Model Application Template for the State Children’s Health Insurance Program

Effective Date: April 1, 2008

Approval Date: 1 MODEL APPLICATION TEMPLATE FOR STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT STATE CHILDREN’S HEALTH INSURANCE PROGRAM

Preamble

Section 4901 of the Balanced Budget Act of 1997 (BBA) amended the Social Security Act (the Act) by adding a new title XXI, the State Children’s Health Insurance Program (SCHIP). Title XXI provides funds to states to enable them to initiate and expand the provision of child health assistance to uninsured, low-income children in an effective and efficient manner. To be eligible for funds under this program, states must submit a state plan, which must be approved by the Secretary. A state may choose to amend its approved state plan in whole or in part at any time through the submittal of a plan amendment.

This model application template outlines the information that must be included in the state child health plan, and any subsequent amendments. It has been designed to reflect the requirements as they exist in current regulations, found at 42 CFR part 457. These requirements are necessary for state plans and amendments under Title XXI.

The Department of Health and Human Services will continue to work collaboratively with states and other interested parties to provide specific guidance in key areas like applicant and enrollee protections, collection of baseline data, and methods for preventing substitution of Federal funds for existing state and private funds. As such guidance becomes available, we will work to distribute it in a timely fashion to provide assistance as states submit their state plans and amendments.

Model Application Template for the State Children’s Health Insurance Program

Effective Date: April 1, 2008

Approval Date: 2 MODEL APPLICATION TEMPLATE FOR STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT STATE CHILDREN’S HEALTH INSURANCE PROGRAM

(Required under 4901 of the Balanced Budget Act of 1997 (New section 2101(b)))

State/Territory:_____________Nevada________________________________________ (Name of State/Territory)

As a condition for receipt of Federal funds under Title XXI of the Social Security Act, (42 CFR, 457.40(b))

________________________________________________________________________ (Signature of Governor, or designee, of State/Territory, Date Signed)

submits the following State Child Health Plan for the State Children’s Health Insurance Program and hereby agrees to administer the program in accordance with the provisions of the approved State Child Health Plan, the requirements of Title XXI and XIX of the Act (as appropriate) and all applicable Federal regulations and other official issuances of the Department.

The following state officials are responsible for program administration and financial oversight (42 CFR 457.40(c)): Name: Charles Duarte

Position/Title: Administrator, Division of Health Care Financing & Policy DHCP Name: Elizabeth Aiello

Position/Title: Deputy Administrator, DHCFP Name: Lynn Carrigan

Position/Title: Administrative Services Officer IV, DHCP

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 0938-0707. The time required to complete this information collection is estimated to average 160 hours (or minutes) per response, including the time to review instructions, search existing data resources, gather the data needed and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, P.O. Box 26684, Baltimore, Maryland 21207 and to the Office of the Information and Regulatory Affairs, Office of Management and Budget, Washington, D.C. 20503.

Model Application Template for the State Children’s Health Insurance Program

Effective Date: July 1, 2009

Approval Date: 3 Section 1. General Description and Purpose of the State Child Health Plans and State Child Health Plan Requirements (Section 2101)

1.1 The state will use funds provided under Title XXI primarily for (Check appropriate box) (42 CFR 457.70):

1.1.1

Obtaining coverage that meets the requirements for a separate child health program (Section 2103); OR

1.1.2.

Providing expanded benefits under the State’s Medicaid plan (Title XIX); OR

1.1.3.

A combination of both of the above.

1.2

Please provide an assurance that expenditures for child health assistance will not be claimed prior to the time that the State has legislative authority to operate the State plan or plan amendment as approved by CMS. (42 CFR 457.40(d))

1.3

Please provide an assurance that the state complies with all applicable civil rights requirements, including title VI of the Civil Rights Act of 1964, title II of the Americans with Disabilities Act of 1990, section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, 45 CFR part 80, part 84, and part 91, and 28 CFR part 35. (42CFR 457.130)

1.4

Please provide the effective (date costs begin to be incurred) and implementation (date services begin to be provided) dates for this plan or plan amendment (42 CFR 457.65):

Effective date: July 1, 2009, add back coverage of non medical vision services, orthodontia and EPSDT per legislative directive. The annual benefit limit of $600 for dental services has been removed per legislative directive. The managed care policy was amended to require a choice of at least two plans where MCO enrollment is mandatory per CHIPRA. The dental benefits section was updated to provide assurance of compliance with CHIPRA.

Implementation date: July 1, 2009

Effective date: September 1, 2008, eliminates coverage of non medical

Model Application Template for the State Children’s Health Insurance Program

Effective Date: July 1, 2009

Approval Date: 4 vision services and orthodontia services. Dental care will have an annual benefit limit. Added exception criteria to coverage differences in State Plan Section 2.1. Differences between Nevada Check Up and Nevada Medicaid as listed in 1) and 2).

Effective date: April 1, 2008, Enrollment Cap Provisions, Premium Increase, Clarification that Managed Care is the primary service deliver model in Nevada Check Up.

Effective date: September 1, 2004, Elimination of Provisional Enrollment Effective date: October 1, 2003; Premium Increase Effective date: 8/24/02; Section 4.1.3, page 13 effective September 28, 2002 Implementation date: 8/24/02; Section 4.1.3, page 14, 10/1/02

Model Application Template for the State Children’s Health Insurance Program

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Approval Date: 5 Section 2. General Background and Description of State Approach to Child Health Coverage and Coordination (Section 2102 (a)(1)- (3)) and (Section 2105)(c)(7)(A)-(B))

2.1. Describe the extent to which, and manner in which, children in the state including targeted low-income children and other classes of children, by income level and other relevant factors, such as race and ethnicity and geographic location, currently have creditable health coverage (as defined in 42 CFR 457.10). To the extent feasible, make a distinction between creditable coverage under public health insurance programs and public- private partnerships (See Section 10 for annual report requirements). (42 CFR 457.80(a))

Uninsured Children Based on the State Demographer’s 2002 population estimates, DHCFP has estimated that there are 69,000 children in Nevada who are uninsured living in families with incomes under 200% of federal poverty level. Of these, as many as 50% may be eligible for Medicaid. These numbers are based on limited and sometimes seemingly contradictory data.

