements specified in this section will be included in any new or the next contract amendment submitted to CMS for review.

The State intends to include the Health Homes payments in the Health Plan capitation rate. Yes

The State provides an assurance that at least annually, it will submit to the regional office as part of their capitated rate Actuarial certification a separate Health Homes section which outlines the following: Any program changes based on the inclusion of Health Homes services in the health plan benefits Estimates of, or actual (base) costs to provide Health Homes services (including detailed a description of the data used for the cost estimates) Assumptions on the expected utilization of Health Homes services and number of eligible beneficiaries (including detailed description of the data used for utilization estimates) Any risk adjustments made by plan that may be different than overall risk adjustments How the final capitation amount is determined in either a percent of the total capitation or an actual PMPM

The State provides assurance that it will design a reporting system/mechanism to monitor the use of Health Homes services by the plan ensuring appropriate documentation of use of services.

The State provides assurance that it will complete an annual assessment to determine if the payments delivered were sufficient to cover the costs to deliver the Health Homes services and provide for adjustments in the rates to compensate for any differences found. No

Indicate which payment methodology the State will use to pay its plans:

Fee for Service

Alternative Model of Payment (describe in Payment Methodology section)

Other

Description:

Other Service Delivery System:

Describe if the providers in this other delivery system will be a designated provider or part of the team of health care professionals and how payment will be delivered to these providers: TN: 16-0002 NEW JERSEY APPROVAL DATE: MAY 12, 2016 EFFECTIVE DATE: JANUARY 01, 2016 New Jersey has in place Statewide Managed Care Organizations (MCOs) that manage the physical health services of NJ FamilyCare enrolled individuals. The current MCO contracts support coordination and non-duplication with BHH services. The contracts require that MCOs refer or coordinate referrals of enrollees with mental illness to mental health/substance abuse providers. Currently, any member of an MCO identified as having a potential care management need receives a detailed comprehensive needs assessment and ongoing care coordination from the MCO. The MCO contract will be amended 1/1/15 to reflect that, for MCO enrollees active with a BHH provider, the MCO will utilize the care management provided at the BHH and not duplicate services. The BHH team members are expected to outreach to the MCO for each enrollee The BHH Care Manager would be the point of contact for the MCO

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The State provides assurance that any contract requirements specified in this section will be included in any new or the next contract amendment submitted to CMS for review.

Transmittal Number: NJ-16-0002 Supersedes Transmittal Number: NJ-14-0015 Proposed Effective Date: Jan 1, 2016 Approval Date:

Attachment 3.1-H Page Number: Health Homes Payment Methodologies

The State's Health Homes payment methodology will contain the following features:

Fee for Service

Fee for Service Rates based on:

Severity of each individual's chronic conditions

Describe any variations in payment based on provider qualifications, individual care needs, or the intensity of the services provided:

Capabilities of the team of health care professionals, designated provider, or health team.

Describe any variations in payment based on provider qualifications, individual care needs, or the intensity of the services provided:

Other: Describe below.

Provide a comprehensive description of the rate-setting policies the State will use to establish Health Homes provider reimbursement fee-for-service rates. Explain how the methodology is consistent with the goals of efficiency, economy and quality of care. Within your description, please explain: the reimbursable unit(s) of service, the cost assumptions and other relevant factors used to determine the payment amounts, the minimum level of activities that the State agency requires for providers to receive payment per the defined unit, and the State's standards and process required for service documentation.

Per Member, Per Month Rates

Provide a comprehensive description of the rate-setting policies the State will use to establish Health Homes provider reimbursement fee for service or PMPM rates. Explain how the methodology is consistent with the goals of efficiency, economy and quality of care. Within your description, please explain: the reimbursable unit(s) of service, the cost assumptions and other relevant factors used to determine the payment amounts, the minimum level of activities that the State agency requires for providers to receive payment per the defined unit, and the State's standards and process required for service documentation.

Incentive payment reimbursement

Provide a comprehensive description of incentive payment policies that the State will use to reimburse in addition to the unit base rates. Explain how the methodology is consistent with the goals of efficiency, economy and quality of care. Within your description, please explain: the incentives that will be reimbursed through the methodology, how the TN: 16-0002 NEW JERSEY APPROVAL DATE: MAY 12, 2016 EFFECTIVE DATE: JANUARY 01, 2016 Children, Adolescents, and Young Adults will receive BHH services through the CSOC. CSOC has an existing network of CMOs that provide a variety of care management and support services reimbursed through a monthly per member per month case rate. The BHH will be an enhancement to the existing CMO services for youth that meet BHH eligibility criteria. CMOs will become Childrens BHHs through a state BHH certification process and national accreditation. The BHH rate will be an enhancement to the current CMO rate to support the functions that are specific to the Behavioral Health Home. The rate is inclusive of the CMO base rate and the add-on of the nurse manager and wellness coach.The BHH is a natural fit into the current CMO structure, which leverages the child/family team process to engage and promote better outcomes, so the nurse and wellness coach will become an integral part of delivering the core health homes services. The rate is a fee for service reimbursement structure. All applicable procedure codes listings and/or rates are published on the Department's fiscal agent's website at www.njmmis.com under the link for "rate code and information".

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supplemental incentive payments are tied to the base rate activities, the criteria used to determine a provider's eligibility to receive the payment, the methodology used to determine the incentive payment amounts, and the frequency and timing through which the Medicaid agency will distribute the payments to providers.

PCCM Managed Care (description included in Service Delivery section)

Risk Based Managed Care (description included in Service Delivery section)

Alternative models of payment, other than Fee for Service or PM/PM payments (describe below)

Tiered Rates based on:

Severity of each individual's chronic conditions

Capabilities of the team of health care professionals, designated provider, or health team.

Describe any variations in payment based on provider qualifications, individual care needs, or the intensity of the services provided:

Rate only reimbursement

Provide a comprehensive description of the policies the State will use to establish Health Homes alternative models of payment. Explain how the methodology is consistent with the goals of efficiency, economy and quality of care. Within your description, please explain the nature of the payment, the activities and associated costs or other relevant factors used to determine the payment amount, any limiting criteria used to determine if a provider is eligible to receive the payment, and the frequency and timing through which the Medicaid agency will distribute the payments to providers.

Explain how the State will ensure non-duplication of payment for similar services that are offered through another method, such as 1915(c) waivers or targeted case management.

The State provides assurance that all governmental and private providers are reimbursed according to the same rate schedule

The State provides assurance that it shall reimburse Health Homes providers directly, except when there are employment or contractual arrangements.

Transmittal Number: NJ-16-0002 Supersedes Transmittal Number: NJ-14-0015 Proposed Effective Date: Jan 1, 2016 Approval Date:

Attachment 3.1-H Page Number: Submission - Categories of Individuals and Populations Provided Health Homes Services

The State will make Health Homes services available to the following categories of Medicaid participants:

Categorically Needy eligibility groups Health Homes Services (1 of 2)

Category of Individuals CN individuals TN: 16-0002 NEW JERSEY APPROVAL DATE: MAY 12, 2016 EFFECTIVE DATE: JANUARY 01, 2016 New Jersey had four 1915(c) waivers that have been subsumed under NJ 1115(a) Comprehensive Waiver with the implementation of Managed Long Term Services and Supports (MLTSS). Those waivers were: Traumatic Brain Injury, Global Options, Community Resource for People with Disabilities, and the AIDS Community Care Alternatives Program. These programs have been consolidated into the Managed Long Term Services and Supports program and are being managed through the states MCOs. The state will pay for MLTSS services through capitated payment to the MCOs. The BHH service is excluded from the MLTSS covered services. However, the MCOs are required to coordinate referrals to the BHH for MLTSS members who meet the eligibility criteria for the BHH and the BHH service is part of the member’s plan of care (POC). The only program under 1915(c) waiver currently in place in NJ is the Community Care Waiver (CCW) that serves individuals with developmental disabilities. Individuals receiving services through the CCW waiver will not be eligible for the BHH services. NJ has instituted an edit in the MMIS system which rejects more than one bill, per individual per month, for duplicative services. This will disallow billing for services duplicative of the BHH, these include TCM 1915(c) CCW and PACT services The providers have been educated on these billing rules

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Application print HHS NJ.1480.R00.01 - Jan 01, 2016 file:///C/Users/Gbb9/Desktop/NJ-16-0002%205%203%2016%20(2).htm[05/16/2016 10:37:31 AM] Description

Licensed Complementary and Alternative Medicine Practitioners Description

Dieticians Description

Nutritionists Description

Other (specify): Name Description

Care Coordination Definition: Describe how health information technology will be used to link this service in a comprehensive approach across the care continuum:

Scope of benefit/service

The benefit/service can only be provided by certain provider types.

Behavioral Health Professionals or Specialists Description

Nurse Care Coordinators Description

Nurses Description

Medical Specialists Description TN: 16-0002 NEW JERSEY APPROVAL DATE: MAY 12, 2016 EFFECTIVE DATE: JANUARY 01, 2016 Care Managers Comprehensive care management services will be provided by care managers and involve: 1. Assessment and documentation of eligibility for BHH Services. 2. Development and periodic revision of service plans based on information collected through the assessments, review of youth's records and input from child and family. 3. Ensuring that implementation of the plan will coordinate access to high quality behavioral health care and facilitate access to health care services that are informed by evidence-based practices, facilitate access to preventative services, specialty medical care and dental care and social services Child with chronic conditions who require the expertise and additional medical support will be delegated to the Nurse Manager Plan will include child/family’s goals and preferences targeted outcomes identified service provider Care Coordination services are provided by Care Manager with support from the Nurse Manager, with the primary goal of implementing the individualized service plan/plan of care, with active involvement by the child/family, to ensure the plan reflects child/family needs and preferences. Care coordination emphasizes access to a wide variety of services required to improve overall health and wellness. Care Managers can be social workers and/or other trained health care professionals. A license in the health care professions is not required. Nurse Manager must be properly licensed and credentialed (minimum RN). The provider standards set by NJDCF require that BHH providers are able to interface with primary care, specialty care, hospitals, and support services. Every provider is required to utilize the State's EHR(CSA). Providers are also expected to use other available means to exchange protected health information safely and securely, to include but not be limited to direct messaging, facsimile, and telephonic services.

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Application print HHS NJ.1480.R00.01 - Jan 01, 2016 file:///C/Users/Gbb9/Desktop/NJ-16-0002%205%203%2016%20(2).htm[05/16/2016 10:37:31 AM] Description

Other (specify): Name Description Health Homes Services (2 of 2)

Category of Individuals CN individuals

Service Definitions

Provide the State's definitions of the following Health Homes services and the specific activities performed under each service:

Comprehensive transitional care from inpatient to other settings, including appropriate follow-up

Definition:

Describe how health information technology will be used to link this service in a comprehensive approach across the care continuum:

Scope of benefit/service

The benefit/service can only be provided by certain provider types.

Behavioral Health Professionals or Specialists

Description

Nurse Care Coordinators

Description

Nurses

Description

Medical Specialists

Description TN: 16-0002 NEW JERSEY APPROVAL DATE: MAY 12, 2016 EFFECTIVE DATE: JANUARY 01, 2016 Health promotion can, and should, be provided by all team members 1.Engaging the child in health promotion planning and activities, including the provision of motivational interventions to increase treatment and medication compliance and support lifestyle changes. 2. Providing health education specific to chronic conditions. 3. Development, with the child and if possible the family, of self-management goals to be included in the service plan. 4. Monitoring progress on self-management goals. 5 Providing support for the self-management goals included in the service plan BHHs provide comprehensive transitional care and follow-up to children transitioning from inpatient care and/or emergency care to the community. Comprehensive transitional care can be provided by the Care Manager or Nurse Manager, as a team member, if inpatient is medical in nature. Comprehensive transitional care is provided for every illness that might require intensive care The provider standards set by NJDCF require that BHH providers are able to interface with primary care, specialty care, hospitals, and support services. Every provider is required to utilize the State's EHR(CSA). Providers are also expected to use other available means to exchange protected health information safely and securely, to include but not be limited to direct messaging, facsimile, and telephonic services. 1. If the child requires inpatient treatment, the BHH Team will facilitate the children’s transition to inpatient primary or behavioral health care or crisis services. This includes interfacing with the treatment team in the inpatient setting, accompanying the child to their admission, and continuing contact with the child while they are receiving inpatient care. 2. If the child receives inpatient care, the BHH team, in collaboration with the hospital or other inpatient care facility, focuses on developing a discharge plan and immediate linkage to community-based care to prevent future emergency room and inpatient admissions. BHH Team members provide care management and care coordination services to ensure that child/family have the requisite support to begin the process of recovery and reintegration into community living. 3 BHH Team members coordinate care management care coordination and treatment planning with hospital-based and community-based physicians nurses social workers discharge planners pharmacists and others to help children and family members better 1. If the child requires inpatient treatment, the BHH Team will facilitate the children’s transition to inpatient primary or behavioral health care or crisis services. This includes interfacing with the treatment team in the inpatient setting, accompanying the child to their admission, and continuing contact with the child while they are receiving inpatient care. 2. If the child receives inpatient care, the BHH team, in collaboration with the hospital or other inpatient care facility, focuses on developing a discharge plan and immediate linkage to community-based care to prevent future emergency room and inpatient admissions. BHH Team members provide care management and care coordination services to ensure that child/family have the requisite support to begin the process of recovery and reintegration into community living. 3 BHH Team members coordinate care management care coordination and treatment planning with hospital-based and community-based physicians nurses social workers discharge planners pharmacists and others to help children and family members better

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Application print HHS NJ.1480.R00.01 - Jan 01, 2016 file:///C/Users/Gbb9/Desktop/NJ-16-0002%205%203%2016%20(2).htm[05/16/2016 10:37:31 AM] Name Description

Referral to community and social support services, if relevant Definition: Describe how health information technology will be used to link this service in a comprehensive approach across the care continuum.

Scope of benefit/service

The benefit/service can only be provided by certain provider types.

Behavioral Health Professionals or Specialists Description

Nurse Care Coordinators Description

Nurses Description

Medical Specialists Description

Physicians Description

Physicians' Assistants Description

Pharmacists Description

Social Workers Description TN: 16-0002 NEW JERSEY APPROVAL DATE: MAY 12, 2016 EFFECTIVE DATE: JANUARY 01, 2016 Provided by care manager or other team member 1.Engaging the family, support system and/or the individual child in services goal of ensuring family engagement in supporting the recovery and health maintenance of children with chronic condition. 2. Identifying family related goals to be included in the service plan. 3. Providing family education sessions focused on health education, illness management, illness prevention and wellness activities. 4. Linking family members to services needed to improve family stability and overall health such as, family therapy and social support services. 5 Helping individuals and families learn how to advocate for the services and supports they require Teaching family members strategies for advocating for the child and family wellness needs Referral to community and social support services involves providing assistance for child/family to obtain necessary community and social supports. CMO’s are well positioned to provide access to needed community supports by having built partnerships for collaborative, effective system of care which are executed locally. The provider standards set by NJDCF require that BHH providers are able to interface with primary care, specialty care, hospitals, and support services. Every provider is required to utilize the State's EHR(CSA). Providers are also expected to use other available means to exchange protected health information safely and securely, to include but not be limited to direct messaging, facsimile, and telephonic services.

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Doctors of Chiropractic Description

Licensed Complementary and Alternative Medicine Practitioners Description

Dieticians Description

Nutritionists Description

Other (specify): Name Description

Health Homes Patient Flow Describe the patient flow through the State's Health Homes system. The State must submit to CMS flow-charts of the typical process a Health Homes individual would encounter:

Medically Needy eligibility groups All Medically Needy eligibility groups receive the same benefits and services that are provided to Categorically Needy eligibility groups. Different benefits and services than those provided to Categorically Needy eligibility groups are provided to some or all Medically Needy eligibility groups. All Medically Needy receive the same services. There is more than one benefit structure for Medically Needy eligibility groups.

Transmittal Number: NJ-16-0002 Supersedes Transmittal Number: NJ-14-0015 Proposed Effective Date: Jan 1, 2016 Approval Date:

Attachment 3.1-H Page Number: Health Homes Monitoring, Quality Measurement and Evaluation

Monitoring TN: 16-0002 NEW JERSEY APPROVAL DATE: MAY 12, 2016 EFFECTIVE DATE: JANUARY 01, 2016 Team members 1. Engaging child/family in referral for community and social supports. Since many children an their families in high risk circumstances are unable or unwilling to accept needed services, the use of evidence-based interventions such as Motivational Interviewing and other evidence-based approaches is essential for engaging children/families to address critical service needs. 2. Identifying community and social supports needs such as disability benefits, housing, legal and employment services. 3. Identifying available and appropriate community and social support services. 4 Referring to community and social support services and providing the support and/or services needed for child/family to obtain these supports such as arranging transportation making appointments arranging for peers or others to accompany child The CSA will continue to screen and prior authorize Atlantic, Bergen, Cape May, Mercer, and Monmouth County residents for CMO service eligibility. The CSA makes referrals directly to the CMO. Children and Youth who are referred to the CMO will then be screened for Health Home services at the CMO and if eligible, the CMO will request prior authorization for the Health Home service from the CSA. This allows the CMO staff to work directly with the children and their families to explain and discuss the BHH services. Enrollees can opt in or opt out of the Health Home services at the CMO. If an individual opts out of the BHH services they will continue to receive the CMO services that they need. If they opt in to BHH service, the individual will receive all of the services of the CMO plus the additional BHH services.

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Application print HHS NJ.1480.R00.01 - Jan 01, 2016 file:///C/Users/Gbb9/Desktop/NJ-16-0002%205%203%2016%20(2).htm[05/16/2016 10:37:31 AM]

Describe the State's methodology for tracking avoidable hospital readmissions, including data sources and measurement specifications:

Describe the State's methodology for calculating cost savings that result from improved coordination of care and chronic disease management achieved through the Health Homes program, including data sources and measurement specifications.

Describe how the State will use health information technology in providing Health Homes services and to improve service delivery and coordination across the care continuum (including the use of wireless patient technology to improve coordination and management of care and patient adherence to recommendations made by their provider). Quality Measurement

The State provides assurance that it will require that all Health Homes providers report to the State on all applicable quality measures as a condition of receiving payment from the State.

The State provides assurance that it will identify measureable goals for its Health Homes model and intervention and also identify quality measures related to each goal to measure its success in achieving the goals.

States utilizing a health team provider arrangement must describe how they will align the quality measure reporting requirements within section 3502 of the Affordable Care Act and section 1945(g) of the Social Security Act. Describe how the State will do this:

Evaluations

The State provides assurance that it will report to CMS information submitted by Health Homes providers to inform the evaluation and Reports to Congress as described in Section 2703(b) of the Affordable Care Act and as described by CMS. Describe how the State will collect information from Health Homes providers for purposes of determining the effect of the program on reducing the following:

Hospital Admissions

Measure:

Measure Specification, including a description of the numerator and denominator.

Data Sources:

Frequency of Data Collection: Monthly Quarterly Annually Continuously Other

Emergency Room Visits

Measure:

Measure Specification, including a description of the numerator and denominator.

Data Sources: TN: 16-0002 NEW JERSEY APPROVAL DATE: MAY 12, 2016 EFFECTIVE DATE: JANUARY 01, 2016 Outcomes (clinical and functional) can be measured through Child and Adolescent Needs and Strengths (CANS) tool. NJ will measure the population based rate of acute hospital inpatient stays during the measurement period that were followed by an acute readmission for any diagnosis within 30 days. Numerator: number of index hospital stays with an unplanned readmission within 30 days for BHH and comparison populations. Denominator: Number of Index Hospital stays for enrolled comparison populations. Data sources include Health Home enrollment data collected through the BHH EHR and NJ MMIS claims encounter data. If a child is being served in the children’s system of care at the age of 18, they can stay in that system to age 21 as the adult and children’s systems work to make a seamless transition. If an individual enters the behavioral health system for the first time at 18 or older, they are served in the adult system. We will measure the change in total spending (Behavioral Health and Physical Health) attributable to BHH enrollment. The Numerator is the sum of costs which is the MMIS FFS Behavioral Health Claims and the MCO provider payments, payments to the state and county psychiatric hospitals for the BHH and the comparison groups. The Denominator is the Person months of enrollment for the BHH comparison groups. All children's BHH providers utilize the Contracted System Administrator's (CSA) electronic record, which is purchased by the State. The State is making amendments to the technology to include specific BHH data parameters. Compare hospital admission rates of BHH enrolled consumers and a comparison group For members up to 21 years of age, the number and rate per 100,000 population of age-sex standardized acute inpatient stays (admissions) during the measurement year. Comparison group will be individuals, up to age 21, who meet the criteria for a BHH but are not receiving BHH services. NJ will use the population from one county where BHH services are not currently available to develop the comparison group.