For example, the U.S. Census Bureau estimates that for 1996, there were 45,000 uninsured children under 200% of federal poverty level in Nevada, but also estimated that there were 77,000 uninsured at all income levels. This would mean that less than 60% of all uninsured would be under 200% of federal poverty level. The national average is 73%. Only five other states (Alaska, Massachusetts, Vermont, Hawaii, and New Jersey) are under 60%, all of whom have significantly higher Medicaid eligibility levels than Nevada, resulting in a greater level of coverage for low-income children.

With regard to demographic data, the best information comes from a survey of the uninsured in Nevada completed in June 2000, and updated as of January 2003, by the Great Basin Primary Care Association and the State Demographer’s 2002 population estimates. The following chart reports on these findings as follows:

Model Application Template for the State Children’s Health Insurance Program

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Approval Date: 6 Number of Uninsured Children in Nevada by Region

Age in Years

Washoe County

Clark County

Rural Counties

Totals

Less than 6

6,209

30,493

3,534

40,236

6 to 18

11,363

51,644

9,015

72,022

TOTAL

17,572

82,137

12,549

112,258

Estimates of Nevada Populations According to the current Nevada State Demographer’s data, Nevada’s total population is 2,210,650. Nevada’s children age 0-19 comprise the following races by age and sex:

Age in Years

White

Black

America n Indian

Asian

Hispani c

Total

<5

103,60 1

11,157

1,594

9,563

33,471

159,386

5 to 19

298,14 8

32,108

4,587

27,521

96,325

458,689

Total

401,74 9

43,265

6,181

37,084

129,796

618,075

Model Application Template for the State Children’s Health Insurance Program

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Approval Date: 7 Language spoken at home by Nevadans According to the 2000 Census Supplementary Survey Summary Tables, Nevada’s language spoken at home is as follows:

Nevadans Age >5 years

No English at home 78% Speak English at home

81% Speak Spanish at home 5% No English at home (see breakdown at right) 19% Speak language other than 17% Don’t speak English well

English or Spanish

Public Health Insurance Coverage Medicaid is Nevada’s major public health insurance program. In 1967, Nevada implemented the Medicaid program for the Aid to Families with Dependent Children (AFDC) now Temporary Assistance for Needy Families (TANF), Child Welfare, Aged, Blind, and Disabled populations, and in 1985 implemented the Child Health Assurance Program (CHAP) for pregnant women and later for pregnant women with children. Nevada is at the federal minimums for eligibility, 133% of the federal poverty level (FPL) for children up to age six and 100% of FPL for children six and older born on or after October 1, 1983. Currently, TANF and CHAP Medicaid eligible children residing in Clark County are enrolled in mandatory managed care, with the exception of disabled children and those children who reside more than 25 miles from a primary care physician (PCP) and participating hospital, pursuant to NAC 695C.160.

Nevada Check Up Nevada Check Up provides access to affordable health insurance to children in working, low-income families. The program features simplified mail-in eligibility applications and low premiums while providing a comprehensive health benefits package.

Differences between Nevada Check Up and Nevada Medicaid – There are some major areas where Medicaid policy and Nevada Check Up policy differ. They are: 1) Residential Treatment Centers (RTC) – In Nevada Check Up, it remains the HMO’s responsibility to provide reimbursement for all medical care (physician, optometry, laboratory, dental and x-ray services, etc.) for participants who are receiving services in an RTC. The RTC bed day rate is covered by FFS.

In Medicaid, those who are admitted to an RTC are disenrolled from the HMO and receive all Medicaid-covered services as FFS recipients.

2) Severely Emotionally Disturbed (SED)/Seriously Mentally Ill (SMI) – In Nevada Check Up, this group must receive evaluation and medically appropriate services through a FFS provider if the family resides in a FFS

Model Application Template for the State Children’s Health Insurance Program

Effective Date:

Approval Date: 8 area. In mandatory HMO geographic areas, SED determinations don’t permit disenrollment from the HMO, so the HMOs will provide appropriate services. In Medicaid, once a diagnosis of SED or SMI is confirmed through evaluation, a recipient may elect to disenroll from the HMO and the HMO must notify DHCFP of such election.

3) Newborns – In Nevada Check Up, if a family is expecting a child, whether the adult female in the home or one of the enrolled children, Nevada Check Up must be notified within 14 days of the birth, the newborn, if eligible, will be added to the family as of its date of birth. If the notification criterion is not met, the child, if eligible, will be added the next administrative month following notification. A newborn cannot be enrolled before a family’s start date. A newborn will begin services at the same time as the other children in the family. In Medicaid, all children born to Medicaid-enrolled mothers are enrolled as of their date of birth.

2.2. Describe the current state efforts to provide or obtain creditable health coverage for uncovered children by addressing: (Section 2102)(a)(2) (42CFR 457.80(b))

2.2.1. The steps the state is currently taking to identify and enroll all uncovered children who are eligible to participate in public health insurance programs (i.e., Medicaid and state-only child health insurance):

Nevada currently has several initiatives to enroll children in Medicaid and Nevada Check Up. These include outreach and referral services to the Women, Infant, and Children (WIC) centers, Federally Qualified Health Centers (FQHCs), Special Children’s Clinic (SCC), Baby Your Baby program (BYB), Family Resource Centers (FRCs), and the Family to Family program. In addition, out stationed eligibility workers are in certain public hospitals and federally qualified health centers in order to provide these outreach and referral services. The descriptions of these programs are as follows:

1. The Medicaid program is administered by the Division of Health Care Financing and Policy and provides health coverage to low-income and disabled Nevada children. Nevada takes the following steps to enroll children in Medicaid:

a. Nevada State Welfare District Offices located throughout the state determine a person’s eligibility for TANF, CHAP, and Medicaid. If

Model Application Template for the State Children’s Health Insurance Program

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Approval Date: 9 applicants appear to be Nevada Check Up eligible, rather than Medicaid, they are appropriately referred. b. Out stationed sites (FQHCs, county hospitals, and local county health departments) help people apply for Medicaid or Nevada Check Up and send their applications and eligibility determination to the local Nevada State Welfare District Office or to the Nevada Check Up office. Local public health agencies identify low income, uninsured children through referrals from a variety of sources including: WIC, child health and immunization clinics, community health and social services agencies, and schools.

2. Women, Infants and Children (WIC) provides nutritious food to supplement the regular diet of pregnant women, infants, and children under age five who meet state income standards. Women and children under five years old qualify if the combined family income is at or below 185% of the federal poverty level. WIC staff encourages pregnant women and parents in this program to apply for Medicaid or Nevada Check Up, depending on their income level.

3. Federally Qualified Health Centers offer health care to low-income people. Nevada has three (3) federally qualified community health centers. The centers provide primary care services including care for acute and chronic illness, injuries, emergency care, diagnostic services and prescriptions.

Community health centers take the following steps to enroll children in Medicaid or Nevada Check Up: 1. Provide a financial screen for each new patient or family 2. Provide information on and explanation of the program(s) for which family members may be eligible. 3. Assist with completing applications and collecting required documentation. 4. Forward applications to the determining agency and communicate with family about eligibility status.

If a patient/family is not eligible for any program, the community health center will provide the health care services and will use its sliding fee scale according to family size and income to determine the fee.

4. Special Children’s Clinic The Nevada Health Division, Special Children’s Clinic (SCC) provides direct services to low-income children ages 0-3 under the Maternal and Child Health Block Grant (Title V). Services include well child clinic

Model Application Template for the State Children’s Health Insurance Program

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Approval Date: 10 services, including developmental and physical assessments and immunizations. Children who appear to qualify for Medicaid or Nevada Check Up are encouraged to apply.

5. Baby Your Baby Program Baby Your Baby staff can provide Nevada Check Up applications and information to expectant mothers for future use in insuring their newborns. The state Title V program supports Baby Your Baby (BYB), which is a statewide multi-media bilingual campaign to promote early entry of pregnant women into prenatal care. In 2002 BYB assisted 9,768 women seeking services through the information referral line, and has assisted 111,035 women since the program’s inception. When appropriate, these women were referred to Medicaid and Title V prenatal care programs.

6. Family Resource Centers A total of 36 Family Resource Centers (FRCs) have been established in high risk neighborhoods throughout Nevada, and an additional 2 are scheduled to open in the next year. The FRCs are community based centers run by not-for-profit organizations with state grants and private contributions. Their aim is to provide information about available social services including Medicaid and Nevada Check Up, and how to access those services. Sites also provide some services (e.g. child care) based on the needs of the community. Nevada Check Up staff have participated with Family Resource Centers in the coordination of health fairs. 7. Community Connections/Family to Family Program The Family to Family program is an initiative aimed at informing new mothers of the services that are available to them and how to access such services. A total of 19 centers have been established throughout the state. These centers are community based and operate as public/private partnerships. New mothers are able to receive a home visit, get questions answered about parenting issues and services available to aid them in raising their children, including health insurance through Medicaid and Nevada Check Up.

8. Tribal Administrators, Tribal Clinics, and Indian Health Services (IHS) Nevada Check Up staff attends and participates in meetings of the Native American Advisory Council, as mandated by Nevada law, in order to share information and receive advice as to the needs of the Native American tribes in Nevada. Application training and program updates are also provided by program staff.

Model Application Template for the State Children’s Health Insurance Program

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Approval Date: 11 9. Covering Kids and Families Grant (Robert Wood Johnson Foundation – RWJ) There are northern, southern and statewide coalitions whose members direct the activities of Covering Kids and Families staff and volunteers. Covering Kids and Families coordinators work with community-based organizations, schools, private businesses, and the state to promote the enrollment of children in appropriate health insurance programs. They provide applications for Medicaid and Nevada Check Up to those who appear to be eligible for public programs when no private insurance is available to them. Their employees also assist applicants in the proper completion and submission of applications.

2.2.2. The steps the state is currently taking to identify and enroll all uncovered children who are eligible to participate in health insurance programs that involve a public-private partnership:

Other than the referrals received from Family Resource Centers, there are no public/private partnerships in Nevada offering health insurance to low- income children.

2.3. Describe the procedures the state uses to accomplish coordination of SCHIP with other public and private health insurance programs, sources of health benefits coverage for children, and relevant child health programs, such as title V, that provide health care services for low-income children to increase the number of children with creditable health coverage. (Previously 4.4.5.) (Section 2102)(a)(3) and 2102(c)(2) and 2102(b)(3)(E)) (42CFR 457.80(c))

This issue is addressed in the above Section 2.2.

Model Application Template for the State Children’s Health Insurance Program

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Approval Date: 12 Section 3. Methods of Delivery and Utilization Controls (Section 2102)(a)(4))

Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan, and continue on to Section 4.

3.1. Describe the methods of delivery of the child health assistance using Title XXI funds to targeted low-income children. Include a description of the choice of financing and the methods for assuring delivery of the insurance products and delivery of health care services covered by such products to the enrollees, including any variations. (Section 2102)(a)(4) (42CFR 457.490(a))

The State assures that the delivery of child health assistance using Title XXI funds will be through a choice of State contracted managed care organizations (MCO) primary care providers, or through individually enrolled Medicaid providers where HMOs are not available. In rural areas, services are delivered through Medicaid fee-for-service providers. The State assures that contracts with managed care organizations will comply with all pertinent sections of 1932 and 1903 (m) of the Social Security Act. Contract quality standards will be based on the following sources: National Association of Insurance Commissioners (NAIC) Model Acts, National Committee for Quality Assurance (NCQA) Accreditation Standards and Quality Improvement System for Managed Care (QISMC) Standards.

The contracted MCOs must develop their own provider networks. The physicians, hospitals and ancillary service providers deliver a comprehensive benefit package described in Section 6.2. The DHCFP requires MCOs to have a sufficient provider network to serve its enrollees. Managed care organizations must offer a contract to Federally Qualified Health Centers (FQHC), Rural Health Centers (RHC), public hospitals, and the University Of Nevada School Of Medicine, at terms that are at least equal to their standard provider contracts. If a child loses Medicaid coverage and becomes eligible for Nevada Check Up, the child will be able to remain with the same HMO.

Reimbursement of HMOs is at a rate determined using actuarial principles. Other Nevada Check Up providers are reimbursed using the Medicaid fee-for-service rates.

3.2. Describe the utilization controls under the child health assistance provided under the plan for targeted low-income children. Describe the systems designed to ensure that enrollees receiving health care services under the state plan receive only appropriate and medically necessary health care consistent with the benefit package described in the approved state plan.