Numerator: Count the number of hospital admissions for enrolled BHH clients and comparison group MMIS claims, encounter and eligibility files; health home enrollment data Comparing number of all cause ED visits for BHH enrolled population vs. comparison population For members up to age 21, the number and rate per 100,000 treat-and-release (i.e., no inpatient admission) all-cause acute emergency department (ED) visits. Comparison group will be individuals, up to age 21, who meet the criteria for a BHH but are not receiving BHH services. NJ will use the population from one county where BHH services are not currently available to develop the comparison group.

Numerator: Number of ED visits in enrolled and comparison populations

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Application print HHS NJ.1480.R00.01 - Jan 01, 2016 file:///C/Users/Gbb9/Desktop/NJ-16-0002%205%203%2016%20(2).htm[05/16/2016 10:37:31 AM]

Frequency of Data Collection: Monthly Quarterly Annually Continuously Other

Skilled Nursing Facility Admissions

Measure:

Measure Specification, including a description of the numerator and denominator.

Data Sources:

Frequency of Data Collection: Monthly Quarterly Annually Continuously Other

Describe how the State will collect information for purpose of informing the evaluations, which will ultimately determine the nature, extent and use of the program, as it pertains to the following:

Hospital Admission Rates

Chronic Disease Management

Coordination of Care for Individuals with Chronic Conditions

Assessment of Program Implementation

Processes and Lessons Learned

Assessment of Quality Improvements and Clinical Outcomes

Estimates of Cost Savings

The State will use the same method as that described in the Monitoring section.

If no, describe how cost-savings will be estimated. TN: 16-0002 NEW JERSEY APPROVAL DATE: MAY 12, 2016 EFFECTIVE DATE: JANUARY 01, 2016 MMIS claims, encounter and eligibility files; health home enrollment data Rate of admission to SNF for BHH population vs. comparison population Skilled nursing facility admission rate, comparing BHH rate to comparison group. Comparison group will be individuals, up to age 21, who meet the criteria for a BHH but are not receiving BHH services. NJ will use the population from one county where BHH services are not currently available to develop the comparison group.

MMIS claims, encounter and eligibility files; health home enrollment data NJ will measure the number and rate per 100,000 population of age-sex standardized acute inpatient stays (Admissions) during the measurement year. The Numerator will be the count of number of hospital admission of enrolled BHH client and a comparison group. The Denominator will be enrolled and comparison populations. Data sources will be MMIS claims data and BHH enrollment files. NJ will require that the BHH report on youth level results of Chronic Disease Management services. Children's services is a collaborative model to assist with disease management, through monitoring and achievement of wellness goals. Utilization management review can be condcuted through CSA for children. New Jersey can also interview BHH providers and conduct onsite monitoring of youth's records. BHH providers are required to participate in a BHH Learning Community in which they will develop a full implementation plan to include the clinical and fiscal models as well as a full IT and QA plan. These implementation plans will be used as the benchmark from which to assess the program implementation. The process will be collaborative between state and program to identify problems and issues for which the state can provide assistance or resources. In addition, the Learning Community members will be convened regularly to self-assess their progress and share information. There will be an ongoing fidelity measurement process for BHH. The learning community will be used as a forum to discuss processes and lessons learned. New Jersey has elected to start BHH services county by county and will use the processes and lessons learned to inform expansion of the service. Each BHH provider will be required, as part of their implementation plan, to develop a full quality improvement plan. Providers will be required to report on the progress of that plan and the outcomes. NJ will use Medicaid claims data and medical records to measure individual BHH identified clinical outcomes as well as those identified by CMS in the Medicaid Director letter of January 15, 2013.

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Alternative Benefit Plan State Name:!New Jersey [3 Attachment3.l-L-D OJ\1B Control Number: 093 8-1148 Transmittal Number: NJ - 16 - 0010 Selection of Benchmark Benefit Package or Benchmark-Equivalent Benefit Package Select one of the following: (' The state/territory is amending one existing benefit package for the population defined in Section 1. (i The state/territory is creating a single new benefit package for the population defined in Section 1. Name of benefit package: IN_J_F_a_m_ily_C_ar _e _A_B_P _______________ Selection of the Section 1937 Coverage Option The state/territory selects as its Section 1937 Coverage option the following type of Benchmark Benefit Package or Benchmark Equivalent Benefit Package under this Alternative Benefit Plan ( check one): (i Benchmark Benefit Package. (' Benchmark-Equivalent Benefit Package. The state/territory will provide the following Benchmark Benefit Package (check one that applies): ABPJ (' The Standard Blue Cross/Blue Shield Preferred Provider Option offered through the Federal Employee Health Benefit Program (FEHBP). (' State employee coverage that is offered and generally available to state employees (State Employee Coverage): (' A commercial HMO with the largest insured commercial, non-Medicaid emollment in the state/territory (Commercial HMO): (i' Secretary-Approved Coverage. (i The state/territory offers benefits based on the approved state plan. (' The state/territory offers an array of benefits from the section 1937 coverage option and/or base benchmark plan benefit packages, or the approved state plan, or from a combination of these benefit packages. (i' The state/territory offers the benefits provided in the approved state plan. (' Benefits include all those provided in the approved state plan plus additional benefits. (' Benefits are the same as provided in the approved state plan but in a different amount, duration and/or scope. (' The state/territory offers only a partial list of benefits provided in the approved state plan. (' The state/territory offers a partial list of benefits provided in the approved state plan plus additional benefits. Please briefly identify the benefits, the source of benefits and any limitations: I State Plan Medicaid package Selection of Base Benchmark Plan Pagel of2 TN: 16-0010 New Jersey Approval Date: 07/03/2019 ABP3 Effective Date: 07/01/2016

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Alternative Benefit Plan The state/territory must select a Base Benchmark Plan as the basis for providing Essential Health Benefits in its Benchmark or Benchmark-Equivalent Package. The Base Benchmark Plan is the same as the Section 1937 Coverage option.EB Indicate which Benchmark Plan described at 45 CFR 156. lOO(a) the state/territory will use as its Base Benchmark Plan: (' Largest plan by emollment of the three largest small group insurance products in the state's small group market. (' Any of the largest three state employee health benefit plans by emollment. (' Any of the largest three national FEHBP plan options open to Federal employees in all geographies by emollment. (i' Largest insured commercial non-Medicaid HMO. Plan name: !Horizon HMO Other Information Related to Selection of the Section 1937 Coverage Option and the Base Benchmark Plan ( optional): The state assures that all services in the base benchmark have been accounted for throughout the benefit chart found in ABP 5. The state assures the accuracy of all information in ABP 5 depicting amount, duration and scope parameters of services authorized in the currently approved Medicaid state plan. PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid 0MB control number. The valid 0MB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 5 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. V.20160722 Page 2 of 2 TN: 16-0010 New Jersey Approval Date: 07/03/2019 ABP3 Effective Date: 07/01/2016

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Alternative Benefit Plan Scope Limit: I Routine foot care, subluxations of the foot and treatment of flat foot conditions are not covered unless medically indicated. I Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: INJ FamilyCare Plan A Standard Medicaid I Benefit Provided: Source: !Dental Services I I state Plan 1905(a) Bl I Authorization: !Authorization required in excess of limitation Amount Limit: I 1 visit for dental exams, flouride and prophylaxis Scope Limit: Provider Qualifications: I ·I !Medicaid State Plan Duration Limit: 1 lper calendar year I space maintainers, flouride varnish and sealants are not covered for adults. Bl I Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: NJ FamilyCare Plan A Standard Medicaid; Prior authorization required for dental exams, flouride treatments and prophylaxis in excess of 1 visit per year, and prior authorization required for prosthodonic replacements, periodontal work and select dental services, including TMJ, and orthodontic work for children under 21. Benefit Provided: !Hospice - Home Care Authorization: INone Amount Limit: INone Scope Limit: Source: 11 State Plan 1905(a) Provider Qualifications: [3 !Medicaid State Plan Duration Limit: I INone Bl I Bl I !Individual must be diagnosed with a terminal illness with a prognosis of a life expectancy of six months or less as certified by a licensed physician. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: NJ FamilyCare Plan A Standard Medicaid; An individual under the age of 21 is eligible to receive hospice services concurrently with services related to the treatment of the child for the condition for which a diagnosis of terminal illness has been made. Benefit Provided: !Abortion Source: 11 State Plan 1905(a) l:Jl Remove I Remove I Remove I Page 4 of 55 TN: 16-0010 New Jersey Approval Date: 07/03/2019 ABP5 Effective Date: 07/01/2016

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Alternative Benefit Plan Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: I NJ FamilyCare Plan A Standard Medicaid; subject to Itv!D exclusion Benefit Provided: Source: I clinic Services - mental health 11 State Plan 1905(a) Bl I Authorization: lother Amount Limit: I 1 service except pychotherapy limited to 3 per day Scope Limit: lpychotherapy services limited to 5 per week. Provider Qualifications: ti !Medicaid State Plan Duration Limit: 1 lper day Bl I Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: NJ FamilyCare Plan A Standard Medicaid; prior authorization for medical necessity for partial care only. Prior authorization is intended to ensure services support client movement toward a stable discharge. No prior authorization required for other mental health services. Established limits may be exceeded based on medical necessity and clinical appropriateness. Prior authorization applies to partial care (same as medical day care) to control over utilization of services. Benefit Provided: Source: !Partial Hospital ] I state Plan 1905(a) Bl I Authorization: Provider Qualifications: IPrior Authorization l:I !Medicaid State Plan Bl Amount Limit: Duration Limit: INone I INone I Scope Limit: I acute partial hospitalization requires prior authorization to ensure acute partial hospital is a diversion from acute inpatient admission and to ensure clients movement toward a stable discharge. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: NJ FamilyCare Plan A Standard Medicaid. Prior authorization applies to partial hospital (same as medical day care and PCA) to control over utilization of services. Benefit Provided: Source: I community Support Services ] I State Plan 1905(a) Bl Authorization: Provider Qualifications: IPrior Authorization [3 !Medicaid State Plan l:J] Remove I Remove I Remove I Page 15 of 55 TN: 16-0010 New Jersey Approval Date: 07/03/2019 ABP5 Effective Date: 07/01/2016

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Alternative Benefit Plan Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: I NJ FamilyCare Plan A Standard Medicaid; also includes Home Health Services and Cognitive Therapy. 1 treatment session is 6 units. Benefit Provided: Source: !Physical Therapy - habilitative 11 State Plan 1905(a) Bl I Authorization: Provider Qualifications: INone ti !Medicaid State Plan Bl Amount Limit: Duration Limit: I 1 treatment session I lper day I Scope Limit: I Provided within the scope of the New Jersey state definition of habilitative services. See "Other information" for definition. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: NJ FamilyCare Plan A Standard Medicaid; Definition of Habilitative Services: Medically necessary services/ equipment recommended by a licensed practitioner, to maintain or slow the deterioration of a person's health status. Absence of services could result in a preventable deterioration of a person's health status or deter the acquisition of a developmental function not yet attained. Benefit Provided: I occupational Therapy - habilitative Authorization: INone Amount Limit: I 1 treatment session Scope Limit: Source: ] I state Plan 1905(a) Provider Qualifications: El !Medicaid State Plan Duration Limit: 1 lper day I Provided within the scope of the New Jersey state definition of habilitative services. information" for definition. See "Other Bl I Bl I Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: NJ FamilyCare Plan A Standard Medicaid; Definition of Habilitative Services: Medically necessary services/ equipment recommended by a licensed practitioner, to maintain or slow the deterioration of a person's health status. Absence of services could result in a preventable deterioration of a person's health status or deter the acquisition of a developmental function not yet attained. Benefit Provided: I speech Therapy - Habilitative Source: 11 State Plan 1905(a) l:JI Remove I Remove I Remove I Page 20 of 55 TN: 16-0010 New Jersey Approval Date: 07/03/2019 ABP5 Effective Date: 07/01/2016

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Alternative Benefit Plan IZl Base Benchmark Benefits Not Covered due to Substitution or Duplication Collapse All D Base Benchmark Benefit that was Substituted: Source: !Primary Care Visit to Treat Injury/Illness I Base Benchmark I I Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: IThis benefit was mapped to ERB 1, and will be duplicated by the Physician Services under the Medicaid State Plan package. I Base Benchmark Benefit that was Substituted: Source: !specialist Visit I Base Benchmark I I Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: 'This benefit was mapped to ERB 1 and will be duplicated by the Physicians Services under the Medicaid State Plan package. I Base Benchmark Benefit that was Substituted: Source: I other Practitioner Office Visit I Base Benchmark I I Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: IThis benefit was mapped to ERB 1 and will be duplicated by the Physicians Services and Pediatric and Family Advanced Practice Nurse Services benefits under the Medicaid State Plan package. I Base Benchmark Benefit that was Substituted: Source: I outpatient Facility Fee I Base Benchmark I I Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: IThis benefit was mapped to ERB 1 and will be duplicated by the Outpatient Hospital benefit under the Medicaid State Plan package. I Base Benchmark Benefit that was Substituted: Source: !Outpatient Surgery: Physician/Surgical Services I Base Benchmark I I Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: IThis benefit was mapped to ERB 1 and will be duplicated by the Outpatient Hospital benefit under the Medicaid State Plan package. I Base Benchmark Benefit that was Substituted: Source: !Hospice Services I Base Benchmark Page 27 of 55 TN: 16-0010 New Jersey Approval Date: 07/03/2019 ABP5 Effective Date: 07/01/2016

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Alternative Benefit Plan Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: 1 1 Remove I IThis benefit was mapped to EHB 1 and EHB 3 and will be duplicated under the Medicaid State Plan Hospice benefit. Base Benchmark Benefit that was Substituted: Source: !Infertility Treatment - Substitution I Base Benchmark I I Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: INew Jersey will be substituting infertility treatment and the limited dental package that was mapped to EHB 1 with the full dental package offered through our Medicaid State Plan package. I Base Benchmark Benefit that was Substituted: Source: !urgent Care Centers or Facilities I Base Benchmark I I Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: IThis benefit was mapped to EHB 1 and will be duplicated under the Medicaid State Plan Clinic Services benefit. I Base Benchmark Benefit that was Substituted: Source: IHome Health Care Services I Base Benchmark I I Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: IThis benefit was mapped to EHB 7 and will be duplicated by the Medicaid State Plan Home Health Care - Nursing & Home Health Aid Services. I Base Benchmark Benefit that was Substituted: Source: !Emergency Room Services I Base Benchmark I I Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: IThis benefit was mapped to EHB 2 and will be duplicated by the Medicaid State Plan package Emergency Hospital Services: Outpatient benefit and Physicians Services. I Base Benchmark Benefit that was Substituted: Source: I Emergency Transportation/Ambulance I Base Benchmark I I Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: IThis benefit was mapped to EHB 2 and will be duplicated by the Medicaid State Plan package Outpatient Hospital Transportation benefit. I Base Benchmark Benefit that was Substituted: Source: I Inpatient Hospital Services I Base Benchmark Page 28 of 55 TN: 16-0010 New Jersey Approval Date: 07/03/2019 ABP5 Effective Date: 07/01/2016

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Alternative Benefit Plan Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: I Remove I This benefit was mapped to EHB 3 and will be duplicated by the Medicaid State Plan package Inpatient Hospital Services benefit. Base Benchmark Benefit that was Substituted: Source: I Inpatient Physician and Surgical Services I Base Benchmark I I Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: This benefit was mapped to EHB 3 and will be duplicated by the Medicaid State Plan package Inpatient Hospital and Physician Services benefit. Base Benchmark Benefit that was Substituted: Source: IBariatric Surgery I Base Benchmark I I Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: This benefit was mapped to EHB 3 and will be duplicated by the Medicaid State Plan package Inpatient Hospital Services benefit. Base Benchmark Benefit that was Substituted: Source: !Prenatal and Postnatal Care I Base Benchmark I I Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: This benefit was mapped to EHB 4 and will be duplicated by the Nurse-Midwife services, Physician and Clinic Services benefits. Base Benchmark Benefit that was Substituted: Source: !Delivery & All Inpatient Maternity Services I Base Benchmark I I Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: This benefit was mapped to EHB 4 and will be duplicated by the Inpatient Hospital benefit. Base Benchmark Benefit that was Substituted: Source: !Mental/Behavioral Health Outpatient Services I Base Benchmark I I Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: This benefit was mapped to EHB 5 and will be duplicated by the Outpatient Hospital - Mental Health, Clinic Services - Mental Health, Partial Hospital, Community Support Services, PACT, and Case Management - Chronically Ill benefits. Page 29 of 55 TN: 16-0010 New Jersey Approval Date: 07/03/2019 ABP5 Effective Date: 07/01/2016

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Alternative Benefit Plan Base Benchmark Benefit that was Substituted: Source: IMentaVBehavioral Health Inpatient Services I Base Benchmark I I Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: This benefit was mapped to EHB 5 and will be duplicated by the Medicaid State Plan Inpatient Mental Health Services, and Inpatient Psychiatric benefits. Base Benchmark Benefit that was Substituted: Source: I Substance Abuse Disorder Outpatient Services I Base Benchmark I I Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: This benefit was mapped to EHB 5 and will be duplicated by the Medicaid State Plan Substance Abuse Disorder Outpatient benefit. Base Benchmark Benefit that was Substituted: Source: I Substance Abuse Disorder Inpatient Services I Base Benchmark I I Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: This benefit was mapped to EHB 5 and will be duplicated by the Medicaid State Plan Substance Abuse Disorder Inpatient Medical Detox and Non-medical Detox benefits. Base Benchmark Benefit that was Substituted: Source: !Prescription Benefits I Base Benchmark I I Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: This benefit was mapped to EHB 6 and will be duplicated by the Medicaid State Plan Prescription drug coverage. Base Benchmark Benefit that was Substituted: Source: !chiropractic Care I Base Benchmark I I Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: This benefit was mapped to EHB 1 and will be duplicated with the Medicaid State Plan package Chiropractic Services/OLP benefit. The benchmark benefit is limited to therapeutic manipulation and 30 visits per year and two modalities per visit. The Medicaid State Plan benefit does not limit by visits or modalities. Base Benchmark Benefit that was Substituted: Source: !Durable Medical Equipment I Base Benchmark Page 30 of 55 TN: 16-0010 New Jersey Approval Date: 07/03/2019 ABP5 Effective Date: 07/01/2016

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Alternative Benefit Plan Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: 1 1 Remove I IThis benefit was mapped to EHB 7 and will be duplicated by the Medicaid State Plan Home Health - Medical Supplies, Equipment and Appliances and Home Health - PT, OT, ST benefits. Base Benchmark Benefit that was Substituted: Source: !Diagnostic Test (X-ray and Lab Work) I Base Benchmark I I Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: IThis benefit was mapped to EHB 8 and will be duplicated by the Medicaid State Plan Laboratory and X-ray I Services benefit. Base Benchmark Benefit that was Substituted: Source: !Imaging (CT/PET Scans, MRl) I Base Benchmark I I Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: IThis benefit was mapped to EHB 8 and will be duplicated by the Medicaid State Plan Diagnostic Services benefit. I Base Benchmark Benefit that was Substituted: Source: !Preventative Care/Screening/Immunization I Base Benchmark I I Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: IThis benefit was mapped to EHB 9 and will be duplicated by the Medicaid State Plan Preventative Services I and Immunizations benefit. Base Benchmark Benefit that was Substituted: Source: IFoot Care I Base Benchmark I I Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: IThis benefit was mapped to EHB 1 and will be duplicated by the Medicaid State Plan Podiatrist Services benefit. I Base Benchmark Benefit that was Substituted: Source: I Acupuncture I Base Benchmark I I Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: IThis benefit was mapped ERB 1 and 3 and will be duplicated by the Medicaid State Plan Outpatient and Impatient Hospital Services benefits. I Base Benchmark Benefit that was Substituted: Source: !Routine Eye Exam for children I Base Benchmark Page 31 of 55 TN: 16-0010 New Jersey Approval Date: 07/03/2019 ABP5 Effective Date: 07/01/2016