Model Application Template for the State Children’s Health Insurance Program

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Approval Date: 13 (Section 2102)(a)(4) (42CFR 457.490(b))

The MCOs which contract with the Nevada Check Up program are primarily responsible for utilization control and review functions. Nevada Check Up contract standards require a participating HMO to have adequate utilization control and review management staff and procedures to assure that covered services provided to enrollees are medically necessary and appropriate. Before being approved for participation in the program, MCOs must develop and have in place utilization review policies and procedures that include protocols for prior approval and denial of services, hospital discharge planning, physician profiling, and retrospective review of both inpatient and ambulatory claims meeting established criteria. MCOs also must develop procedures for identifying and correcting patterns of over and under utilization on the part of their enrollees.

The MCOs may require a prior authorization for a given service. The child’s primary care physician (PCP) is responsible for obtaining all necessary prior authorizations. MCOs are not permitted to require prior authorization for emergency care or preventive services.

MCO compliance with utilization management contracts standards will be monitored by DHCFP staff and/or an external quality review organization (EQRO). To the extent feasible, compliance monitoring will be combined for Medicaid and Nevada Check Up.

Managed care plans are contractually required to track the utilization of benefit services and to submit such data to DHCFP on a monthly and/or quarterly basis. Examples of the data include:

• hospital admissions: diagnosis, length of stay • ambulatory services - visits to primary care physicians and specialists • drugs

The data collected is analyzed by DHCFP and/or the EQRO to identify utilization issues. Said entities work with the health plans as necessary to resolve identified problems. More information can be found on utilization control in Section 7 - Quality and Appropriateness of Care.

Check Up participants not residing in managed care service areas receive service coverage from individual Medicaid providers who must adhere to Medicaid fee-for-service policies and procedures. Utilization review policies and procedures will follow Medicaid Title XIX practices, including protocols for prior approval and denial of services, hospital discharge planning, physician profiling, and retrospective review of both inpatient and ambulatory claims criteria.

Model Application Template for the State Children’s Health Insurance Program

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Approval Date: 14 Utilization review is done cooperatively with Nevada Medicaid’s Surveillance, Utilization and Review Subsystem (SURS) Unit.

Model Application Template for the State Children’s Health Insurance Program

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Approval Date: 15 Section 4. Eligibility Standards and Methodology. (Section 2102(b))

Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan, and continue on to Section 5.

4.1. The following standards may be used to determine eligibility of targeted low- income children for child health assistance under the plan. Please note whether any of the following standards are used and check all that apply. If applicable, describe the criteria that will be used to apply the standard. (Section 2102)(b)(1)(A)) (42CFR 457.305(a) and 457.320(a))

4.1.1.

Geographic area served by the Plan: The plan is available statewide, in all 17 Nevada counties. 4.1.2.

Age: The plan is available to children 0 to 18 years of age. 4.1.3.

Income: Eligible children are from families whose gross annual incomes are at or below 200% of the federal poverty level. Income for the purposes of this plan means gross income before deduction of income taxes, employees’ social security taxes, non-health care insurance premiums, bonds, etc. Income includes the: 1. Monetary compensation for services, including wages, salary, tips, commissions or fees; 2. Net income from farm employment; 3. Social Security; 4. Dividends or interest on savings bonds, income from estates or trusts, net rental income, or income from any other source; 5. Government civilian employee or military retirement or pensions or veteran’s payments; 6. Private pensions or annuities; 7. Alimony or child support payments; 8. Regular contributions from persons not living in the household; 9. Other cash income. Other cash income includes, but is not limited to, cash amounts received or withdrawn from any source, including savings, investments, trust accounts, and other resources that are readily available to the family; and 10. Unemployment Insurance Benefits.

4.1.4.

Resources (including any standards relating to spend downs and disposition of resources): The title XXI program has no resource requirements. 4.1.5.

Residency (so long as residency requirement is not based on length of time in state): Nevada residency is required. In order

Model Application Template for the State Children’s Health Insurance Program

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Approval Date: 16 to be considered for enrollment in Nevada Check Up, a child must be a citizen of the United States, or be an alien who has legal immigration status. Nevada assures that the term qualified alien is, as defined by Public Law 104-193 as amended, a person who has been in the United States in a qualified alien status for at least five years, or is not subject to the five-year bar set forth in section 403 of Public Law 104-193. Such a child is eligible for the Children’s Health Insurance Program (CHIP). 4.1.6.

Disability Status (so long as any standard relating to disability status does not restrict eligibility): No child is denied eligibility based on disability status. If the child receives SSI and is eligible for Medicaid, the child will be referred to Medicaid and not enrolled in Nevada Check Up. 4.1.7.

Access to or coverage under other health coverage: Questions about access to health care coverage, both public and private, are included on the application form. Monthly Third Party Liability cross matches are conducted for verification of health insurance coverage. A child will be found ineligible for the following reasons:

1) He/she has creditable health insurance;

2) He/she is eligible for health benefits coverage under the Public Employees Benefit Program (PEBP) based on a family member’s employment with a public agency in the State; or,

3) He/she has had coverage under an employer plan within six months prior to the date of application. The six month waiting period may be waived if the applicant provides evidence that the loss of insurance was due to actions outside the applicant’s control. These include insurance coverage that was terminated due to the following reasons:

a. Loss of employment other than voluntary termination; b. Death of the parent who was responsible for insurance coverage; c. Change to new employment that does not provide an option for dependant coverage; d. Change of address that results in no employer-sponsored coverage; e. Discontinuation of health benefits to all employees of the applicant’s employer; f. Expiration of coverage periods established by the Consolidated Omnibus Reconciliation Act of 1985 (COBRA);

Model Application Template for the State Children’s Health Insurance Program

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Approval Date: 17 g. Self-employment; h. Termination of health benefits due to a long-term disability; i. Termination of dependant coverage due to an extreme economic hardship on the part of either the employee or the employer. j. Extreme financial hardship related to the cost of premiums, deductible payments, and/or co-payments. 4.1.8.

Duration of eligibility: Once a child has been determined eligible and enrolled, he or she is eligible for up to 12 months of continuous coverage until the annual eligibility redetermination date, no later than one year from the most recent date of enrollment. The child may become ineligible when one or more of the following conditions apply: 1) The child moves out of state; 2) The child becomes enrolled in Medicaid; 3) The child obtains other creditable health insurance; 4) The child turns 19 years old; 5) The child is incarcerated in a penal institution; 6) The child becomes deceased; 7) The child gets married or is ordered a Decree of Emancipation; 8) The parent/guardian fails to pay quarterly premiums. (Written notice will be provided to families who have failed to make timely premium payments. Families are given a reasonable period of time in which to make payment arrangements prior to disenrollment. If disenrolled due to non-payment of premium a new application must be submitted and payments of any past due amounts will be collected before eligibility begins.); 9) The child is a patient (ward of the state) in an institution for mental diseases at the time of initial enrollment or redetermination; 10) During the course of a case review or audit process, it is determined the family provided erroneous information to the state or errors were made in the original determination or redetermination process, resulting in an incorrect eligibility determination; 11) Nevada Check Up (NCU) is requested by the parent/guardian to voluntarily terminate the case; 12) NCU loses contact with the household (is unable to contact the household by mail or phone). Written notice will be provided to families when the quarterly premium is thirty days past due; Thirty additional days will be allowed to receive payment. Consequently, a sixty day grace period is allowed prior to disenrollment for failure to pay the

Model Application Template for the State Children’s Health Insurance Program

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Approval Date: 18 quarterly premium. Children can remain in the program annually, if they continue to meet the eligibility criteria. 4.1.9.

Other standards (identify and describe): Social Security numbers are required for children being enrolled in the Nevada Check Up program, except for newborns. Social Security Numbers for newborns will be required at the time of the annual redetermination.

4.2. The state assures that it has made the following findings with respect to the eligibility standards in its plan: (Section 2102)(b)(1)(B)) (42CFR 457.320(b))

4.2.1.

These standards do not discriminate on the basis of diagnosis. 4.2.2.

Within a defined group of covered targeted low-income children, these standards do not cover children of higher income families without covering children with a lower family income. 4.2.3.

These standards do not deny eligibility based on a child having a pre-existing medical condition.

Model Application Template for the State Children’s Health Insurance Program

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Approval Date: 19 4.3. Describe the methods of establishing eligibility and continuing enrollment. (Section 2102)(b)(2)) (42CFR 457.350) Eligibility is determined through the completion of an application form which includes the following information: 1) Name, date of birth, resident address, gender, Social Security Number, age, ethnicity (optional), and relationship to applicant of all children in the household who are seeking enrollment; 2) Name of person(s) responsible for health care costs of a child; 3) All sources of income as defined in 4.1.3 from all persons residing in the household and contributing to or benefiting from the support of the household; 4) All adults residing in the household; 5) Insurance status, including whether a child is currently or has been insured within the last six months; and 6) If determined eligible: if the applicant has not declared the child/ren are citizens, verification of residency and/or immigration status is completed.

In addition, the applicant must provide proof of income for each employed adult in the household. Proof of income may include but is not limited to copies of two current pay stubs from each job dated within 90 days prior to the eligibility determination. For newly hired employees, a signed statement from their employer may be accepted. If self-employed, the applicant may be required to submit a copy of the most recently filed federal/state income tax return.

Nevada Check Up (NCU) may require additional documentation to determine projected gross annual income from self employment (including but not limited to bank statements and information about household expenses).

The applications are processed and those individuals found eligible are enrolled. If the family is found to have a prior unpaid premium balance, an approval letter is sent requesting the past due balance be paid, at which time the child will be enrolled. For those individuals found eligible without past due balances, an enrollment letter is sent along with an invoice for the first premium (which may be an amount sufficient to cover one, two, or three months, depending on the date enrollment begins). Program enrollment begins on the first day of the next administrative month. The enrollment letter includes the following information: • Household Nevada Check Up ID number; • Names of eligible children and their ID numbers; • Name of health plan (Managed Care Organization (MCO) or Fee For Service (FFS)); • Effective month of enrollment; and • The current amount due and the quarterly premium amount.

Model Application Template for the State Children’s Health Insurance Program

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Approval Date: 20

Native Americans who are members of federally recognized Tribes and Alaska Natives are exempt from premium payment.

For subsequent eligibility determinations, all children enrolled in the program will stay in the program as long as the family income is below the program maximum and they meet all eligibility requirements. If necessary, the applicant is sent a letter requesting additional or missing information.

Enrollees are required to notify Nevada Check Up immediately with any changes to their address and/or telephone number. Any mail returned indicating the family is no longer at the address may cause disenrollment due to “Loss of Contact”.

4.3.1 Describe the state’s policies governing enrollment caps and waiting lists (if any). (Section 2106(b)(7)) (42CFR 457.305(b))

Check here if this section does not apply to your state.

Nevada Check Up will monitor the status of available State and Federal SCHIP funds. An enrollment cap will be placed on the number of new enrollees if it is necessary for the program to stay within available funds. Prior to implementation of an enrollment cap and waiting list, pursuant to NRS 422.2368, the State will provide 30 days of public notice and will conduct a public hearing. The State also will provide notification to CMS.

The enrollment cap may be set above or below current enrollment. If the cap is set below current enrollment levels, enrollment will be closed until the level of the cap is reached. If the cap is set above current enrollment levels, enrollment may continue until the cap is reached, and then enrollment will be closed. Once enrollment is closed, new applications will continue to be accepted through the normal process. NCU eligibility would be run on all applications. The applications of individuals that appear to be eligible for Medicaid would be forwarded to Medicaid for eligibility determination. Those applicants not eligible for Nevada Check Up will be denied with the appropriate reason. The applicants that are eligible for Nevada Check Up but are not able to be enrolled due to the enrollment cap will be denied utilizing the standard program denial process. Their denial reason will be, “denied enrollment due to enrollment cap. These applicants will be notified of the waitlist process. They will also be notified that their child/ren may be eligible for Medicaid if their circumstances change while they are on the waitlist. They will be put on the wait list with a wait list date equal to the date when Nevada Check Up received the completed application.