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Alternative Benefit Plan Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: I Remove I This benefit was mapped to EHB 10 and will be duplicated by Medicaid State Plan EPSDT benefits. Base Benchmark Benefit that was Substituted: Source: !Dental Check-up for Children I Base Benchmark I I Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: This benefit was mapped to EHB 10 and will be duplicated by Medicaid State Plan EPSDT benefits. Base Benchmark Benefit that was Substituted: Source: !Autism/Developmental Disabilities - Speech Therapy I Base Benchmark I I Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: This benefit was mapped to EHB 10 and will be duplicated by the Medicaid State Plan EPSDT benefit. This benefit under the base benchmark includes a 30 visit per calendar year limit. The Medicaid State Plan does not include a visit limit. Base Benchmark Benefit that was Substituted: Source: !Autism/Developmental Disabilities-Physical Therapy I Base Benchmark I I Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: This benefit was mapped to EHB 10 and will be duplicated by the Medicaid State Plan EPSDT benefit. This benefit under the base benchmark includes a 30 visit per calendar year limit. The 30 visit limit is a combined limit with Occupational Therapy. The Medicaid State Plan does not include a visit limit. Base Benchmark Benefit that was Substituted: Source: !Autism/Developmental Disability-Occupational Thera I Base Benchmark I I Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: This benefit was mapped to EHB 10 and will be duplicated by the Medicaid State Plan EPSDT benefit. This benefit under the base benchmark includes a 30 visit per calendar year limit. The 30 visit limit is a combined limit with Physical Therapy. The Medicaid State Plan does not include a visit limit. Base Benchmark Benefit that was Substituted: Source: !Inherited Metabolic Disease - PKU I Base Benchmark I I Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: This benefit was mapped to EHB 7 and will be duplicated under the Medicaid State Plan Home Health- Medical Supplies, Equipment and Appliances Benefit. Page 32 of 55 TN: 16-0010 New Jersey Approval Date: 07/03/2019 ABP5 Effective Date: 07/01/2016

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Alternative Benefit Plan Base Benchmark Benefit that was Substituted: Source: !Blood, blood products and blood transfusions I Base Benchmark I I Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: IThis benefit was mapped to EHB 1 and 3 and will be duplicated by the Medicaid State Plan Inpatient Hospital Services, Outpatient Hospital Services and Clinic Services benefits. I Base Benchmark Benefit that was Substituted: Source: !Dental Care and Treatment: Illness and Injury I Base Benchmark I I Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: INew Jersey will be substituting infertility treatment and the limited dental package that was mapped to EHB 1 with the full dental package offered through our Medicaid State Plan package. I Base Benchmark Benefit that was Substituted: Source: !Dental Care and Treatment: Anesthesia I Base Benchmark I I Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: INew Jersey will be substituting infertility treatment and the limited dental package that was mapped to EHB 1 with the full dental package offered through our Medicaid State Plan package. I Base Benchmark Benefit that was Substituted: Source: ITemporomandibular Joint Disorder I Base Benchmark I I Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: IThis benefit was mapped to EHB 1 and will be duplicated by the Medicaid State Plan package Dental Services benefit. I Base Benchmark Benefit that was Substituted: Source: I cancer Clinical Trials I Base Benchmark I I Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: IThis benefit was mapped to EHB 1 and 3 will be duplicated by the Medicaid State Plan package Outpatient I Hospital and Inpatient Hospital benefits. Base Benchmark Benefit that was Substituted: Source: !Pain Management Services I Base Benchmark I I Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: 'This benefit was mapped to EHB 1 and will be duplicated by the Medicaid State Plan package Physicians Services benefit. I Page 33 of 55 TN: 16-0010 New Jersey Approval Date: 07/03/2019 ABP5 Effective Date: 07/01/2016

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Alternative Benefit Plan Base Benchmark Benefit that was Substituted: Source: !chelation Therapy I Base Benchmark I I Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: IThis benefit was mapped to EHB 1 and 3 and will be duplicated by the Medicaid State Plan Inpatient Hospital Services, Outpatient Hospital Services, and Clinic Services Benefits. I Base Benchmark Benefit that was Substituted: Source: I Chemotherapy I Base Benchmark I I Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: IThis benefit was mapped to EHB 1 and 3 and will be duplicated by the Medicaid State Plan Inpatient Hospital Services, Outpatient Hospital Services, and Clinic Services Benefits. I Base Benchmark Benefit that was Substituted: Source: !Dialysis Treatment I Base Benchmark I I Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: IThis benefit was mapped to EHB 1 and 3 and will be duplicated by the Medicaid State Plan Inpatient Hospital Services, Outpatient Hospital Services, and Clinic Services Benefits. I Base Benchmark Benefit that was Substituted: Source: !Radiation therapy I Base Benchmark I I Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: IThis benefit was mapped to EHB 1 and 3 and will be duplicated by the Medicaid State Plan Inpatient Hospital Services, Outpatient Hospital Services, and Clinic Services Benefits. I Base Benchmark Benefit that was Substituted: Source: !Infusion Therapy I Base Benchmark I I Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: IThis benefit was mapped to EHB 1 and 3 and will be duplicated by the Medicaid State Plan Inpatient and Outpatient Hospital Benefits. I Base Benchmark Benefit that was Substituted: Source: I Transplants I Base Benchmark I I Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: IThis benefit was mapped to EHB 3 and will be duplicated by the Medicaid State Plan package Inpatient Hospital Services benefit. I Page 34 of 55 TN: 16-0010 New Jersey Approval Date: 07/03/2019 ABP5 Effective Date: 07/01/2016

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Alternative Benefit Plan Base Benchmark Benefit that was Substituted: Source: !Hemophilia Services I Base Benchmark I I Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: I This benefit was mapped to EHB 1, 3, and 7 and will be duplicated by the Medicaid State Plan Inpatient Hospital, Outpatient Hospital, Clinic Services and Home Health Care benefits. I Base Benchmark Benefit that was Substituted: Source: lorthotics and Prosthetics I Base Benchmark I I Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: I This benefit was mapped to EHB 7 and will be duplicated by the Medicaid State Plan Orthotics and Prosthetics benefit. I Base Benchmark Benefit that was Substituted: Source: !Newborn Hearing Screening I Base Benchmark I I Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: I This benefit was mapped to EHB 4 and will be duplicated under the Medicaid State Plan Newborn Hearing I Screening benefit. Base Benchmark Benefit that was Substituted: Source: I Mammograms I Base Benchmark I I Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: I This benefit was mapped to EHB 9 and will be duplicated by the Medicaid State Plan Preventative Services I benefit. Base Benchmark Benefit that was Substituted: Source: !Mastectomy inpatient stay I Base Benchmark I I Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: I This benefit was mapped to EHB 3 and will be duplicated by the Medicaid State Plan Inpatient Hospital Benefit. I Base Benchmark Benefit that was Substituted: Source: IReconstructive breast surgery I Base Benchmark I I Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: I This benefit was mapped to EHB 3 and will be duplicated by the Medicaid State Plan Inpatient Hospital Benefit. I Page 35 of 55 TN: 16-0010 New Jersey Approval Date: 07/03/2019 ABP5 Effective Date: 07/01/2016

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Alternative Benefit Plan Base Benchmark Benefit that was Substituted: Source: !Diabetes Treatment - services and supplies I Base Benchmark I I Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: This benefit was mapped to EHB 9 and will be duplicated under the Medicaid State Plan Diabetic Supplies & Equipment benefit. Base Benchmark Benefit that was Substituted: Source: !Nutritional Counseling I Base Benchmark I I Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: This benefit was mapped to EHB 9 and will be duplicated by the Medicaid State Plan Preventive Services benefit. Base Benchmark Benefit that was Substituted: Source: I Skilled Nursing Facility - Skilled Nursing Care I Base Benchmark I I Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: This benefit was mapped to EHB 7 and will be duplicated by the Medicaid State Plan Nursing Facility/ Skilled Nursing Facility Services benefit. Base Benchmark does not have a duration limit but prior authorization is required for medical necessity. Duration based on plan of care documents and progress of individual. Custodial Care is not covered under the base benchmark. Base Benchmark Benefit that was Substituted: Source: I Speech and Cognitive Therapy - Rehab/Rab I Base Benchmark I I Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: This benefit was mapped to EHB 7 and will be duplicated by the Medicaid State Plan Speech Therapy benefit. The base benchmark includes a combined 30 visit per calendar year limit and is limited to 1 session per day. The Medicaid State Plan does not include a visit limit. Cognitive Therapy is a part of the Medicaid State Plan Speech Therapy benefit. Base Benchmark Benefit that was Substituted: Source: !Physical and Occupational Therapy - Rehab/Rab I Base Benchmark I I Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: This benefit was mapped to EHB 7 and will be duplicated by the Medicaid State Plan Physical Therapy and Occupational benefit. The base benchmark includes a combined 30 visit per calendar year limit and is limited to 1 session per day. The Medicaid State Plan does not include a visit limit. Base Benchmark Benefit that was Substituted: Source: !Autism/Developmental Disabilities - ABA or Related I Base Benchmark Page 36 of 55 TN: 16-0010 New Jersey Approval Date: 07/03/2019 ABP5 Effective Date: 07/01/2016

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Alternative Benefit Plan Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: 11 Remove I IThis benefit was mapped to EHB 10 and will be substituted by the Medicaid State Plan EPSDT benefit. Base Benchmark Benefit that was Substituted: Source: !Abortion - Hyde Amendment I Base Benchmark I I Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: 'This benefit was mapped to EHB 1 and is duplicated by the Medicaid State Plan Abortion benefit. I Base Benchmark Benefit that was Substituted: Source: !Eyeglasses for Children I Base Benchmark I I Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: IThis benefit was mapped to EHB 10 and is duplicated by the Medicaid State Plan EPSDT benefit. The benchmark benefit is limited to children ages 18 and under. I Base Benchmark Benefit that was Substituted: Source: !Hearing Aid Services I Base Benchmark I I Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: IThis benefit was mapped to EHB 10 and is duplicated by the Medicaid State Plan EPSDT benefit. The benchmark benefit is limited to children ages 15 and under. I Base Benchmark Benefit that was Substituted: Source: !Routine Eye Exam - Adult I Base Benchmark I I Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: IThis benefit was mapped to EHB 1 and is duplicated by the Medicaid State Plan Physicians Services benefit. I Base Benchmark Benefit that was Substituted: Source: I Outpatient Rehabilitation Services I Base Benchmark I I Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: IThis benefit was mapped to EHB 7 and is duplicated by the Medicaid State Plan Physical Therapy and Related Services, Speech Therapy, and Occupational Therapy benefits. I Base Benchmark Benefit that was Substituted: Source: IHabilitation Services I Base Benchmark Page 37 of 55 TN: 16-0010 New Jersey Approval Date: 07/03/2019 ABP5 Effective Date: 07/01/2016

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Alternative Benefit Plan Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: 1 1 Remove I IThis benefit was mapped to EHB 7 and is duplicated by the Medicaid State Plan Physical Therapy and Related Services, Speech Therapy, and Occupational Therapy benefits. Base Benchmark Benefit that was Substituted: Source: !Diabetes Care Management I Base Benchmark I I Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: IThis benefit was mapped to EHB 1 and is duplicated under the Physicians Services benefit. I Base Benchmark Benefit that was Substituted: Source: I second Opinion I Base Benchmark I I Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: IThis benefit was mapped to EHB 1 and is duplicated by the Physicians Services benefit. I Base Benchmark Benefit that was Substituted: Source: I Third Opinion I Base Benchmark I I Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: 'This benefit was mapped to EHB 1 and is duplicated by the Physicians Services benefit. I Base Benchmark Benefit that was Substituted: Source: !Domestic Violence Treatment I Base Benchmark I I Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: IThis benefit was mapped to EHB 5 and is duplicated by the Clinic Services - mental health benefit. I Base Benchmark Benefit that was Substituted: Source: !Respiration Therapy I Base Benchmark I I Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: IThis benefit was mapped to EHB 3 and 7 and is duplicated by the Inpatient Hospital and Home Health: Nursing and Home Health Aide Services benefits. I I Add I Page 38 of 55 TN: 16-0010 New Jersey Approval Date: 07/03/2019 ABP5 Effective Date: 07/01/2016

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Alternative Benefit Plan I Remove I Other 1937 Benefit Provided: Source: I Substance Use Disorder - Partial Care I Section 1937 Coverage Option Benchmark Benefit I Remove I Package Authorization: Provider Qualifications: lother tJ !Medicaid State Plan l:J] Amount Limit: Duration Limit: INone I INone I Scope Limit: !None Other: Full benefit name: Rehabilitative Services - Substance Use Disorder - Partial Care Service covered under the State Plan Authority 1905( a)(l 3) Service Descriptions: Partial Care-Day or Evening - A licensed rehabilitative program that provides a broad range of clinically intensive treatment services in a structured environment for a minimum of twenty (20) hours a week, during the day or evening hours. Services are delivered for no less than 4 hours per day and include individual, group, family therapy. Independent assessment is required utilizing ASAM criteria to ensure beneficiary meets ASAM Level II.5. Services include: -Physician visit: Physician or APN under supervision of a physician. -Individuals counseling-Licensed clinical professional (LCP) or clinical staff supervised by a LCP -Group substance abuse counseling-LCP or clinical staff supervised by a LCP -Group counseling-LCP or clinical staff supervised by a LCP -Family Counseling -LCP or clinical staff supervised by a LCP -Laboratory services-Medically Licensed clinical professional Service Limitations: Service admission is recommended by a physician or other licensed practitioner of the healing arts within their scope of practice under State law. If an individuals needs more than 20 hours per week, services can be increased if medically necessary or an individual is reassessed for appropriate level of care. Provider Specifications: -NJ DRS Licensed Substance Abuse Facility -NJ Medicaid Licensed Independent Clinic Unit of Service = 1 day, up to 5 days/wk Licensing Entity: DRS Regulation Cite: NJAC 10:161B Page 41 of 55 TN: 16-0010 New Jersey Approval Date: 07/03/2019 ABP5 Effective Date: 07/01/2016

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Alternative Benefit Plan Other 1937 Benefit Provided: Source: I I Section 1937 Coverage Option Benchmark Benefit S_u_b_sta_n_ce _lJ_s_e _D_ i_s _or_d_e_r _In_ te_n _si_v_e _O_ u_ t_p _at_ie_ n_t ____ Package Authorization: Provider Qualifications: l._o_th_er _________________ a"""... !Medicaid State Plan Amount Limit: Duration Limit: Scope Limit: !None Other: Full benefit name: Rehabilitative Services - Substance Abuse Disorder Intensive Outpatient Service under the State Plan Authority 1905(a)(13) Bl Service Descriptions: A rehabilitative service designed to help clients change his or her alcohol or other drug using and related behaviors. This service consists of approximately nine to 12 hours of services each week and provides counseling about substance related problems. Services delivered are at a minimum of three hours per day for a minimum of three days per week. Independent assessment is required utilizing ASAM criteria to ensure beneficiary meets ASAM Level II. l. Services include: -Physician visit: Physician or APN under supervision of a physician. -Individuals counseling-Licensed clinical professional (LCP) or clinical staff supervised by a LCP -Group substance abuse counseling-LCP or clinical staff supervised by a LCP -Group counseling-LCP or clinical staff supervised by a LCP -Family Counseling -LCP or clinical staff supervised by a LCP -Laboratory services-Medically Licensed clinical professional Service Limitations: -Service admission is recommended by a physician or other licensed practitioner of the healing arts within their scope of practice under State law. -Services delivered are at a minimum of three hours per day for a minimum of three days per week. -If an individuals needs more than 12 hours per week, services can be increased if it is medically necessary or an individual is reassessed for appropriate level of care. Provider Specifications: -NJ DRS Licensed Substance Abuse Facility -NJ Medicaid Licensed Independent Clinic lJnit of Service: Per diem Licensing Entity: DRS Regulation Cite: NJAC 10:161B Page 42 of 55 TN: 16-0010 New Jersey Approval Date: 07/03/2019 ABP5 Effective Date: 07/01/2016

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Alternative Benefit Plan needed; prescnpt10n and momtormg ot med1cat10n; as well as superv1s10n and consultation with PbK:::i program staff. Consumer Participation Criteria These rehabilitation services are provided as part of a comprehensive specialized psychiatric program available to all Medicaid eligible consumers. PERS services must be medically necessary. The medical necessity for these rehabilitative services must be recommended by a licensed practitioner of the healing arts who is acting within the scope of his/her professional licensed and applicable state law to promote the maximum reduction of symptoms and/or restoration of an individual to his/her best age-appropriate functional level. All individuals who are identified as experiencing a seriously acute psychological/ emotional change which results in a marked increase in personal distress and which exceeds the abilities and the resources of those involved to effectively resolve it are eligible. Individuals may choose from any providers meeting the established provider qualifications outlined in this SPA Provider Qualifications: Programs shall be certified by Medicaid and/or its designee as meeting state requirements for PERS programs. PERS services are delivered by certified assessors, temporary assessors, PERS specialists, and licensed professionals of the healing arts. Prior to achieving full status as a certified assessor, an individual shall serve as a temporary assessor for one year, complete certification training, and pass a proficiency exam. Certified assessors must have: 1. a MA/MS in a mental health related field from an accredited institution, plus one year of post-master's full time professional experience in a psychiatric setting; OR 2. a BA/BS in a mental health related field from an accredited institution, plus three years of post-bachelor's full time professional experience in a mental health setting, one of which is in a crisis setting; OR 3. a BA/BS in a mental health related fiend from an accredited institution, plus two years of post-bachelor's full time professional experience in a mental health setting, one of which is in a crisis setting and currently enrolled in a master's program; OR 4. a licensed registered nurse with three years full-time, post RN, professional experience in the mental health field, one of which is in a crisis setting. PERS specialists shall have: 1. A MAIMS in a mental health related field from an accredited institution; OR 2. A BA/BS in a mental health related field from an accredited institution, plus two years of full time professional experience in a psychiatric setting; OR 3. Licensure as a registered professional nurse. Each PERS program is supervised by a medical director who is a psychiatrist. A licensed professional of the healing arts who is acting within the scope of his/her professional licensed and applicable state law is available for consultation and able to recommend treatment 24 hours a day, seven days a week to the PERS program. Amount, Duration and Scope: A unit of service is defined according to the HCPCS approved code set unless otherwise specified. PERS services by their nature are crisis services and are not subject to prior approval. Components that are not provided to, or directed exclusively toward the treatment of, the Medicaid eligible individual are not eligible for Medicaid coverage. The PERS services should follow any established crisis plan already developed for the consumer as part of an individualized treatment plan, called a care plan. The PERS activities must be intended to achieve identified care plan goals or objectives. Page 45 of 55 TN: 16-0010 New Jersey Approval Date: 07/03/2019 ABP5 Effective Date: 07/01/2016