On a monthly basis, Nevada Check Up will make an assessment of the

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Approval Date: 21 number of enrollees against the appropriated funds for the program. As additional funds become available (either through attrition of enrollees or more funding is identified) a determination will be made as to the number of new enrollees that can be accommodated with the identified funds. The applicants on the wait list will be notified of the availability of coverage. Notification will go out first to those applicants with the earliest wait list date; thus a first come, first served process. To update eligibility, if the update is within the 12 month continuous coverage period, applicants would need to attest that there have not been any changes to their family circumstances (e.g. number in household, income, insurance status, and the like). If changes have occurred, the new information would be added into the Nevada Check Up database and eligibility redetermined. Enrollees determined eligible prior to any enrollment cap will not be impacted by this particular change so long as they continue to pay premiums timely and comply with any requests for information, including income, household, citizenship and identity verification. Enrollees who are disenrolled from the program for failure to timely pay premiums or for failure to timely complete their redetermination process or provide requested information will be precluded from reenrollment during any cap period and will be added to the wait list. These members will receive notice by direct mail informing them of their review rights as required by governing regulations.

4.4. Describe the procedures that assure that:

4.4.1. Through the screening procedures used at intake and follow-up eligibility determination, including any periodic redetermination, that only targeted low-income children who are ineligible for Medicaid or not covered under a group health plan or health insurance coverage (including a state health benefits plan) are furnished child health assistance under the state child health plan. (Section 2102)(b)(3)(A)) (42CFR 457.350(a)(1) and 457.80(c)(3))

Nevada Check Up uses screening procedures at intake, annual eligibility determinations, and reevaluations that target low-income children, who are ineligible for Medicaid or not covered under a group health plan or health insurance coverage (including access to a state health benefits plan). Children who are found eligible may receive health benefits under Nevada Check Up. (Section 2102)(b)(3)(A)) and 2110(b)(2)(B)) (42 CFR 457.310(b) (42 CFR 457.350(a)(1)) 457.80(c)(3))

The application contains a screening question asking if the child has had other health care insurance or Medicaid coverage. If the child had past

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Approval Date: 22 health care coverage, follow up questions are asked as to when and why the coverage ended.

In order to be enrolled in Nevada Check Up, children must have been without creditable insurance for at least six months prior to the date of application. This should provide a disincentive to families to drop current coverage. The exceptions to the six-month waiting period are for children losing Medicaid and for families who lose insurance due to circumstances beyond their control. In those cases, Nevada Check Up coverage would not be a substitution for coverage under group health plans and the six- month “waiting period” does not apply.

In order to ensure that those eligible for coverage under a State health plan are not enrolled in Nevada Check Up, completed applications and income documentation are screened to determine the place and nature of employment. Anyone who is identified as working for an organization listed in the Public Employee Benefit Program employer list and/or those who provide a State agency pay stub and are eligible for benefits based on employment status, are denied coverage.

Nevada Check Up also provides Third Party Liability cross matches on a monthly basis with any participant who has been identified to have other medical coverage. Those participants appear on a report that identifies the policy holder, the policy carrier, effective dates of coverage and the policy type. This information is used to disenroll the participants who have other medical coverage and are receiving Nevada Check Up benefits.

4.4.2. The Medicaid application and enrollment process is initiated and facilitated for children found through the screening to be potentially eligible for medical assistance under the state Medicaid plan under Title XIX. (Section 2102)(b)(3)(B)) (42CFR 457.350(a)(2))

In order to assure that Medicaid eligible children are enrolled in Medicaid, Nevada takes the following steps:

1) The Nevada Check Up application functions as both an application for Nevada Check Up and a pre-screening tool for Medicaid eligibility. Nevada Check Up screens all initial applications, redeterminations and reevaluations for Medicaid through the use of an electronic screening tool that determines if a child may be eligible for Medicaid. 2) The Nevada Check Up application asks whether the application is to be considered as a referral to Medicaid. If the applicant selects “no” and appears to be Medicaid eligible, Nevada Check Up will deny coverage in writing without referring the applicant to Nevada State

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Approval Date: 23 Division of Welfare and Supportive Services (DWSS) for a Medicaid eligibility determination. 3) If the applicant selects “yes” and the child appears to be eligible for Medicaid based on the results of the screening tool, coverage is denied for Nevada Check Up and a referral is made to DWSS for an eligibility determination for Medicaid. 4) Nevada Check Up enrollees are electronically screened daily to ensure that children are not enrolled in both Nevada Check Up and Medicaid. 5) Nevada Check Up also monitors referrals to DESS to ensure timely Medicaid determinations.

4.4.3. The State is taking steps to assist in the enrollment in SCHIP of children determined ineligible for Medicaid. (Sections 2102(a)(1) and (2) and 2102(c)(2)) (42CFR 431.636(b)(4))

A file containing detailed information about children who have been found ineligible for Medicaid is provided electronically to the Nevada Check Up program. This file will provide information on children who appear to meet the eligibility requirements for Nevada Check Up. This information is uploaded electronically into the Nevada Check Up database and these children are enrolled on the first day of the next administrative month following eligibility verification. At the same time the family is notified of eligibility, they are billed for the Nevada Check Up premium, including a date by which premium must be paid.

Children already enrolled in Nevada Check Up who are subsequently placed in the custody or financial responsibility of an agency which provides child welfare services pursuant to the provisions of NRS 62A.380 or 432.010 to 432.085, inclusive, or Chapter 432B of NRS are disenrolled and made eligible for Medicaid. Once the child is returned home, the household must notify Nevada Check Up of his/her residency status in order to re-enroll the child.

4.4.4 The insurance provided under the state child health plan does not substitute for coverage under group health plans. Check the appropriate box. (Section 2102)(b)(3)(C)) (42CFR 457.805) (42 CFR 457.810(a)-(c))

4.4.4.1. Coverage provided to children in families at or below 200% FPL: describe the methods of monitoring substitution.

Persons covered by insurance providing hospital and

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Approval Date: 24 medical services are not eligible for benefits under Nevada Check Up. In order to apply for Nevada Check Up, children are required to have been without creditable insurance for at least six months prior to the date of enrollment. (Certain exceptions apply as noted in 4.1.7 and also include those whose only coverage was Medicaid) The Nevada Check Up application form includes a question regarding other insurance coverage within the last six-month period. The State gathers information on a monthly basis on the number of applicants who were denied because they had other insurance coverage in the last six months. This provides a disincentive to families to drop current coverage. Caseworkers review the applicants’ pay stubs to determine if dependant premiums are being deducted by the employer.

The Division of Health Care Financing and Policy (DHCFP) monitors overall health insurance coverage for children and determines additional steps to be taken if substitution (crowd out) appears to be taking place. When applicants indicate they have had previous coverage within the past six months, there is further screening to determine the circumstances by which that coverage ended. The fiscal agent and the Managed Care Organizations screen claims for other insurance coverage and inform Nevada Check Up if other insurance is found, in which case a disenrollment notice is sent for the next administrative month.

4.4.4.2. Coverage provided to children in families over 200% and up to 250% FPL: describe how substitution is monitored and identify specific strategies to limit substitution if levels become unacceptable.

4.4.4.3. Coverage provided to children in families above 250% FPL: describe how substitution is monitored and identify specific strategies in place to prevent substitution.

4.4.4.4. If the state provides coverage under a premium assistance program, describe:

The minimum period without coverage under a group health plan, including any allowable exceptions to the waiting period.

The minimum employer contribution.

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The cost-effectiveness determination.

4.4.5 Child health assistance is provided to targeted low-income children in the state who are American Indian and Alaska Native. (Section 2102)(b)(3)(D)) (42 CFR 457.125(a))

Native American and Alaska Native children are provided the same opportunity for enrollment as all other children. These families are exempt from cost sharing.

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Approval Date: 26 Section 5. Outreach (Section 2102(c))

Describe the procedures used by the state to accomplish:

Outreach to families of children likely to be eligible for child health assistance or other public or private health coverage to inform them of the availability of the programs, and to assist them in enrolling their children in such a program: (Section 2102(c)(1)) (42CFR 457.90)

Nevada Check Up conducts multi-faceted outreach and referral efforts to inform families of the availability of state sponsored health care coverage for children under both Nevada Check Up and Medicaid. These efforts are supported by the Northern and Southern Covering Kids and Families Coalitions’ outreach efforts as well as other community partners.

Nevada has established a toll free telephone number for people who want an application form mailed. The number is also used for providing assistance in completing the application and answering questions about the program.

Assistance in Enrolling Children The most important “assistance” provided is the use of a simple application form which enables most parents to submit applications without direct help. Community-based organizations are trained to assist families in filling out the application and answer questions applicants may have about the program.

Nevada Check Up also has an internet website which includes applications in English and Spanish for downloading. Families can print this application, complete it and mail to Nevada Check Up with the necessary additional documents. The website also includes an on-line application which can be completed and submitted electronically. The family is required to mail the income verification and other required documentation to be matched with the internet application.

In the future, through collaboration with the NSWD, there will be a joint Welfare/ Medicaid/Nevada Check Up electronic application. At the present time, budget constraints have placed this project on hold.

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Approval Date: 27 Section 6. Coverage Requirements for Children’s Health Insurance (Section 2103)

Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan, and continue on to Section 7.

6.1. The state elects to provide the following forms of coverage to children: (Check all that apply.) (42CFR 457.410(a))

6.1.1.

Benchmark coverage; (Section 2103(a)(1) and 42 CFR 457.420)

6.1.1.1. FEHBP-equivalent coverage; (Section 2103(b)(1)) (If checked, attach copy of the plan.) 6.1.1.2. State employee coverage; (Section 2103(b)(2)) (If checked, identify the plan and attach a copy of the benefits description.) 6.1.1.3. HMO with largest insured commercial enrollment (Section 2103(b)(3)) (If checked, identify the plan and attach a copy of the benefits description.)

6.1.2.

Benchmark-equivalent coverage; (Section 2103(a)(2) and 42 CFR 457.430) Specify the coverage, including the amount, scope and duration of each service, as well as any exclusions or limitations. Please attach a signed actuarial report that meets the requirements specified in 42 CFR 457.431. See instructions.

6.1.3.

Existing Comprehensive State-Based Coverage; (Section 2103(a)(3) and 42 CFR 457.440) [Only applicable to New York; Florida; Pennsylvania] Please attach a description of the benefits package, administration, date of enactment. If existing comprehensive state-based coverage is modified, please provide an actuarial opinion documenting that the actuarial value of the modification is greater than the value as of 8/5/97 or one of the benchmark plans. Describe the fiscal year 1996 state expenditures for existing comprehensive state-based coverage.

6.1.4.

Secretary-Approved Coverage. (Section 2103(a)(4)) (42 CFR 457.450)

6.1.4.1. Coverage the same as Medicaid State plan 6.1.4.2. Comprehensive coverage for children under a Medicaid Section 1115 demonstration project

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Approval Date: 28 6.1.4.3. Coverage that either includes the full EPSDT benefit or that the state has extended to the entire Medicaid population 6.1.4.4. Coverage that includes benchmark coverage plus additional coverage 6.1.4.5. Coverage that is the same as defined by existing comprehensive state-based coverage 6.1.4.6. Coverage under a group health plan that is substantially equivalent to or greater than benchmark coverage through a benefit by benefit comparison (Please provide a sample of how the comparison will be done) 6.1.4.7. Other (Describe)

6.2. The state elects to provide the following forms of coverage to children: (Check all that apply. If an item is checked, describe the coverage with respect to the amount, duration and scope of services covered, as well as any exclusions or limitations) (Section 2110(a)) (42CFR 457.490)

6.2.1.

Inpatient services (Section 2110(a)(1)) Inpatient services include all physician, surgical and other services delivered during a hospital stay. Inpatient services covered in full. 6.2.2.

Outpatient services (Section 2110(a)(2)) Outpatient services include outpatient surgery – covered in full. 6.2.3.

Physician services (Section 2110(a)(3)) Physician services include medical office visits with a physician, mid-level practitioner or specialist. Covered in full. Preventive care (well baby) and immunizations covered in full. 6.2.4.

Surgical services (Section 2110(a)(4)) Covered in full. See 6.2.1 for inpatient surgical services and 6.2.2 for outpatient surgical services. 6.2.5.

Clinic services (including health center services) and other ambulatory health care services. (Section 2110(a)(5)) See section 6.2.2. 6.2.6.

Prescription drugs (Section 2110(a)(6)) Covered for inpatient and outpatient prescription drugs with no co-payment. 6.2.7.