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Alternative Benefit Plan lt no cnsis plan has yet been developed tor the consumer, then the r'bK:-i services should stabilize the individual, identify appropriate aftercare for the consumer including referral and linkage to a community provider who will develop a formal care plan, admission to an inpatient/residential setting where a formal I Remove I care plan will be developed or the development of an alternative care plan by the certified assessor. In all circumstances, the goal of PERS should be the de-escalation and stabilization of the individual as well as determining longer-term care goals through the implementation of or development of a care plan either directly or through referral. The crisis/aftercare/care plan (care plan) should be developed in a person- centered manner with the active participation of the individual, family and providers and be based on the individual's condition and the standards of practice for the provision of these specific rehabilitative services. An individual in crisis may be represented by a family member or other collateral contact who has knowledge of the individual's capabilities and functioning. The care plan should identify the medical or remedial services intended to reduce the identified condition as well as the anticipated outcomes of the individual. The care plan must specify the frequency, amount and duration of services. The care plan must be recommended by a licensed practitioner of the healing arts and should, where possible, be signed by the consumer as appropriate for his or her diagnosis. The care plan developed during PERS will specify a timeline for reevaluation as applicable. Ideally, the care plan developed in PERS will be replaced almost immediately (e.g., in a few weeks) by a more permanent care plan once the individual is stabilized and in a longer term community or institutional placement. The reevaluation should involve the individual, family and providers and include a reevaluation of plan to determine whether services have contributed to meeting the stated goals. A new care plan should be developed if there is no measureable reduction of disability or restoration of functional level. The new plan should identify a different rehabilitation strategy with revised goals and services. Coordination with crisis intervention teams in community support services is required and includes receiving referrals from individuals emolled in that program and ensuring coordination back to that community program where necessary de-escalation and stabilization has occurred. Substance use must be recognized and addressed in an integrated fashion as it may add to the risk of increasing the need for engagement in care. Individuals may not be excluded from service due to active, current, substance abuse or history of substance abuse. Limitations: Providers must maintain medical records that include a copy of the care plan, the name of the individual, dates of services provided, nature, content and units of rehabilitation services provided, and progress made toward functional improvement and goals in the care plan. Services cannot be provided to a resident of an institution including any residents of Institutions for Mental Disease (IMD). Room and board is not included in Medicaid coverage of PERS. Services provided to children and youth must include communication and coordination with the family and/ or legal guardian and custodial agency for children in state custody. Coordination with other child serving systems should occur as needed to achieve the treatment goals and should include appropriate referrals to the child mobile response program (s). All coordination must be documented in the youth's medical record. Other 1937 Benefit Provided: Source: I I Section 1937 Coverage Option Benchmark Benefit ôB_e _ha_ v_i_·o _ra_l _H:_e_a _lt _h_H:_o_mGe _(AGdulGt)!!!!!!!!õ- Package Authorization: Provider Qualifications: lother [3 !Medicaid State Plan tJ] Amount Limit: Duration Limit: I INone I Page 46 of 55 TN: 16-0010 New Jersey Approval Date: 07/03/2019 ABP5 Effective Date: 07/01/2016

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Alternative Benefit Plan Scope Limit: !Adults with SMI who are at risk for high utilization of medical and behavioral health care services. Other: This benefit is identical to NJ FamilyCare Plan A Standard Medicaid Plan 1945 described on pages: Attachment 3.1 H page 9 of 48 to page 48 of 48. Service Descriptions: Comprehensive Care Management: Care Management is the primary coordinating function in a BHH. The goal of Care Management is the assessment of consumer needs, development of the care plan, coordination of the services identified in the care plan and the ongoing assessment and revisions to the plan based on evaluation of the consumer's needs. The Care Manager is the Team Leader. Comprehensive care management services are conducted by registered nurses, physician's assistants or advanced practice nurses. Service Limitations: Entry to this service is based on diagnostic and service utilization criteria. An adult consumer must have a diagnosis of Serious Mental Illness (SMI) and be at risk for high utilization of services. Consumer Eligibility: NJ plans to provide Behavioral Health Home (BHH) services to adults with a Serious Mental Illness (SMI) who are high utilizers of services or who are at risk of high utilization of services in the counties identified in the NJ FamilyCare Plan A Standard Medicaid Plan 1945 described on pages: Attachment 3.1 H page 9 of 48 to page 48 of 48. For this service SMI is defined a mental illness that causes serious impairments in emotional and behavioral functioning that interfere with an individual's capacity to remain in the community unless supported by treatment and services. The determination of risk is made using the Chronic Illness and Disability Payment System (CDPS). Emollment: NJ Division of Medical Assistance and Health Services (DMAHS) and Division Mental Health and Addiction Services (DMHAS) will partner with providers to identify and refer to the BHH service. Using claims data, DMAHS will identify consumers for the BHH service. NJ DMAHS will notify the consumers via hard copy mail of their eligibility, how to engage in the service, and choice of provider. Individuals will not be auto emolled in the BHH service. For those individuals receiving the ABP benefit package, BHH eligibility is driven by diagnosis. The list of BHH eligible diagnosis will be available to BHH providers enabling them to screen individuals for eligibility and emoll in the BHH. The BHH will also be required to outreach to consumers who are not currently receiving services. Provider Specifications: • A mental health treatment provider licensed by DHS. • Certified to provide BHH by DHS • Accredited by NCQA or other nationally recognized accrediting body as a Health Home within two years of initial state certification Provider Eligibility: All BHH provider agencies must be licensed as a mental health provider by the New Jersey Department of Human Services (NJDHS) and serve Bergen County and Mercer County residents. The DMHAS will use a qualification process to certify licensed mental health providers as BHHs. Providers will have two years from certification as a BHH to become accredited as a BHH by a nationally recognized and state approved accrediting body. Provider Infrastructure: The BHH Core Team will include: a Nurse Care Manager, a Care Coordinator, a Health and Wellness Educator, consultative services of a Psychiatrist and a Primary Care Physician, and Support Staff Physician time for BHH services is limited to the time spent in face to face team meetings and consultation. Optional team members include a nutritionist/dietician, Peer, pharmacist and Hospital Page 47 of 55 TN: 16-0010 New Jersey Approval Date: 07/03/2019 ABP5 Effective Date: 07/01/2016

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Alternative Benefit Plan Liaison. upport tor both the reqmred and optional members were bU1lt mto the BHH rate. Staff Qualifications: Care Management is the primary coordinating function in a BHH (BHH). The goal of Care Management is I Remove I the assessment of consumer needs, development of the care plan, coordination of the services identified in the care plan and the ongoing assessment and revisions to the plan based on evaluation of the consumer's needs. The Care Manager is the Team Leader. Comprehensive care management services are conducted by licensed registered nurses, physician's assistants or advanced practice nurses. Care Coordination services are provided by Care Coordinators and other Health Team members with the primary goal of implementing the individualized service plan, with active involvement by the consumer, to ensure the plan reflects consumer needs and preferences. Care coordination emphasizes access to a wide variety of services required to improve overall health and wellness. Care Coordinators can be trained social workers or Licensed Practical Nurses. Health promotion activities are conducted with an emphasis on empowering the consumer to improve health and wellness. Health Promotion can be provided by any member of the team, a certified peer wellness counselor or other certified health educator. Individual and family support services (including authorized representatives) can be delivered by nurse care manager or other members of the home health team. Helping the individual and family recognize the importance of family and community support in recovery, health and wellness, and helping them develop and strengthen family and community supports to aid in the process of recovery and health maintenance. BHHs provide comprehensive transitional care and follow-up to consumers transitioning from inpatient care and/or emergency care to the community. Comprehensive transitional care can be provided by the Nurse Care Manager or other BHH team members. Referral to community and social support services involves providing assistance for consumers to obtain necessary community and social supports. Referral activities are most often provided by the Care Coordinator but can be performed by any member of the team. SERVICE BASED ON STAGES OF INVOLVEMENT: o Engagement o Active o Maintenance Unit of Service = Monthly Case Rate for the service based on level of involvement Licensing Entity: DHS Accredited by: Accredited by NCQA, JACHO, CARF or other nationally recognized accrediting body as a Health Home within two years of initial state certification Other 1937 Benefit Provided: Source: I I Section 1937 Coverage Option Benchmark Benefit P_e_r _so_n_ a_l _c_ a_r_e _S_e_rvic_e_s- Package Authorization: Provider Qualifications: !other [3 !Medicaid State Plan tJ] Amount Limit: Duration Limit: 140 hours per week I INone I Page 48 of 55 TN: 16-0010 New Jersey Approval Date: 07/03/2019 ABP5 Effective Date: 07/01/2016

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Alternative Benefit Plan Other: NJ FamilyCare Plan A Standard Medicaid; Source: State Plan 1905(a); No prior authorization needed; I Remove I subject to IMD exclusion i.e. sixteen beds or less. Residential Levels of Care: • Supervised Residence A+: refers to licensed group homes or apartments. Community mental health rehabilitation services are available to consumer residents up to 23 hours per day as needed when clinically necessary, seven days a week. This includes awake overnight staff coverage. • Supervised Residence A: refers to licensed group homes or apartments. Community mental health rehabilitation services are available to consumer residents 12 hours or more per day, (but less than 24 hours per day), seven days per week. • Supervised Residence B: refers to licensed group homes or apartments. Community mental health rehabilitation services are available to consumer residents for 4 or more hours per day, (but less than 12 hours per day), seven days per week. • Supervised Residence C: refers to licensed group homes or apartments. Community mental health rehabilitation services are available to consumer residents for one or more hours per week, (but less than 4 hours per day). • Family Care (Level D): refers to a licensed program in a private home or apartment in which community mental health rehabilitation services are available to consumer residents for 23 hours per day by a Family Care Home provider. Other 1937 Benefit Provided: Source: !Behavioral Health Home (Children) I Section 1937 Coverage Option Benchmark Benefit Package Authorization: Provider Qualifications: !other l:I !Medicaid State Plan Bl Amount Limit: Duration Limit: INone I INone I Scope Limit: I Young adults, children, and adolescents with serious emotional disturbance (SED) and a chronic medical condition. Other: This benefit is identical to NJ FamilyCare Plan A Standard Medicaid State Plan 1945 described on pages: Attachment 3.1.H page 9 of 46 to page 46 of 46. Service Descriptions: Comprehensive Care Management: Care Management is the primary coordinating function in a BHH. The goal of Care Management is the assessment of consumer needs, development of the care plan, coordination of the services identified in the care plan and the ongoing assessment and revisions to the plan based on evaluation of the child's needs. The Care Manager is the Team Leader. The BHH Team enhances the existing care management team by providing the medical expertise and support needed to help the child and family manage the chronic condition. Care Coordination: Care Coordination services are provided by the Care Manager with support from the Nurse Manager, with the primary goal of implementing the individualized service plan/plan of care, with active involvement by the child/family, to ensure the plan reflects the child/family needs and preferences. Care coordination emphasized access to a wide variety of services required to improve overall health and wellness. Care Managers can be social workers and/or other trained health care professionals. A license in Page 53 of 55 TN: 16-0010 New Jersey Approval Date: 07/03/2019 ABP5 Effective Date: 07/01/2016

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Attachment 4.19 – B Page 36 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE OF NEW JERSEY METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES FOR NON- INSTITUTIONAL SERVICES 18-0001 MA (NJ) TN: 18-0001 MA (NJ) SUPERCEDES: 17-0003 Approval Date: November 15, 2019 Effective Date: January 1, 2018 FEE SCHEDULE EFFECTIVE DATES AND LINKS The fees in the State’s fee schedules referenced in Attachment 4.19-B were set on January 1, 2018 and are effective for services provided on or after that date. Except as otherwise noted in the plan, state- developed fee schedule rates are the same for both governmental and private providers of the Medicaid services listed below. Services for both ABP and non-ABP beneficiaries utilize the same rates unless otherwise noted in the plan. All applicable procedure code listings and/or rates are published on the State’s website at www.njmmis.com under the link for ‘Rate and Code Information’ and can be found in the following locations: • Medicaid Fee Schedules: • Location: Procedure Master Listing – Medicaid Fee for Service - CY 2018 (last updated in SPA 18-0001 effective 1/1/2018) • Description: Main file of procedure codes billable to Medicaid for all services except as listed below. • Children’s Rates: (excluding Special Education Medicaid Initiative (SEMI)) All applicable procedure code listings and/or rates are published on the State’s website at www.njmmis.com under the link for ‘Rate and Code Information’ and can be found in the following locations: • Location: Procedure Master Listing – Children’s Rates – CY 2018 (SPA 18-0001 – effective 1/1/2018) • Description: File contains procedure codes billable to Medicaid for services provided to beneficiaries under the age of 21 except as listed below. • Outpatient Laboratory Billing Only: All applicable procedure code listings and/or rates are published on the State’s website at www.njmmis.com under the link for ‘Rate and Code Information’ and can be found in the following locations: • Location: Procedure Master Listing - Outpatient Hospital Laboratory Billing Only – CY 2018 (SPA NJ 18-0001 effective 1/1/2018) • Description: File contains procedure codes billable to Medicaid for laboratory services conducted in an outpatient hospital setting as described beginning on Page 2 of this Section.

(nj-18-0001)(approval-document)(page-5)Page 5#

Attachment 4.19 – B Page 36a STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE OF NEW JERSEY METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES FOR NON- INSTITUTIONAL SERVICES FEE SCHEDULE EFFECTIVE DATES AND LINKS (Cont’d) • Outpatient Psychiatric Services Only: The fees in the State’s fee schedules referenced in Attachment 4.19-B were set on January 1, 2018 and are effective for services provided on or after that date. Except as otherwise noted in the plan, state- developed fee schedule rates are the same for both governmental and private providers of the Medicaid services listed below. Services for both ABP and non-ABP beneficiaries utilize the same rates unless otherwise noted in the plan. All applicable procedure code listings and/or rates are published on the State’s website at www.njmmis.com under the link for ‘Rate and Code Information’ and can be found in the following locations: • Location: Procedure Code Master Listing – Outpatient Psychiatric Services Only – CY 2018(last updated in SPA 18-0001 effective 1/1/2018) • Description: File containing Revenue Codes and rates for Outpatient Psychiatric Services provided to adults and children, as described under Outpatient Mental Health Services on Page 2a of this Section. • Home Health Rates Only: The fees in the State’s fee schedules referenced in Attachment 4.19-B were set on January 1, 2016 and are effective for services provided on or after that date. Except as otherwise noted in the plan, state- developed fee schedule rates are the same for both governmental and private providers of the Medicaid services listed below. Services for both ABP and non-ABP beneficiaries utilize the same rates unless otherwise noted in the plan. All applicable procedure code listings and/or rates are published on the State’s website at www.njmmis.com under the link for ‘Rate and Code Information’ and can be found in the following locations: • Location: Skilled Nursing Service Rates – Statewide and Provider Specific Rates • Description: File containing Revenue Codes and rates for statewide Home Health services as described on Page 6a of this Section. 18-0001 MA (NJ) TN: 18-0001 MA (NJ) SUPERCEDES: 17-0003 Approval Date: November 15, 2019 Effective Date: January 1, 2018

(nj-18-0009)(approval-document)(page-7)Page 7#

Attachment 4.19 —-B Page 36

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE OF NEW JERSEY

METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES FOR NON- INSTITUTIONAL SERVICES

FEE SCHEDULE EFFECTIVE DATES AND LINKS

The fees in the State’s fee schedules referenced in Attachment 4.19-B were set on July 1, 2018 and are effective for services provided on or after that date. Except as otherwise noted in the plan, state- developed fee schedule rates are the same for both governmental and private providers of the Medicaid services listed below. Services for both ABP and nan-ABP benoficiaries utilize the same rates unless otherwise noted in the plan. All applicable procedure code listings and/or rates are published on the State's website at www.nimmis.com under the link for ‘Rate and Code Information’ and can be found in the following locations:

Medicaid Fee Schedules:

« Location: Procedure Master Listing — Medicaid Fee for Service - CY 2018 (last updated in SPA 18-0009 effective 10/1/2018) « Description: Main file of procedure codes billable to Medicaid for all services except as listed below.

Children’s Rates: (excluding Special Education Medicaid Initiative (SEMI)

All applicable procedure code listings and/or rates are published on the State's website at www.njmmis.com under the link for ‘Rate and Code Information’ and can be found in the following locations:

« Location: Procedure Master Listing — Children’s Rates — CY 2018 (SPA 18-0001 — effective 1/1/2018)

¢ Description: File contains procedure codes billable to Medicaid for services provided to beneficiaries under the age of 21 except as listed below.

Outpatient Laboratory Billing Only:

« Location: Procedure Master Listing - Outpatient Hospital Laboratory Billing Only — CY 2018 (SPA NJ 18-0001 effective 1/1/2018)

¢ Description: File contains procedure codes billable to Medicaid for laboratory services conducted in an outpatient hospital setting as described beginning on Page 2 of this Section.

18-0009 MA (NJ) TN: 18-0009 MA (NJ) Approval Date:_03/10/2020

SUPERCEDES: 18-0003 Effective Date:_10/01/2018

(nj-19-0007)(approval-document)(page-5)Page 5#

ATTACHMENT 4.19-A, Page tV-41.1

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT Reimbursement for Cartain Specialized hospitals

PROCEDURES AND METHODOLOGY

Reimbursement

(a) Special hospitals (a hospital licensed by the Departrnent of Health which maintains and operates facilites and services for the diagnosis, treatment or care of persons suffering from acute illness, injury or deformity In which comprehensive specialized diagnosis, cara, traatment and rahablititation are administered or performed) with more than 60 but less than 102 special beds shall be raimbursed as follows:

) For services rendered prior to July 1, 2017, cost reports will be settlad in. accordance with Medicare principles of ralmbursement and subject to TEFRA

targat Ilmitations,

i. For services rendered July 1, 2017 and after, a per diem rate of $981 will be provided. The per diem rate will be updated annually by trending It using the Medicare market basket percentage Incraase at 42 CFR 413.40(a)(3).

WwW. Bach time after July 1, 2017 the Division becomes aware the number of licensed bede avaliable far usa (maintained beds) as reported on the CMS 2552, Worksheet $3, Part !, Column 2, Line 1 has increased or decreased by a cumulative 20%, the hospital's prospective per diem will be re-determined,

iv, The redetermined per diem rate shall be calculated using finalized and audited data from the CMS-2552 reported In the year subsequent tp the one used in (iil) above, The rate will be computed using the total alowabla Medicaid inpatient casts from the CMS-2552, Worksheet D-1, Line 49 for Title XIX-/P divided by the total Medicaid days from Worksheet D-1, Line 9 of the same worksheet.

Vv. The re-determined per diem will be effactive the first day of the hospital's fiscal year for the cost report fiscal year Used in (iv) above,

(b) The Dhision's determination is subject to an appeals process. If a hospital is not gatistied with the Division's detennination, the hospital may request an administrative hearing within 20 days, An Administrative Law Judge In the Office of Administrative Law will review the reasonableness of the Division's decision based on the documentation that was presented to the Division. The Division Director shall then render a final agency decision, Further appeal Is avallable In tha New Jersey Superior Court Appellate Division.

17-0007 MA (NJ)

TN: 17-0007-MA (NJ} Approval Date Supersedes: NEW Effective Date

JUL 01 207

(nj-19-0013)(approval-document)(page-3)Page 3#

DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICIAD SERVICES FORM APPROVED 0MB NO. 0938-0193 TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES 1. TRANSMITTAL NUMBER: 19-0013 MA 2. STATE New Jersey 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) TO: REGIONAL ADMINISTRATOR CENTERS FOR MEDICARE & MEDICAID SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES 4. PROPOSED EFFECTIVE DATE July 1, 2019 5, TYPE OF PLAN MATERIAL (Check One): D NEW STATE PLAN D AMENDMENT TO BE CONSIDERED AS NEW PLAN S AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate Transmiltal for each amendment} 6. FEDERAL STATUTE/REGULATION CITATION: | 7. FEDERAL BUDGET IMPACT: 42 U.S. C. 1396a(a)(30)(A); 42 USC 1396d(a)(13) a. FFY 2019 $35, 000 b. FFY 2020 $165, 000 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: Addendum to Attachment 3. 1-A Page 13(d). 9k1-5 Attachment 4. 19B Page 36 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable): New same 10. SUBJECT OF AMENDMENT: Opioid Overdose Recovery Program 1. GOVERNOR'S REVIEW (Check One): D GOVERNOR'S OFFICE REPORTED NO COMMENT D COMMENTS OF GOVERNOR'S OFFICE ENCLOSED NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL OTHER, AS SPECIFIED: Not required, pursuant to 7.4 of the Plan TE AGENCY OFFICIAL 14.*-T1TLE: Commissioner, Department of Human Services ESUBMITTED: ^\^ 15. DATE SUBMITTED: 16. RETURN TO: Jennifer Langer Jacobs, Assistant Commissioner Division of Medical Assistance and Health Services P. O. Box 712, Mail Code #26 Trenton, NJ 08625-0712 FOR REGIONAL OFFICE USE ONLY 17. DATE RECEIVED: 18. DATE APPROVED: PLAN APPROVED - ONE COPY ATTACHED 19. EFFECTIVE DATE OF APPROVED MATERIAL: 20. SIGNATURE OF REGIONAL OFFICIAL: 21. TYPED NAME: 23. REMARKS: 22. TITLE: FORM CMS-179 (07-92) Instructions on Back PEN/INK AUTHORIZATIONS: Block 8: Please remove 3.1-A and 4.19B pages as listed in original and replace with "NEW PAGE - Addendum to Attachment 3.1A Page 13(d).9k1-3" and 'NEW PAGE - Supplement 1 to Attachment 4.19-B Page 8' Block 9: Please remove as listed and replace with "NEW PAGE - Addendum to Attachment 3.1A Page 13(d).9k1-3" and 'NEW PAGE - Supplement 1 to Attachment 4.19-B Page 8' Acting Deputy Director New York Regional Operations Group Nicole McKnight November 13, 2019 July, 01, 2019

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19-0013-MA (NJ) TN 19-0013 Approval Date Supersedes TN NEW Effective Date Addendum to Attachment 3.1-A Page 13(d).9k1 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT Limitations on Amount, Duration and Scope of Services Provided to the Categorically Needy 13(d).9 Rehabilitation Services Community Mental Health Rehabilitation Services – Opioid Overdose Recovery Program (OORP) Opioid Overdose Recovery Services Opioid Overdose Recovery Program (OORP) services must be recommended by a physician or other licensed practitioner of the healing arts, within the scope of his practice under state law. OORP services must begin in an emergency department of an acute care hospital following a Naloxone reversal of an opioid overdose. Naloxone, while essential in saving lives, is not sufficient to encourage continued substance use disorder (SUD) treatment or recovery support. Individuals who survive an opioid overdose have a significant risk to overdose again if they do not get connected to treatment for their addiction. Staff from OORP work to increase linkage to appropriate follow-up care in the community, expand appropriate service delivery and end the cycle of beneficiaries going in and out of emergency departments but never connecting to treatment or recovery supports. Peers work with these beneficiaries to promote improved recovery, wellness and a healthier lifestyle. This reduces public health care expenditures and reduces behavioral health and physical health risks such as HIV, hepatitis and liver disease. The goal of the program is continued treatment which leads to improved health behaviors, improved clinical outcomes and an improved quality of life. Service Descriptions: Peer Support Services. Peer support services assist beneficiaries with developing the skills and the resources needed to initiate and sustain recovery and are coordinated with an individualized, person-centered plan of care. Services may include family members, but all services are for the direct benefit of the beneficiary. Peer support services are provided by peer support specialists under the direction of the program supervisor. 11/13/2019 07/01/2019

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7/6/2020 Medicaid State Plan Print View

DEPARTMENT OF HEALTH & HUMAN SERVICES, Centers for Medicare & Medicald Services

New York Regional Office

26 Federal Plaza Room 37-100

New York, NY 10278

CENTERS FOR MEDICARE & MEDICAID SERVICES

Division of Medicaid and Children's Health Operations October 28, 2019

Carole Johnson

Commissioner

Dept of Human Services - Division of Medical Assistance and Health Services Quakerbridge Plaza

Hamilton, NJ 08619

Re: Approval of State Plan Amendment Nj-19-0017

Dear Ms. Johnson:

On September 10, 2019, the Centers for Medicare and Medicaid Services (CMS) received New Jersey State Plan Amendment (SPA) NJ-19-0017 to NJ Medicaid State Plan to exclude income from temporary employment related to Census activities paid to an individual by the United States Census Bureau beginning with the 2020 Census when determining Medicaid /Nj FamilyCare eligibility for applicable eligibility groups under Section 1902(r)(2) of the Social Security Act..

We approve New Jersey State Plan Amendment (SPA) NJ-19-0017 on October 28, 2019 with an effective date(s) of July 01, 2019.

| Name Date Created

No items available

Ifyou have any questions regarding this amendment, please contact Michael Cutler at michael.cutler@cms.hhs.gov.

Sincerely, Nicole McKnight

‘Acting Deputy Director Regional Operations Group Division of Medicaid Field Operations East

Division of Medicaid and Children's Health Operations

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | Nj2019MS00040 | Nj-19-0017 Package Header

Package ID Nj2019Ms00040 SPAID Nj-19-0017 Submission Type Official Initial Submission Date 9/10/2019 Approval Date 10/28/2019 Effective Date N/A

Superseded SPAID N/A

State Information

State/Territory Name: New Jersey Medicaid Agency Name: Dept of Human Services - Division of Medical Assistance and Health Services Submission Component @ State Plan Amendment @ Medicaid OcHIP

https://macpro.cms.gov/suite/tempo/records/item/UBGxuxnAYNew8V8rAi1iLjGeHwXRmZtl2LIcjf-vAMo-BtAWpTgO6QfW7sfytGujTskhdvPqCEg8Oq3... 2/55

(nj-19-0017)(approval-document)(page-6)Page 6#

716/2020

Submission - Public Comment MEDICAID | Medicald State Plan { Eligibliity | NJ2019MS00040 | NJ-19-0017 Package Header Package ID Nj2019MS90060 Submission Type Official Approval Date 10/28/2019 Superseded SPAID N/A

whether public was with respect to thls submission.

@ Public notice was federally required and comment was solicited

Indicate how public comment was solleited:

(Z Newspaper Announcement

Date of Publication:

71572819 Newark Star Ledger | 5/2019 “ Aatantic chy Pross ~ . | nsao%s ; i Camden Courier Post | 1512019 , "Trenton Times | 75/2019

{C]Publication in state's administrative record, In accordance with the administrative procedures requirements

{Email to Electronic Mailing List or Similar Mechanism

(Cl website Notice

(Cl Public Hearing or Meeting [other method

Upload caples of public notices and other documents used

¢ Name

| notice as published

Upload with this application a written

ry of publte

Indicate the key issues raised during the public comment period (aptional} Cl Access.

Clquatiry

[icost

[) Payment methodology

Coetigibitty

{Benefits

Ciservice delivery

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Medicaid State Plan Print View

SPAID NJ-19-0017 Initial Submission Date 9/10/2019 Effectiva Date N/A

Locations covered:

Bergen county NJ and surrounding areas

Newark NJ and surrounding areas

| Atlantic County and surrounding areas

| Carden County N) and surrounding areas |

Trenton NJ and surrounding areas

Date of Emall or other slectronie Jun 28, 2019 notification:

Description of mailing list, in State partners, stakeholders, and individuals requesting to particular parties and receive such Notices, organizations Includad, and, if not email, description of similar mechantam used:

Select the type of website {Website of the State Medicaid Agency of Responsible Agency Date of Posting: Jun 28, 2019

Website URL: http://www.state.nj.us/humanservices/providers/grants/pubtic/in

dex.htmi []Website for state Regulations (other

| Date Created

| | } 9/29/2019 1:53 PM EDT |

Data Created

No items available

https://macpro.cms.gow/suite/tempo/records/item/UBGxuxnAY New8V8rAitiLiGeHwXRmZtl2LIcjf-vAMo-BtAWpTgO6QiW7sfytGJjTskhdvPqCEg8Oq3...

6/56

(nj-19-0017)(approval-document)(page-8)Page 8#

7/6/2020 Medicaid State Plan Print View

Medicaid State Plan Eligibility Income/Resource Methodologies

Eligibility Determinations of Individuals Age 65 or Older or Who Have Blindness or a Disability MEDICAID | Medicaid State Plan | Eligibility | Nj2019MS00040 | NJ-19-0017 Package Header

Package ID Nj2019MS00040 SPAID NJ-19-0017 Submission Type Official Initial Submission Date 9/10/2019 Approval Date 10/28/2019 Effective Date 7/1/2019

Superseded SPAID 19-0017 User-Entered

A. Eligibility Determinations of Individuals Who Are Age 65 or Older or Who Have Blindness or a Disability Eligibility determinations of individuals who are age 65 or older or who have blindness or a disability are based on one of the following:

@ 1. SSA Eligibility Determination State (1634 State)

The state has an agreement under section 1634 of the Social Security Act for the Social Security Administration to determine Medicaid eligibility of SSI beneficiaries. For all other individuals who seek Medicaid eligibility on the basis of being age 65 or older or having blindness or a disability, the state requires a separate Medicaid application and determines financial eligibility based on SSI income and resource methodologies.

©2. State Eligibility Determination (SSI Criteria State) ‘The state requires all individuals who seek Medicaid eligibility on the basis of being age 65 or older or having blindness or a disability, including SSI beneficiaries, to file a separate Medicaid application, and determines financial eligibility based on SSI income and resource methodologies.

© 3. State Eligibility Determination (209(b) State) ‘The state requires all individuals who seek Medicaid eligibility on the basis of being age 65 or older or having blindness or a disability, including SSI beneficiaries, to file a separate Medicaid application, and determines financial eligibility using income and resource methodologies more restrictive than SSI.

B. Additional information (optional)

https://macpro.cms.gov/suite/tempo/records/item/UBGxuxnAY New8V8rAi1iLjGeHwXRmZtl2LIcjf-vAMo-BtAWpTgO6QfW7sfytGujTskhdvPqCEg80q3 8/55

(nj-19-0017)(approval-document)(page-31)Page 31#

7/6/2020

Medicaid State Plan Eligibility

Optional Eligibility Groups

MEDICAID | Medicaid State Plan | Eligibility | NJ2019MS00040 | NJ-19-0017

Package Header Package ID Submission Type Approval Date Superseded SPA ID

Nj2019Ms00040, Official 10/28/2019 19-0017

UserEntered

A. Options for Coverage

‘The state provides

@Yes No

to specified

groups of

SPAID Nyj-t9-0017

Initial Submission Date 9/10/2019

Effective Date 7/1/2019

The optlanal eligibllity groups covered In the state plan are {elections made in this screen may not be comprehensive during the transition perlod from the paper-based state plan to MACPra):

Families and Adults

| pligttey Group Name

Optional Coverage of Parents + and Other Caretaker Relatives

Reasonable Classifications of individuals under Age 21

Children with Nomiv-E * adaption Assistance

Independent Foster Care Adolescents

Optional Targeted Low Income children

Individuals above 133% FPL under Age 65

Individuals Needing Treatment for Breast or Cervical Cancer

Individuals Ellgible for Farnily Planning Services

Individuals with Tuberculosis

Individuals Electing COBRA Continuation Coverage

Aged, Blind and Disabled Elighbillty Group Name

» Individuals Eflgible for but Not Receiving Cash Assistance

Individuats Eligible tor Cash Except for Institutionatization

Individuats Recelving Home and | Community- Based Walver ervices under Institutional Rules

Optionat State Supplement Geneficlartes

Individuals In Institutions Fliglble under a Spectal income Level

PACE Participants

Individuals Receiving Hospice

Chitdren under Age 19 with a Olsability

Poverty Level

Work Incentives ‘Ticket to Work Basic

Ticket to Wark Medical Improvements

‘Age and Disability-Retated

aCe

OOOH

Covered In State Plan

im}

O.og:o niog.oi nina

Covered In State Plan

Include RU in Package @

Include RU tn Package @

sSubnsisslun Package

.°)

Included In Another

.@)

00000000000

Included In Another

Submission Package

Source Tyee

CONVERTED

APPROVED

APPROVED.

NEW

https://macpro.cms.gov/sulte/tempo/records/item/IUBGxuxnAY New8V8rAitiLjGeHwx RmZti2LIcjf-vAMo-BtAWpTgOGOMW7sfytGJjTskhdvPqCEgsOq...

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DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services New York Regional OŰce 26 Federal Plaza Room 37-100 New York, NY 10278 Division of Medicaid and Children's Health Operations March 19, 2020 Jennifer Langer Jacobs Assistant Commissioner Dept of Human Services - Division of Medical Assistance and Health Services Quakerbridge Plaza Hamilton, NJ 08619 Re: Approval of State Plan Amendment NJ-19-0021 Dear Ms. Jacobs: On December 26, 2019, the Centers for Medicare and Medicaid Services (CMS) received New Jersey State Plan Amendment (SPA) NJ-19-0021 to to implement the Family Planning eligibility group. We approve SPA NJ-19-0021 with an eſective date of October 01, 2019. We approve New Jersey State Plan Amendment (SPA) NJ-19-0021 on March 19, 2020 with an eſective date(s) of October 01, 2019. CMS notes that, in the course of reviewing the state’s family planning eligibility group state plan amendment, we determined that New Jersey’s renewal and electronic notices policies are not in compliance with regulatory requirements at 42 CFR 435.916 and 42 CFR 435.918 respectively. We understand that these compliance issues are not unique to the family planning eligibility group. CMS will work with the state to achieve compliance regarding these requirements. Name Date Created No items available If you have any questions regarding this amendment, please contact Michael Cutler at michael.cutler@cms.hhs.gov. Sincerely, James G. Scott Director Division of Medicaid and Children's Health Operations Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | NJ2019MS0008O | NJ-19-0021 Package Header Package ID NJ2019MS0008O Submission Type OŰcial Approval Date 3/19/2020 Superseded SPA ID N/A SPA ID NJ-19-0021 Initial Submission Date 12/26/2019 Eſective Date N/A State Information State/Territory Name: New Jersey Medicaid Agency Name: Dept of Human Services - Division of Medical Assistance and Health Services Submission Component State Plan Amendment Medicaid CHIP

(nj-19-0022)(approval-document)(page-3)Page 3#

DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICIAD SERVICES

FORM APPROVED OMB NO. 0938-0193

TRANSMITTAL AND NOTICE OF APPROVAL OF STATE.PLAN MATERIAL

. 4. TRANSMITTAL NUMBER; {2 STATE 19-0022:MA | Newdersey

FOR: CENTERS FOR MEDICARE & MEDICAID. SERVICES

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

TO: REGIONAL ADMINISTRATOR: CENTERS FOR MEDICARE & MEDICAID SERVICES

DEPARTMENT OF HEALTH AND-HUMAN SERVICES... .

4, PROPOSED EFFECTIVE DATE October 1, 2019

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

[J NEW STATE PLAN (| AMENDMENT TO BE CONSI

DERED.AS NEW PLAN $3 AMENDMENT

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

6. FEDERAL STATUTE/REGULATION CITATION:

Social Security Act 1905(a)(4)(C) and 1902(a)(10)(A)(ii)(XXI); 42 CFR 435.214

7.. FEDERAL BUDGET IMPACT:

a. FFY 2020°$21,400,000 b. FFY 2020 $21,400,000

8, PAGE NUMBER OF THE-PLAN SECTION OR ATTACHMENT:

Attachment 3.1-A Page 2.1-2.3

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

|, New

10, SUBJECT OF AMENDMENT:

Family Planning and Family Planning Related Services

under the State Eligibility Option: for.-Family

Planning Services (companion SPA to NJ 19-0021: State e Eligibility Option for Family Plarining Services)

11. GOVERNOR'S REVIEW (Check One):

[) GOVERNOR'S OFFICE REPORTED NO COMMENT

[] COMMENTS OF GOVERNOR'S OFFICE: ENCLOSED

oO i Recenyee WITHIN 45:DAYS OF SUBMITTAL

‘BRLOTHER, AS:SPECIFIED: Not required; pursuant to’7.4 of the Plan

12. RE GF STATE AGENCY: OFFICIAL: 16. RETURN TO; ~ Meh NAME Oooo nD ao me ifer Langer Jacobs, Assistant Commissioner ‘8. , (a NAME: Carola il _Division-éf, Medical Assistance and Health 14. TITLE: Commissioner, | Services Department of Human-Services P.O, Box 712,:Mail Code #26 15. DATE SUBMITTED: fo / Trenton, NJ 08625-0712 rLfeoh4 FOR REGIONAL OFFICE USE ONLY

17. DATE RECEIVED: 18.:DATE APPROVED:

12/26/2019 _. 03/10/2020... : :

PLAN APPROVED — ONE COPY ATTACHED : eS ee

19, EFFECTIVE DATE. OF APPROVED MATERIAL: _ — .

10/01/2019 Lo 21. TYPED NAME: (220 TITLE: . j ee

James G. Scott Director, Division of. Program Operations 23. REMARKS:

FORM CMS-179 (07-92)

instructions on Back

(nj-20-0003)(approval-document)(page-2)Page 2#

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-26-12 Baltimore, Maryland 21244-1850 July 2 2020 Jennifer Langer Jacobs Assistant Commissioner NJ Department of Human Services Division of Medical Assistance and Health Services PO Box 712, Mail Code #26 Trenton, NJ 08625-0712 Re: New Jersey State Plan Amendment (SPA) 20-0003 Dear Assistant Commissioner Jacobs: We have reviewed the proposed amendment to add section 7.4 Medicaid Disaster Relief for the COVID-19 National Emergency to your Medicaid state plan, as submitted under transmittal number (TN) 20-0003. This amendment proposes to implement temporary policies, which are different from those policies and procedures otherwise applied under your Medicaid state plan, during the period of the Presidential and Secretarial emergency declarations related to the COVID-19 outbreak (or any renewals thereof). On March 13, 2020, the President of the United States issued a proclamation that the COVID-19 outbreak in the United States constitutes a national emergency by the authorities vested in him by the Constitution and the laws of the United States, including sections 201 and 301 of the National Emergencies Act (50 U.S.C. 1601 et seq.), and consistent with section 1135 of the Social Security Act (Act). On March 13, 2020, pursuant to section 1135(b) of the Act, the Secretary of the United States Department of Health and Human Services invoked his authority to waive or modify certain requirements of titles XVIII, XIX, and XXI of the Act as a result of the consequences of the COVID-19 pandemic, to the extent necessary, as determined by the Centers for Medicare & Medicaid Services (CMS), to ensure that sufficient health care items and services are available to meet the needs of individuals enrolled in the respective programs and to ensure that health care providers that furnish such items and services in good faith, but are unable to comply with one or more of such requirements as a result of the COVID-19 pandemic, may be reimbursed for such items and services and exempted from sanctions for such noncompliance, absent any determination of fraud or abuse. This authority took effect as of 6PM Eastern Standard Time on March 15, 2020, with a retroactive effective date of March 1, 2020. The emergency period will terminate, and this state plan provision will no longer be in effect, upon termination of the public health emergency, including any extensions.

(nj-20-0003)(approval-document)(page-3)Page 3#

Pursuant to section 1135(b)(5) of the Act, for the period of the public health emergency, CMS is modifying the requirement at 42 C.F.R. 430.20 that the state submit SPAs related to the COVID- 19 public health emergency by the final day of the quarter, to obtain a SPA effective date during the quarter, enabling SPAs submitted after the last day of the quarter to have an effective date in a previous quarter, but no earlier than the effective date of the public health emergency. 7KH 6WDWH RI 1HZ -HUVH\ DOVR UHTXHVWHG D ZDLYHU RI SXEOLF QRWLFH UHTXLUHPHQWV DSSOLFDEOH WR WKH 63$ VXEPLVVLRQ SURFHVV 3XUVXDQW WR VHFWLRQ E

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

& RI WKH $FW &06 LV DSSURYLQJ WKH VWDWH¶V UHTXHVW WR ZDLYH WKHVH QRWLFH UHTXLUHPHQWV RWKHUZLVH DSSOLFDEOH WR 63$ VXEPLVVLRQV These ZDLYHUV RU modifications of the requirements related to SPA submission timelines DQG public notice apply only with respect to SPAs that meet the following criteria: (1) the SPA provides or increases beneficiary access to items and services related to COVID-19 (such as by waiving or eliminating cost sharing, increasing payment rates or amending ABPs to add services or providers); (2) the SPA does not restrict or limit payment or services or otherwise burden beneficiaries and providers; and (3) the SPA is temporary, with a specified sunset date that is not later than the last day of the declared COVID-19 public health emergency (or any extension thereof). We nonetheless encourage states to make all relevant information about the SPA available to the public so they are aware of the changes. We conducted our review of your submittal according to the statutory requirements at section 1902(a) of the Act and implementing regulations. This letter is to inform you that New Jersey’s Medicaid SPA Transmittal Number 20-0003 is approved effective March 1, 2020. Enclosed is a copy of the CMS-179 summary form and the approved state plan pages. Please contact Michael Cutler at (212) 616-2421 or by email at Michael.Cutler@cms.hhs.gov if you have any questions about this approval. We appreciate the efforts of you and your staff in responding to the needs of the residents of the State of New Jersey and the health care community. Sincerely, Anne Marie Costello Deputy Director Center for Medicaid & CHIP Services Enclosures Anne M. Costello -S Digitally signed by Anne M. Costello -S Date: 2020 07.23 14:31 09 -04'00'

(nj-20-0003)(approval-document)(page-4)Page 4#

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED

CENTERS FOR MEDICARE & MEDICIAD SERVICES OMB NO. 0938-0193 TRANSMITTAL AND NOTICE OF APPROVAL OF | 1. TRANSMITTAL NUMBER: 2. STATE STATE PLAN MATERIAL 20-0003 New Jersey 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES SOCIAL SECURITY ACT (MEDICAID) TO: REGIONAL ADMINISTRATOR 4. PROPOSED EFFECTIVE DATE CENTERS FOR MEDICARE & MEDICAID SERVICES March 1, 2020 DEPARTMENT OF HEALTH AND HUMAN SERVICES

5. TYPE OF PLAN MATERIAL (Check One):

(_] NEW STATE PLAN (_] AMENDMENT TO BE CONSIDERED AS NEW PLAN AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate Transmittal for each amendment)

6. FEDERAL STATUTE/REGULATION CITATION: 7. FEDERAL BUDGET IMPACT:

Title 19 of the Social Security Act; a. FFY 2020: $0 National Emergencies Act (50 U.S. C. 1601 et seq.); Section 1135 of the Social Security Act b. FFY 2021:$ 0 8. PAGE NUMBER OF THE PLAN SECTION OR 9. PAGE NUMBER OF THE SUPERSEDED PLAN ATTACHMENT: SECTION OR ATTACHMENT (/f Applicable): Section 7.4 Pages 89 a through 89 | New

10. SUBJECT OF AMENDMENT: Disaster Relief SPA 11. GOVERNOR'S REVIEW (Check One): (_] GOVERNOR'S OFFICE REPORTED NO COMMENT XX] OTHER, AS SPECIFIED: _] COMMENTS OF GOVERNOR'S OFFICE ENCLOSED Not required, pursuant to 7.4 of the Plan L] NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL

12. SIGNATURE O F STATE AGENCY OFFICIAL: 16. RETURN TO:

Jennifer Langer Jacobs, Assistant Commissioner Division of Medical Assistance and Health Services

13. TYPED NAME: Carole Johnson P.O. Box 712, Mail Code #26 Trenton, NJ 08625-0712

14. TITLE: Commissioner, Department of Human Services 15. DATE SUBMITTED: 5/4/9020

FOR REGIONAL OFFICE USE ONLY

17. DATE RECEIVED: 05/01/2020 18. DATE APPROVED: 07/23/2020 PLAN APPROVED - ONE COPY ATTACHED 19. EFFECTIVE DATE OF APPROVED MATERIAL: 20. SIGNATURE OF REGIONAL OFFICIAL icity signed by Anne M. 03/01/2020 Ane M. Costello 5 ra ora 21. TYPED NAME: . 22. TITLE: Deputy Director Anne Marie Costello Center for Medicaid & CHIP Services —

23. REMARKS:

FORM CMS-179 (07-92) Instructions on Back

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89 a State/Territory: ________New Jersey

TN: 20-0003 Approval Date: July 23, 2020 Supersedes TN: New Effective Date: March 01, 2020

Section 7 – General Provisions 7.4. Medicaid Disaster Relief for the COVID-19 National Emergency

On March 13, 2020, the President of the United States issued a proclamation that the COVID-19 outbreak in the United States constitutes a national emergency by the authorities vested in him by the Constitution and the laws of the United States, including sections 201 and 301 of the National Emergencies Act (50 U.S.C. 1601 et seq.), and consistent with section 1135 of the Social Security Act (Act). On March 13, 2020, pursuant to section 1135(b) of the Act, the Secretary of the United States Department of Health and Human Services invoked his authority to waive or modify certain requirements of titles XVIII, XIX, and XXI of the Act as a result of the consequences COVID-19 pandemic, to the extent necessary, as determined by the Centers for Medicare & Medicaid Services (CMS), to ensure that sufficient health care items and services are available to meet the needs of individuals enrolled in the respective programs and to ensure that health care providers that furnish such items and services in good faith, but are unable to comply with one or more of such requirements as a result of the COVID-19 pandemic, may be reimbursed for such items and services and exempted from sanctions for such noncompliance, absent any determination of fraud or abuse. This authority took effect as of 6PM Eastern Standard Time on March 15, 2020, with a retroactive effective date of March 1, 2020. The emergency period will terminate, and waivers will no longer be available, upon termination of the public health emergency, including any extensions.

The State Medicaid agency (agency) seeks to implement the policies and procedures described below, which are different than the policies and procedures otherwise applied under the Medicaid state plan, during the period of the Presidential and Secretarial emergency declarations related to the COVID-19 outbreak (or any renewals thereof), or for any shorter period described below:

Describe shorter period here.

NOTE: States may not elect a period longer than the Presidential or Secretarial emergency declaration (or any renewal thereof). States may not propose changes on this template that restrict or limit payment, services, or eligibility, or otherwise burden beneficiaries and providers. Request for Waivers under Section 1135 x The agency seeks the following under section 1135(b)(1)(C) and/or section 1135(b)(5) of the Act: a. x SPA submission requirements – the agency requests modification of the requirement to submit the SPA by March 31, 2020, to obtain a SPA

(nj-20-0003)(approval-document)(page-8)Page 8#

89 d State/Territory: ________New Jersey

TN: 20-0003 Approval Date: July 23, 2020 Supersedes TN: New Effective Date: March 01, 2020 1902(a)(47)(B) of the Act and 42 CFR 435.1110, provided that the agency has determined that the hospital is capable of making such determinations.

Please describe the applicable eligibility groups/populations and any changes to reasonable limitations, performance standards or other factors.

During the emergency, allow hospitals to make presumptive eligibility determinations for the following non-MAGI populations: x Individuals Eligible For But Not Receiving Cash Assistance (all populations) —section 1902(a)(10)(A)(ii)(I) of the Act x Individuals Eligible for Cash Except for Institutionalization—section 1902(a)(10)(A)(ii)(IV) of the Act x Both “217-Like” eligibility populations (“Special Income Level” and “Aged and Disabled”) served under the terms of the New Jersey FamilyCare Comprehensive 1115 Demonstration. x Optional State Supplement Beneficiaries—section 1902(a)(10)(A)(ii)(XI) of the Act x Individuals in Institutions Eligible under a Special Income Level (ABD only)—section 1902(a)(10)(A)(ii)(V) of the Act x Age and Disability-Related Poverty Level Group—section 1902(a)(10)(A)(ii)(X) of the Act

As is noted below, New Jersey requests the authority to add an additional presumptive eligibility period to all groups during the COVID-19 crisis. Our approved state plan currently allows one such period per pregnancy or per 12 month period for all other individuals. We are requesting that this be expanded to two such periods during the emergency. The 12-month period begins with the effective date of the initial PE determination.

2. ___x The agency designates itself as a qualified entity for purposes of making presumptive eligibility determinations described below in accordance with sections 1920, 1920A, 1920B, and 1920C of the Act and 42 CFR Part 435 Subpart L.

Please describe any limitations related to the populations included or the number of allowable PE periods.

During the emergency period, allow DMAHS to make presumptive eligibility determinations for the following populations; Medicaid and infants and children up to age 19, (42 CFR 435.118) parents, (42 CFR 435.110) single adults between the ages of 19-64 (42 CFR 435.119), and pregnant women (42 CFR 435.116).

(nj-20-0003)(approval-document)(page-9)Page 9#

89 e State/Territory: ________New Jersey

TN: 20-0003 Approval Date: July 23, 2020 Supersedes TN: New Effective Date: March 01, 2020 As is noted below, New Jersey requests the authority to add an additional presumptive eligibility period to all groups during the COVID-19 crisis. Our approved state plan currently allows one such period per pregnancy or per 12 month period for all other individuals. We are requesting that this be expanded to two such periods during the emergency. The 12-month period begins with the effective date of the initial PE determination.

3. _x___ The agency designates the following entities as qualified entities for purposes of making presumptive eligibility determinations or adds additional populations as described below in accordance with sections 1920, 1920A, 1920B, and 1920C of the Act and 42 CFR Part 435 Subpart L. Indicate if any designated entities are permitted to make presumptive eligibility determinations only for specified populations.

Please describe the designated entities or additional populations and any limitations related to the specified populations or number of allowable PE periods. Reference New Jersey approved SPA 13-0011 where the state has elected to designate certain qualified entities to make PE determinations for these MAGI groups: Adults 19-64 up to 133%FPL, Children, Pregnant Women, and Parents and Caretaker Relatives. New Jersey requests to increase the number of PE periods from one per pregnancy to two, and from one per twelve month period beginning with the effective date of the initial PE period to two.

4. _____ The agency adopts a total of _____ months (not to exceed 12 months) continuous eligibility for children under age enter age _____ (not to exceed age 19) regardless of changes in circumstances in accordance with section 1902(e)(12) of the Act and 42 CFR 435.926.

5. _____ The agency conducts redeterminations of eligibility for individuals excepted from MAGI-based financial methodologies under 42 CFR 435.603(j) once every _____ months (not to exceed 12 months) in accordance with 42 CFR 435.916(b).

6. _____ The agency uses the following simplified application(s) to support enrollment in affected areas or for affected individuals (a copy of the simplified application(s) has been submitted to CMS). a. _____ The agency uses a simplified paper application. b. _____ The agency uses a simplified online application. c. _____ The simplified paper or online application is made available for use in call-centers or other telephone applications in affected areas.

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89 g State/Territory: ________New Jersey _ TN: 20-0003 Approval Date: July 23, 2020 Supersedes TN: New Effective Date: March 01, 2020 Personal Care Assistant Services (PCA): New Jersey is requesting authority to allow that PCA services can be provided by family members other than legally responsible relatives. Authority to allow PCA services provided by legally responsible relatives was separately requested in New Jersey’s 1135 request.

Care Management Organization (CMO) Targeted Case Management Staffing requirements: New Jersey’s State Plan at Supplement 1 B to Attachment 3.1A page 2a provides for a ratio of one supervisor for each 10 care coordinators. New Jersey is requesting a suspension of these minimum staffing ratios impacted by COVID-19 for Children’s System of Care (CSOC) providers.

3. x The agency assures that newly added benefits or adjustments to benefits comply with all applicable statutory requirements, including the statewideness requirements found at 1902(a)(1), comparability requirements found at 1902(a)(10)(B), and free choice of provider requirements found at 1902(a)(23).

4. x___ Application to Alternative Benefit Plans (ABP). The state adheres to all ABP provisions in 42 CFR Part 440, Subpart C. This section only applies to states that have an approved ABP(s). a. _x_ The agency assures that these newly added and/or adjusted benefits will be made available to individuals receiving services under ABPs. b. _____ Individuals receiving services under ABPs will not receive these newly added and/or adjusted benefits, or will only receive the following subset:

Please describe.

Telehealth: 5. x The agency utilizes telehealth in the following manner, which may be different than outlined in the state’s approved state plan:

Please describe.

To the extent permitted by state law and regulations (including all state Executive Orders and waivers), Medicaid will reimburse for any service provided via telehealth and associated telecommunication at the same rate that would be paid had the service been provided in-person. No specific prior authorization is required based on telehealth modality. Documentation requirements and licensure standards remain unchanged.

(nj-20-0003)(approval-document)(page-12)Page 12#

89 h State/Territory: ________New Jersey

TN: 20-0003 Approval Date: July 23, 2020 Supersedes TN: New Effective Date: March 01, 2020 Services provided via telehealth and telecommunication shall be required to meet all requirements in state or federal statutes or regulations for the provision of telehealth and telecommunication as well as the service being provided. In the absence of a statute or regulation pertaining to specific provisions for telehealth or telecommunication, services are provided following all applicable laws and regulations for the base service being provided.

Drug Benefit: 6. __x The agency makes the following adjustments to the day supply or quantity limit for covered outpatient drugs. The agency should only make this modification if its current state plan pages have limits on the amount of medication dispensed.

Please describe the change in days or quantities that are allowed for the emergency period and for which drugs.

The current prescription refill policy consists of reimbursement for pharmacy claims for a 34 day’s supply or 100 units, whichever is greater. During the COVID-19 emergency, this policy will be loosened to provide for early prescription refills and drug quantities up to a 90 day’s supply.

Although Medicaid does not pay for non-FDA approved, investigational, cosmetic, experimental or clinical trial products, exception may be made at the State’s discretion during the COVID-19 emergency for investigational products for the specific purpose of COVID-19 treatment

7. _x ___ Prior authorization for medications is expanded by automatic renewal without clinical review, or time/quantity extensions.

8. The agency makes the following payment adjustment to the professional dispensing fee when additional costs are incurred by the providers for delivery. States will need to supply documentation to justify the additional fees.

Please describe the manner in which professional dispensing fees are adjusted.

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DEPARTMENT OF HEALTH AND HUMAN SERVICES. FORM APPROVED

CENTERS FOR MEDICARE & MEDICIAD SERVICES OMB NO. 0938-0193 TRANSMITTAL AND NOTICE OF APPROVAL OF | 1. TRANSMITTAL NUMBER: 2. STATE STATE PLAN MATERIAL 20-0007-MA New Jersey

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

TO: REGIONAL ADMINISTRATOR 4. PROPOSED EFFECTIVE DATE CENTERS FOR MEDICARE & MEDICAID SERVICES July 3, 2020 DEPARTMENT OF HEALTH AND HUMAN SERVICES

5. TYPE OF PLAN MATERIAL (Check One):

FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES

LJ NEW STATE PLAN (_] AMENDMENT TO BE CONSIDERED AS NEW PLAN XX 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: Social Security Act 42 U.S.C. 1396r-4 FFY 2020 $33,625,000.00 FFY 2021 $0 8. PAGE NUMBER OF THE PLAN SECTION OR 9. PAGE NUMBER OF THE SUPERSEDED PLAN ATTACHMENT: SECTION OR ATTACHMENT (if Applicable): e Attachment 4.19-A Page I-262 e Attachment 4.19-A Page I-262. e Attachment 4.19-A Page I-262.1 e Attachment 4.19-A Page I-262.1 e Attachment 4.19-A Page I-262.2 e Attachment 4.19-A Page I-262.2

10. SUBJECT OF AMENDMENT: SFY 2020 Extension Charity Care Subsidy

11. GOVERNOR'S REVIEW (Check One): (_] GOVERNOR'S OFFICE REPORTED NO COMMENT XX] OTHER, AS SPECIFIED: (_] COMMENTS OF GOVERNOR'S OFFICE ENCLOSED Not required, pursuant to 7.4 of the Plan L_] NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL

ENCY OFFICIAL: 16. RETURN TO:

Jennifer Jacobs, Assistant Commissioner Division of Medical Assistance and Health

13. TYPED NAME: Carole Johnson Services ; P.O. Box 712, Mail Code #1 14. TITLE: Commissioner, Trenton, NJ 08625-0712

Department of Human Services

15. DATE SUBMITTED: 8/27/2020

FOR REGIONAL OFFICE USE ONLY 17. DATE RECEIVED: 18. DATE APPROVED:

11/18/20

PLAN APPROVED — ONE COPY ATTACHED 19. EFFECTIVE DATE OF APPROVED MATERIAL: 2 July 3, 2020 For

21. TYPED NAME: 2. TILE: Rory Howe Acting Director

23. REMARKS:

FORM CMS-179 (07-92) Instructions on Back

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

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICIAD SERVICES OMB NO. 0938-0193 TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES 1. TRANSMITTAL NUMBER: 20-0011 MA 2. STATE New Jersey 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) TO: REGIONAL ADMINISTRATOR CENTERS FOR MEDICARE & MEDICAID SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES 4. PROPOSED EFFECTIVE DATE January 1, 2021 5. TYPE OF PLAN MATERIAL (Check One): NEW STATE PLAN AMENDMENT TO BE CONSIDERED AS NEW PLAN AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate Transmittal for each amendment) 6. FEDERAL STATUTE/REGULATION CITATION: 42 U.S. C. 1396a(a)(30)(A); 42 USC 1396d(a)(13) 7. FEDERAL BUDGET IMPACT: a. FFY 2021: $50,000 b. FFY 2022: $66,600 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: Addendum to Attachment 3.1-A Page 13(c)(2a1)-(2a2) Attachment 4.19B page 35.1 Addendum to Attachment 3.1-B Page 13(c)(2a1) 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable): New New New 10. SUBJECT OF AMENDMENT: Doula Services 11. GOVERNOR’S REVIEW (Check One): GOVERNOR’S OFFICE REPORTED NO COMMENT OTHER, AS SPECIFIED: COMMENTS OF GOVERNOR’S OFFICE ENCLOSED Not required, pursuant to 7.4 of the Plan NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL 12. SIGNATURE OF STATE AGENCY OFFICIAL: 16. RETURN TO: Jennifer Langer Jacobs, Assistant Commissioner Division of Medical Assistance and Health Services P.O. Box 712, Mail Code #26 Trenton, NJ 08625-0712 13. TYPED NAME: Carole Johnson 14. TITLE: Commissioner, Department of Human Services 15. DATE SUBMITTED: 11/23/20 FOR REGIONAL OF FICE USE ONLY 17. DATE RECEIVED: 11/23/2020 18. DATE APPROVED: PLAN APPROVED – ON E COPY ATTACHED 19. EFFECTIVE DATE OF APPROVED MATERIAL: 01/01/2021 20. SIGNATU 21. TYPED NAME: 5XWK+XJKHV 22.TITLE: $FWLQJ'irector Division of Program Operations FORM CMS-179 (07-92) Instructions on Back DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICIAD SERVICES OMB NO. 0938-0193 23. REMARKS:

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DEPARTMENT OF HEAL TH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES TO: CENTER DIRECTOR CENTERS FOR MEDICAID & CHIP SERVICES DEPARTMENT OF HEAL TH AND HUMAN SERVICES 1. TRANSMITTAL NUMBER 2. STATE 2 2 - 0 0 1 0 NJ -- ---- -- 3. PROGRAM IDENTIFICATION: TITLE OF THE SOCIAL SECURITY ACT @ XIX Q XXI 4. PROPOSED EFFECTIVE DATE January 1, 2022 FORM APPROVED 0 MB No. 0938--0193 5. FEDERAL STATUTE/REGULATION CITATION 6. FEDERAL BUDGET IMPACT (Amounts in WHOLE dollars) Social Security Act 1902(a)(25)(E) a FFY 2022 $ 0 b. FFY 2023 $ 0 7. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT 8. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable) Pege 69 Section 4 page 69 and 69a Same Scpple111e11t 2 to AtteehmeRl 4.z!z! Page ~ Attachment 4.22-B Page 1b New 9. SUBJECT OF AMENDMENT State Plan Amendment to update the Third Party Liability (TPL) section of the State Plan to comply w ith current law. 10. GOVERNOR'S REVIEW (Check One) 0 GOVERNOR'S OFFICE REPORTED NO COMMENT 0 COMMENTS OF GOVERNOR'S OFFICE ENCLOSED 0 NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL FFICIAL ® OTHER, AS SPECIFIED: 15. RETURN TO Jennifer Langer Jacobs, Assistant Commissioner -------------------------t Division of Medical Assistance and Health Services 12. TYPED NAME Sarah Adelman P.O. Box 712, Mail Code #26 ---------------------Trenton, NJ 08625-0712 13. TITLE Acting Commissioner, Department of Human Services 14. DATE SUBMITTED 3/29/22 16. DATE RECEIVED 3/29/22 FOR CMS USE ONLY 17. DATE APPROVED 4/27/22 PLAN APPROVED - ONE COPY ATTACHED 18. EFFECTIVE DATE OF APPROVED MATERIAL 1/ 1/22 20. TYPED NAME OF APPROVING OFFICIAL Ruth A. Hughes 22. REMARKS 21. TITLE OF APPROVING OFFICIAL Acting Director, Division of Program Operations 4/25/22 - State requested P&I changes to the CMS-179 to align with revisions made to the submission during the review process. FORM CMS-179 (09/24} Instructions on Back

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Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | NJ2023MS0001O | NJ-23-0005 Package Header Package ID NJ2023MS0001O Submission Type Official Approval Date 5/25/2023 Superseded SPA ID N/A SPA ID NJ-23-0005 Initial Submission Date 3/13/2023 Effective Date N/A Governor's Office Review Describe Not required pursuant to Section 7.4 of the Title 19 NJ Medicaid State Plan. PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state’s program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. This view was generated on 6/9/2023 11:33 AM EDT No comment Comments received No response within 45 days Other 0 0 0 0

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Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  SSI Beneficiaries NEW Closed Eligibility Groups NEW Individuals Deemed To Be Receiving SSI NEW Working Individuals under 1619(b) NEW Qualified Medicare Beneficiaries NEW Qualified Disabled and Working Individuals NEW Specified Low Income Medicare Beneficiaries NEW Qualifying Individuals NEW B. The state elects the Adult Group, described at 42 CFR 435.119. Families and Adults Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Adult Group CONVERTED C. Additional Information (optional) Eligibility Groups Deselected from Coverage The following eligibility groups were previously covered in the source approved version of the state plan and deselected from coverage as part of this submission package: N/A PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state’s program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244- 1850.

Yes No

[!] □ 0 [!] □ 0 [!] ~ □ 0 [!] ~ □ 0 [!] 6a □ 0 [!] 6a □ 0 [!] 6a □ 0 [!] □ 0 0 0 □ 0

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Records / Submission Packages - View All NJ - Submission Package - NJ2023MS0001O - (NJ-23-0005) - Eligibility Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter Transaction Logs News Related Actions Medicaid State Plan Eligibility Eligibility Groups - Mandatory Coverage Former Foster Care Children MEDICAID | Medicaid State Plan | Eligibility | NJ2023MS0001O | NJ-23-0005 Individuals under the age of 26, who were in foster care and on Medicaid when they turned age 18 or aged out of foster care. CMS-10434 OMB 0938-1188 Package Header Package ID NJ2023MS0001O Submission Type Official Approval Date 5/25/2023 Superseded SPA ID NJ-13-0011-MM1 User-Entered SPA ID NJ-23-0005 Initial Submission Date 3/13/2023 Effective Date 1/1/2023 The state covers the mandatory former foster care children group in accordance with the following provisions: A. Characteristics Individuals qualifying under this eligibility group must meet the following criteria: 1. Are under age 26 2. Were in foster care upon attaining age 18 or a higher age at which the state's or Tribe's foster care assistance ends under title IV-E of the Act (up to age 21). 3. Are described under either Section B. or C. B. Individuals Covered For individuals who turn 18 before January 1, 2023: 1. The state covers individuals who: a. Upon attaining age 18 or a higher age at which the state's or Tribe's foster care assistance ends under title IV-E of the Act (up to age 21) were: i. In foster care under the responsibility of the state or a Tribe within the state (including children who were cared for through a grant to the state under the unaccompanied refugee minor program); and ii. Enrolled in Medicaid under the state's Medicaid state plan or 1115 demonstration; and b. 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. 2. In addition to B.1., the state elects to cover individuals who were in foster care under the responsibility of the state or a Tribe within the state (including children who were cared for through a grant to the state under the unaccompanied refugee minor program) when they turned 18 or a higher age at which the state's or Tribe's foster care assistance ends under title IV-E of the Act, and meet the following criteria: C. Individuals Covered For individuals who turn 18 on or after January 1, 2023: 1. The state covers individuals who: a. Upon attaining age 18 or a higher age at which the state's or Tribe's foster care assistance ends under title IV-E of the Act (up to age 21) were: i. In foster care under the responsibility of any state or a Tribe within any state (including children who were cared for through a grant to the state under the unaccompanied refugee minor program); and ii. Enrolled in Medicaid under a state's Medicaid state plan or 1115 demonstration; and b. Are not enrolled in mandatory coverage under the state plan, except that eligibility under this group takes precedence over eligibility under the Adult Group. a. They were enrolled in Medicaid under the state's Medicaid state plan or 1115 demonstration at any time during the foster care period in which they turned 18 or a higher age at which the state's or Tribe's foster care assistance ends. b. They were placed by the state or Tribe in another state and were enrolled in Medicaid under the other state’s Medicaid state plan or 1115 demonstration project when they turned 18 or a higher age at which the state's or Tribe's foster care assistance ends. c. They were placed by the state or Tribe in another state and were enrolled in Medicaid under the other state’s Medicaid state plan or 1115 demonstration project at any time during the foster care period in which they turned 18 or a higher age at which the state's or Tribe's foster care assistance ends. Iii □ ~

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Former Foster Care Children MEDICAID | Medicaid State Plan | Eligibility | NJ2023MS0001O | NJ-23-0005 Package Header Package ID NJ2023MS0001O Submission Type Official Approval Date 5/25/2023 Superseded SPA ID NJ-13-0011-MM1 User-Entered SPA ID NJ-23-0005 Initial Submission Date 3/13/2023 Effective Date 1/1/2023 D. Additional Information (optional) PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state’s program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. This view was generated on 6/9/2023 11:37 AM EDT

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Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | NJ2022MS0004O | NJ-23-0009 Package Header Package ID NJ2022MS0004O Submission Type Official Approval Date 07/21/2023 Superseded SPA ID N/A SPA ID NJ-23-0009 Initial Submission Date 5/30/2023 Effective Date N/A Governor's Office Review Describe No required pursuant to Section 7.4 of New Jersey State Plan. PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state’s program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. This view was generated on 7/24/2023 6:20 AM EDT No comment Comments received No response within 45 days Other 0 0 0 0

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Optional Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | NJ2022MS0004O | NJ-23-0009 Package Header Package ID NJ2022MS0004O Submission Type Official Approval Date 07/21/2023 Superseded SPA ID NJ-19-0021 System-Derived SPA ID NJ-23-0009 Initial Submission Date 5/30/2023 Effective Date 4/1/2023 C. Additional Information (optional) Eligibility Groups Deselected from Coverage The following eligibility groups were previously covered in the source approved version of the state plan and deselected from coverage as part of this submission package: N/A PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state’s program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. This view was generated on 7/24/2023 6:21 AM EDT

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Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | NJ2023MS0003O | NJ-23-0025 Package Header Package ID NJ2023MS0003O Submission Type Official Approval Date 03/06/2024 Superseded SPA ID N/A SPA ID NJ-23-0025 Initial Submission Date 12/18/2023 Effective Date N/A Governor's Office Review Describe Not required pursuant to Section 7.4 of NJ Title XIX State plan. PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state’s program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. This view was generated on 3/13/2024 10:18 AM EDT No comment Comments received No response within 45 days Other • • • 0

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Mandatory Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | NJ2023MS0003O | NJ-23-0025 Package Header Package ID NJ2023MS0003O Submission Type Official Approval Date 03/06/2024 Superseded SPA ID NJ-23-0005 System-Derived SPA ID NJ-23-0025 Initial Submission Date 12/18/2023 Effective Date 10/1/2023 B. The state elects the Adult Group, described at 42 CFR 435.119. Families and Adults Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Adult Group CONVERTED C. Additional Information (optional) Eligibility Groups Deselected from Coverage The following eligibility groups were previously covered in the source approved version of the state plan and deselected from coverage as part of this submission package: N/A PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state’s program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. This view was generated on 3/13/2024 10:19 AM EDT Yes No

0 0 □ □ 0

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Qualified Medicare Beneficiaries MEDICAID | Medicaid State Plan | Eligibility | NJ2023MS0003O | NJ-23-0025 Package Header Package ID NJ2023MS0003O Submission Type Official Approval Date 03/06/2024 Superseded SPA ID NJ-10-03 User-Entered SPA ID NJ-23-0025 Initial Submission Date 12/18/2023 Effective Date 10/1/2023 F. Additional Information (optional) PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state’s program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. This view was generated on 3/13/2024 10:19 AM EDT

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Optional Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | NJ2023MS0003O | NJ-23-0025 Package Header Package ID NJ2023MS0003O Submission Type Official Approval Date 03/06/2024 Superseded SPA ID NJ-23-0009 System-Derived SPA ID NJ-23-0025 Initial Submission Date 12/18/2023 Effective Date 10/1/2023 C. Additional Information (optional) Eligibility Groups Deselected from Coverage The following eligibility groups were previously covered in the source approved version of the state plan and deselected from coverage as part of this submission package: N/A PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state’s program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. This view was generated on 3/13/2024 10:21 AM EDT

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Medically Needy Pregnant Women MEDICAID | Medicaid State Plan | Eligibility | NJ2023MS0003O | NJ-23-0025 Package Header Package ID NJ2023MS0003O Submission Type Official Approval Date 03/06/2024 Superseded SPA ID NJ-10-01 User-Entered SPA ID NJ-23-0025 Initial Submission Date 12/18/2023 Effective Date 10/1/2023 F. Additional Information (optional) PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state’s program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. This view was generated on 3/13/2024 10:24 AM EDT

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Medically Needy Children under Age 18 MEDICAID | Medicaid State Plan | Eligibility | NJ2023MS0003O | NJ-23-0025 Package Header Package ID NJ2023MS0003O Submission Type Official Approval Date 03/06/2024 Superseded SPA ID NJ-10-01 User-Entered SPA ID NJ-23-0025 Initial Submission Date 12/18/2023 Effective Date 10/1/2023 PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state’s program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. This view was generated on 3/13/2024 10:25 AM EDT

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Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | NJ2024MS0002O | NJ-24-0003 Package Header Package ID NJ2024MS0002O Submission Type Official Approval Date 04/19/2024 Superseded SPA ID N/A SPA ID NJ-24-0003 Initial Submission Date 3/26/2024 Effective Date N/A Governor's Office Review Describe No comment is required pursuant to Section 7.4 of New Jersey's Title 19 State Plan. PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state’s program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. This view was generated on 4/29/2024 7:02 AM EDT No comment Comments received No response within 45 days Other • • • 0

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Records / Submission Packages - View All NJ - Submission Package - NJ2024MS0002O - (NJ-24-0003) - Eligibility Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter Transaction Logs News Related Actions Medicaid State Plan Eligibility Eligibility and Enrollment Processes Continuous Eligibility for Children MEDICAID | Medicaid State Plan | Eligibility | NJ2024MS0002O | NJ-24-0003 CMS-10434 OMB 0938-1188 Package Header Package ID NJ2024MS0002O Submission Type Official Approval Date 04/19/2024 Superseded SPA ID NJ-24-0003 User-Entered SPA ID NJ-24-0003 Initial Submission Date 3/26/2024 Effective Date 1/1/2024 The state provides continuous eligibility for children in accordance with the following provisions: A. Mandatory Continuous Eligibility for Hospitalized Children The state provides Medicaid to a child eligible for and enrolled under the Infants and Children under Age 19 (42 CFR 435.118) eligibility group until the end of an inpatient stay for which inpatient services are covered, if the child: 1. Was receiving inpatient services covered by Medicaid on the date the child becomes ineligible under the eligibility group based on the child's age; and 2. Would remain eligible but for attaining such age. B. Mandatory Continuous Eligibility for Children The state provides continuous eligibility to all children under age 19 and that: 1. The continuous eligibility period begins on the effective date of the child's most recent determination or redetermination of eligibility, and ends the last day of the earlier of the following periods: a. The month that the child turns 19 years old; b. 12 months. 2. Continuous eligibility is provided to children eligible under all mandatory and optional eligibility groups (excluding Medically Needy) who would otherwise lose eligibility because of any change in circumstances, unless: a. The child dies; b. The child or the child's representative voluntarily requests a termination of the child's eligibility; c. The child ceases to be a resident of the state; d. The Medicaid agency determines that eligibility was determined incorrectly at the most recent determination or redetermination of eligibility because of agency error or fraud, abuse, or perjury attributed to the child or the child's representative; or e. The child attains the maximum age specified in B. C. Additional Information (optional) PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state’s program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

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Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | NJ2024MS0001O | NJ-24-0005 Package Header Package ID NJ2024MS0001O Submission Type Official Approval Date 05/17/2024 Superseded SPA ID N/A SPA ID NJ-24-0005 Initial Submission Date 3/25/2024 Effective Date N/A Governor's Office Review Describe Not required pursuant to Section 7.4 of New Jersey State Plan PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state’s program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. This view was generated on 5/28/2024 10:59 AM EDT No comment Comments received No response within 45 days Other • • • 0

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Optional Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | NJ2024MS0001O | NJ-24-0005 Package Header Package ID NJ2024MS0001O Submission Type Official Approval Date 05/17/2024 Superseded SPA ID NJ-23-0025 User-Entered SPA ID NJ-24-0005 Initial Submission Date 3/25/2024 Effective Date 2/1/2024 C. Additional Information (optional) Eligibility Groups Deselected from Coverage The following eligibility groups were previously covered in the source approved version of the state plan and deselected from coverage as part of this submission package: Ticket to Work Basic PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state’s program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. This view was generated on 5/28/2024 11:00 AM EDT

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Records / Submission Packages - View All NJ - Submission Package - NJ2024MS0001O - (NJ-24-0005) - Eligibility ⇐ All Reviewable Units ← Optional Eligibility Groups | Ticket to Work Basic → View Compare Doc Eligibility Groups - Options for Coverage Work Incentives MEDICAID | Medicaid State Plan | Eligibility | NJ2024MS0001O | NJ-24-0005 Individuals with a disability with income below 250% of the FPL, who would qualify for SSI except for earned income. Spell Check Instructions | Request System Help CMS-10434 OMB 0938-1188 Not Started In Progress Complete Package Header Package ID NJ2024MS0001O Submission Type Official Approval Date 05/17/2024 Superseded SPA ID NJ-23-0009 User-Entered SPA ID NJ-24-0005 Initial Submission Date 3/25/2024 Effective Date 2/1/2024 View Implementation Guide The state covers the optional Work Incentives eligibility group in accordance with the following provisions: A. Characteristics Collapse Individuals qualifying under this eligibility group must meet the following criteria: 1. Have earned income. 2. Meet the SSI definition of disability, but for earned income. 3. Meet income and resource standards following a two-step process, which includes: a. Step One - A comparison of family net income to 250% FPL; and b. Step Two - A comparison of individual net income and resources to the SSI standards, excluding earned income. B. Step One Financial Methodologies and Income Test Collapse 1. Financial methodologies a. SSI methodologies are used in calculating family income. Please refer as necessary to Non-MAGI Methodologies, completed by the state. View approved version of Non-MAGI Methodologies b. Less restrictive methodologies are used in calculating countable income. The less restrictive income methodologies are: VIEW PRINT PREVIEW Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter Transaction Logs News Related Actions VIEW ALL RESPONSES Yes No All income is disregarded. No income test is applied. □ 0 0

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2. Income Test Family net income must be less than 250% FPL. Please refer as necessary to Non-MAGI Methodologies for the definition of family size. View approved version of Non-MAGI Methodologies C. Step Two Financial Methodologies and Income/Resource Test Collapse 1. Financial methodologies a. SSI methodologies are used in calculating income and resources, except that earned income is not counted. Please refer as necessary to Non-MAGI Methodologies, completed by the state. View approved version of Non-MAGI Methodologies b. Less restrictive methodologies are used in calculating countable income. The less restrictive income methodologies are: c. Less restrictive methodologies are used in calculating countable resources. The less restrictive resource methodologies are: 2. Income Test For individuals who pass Step One, in Step Two, the individual's unearned income (plus deemed income, if appropriate) must be less than one of the following income standards: 3. Resource Test The individual's resources must be less than the SSI resource standard. D. Premiums and Cost Sharing Collapse Requirements for premiums and cost sharing for this group are found in the premium and cost sharing sections of the state plan. E. Additional Information (optional) Collapse PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state’s program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. Yes No All income is disregarded. No income test is applied. Yes No All resources are disregarded. No resource test is applied. a. The SSI income standard. b. The income standard of the state supplement program. □ □ 0 0 0 0 0 0

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Records / Submission Packages - View All NJ - Submission Package - NJ2024MS0001O - (NJ-24-0005) - Eligibility Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter Transaction Logs News Related Actions Medicaid State Plan Eligibility Eligibility Groups - Options for Coverage Ticket to Work Basic MEDICAID | Medicaid State Plan | Eligibility | NJ2024MS0001O | NJ-24-0005 Individuals between ages 16 and 64 with a disability, who have earned income. CMS-10434 OMB 0938-1188 Package Header Package ID NJ2024MS0001O Submission Type Official Approval Date 05/17/2024 Superseded SPA ID NJ-23-0009 User-Entered SPA ID NJ-24-0005 Initial Submission Date 3/25/2024 Effective Date 2/1/2024 Group No Longer Covered Covered Through 1/31/2024 Terminated As Of 2/1/2024 PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state’s program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. This view was generated on 5/28/2024 11:01 AM EDT 0 0

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DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 601 E. 12th St., Room 355 Kansas City, Missouri 64106 Medicaid and CHIP Operations Group September , 2025 Gregory Woods Assistant Commissioner Division of Medical Assistance Health Services P.O. Box 712, Mail Code #26 Trenton, NJ 08625-0712 Re: New Jersey State Plan Amendment (SPA) – 25-0003 Dear Assistant Commissioner Woods: The Centers for Medicare & Medicaid Services (CMS) is sending this companion letter to NJ 25-0003, approved on September , 2025. This State Plan Amendment (SPA) amends the Medicaid State Plan to provide for mandatory coverage in accordance with section 1902(a)(84) (D) of the Social Security Act (the Act) for eligible juveniles who are incarcerated in a public institution post-adjudication of charges. As noted in the approval letter and State Plan, this SPA is effective January 1, 2025, and will sunset on December 31, 2026. The state must complete the actions identified in this letter by the sunset date. Once these actions are completed, the state should submit a SPA to remove the sunset date from the State Plan. Effective January 1, 2025, section 1902(a)(84)(D) of the Act requires states to have an internal operational plan and, in accordance with such plan, provide for the following for eligible juveniles as defined in section 1902(nn) of the Act (individuals who are under 21 years of age and determined eligible for any Medicaid eligibility group, or individuals determined eligible for the mandatory eligibility group for former foster care children under 42 C.F.R. § 435.150 who are at least age 18 but under age 26) who are within 30 days of their scheduled date of release from a public institution following adjudication: x In the 30 days prior to release (or not later than one week, or as soon as practicable, after release from the public institution), and in coordination with the public institution, the state must provide any screenings and diagnostic services which meet reasonable standards of medical and dental practice, as determined by the state, or as otherwise indicated as medically necessary, in accordance with the Early and Periodic Screening, Diagnostic, and Treatment requirements, including a behavioral health screening or diagnostic service. x In the 30 days prior to release and for at least 30 days following release, the state must provide targeted case management (TCM) services, including referrals to appropriate care

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Supplement..§... to Attachment 3.1-A Page 3 State Plan under Title XIX of the Social Security Act State/Territory: New Jersey TARGETED CASE MANAGEMENT SERVICES FOR ELIGIBLE JUVENILES • services are being furnished in accordance with the individual's care plan; • services in the care plan are adequate; and • changes in the needs or status of the individual are reflected in the care plan. Monitoring and follow-up activities include making necessary adjustments in the care plan and service arrangements with providers. Frequency of additional monitoring: Specify the type and frequency of monitoring (check all that apply) 181 Telephonic. Frequency: Click or tap here to enter text. 181 In-person. Frequency: Click or tap here to enter text. □ Other [explain]: Click or tap here to enter text. Frequency to be dependent on needs identified in individual care plans. Minimum of one additional monitoring in 30 days post-release 0 Case management includes contacts with non-eligible individuals that are directly related to identifying the eligible individual's needs and care, for the purposes of helping the eligible individual access services; identifying needs and supports to assist the eligible individual in obtaining services; providing case managers with useful feedback, and alerting case managers to changes in the eligible individual's needs. For instance, a case manager might also work with state children and youth agencies for children who are involved with the foster care system. (42 CFR 440.169(e)) 181 If another case manager is involved upon release or for case management after the 30-day post release mandatory service period, states should ensure a warm hand off to transition case management and support continuity of care of needed services that are documented in the person-centered care plan. A warm handoff should include a meeting between the eligible juvenile, and both the pre-release and post-release case manager. It also should include a review of the person-centered care plan and next steps to ensure continuity of case management and follow-up as the eligible juvenile transitions into the community. PRA Disclosure Statement -This use of this fonn is mandatory and the information is being collected to assist the Centers for Medicare & Medicaid Services in implementing Section 5121 of the Consolidated Appropriations Act, 2023. Under the Privacy Act of 1974, any personally identifying info1mation obtained will be kept private to the extent of the law. An agency may not conduct or sponsor, and a person is not required to respond to a collection of info1mation unless it displays a cuffently valid Office of Management and Budget (0MB) control number. The 0MB control number for this project is 0938-1148 (CMS-10398 #85). Public burden for all of the collection of information requirements under this control number is estimated to take about 15 hours per response. Send comments regarding this burden estimate or any other aspect of this collection of infonnation, including suggestions for reducing this burden, to CMS, 7500 Security Boulevard, Attn: Pape1work Reduction Act Repo11s Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN 2 5 -0003 Supersedes TN: New Approval Date September 12, 2025 Effective Date January 1, 2025

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Service Providers: Case Manager: Must possess a minimum of a bachelor’s degree in a behavioral health related profession including, but not limited to nursing, psychology, counseling or social work or a bachelor’s degree with two years of care management experience. Case Management supervisor: An individual who is responsible for the oversight, direction, provision and quality of post-release re-entry case management services. Supervisors must be a licensed clinician in a healthcare profession. Care Manager Supervisor: An individual who is responsible for the oversight, direction, provision and quality of re-entry services. Supervisors must be a licensed clinician but not limited to: Psychologist Registered Nurse (RN) Licensed Social Worker (LSW) Licensed Professional Counselor (LPC) Licensed Marriage and Family Therapist (LMFT) Licensed Clinical Alcohol and Drug Counselor (LCADC) Physician Advance Practice Nurse TN: 25-0003 Supersedes TN: New Approval Date: September , 2025 Effective Date: January 1, 2025

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Supplement..s_ to Attachment 3.1-A Page 5 State Plan under Title XIX of the Social Security Act State/Territory: New Jersey TARGETED CASE MANAGEMENT SERVICES FOR ELIGIBLE JUVENILES Freedom of choice (42 CFR 441.18(a}(1 }): 181 The State assures that the provision of case management services will not restrict an individual's free choice of providers in violation of section 1902(a)(23) of the Act. 1. Eligible individuals will have free choice of any qualified Medicaid provider within the specified geographic area identified in this plan. 2. Eligible individuals will have free choice of any qualified Medicaid providers of other medical care under the plan. Freedom of Choice Exception (§1915(g)(1) and 42 CFR 441.18(b)): □ Target group consists of eligible individuals with developmental disabilities or with chronic mental illness. Providers are limited to qualified Medicaid providers of case management services capable of ensuring that individuals with developmental disabilities or with chronic mental illness receive needed services: [Identify any limitations to be imposed on the providers and specify how these limitations enable providers to ensure that individuals within the target groups receive needed services below.] Click or tap here to enter text. PRA Disclosure Statement - This use of this fonn is mandatory and the information is being collected to assist the Centers for Medicare & Medicaid Services in implementing Section 5121 of the Consolidated Appropriations Act, 2023. Under the Privacy Act of 1974, any personally identifying info1mation obtained will be kept private to the extent of the law. An agency may not conduct or sponsor, and a person is not required to respond to a collection of info1mation unless it displays a cuffently valid Office of Management and Budget (0MB) control number. The 0MB control number for this project is 0938-1148 (CMS-10398 #85). Public burden for all of the collection of information requirements under this control number is estimated to take about 15 hours per response. Send comments regarding this burden estimate or any other aspect of this collection of infonnation, including suggestions for reducing this burden, to CMS, 7500 Security Boulevard, Attn: Pape1work Reduction Act Repo11s Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN 2 5 -0003 Supersedes TN: New Approval Date September 12, 2025 Effective Date January 1, 2025

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Supplement.L to Attachment 3.1-A Page 6 State Plan under Title XIX of the Social Security Act State/Territory: New Jersey TARGETED CASE MANAGEMENT SERVICES FOR ELIGIBLE JUVENILES Access to Services {42 CFR 441.18{a){2). 42 CFR 441.18{a){3). 42 CFR 441.18{a){6)}: 181 The state assures the following: • • • • Case management (including targeted case management) services will not be used to restrict an individual's access to other services under the plan. Individuals will not be compelled to receive case management services, condition receipt of case management (or targeted case management) services on the receipt of other Medicaid services, or condition receipt of other Medicaid services on receipt of case management (or targeted case management) services; and Providers of case management services do not exercise the agency's authority to authorize or deny the provision of other services under the plans. Delivery of TCM and the policies, procedures, and processes developed to support implementation of these provisions are built in consideration of the individuals release and will not effectuate a delay of an individual's release or lead to increased involvement in the juvenile and adult justice systems. Payment (42 CFR 441.18(a)(4)): 181 The state assures payment for case management or targeted case management services under the plan does not duplicate payments made to public agencies or private entities under other program authorities for this same purpose. Case Records (42 CFR 441.18(a)(7)): 181 The state assures providers maintain case records that document for all individuals receiving case management as follows: (i)The name of the individual; (ii) The dates of the case management services; (iii)The name of the provider agency (if relevant) and the person providing the case management service; (iv) The nature, content, units of the case management services received and whether goals specified in the care plan have been achieved; (v) Whether the individual has declined services in the care plan; (vi) The need for, and occurrences of, coordination with other case managers; (vii) A timeline for obtaining needed services; (viii) A timeline for reevaluation of the plan. Limitations: 181 The state assures that case management does not include, and Federal Financial Participation (FFP) is not available in expenditures for, services defined in §440.169 when the case management activities are an integral and inseparable component of another covered Medicaid service (State Medicaid Manual (SMM) 4302.F). PRA Disclosure Statement -This use of this fonn is mandatory and the information is being collected to assist the Centers for Medicare & Medicaid Services in implementing Section 5121 of the Consolidated Appropriations Act, 2023. Under the Privacy Act of 1974, any personally identifying info1mation obtained will be kept private to the extent of the law. An agency may not conduct or sponsor, and a person is not required to respond to a collection of info1mation unless it displays a cuffently valid Office of Management and Budget (0MB) control number. The 0MB control number for this project is 0938-1148 (CMS-10398 #85). Public burden for all of the collection of information requirements under this control number is estimated to take about 15 hours per response. Send comments regarding this burden estimate or any other aspect of this collection of infonnation, including suggestions for reducing this burden, to CMS, 7500 Security Boulevard, Attn: Pape1work Reduction Act Repo11s Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN 2 5 -0003 Supersedes TN: New Approval Date September 12, 2025 Effective Date January 1, 2025

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Supplement__ to Attachment 3.1-$ Page PRA Disclosure Statement - TKLV XVH RI WKLV IRUP LV PDQGDWRU\ DQG WKH LQIRUPDWLRQ LV EHLQJ FROOHFWHG WR DVVLVW WKH &HQWHUV IRU 0HGLFDUH 0HGLFDLG 6HUYLFHV LQ LPSOHPHQWLQJ 6HFWLRQ RI WKH &RQVROLGDWHG $SSURSULDWLRQV $FW 8QGHU WKH 3ULYDF\ $FW RI DQ\ SHUVRQDOO\ LGHQWLI\LQJ LQIRUPDWLRQ REWDLQHG ZLOO EH NHSW SULYDWH WR WKH H[WHQW RI WKH ODZ $Q DJHQF\ PD\ QRW FRQGXFW RU VSRQVRU DQG D SHUVRQ LV QRW UHTXLUHG WR UHVSRQG WR D FROOHFWLRQ RI LQIRUPDWLRQ XQOHVV LW GLVSOD\V D FXUUHQWO\ YDOLG 2IILFH RI 0DQDJHPHQW DQG %XGJHW 20% FRQWURO QXPEHU 7KH 20% FRQWURO QXPEHU IRU WKLV SURMHFW LV &06 3XEOLF EXUGHQ IRU DOO RI WKH FROOHFWLRQ RI LQIRUPDWLRQ UHTXLUHPHQWV XQGHU WKLV FRQWURO QXPEHU LV HVWLPDWHG WR WDNH DERXW KRXUV SHU UHVSRQVH 6HQG FRPPHQWV UHJDUGLQJ WKLV EXUGHQ HVWLPDWH RU DQ\ RWKHU DVSHFW RI WKLV FROOHFWLRQ RI LQIRUPDWLRQ LQFOXGLQJ VXJJHVWLRQV IRU UHGXFLQJ WKLV EXUGHQ WR &06 6HFXULW\ %RXOHYDUG $WWQ 3DSHUZRUN 5HGXFWLRQ $FW 5HSRUWV &OHDUDQFH 2IILFHU 0DLO 6WRS & %DOWLPRUH 0DU\ODQG State Plan under Title XIX of the Social Security Act State/Territory: 1HZ -HUVH\ TARGETED CASE MANAGEMENT SERVICES FOR ELIGIBLE JUVENILES Case management does not include, and Federal Financial Participation (FFP) is not available in expenditures for, services defined in §440.169 when the case management activities constitute the direct delivery of underlying medical, educational, social, or other services to which an eligible individual has been referred, including for foster care programs, services such as, but not limited to, the following: research gathering and completion of documentation required by the foster care program; assessing adoption placements; recruiting or interviewing potential foster care parents; serving legal papers; home investigations; providing transportation; administering foster care subsidies; making placement arrangements. (42 CFR 441.18(c)) FFP only is available for case management services or targeted case management services if there are no other third parties liable to pay for such services, including as reimbursement under a medical, social, educational, or other program except for case management that is included in an individualized education program or individualized family service plan consistent with §1903(c) of the Act. (§§1902(a)(25) and 1905(c)) տ State has additional limitations [Specify any additional limitations.] Click or tap here to enter text. 6 TN: 25-0003 Supersedes TN: New Approval Date: September , 2025 Effective Date: January 1, 2025

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Mandatory Coverage for Eligible Juveniles who are Inmates of a Public Institution Post Adjudication of Charges StatefI erritory: New Jersey Attachment 3.1-M Page 1 General assurances. State must indicate compliance with all four items below with a check. m fu accordance with section 1902(a)(84)(D) of the Social Security Act, the state has an internal operational plan and, in accordance with such plan, provides for the following for eligible juveniles as defined in 1902(nn) (individuals who are under 21 years of age and dete1mined eligible for any Medicaid eligibility group, or individuals dete1mined eligible for the mandato1y eligibility group for fo1mer foster care children age 18 up to age 26, immediately before becoming an inmate of a public institution or while an inmate of a public institution) who are within 30 days of their scheduled date of release from a public institution following adjudication: m fu the 30 days prior to release ( or not later than one week, or as soon as practicable, after release from the public institution), and in coordination with the public institution, any screenings and diagnostic services which meet reasonable standards of medical and dental practice, as dete1mined by the state, or as othe1wise indicated as medically necessaiy, in accordance with the Early and Periodic Screening, Diagnostic, and Treatment requirements, including a behavioral health screening or diagnostic service. m fu the 30 days prior to release and for at least 30 days following release, targeted case management services, including refenals to appropriate care and services available in the geographic region of the home or residence of the eligible juvenile, where feasible, under the Medicaid state plan ( or waiver of such plan). m The state acknowledges that a conectional institution is considered a public institution and may include prisons, jails, detention facilities, or other penal settings ( e.g., boot camps or wilderness camps). PRA Disclosure Statement - This use of this fonn is mandato1y and the information is being collected to assist the Centers for Medicare & Medicaid Services in implementing Section 5121 of the Consolidated Appropriations Act, 2023. Under the Privacy Act of 1974, any personally identifying info1mation obtained will be kept private to the extent of the law. An agency may not conduct or sponsor, and a person is not required to respond to a collection of info1mation unless it displays a cuffently valid Office of Management and Budget (0MB) control number. The 0MB control number for this project is 0938-1148 (CMS-10398 #85). Public burden for all of the collection of information requirements under this control number is estimated to take about 50 hours per response. Send collllllents regarding this burden estimate or any other aspect of this collection of infonnation, including suggestions for reducing this burden, to CMS, 7 500 Security Boulevard, Attn: Paperv.•ork Reduction Act Repo11s Clearance Officer, Mail Stop C4-26-05, Baltimore, Ma1yland 21244-1850. TN: 25-0003 Supersedes TN :_N_e_w _ _

_ Approval Date: September 12, 2025 Effective Date: January 11 2025

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TN:_________ Supersedes TN:_________ Approval Date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

3DSHUZRUN 5HGXFWLRQ $FW 5HSRUWV &OHDUDQFH 2IILFHU 0DLO 6WRS & %DOWLPRUH 0DU\ODQG Attachment 3.1-M Page 2 Additional information provided (optional): ܆No ܆Yes [provide below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㾎 The authority to provide for mandatory coverage for eligible juveniles who are inmates of a public institution post adjudication of charges will cease on December 31, 2026. 25-0003 1ew

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TN: 25-0003 Supersedes: NEW Approval Date: September , 2025 Effective Date: January 1, 2025 Attachment 4.19-B Page 20.2 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE OF NEW JERSEY METHODS AND STANDARD FOR ESTABLISHING PAYMENT RATES FOR NON-INSTITUTIONAL SERVICES REIMBURSMENT FOR PRE-RELEASE AND POST RELEASE SERVICES FOR JUSTICE INVOLVED YOUTH x EPSDT Routine - Full set of routine services per EPSDT guidelines including: o A 40-minute interval history and full physical evaluation including measurements, Tuberculosis screening, and anticipatory guidance o Sensory screenings o Behavioral health screenings as indicated (behavioral / social / emotional screening, substance use screening, depression and suicide risk screening) o Dental exams (oral evaluation, caries/cavities risk assessment, oral hygiene instructions) o Sexually Transmitted Infection (STI) testing x EPSDT Routine Plus - Full set of routine services plus additional services to address medical gaps or needs. This includes: o All services in the ‘Routine’ category o Specialized services (Dental treatment, immunizations, etc.) o Screenings and assessments based on individual health history and needs The fee covers the activities necessary for the physician to determine a recipient’s need for services, deliver a treatment plan, or if necessary, modify an existing treatment plan. Services within each bundle are aligned to EPSDT services as described in State Plan 3.1A, service 4b “early and periodic screening diagnostic and treatment services for individuals under 21 years of age” and are not a multi-benefit category bundle. Bundles are encounter based and daily. Providers delivering services to 5121 eligible individuals through this bundle will be paid through the bundle payment rate and cannot bill separately; Medicaid providers delivering separate services outside of the bundle may bill for those separate services. At least one of the services included in the bundle must be provided for providers to bill the bundled rate. This rate does not contain costs related to room and board or other unallowable facility costs.

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Attachment 4.19 – B Page 36 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE OF NEW JERSEY METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES FOR NON- INSTITUTIONAL SERVICES 25-0003 MA (NJ) TN: 25-0003 SUPERSEDES: 25-0001 Approval Date: September , 2025 Effective Date: January 1, 2025 FEE SCHEDULE EFFECTIVE DATES AND LINKS Except where noted otherwise, the fees in the State’s fee schedules referenced in Attachment 4.19-B below were set on January 1, 2025 and are effective for services provided on or after that date. Except as otherwise noted in the plan, state-developed fee schedule rates are the same for both governmental and private providers of the Medicaid services listed below. Services for both ABP and non-ABP beneficiaries utilize the same rates unless otherwise noted in the plan. All applicable procedure code listings and/or rates are published on the State’s website at www.njmmis.com under the link for ‘Rate and Code Information’ and can be found in the following locations: x Medicaid Fee Schedules: x Location: Procedure Master Listing – Medicaid Fee for Service - CY 2025 (last updated in SPA 25-0003 effective 1/1/25) x Description: Main file of procedure codes billable to Medicaid for all services except as listed below. x Children’s Rates: (excluding Special Education Medicaid Initiative (SEMI)) All applicable procedure code listings and/or rates are published on the State’s website at www.njmmis.com under the link for ‘Rate and Code Information’ and can be found in the following locations: x Location: Procedure Master Listing – Children’s Rates – CY 2024 (last updated in SPA 24- 0001– effective 1/1/2024) x Description: File contains procedure codes billable to Medicaid for services provided to beneficiaries under the age of 21 except as listed below. x Outpatient Laboratory Billing Only: All applicable procedure code listings and/or rates are published on the State’s website at www.njmmis.com under the link for ‘Rate and Code Information’ and can be found in the following locations: x Location: Procedure Master Listing - Outpatient Hospital Laboratory Billing Only – CY 2024 (SPA NJ 24-0001 effective 1/1/2024) x Description: File contains procedure codes billable to Medicaid for laboratory services conducted in an outpatient hospital setting as described beginning on Page 2 of this Section.

(nj-09-03-m)(approval-document)New Jersey Medicaid SPA NJ-09-03 M: Approval Document (approved June 23, 2009, effective May 1, 2009)#

(nj-09-03-m)(approval-document)New Jersey Medicaid SPA NJ-09-03 M: Approval Document (approved June 23, 2009, effective May 1, 2009)#

(nj-09-03-m)(attachment)New Jersey Medicaid SPA NJ-09-03 M: Attachment (approved June 23, 2009, effective May 1, 2009)#

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(nj-09-03-m)(form-cms-179)New Jersey Medicaid SPA NJ-09-03 M: Form CMS-179 (approved June 23, 2009, effective May 1, 2009)#

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(nj-11-06-m)(approval-document)New Jersey Medicaid SPA NJ-11-06 M: Approval Document (approved February 8, 2012, effective April 1, 2011)#

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(nj-11-06-m)(attachment)New Jersey Medicaid SPA NJ-11-06 M: Attachment (approved February 8, 2012, effective April 1, 2011)#

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(nj-11-06-m)(form-cms-179)New Jersey Medicaid SPA NJ-11-06 M: Form CMS-179 (approved February 8, 2012, effective April 1, 2011)#

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(nj-11-18-m)(approval-document)New Jersey Medicaid SPA NJ-11-18 M: Approval Document (approved March 27, 2012, effective October 1, 2011)#

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(nj-11-18-m)(attachment)New Jersey Medicaid SPA NJ-11-18 M: Attachment (approved March 27, 2012, effective October 1, 2011)#

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(nj-11-18-m)(form-cms-179)New Jersey Medicaid SPA NJ-11-18 M: Form CMS-179 (approved March 27, 2012, effective October 1, 2011)#

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(nj-13-06-m)(approval-document)New Jersey Medicaid SPA NJ-13-06 M: Approval Document (approved September 12, 2013, effective April 1, 2013)#

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(nj-13-06-m)(attachment)New Jersey Medicaid SPA NJ-13-06 M: Attachment (approved September 12, 2013, effective April 1, 2013)#

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(nj-13-06-m)(form-cms-179)New Jersey Medicaid SPA NJ-13-06 M: Form CMS-179 (approved September 12, 2013, effective April 1, 2013)#

(nj-13-06-m)(form-cms-179)(page-1)Page 1#

(nj-13-0011-mm1)(approval-document)New Jersey Medicaid SPA NJ-13-0011-MM1: Approval Document (approved February 28, 2014, effective January 1, 2014)#

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(nj-13-0016-mm3)(approval-document)New Jersey Medicaid SPA NJ-13-0016-MM3: Approval Document (approved December 3, 2013, effective January 1, 2014)#

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(nj-13-0017-mm6)(approval-document)New Jersey Medicaid SPA NJ-13-0017-MM6: Approval Document (approved February 5, 2014, effective January 1, 2014)#