Over-the-counter medications (Section 2110(a)(7)) Over-the-counter medications are covered when prescribed by an authorized medical provider. The participant may have up to two over-the-counter medications within a therapeutic class before a prior authorization is required.

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Approval Date: 29 6.2.8.

Laboratory and radiological services (Section 2110(a)(8)) Covered in full for physician-ordered services. 6.2.9.

Prenatal care and pre-pregnancy family services and supplies (Section 2110(a)(9)) Family planning and prenatal maternity care covered in full. 6.2.10.

Inpatient mental health services, other than services described in 6.2.18., but including services furnished in a state-operated mental hospital and including residential or other 24-hour therapeutically planned structural services (Section 2110(a)(10)) Services covered with continuing stay authorized by Quality Improvement Organization (QIO) like vendor. All covered treatment consistent with Medicaid Services Manual, Chapter 400. 6.2.11.

Outpatient mental health services, other than services described in 6.2.19, but including services furnished in a state-operated mental hospital and including community-based services (Section 2110(a)(11) Mental health professionals are subject to the following utilization criteria: Utilization criteria are based on the Intensity of Needs Determination. A standardized mechanism to determine the intensity of services needed based upon the severity of the recipient’s condition. The intensity of needs determination is to be utilized in conjunction with the clinical judgment of the Qualified Mental Health Professional (QMHP) and/or trained Qualified Mental Health Associate (QMHA). This assessment was previously known as a level of care assessment. Currently, DHCFP recognizes the Level of Care Utilization System (LOCUS) for adults and the Child and Adolescent Screening Intensity Instrument (CASII) for children and adolescents. There is no level of care assessment tool recognized by DHCFP for children below age six, however, providers must utilize a tool comparable to the CASII and recognized as a standard of practice in determining the intensity of needs for this age group. 6.2.12.

Durable medical equipment and other medically-related or remedial devices (such as prosthetic devices, implants, eyeglasses, hearing aids, dental devices, and adaptive devices) (Section 2110(a)(12)) Durable medical equipment is dispensed, on prescription signed by a physician or physician extender (APN, PA), based on medical necessity and prior authorization. There are limitations which may only be overridden by authorized approval of written, medical justification. 6.2.13.

Disposable medical supplies (Section 2110(a)(13))

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Approval Date: 30 6.2.14.

Home and community-based health care services (See instructions) (Section 2110(a)(14)) 6.2.15.

Nursing care services (See instructions) (Section 2110(a)(15)) Skilled nursing covered with no limitations as long as medical necessity requirements have been met. 6.2.16.

Abortion only if necessary to save the life of the mother or if the pregnancy is the result of an act of rape or incest (Section 2110(a)(16) 6.2.17.

Dental services (Section 2110(a)(17)) Coverage for preventive, diagnostic and treatment, and other general dental services and emergency assessments. Medically necessary orthodontia is a benefit requiring prior authorization.

6.2.-D

The State will provide dental coverage to children through one of the following. Dental services provided to children eligible for dental-only supplemental services must receive the same dental services as provided to otherwise eligible CHIP children (Section 2103(a)(5)(c):

6.2.1-D

State Specific Dental Benefit Package. The State assures dental services represented by the following categories of common dental terminology (CDT) codes are included in the dental benefits: 1. Diagnostic (i.e., clinical exams, x-rays)(CDT codes: D0100-D0999)(must follow periodicity schedule). 2. Preventive (i.e., dental prophylaxis, topical fluoride treatments)(CDT codes: D1000-D1999)(must follow periodicity schedule). 3. Restorative (i.e., fillings, crowns)(CDT codes: D2000- D2999). 4. Endodontic (i.e., root canals)(CDT codes; D3000- D3999) 5. Periodontic (treatment of gum disease)(CDT codes: D4000-D4999) 6. Prosthodontic (dentures)(CDT codes: D5000-D5999, D5900-D5999, and D6200-D6999). 7. Olral and Maxillofacial Surgery(i.e., extractions of teeth and other oral surgical procedures)(CDT codes: D7000-D7999). 8. Orthodontics (i.e., braces)(CDT codes: D8000-D8999). 9. Emergency Dental Services.

6.2.1.2-D Periodicity Schedule. The State has adopted the following periodicity schedule:

State-developed Medicaid-specific

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Approval Date: 31

American Academy of Pediatric Dentistry

Other Nationally recognized periodicity schedule

Other (description attached)

6.2.2-D

Benchmark coverage (Section 2103(c)(5), 42 CFR 457.410, and CFR 457.420)

6.2.2.1-D FEHBP – equivalent coverage (Section 2103(c)(5)(C)(i))(If checked, attach copy of the dental supplemental plan benefits description and the applicable CDT codes. If the State chooses to provide supplemental services, please also attach a description of the services and applicable CDT codes)

6.2.2.2-D State employee coverage (Section 2103(c)(5)(C)(ii))(If checked, identify the plan and attach a copy of the benefits description and the applicable CDT codes. If the State chooses to provide supplemental services, please also attach a description of the services and applicable CDT codes)

6.2.2.3-D HMO with largest insured commercial enrollment (Section 2103(c)(5)(C)(iii)) (If checked, identify the plan and attach a copy of the benefits description of the services and applicable CDT codes.)

6.2.18.

Inpatient substance abuse treatment services and residential substance abuse treatment services (Section 2110(a)(18)) Detoxification – Limited to 5 hospital days, more if medical necessity warrants. Treatment – Limited to 21 hospital days, more if medical necessity warrants. 6.2.19.

Outpatient substance abuse treatment services (Section 2110(a)(19)) The benefit is the same as 6.2.11 above. 6.2.20.

Case management services (Section 2110(a)(20)) Targeted case management services are required to be provided by the Nevada Check Up program, consistent with the Medicaid Title XIX State Plan.

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Approval Date: 32 6.2.21.

Care coordination services (Section 2110(a)(21)) Care coordination services are required to be provided by the MCOs in the managed care portion of the Nevada Check Up program. Care coordination services are not currently available in the fee-for-service areas. 6.2.22.

Physical therapy, occupational therapy, and services for individuals with speech, hearing, and language disorders (Section 2110(a)(22)) Therapy Services, including group and individual treatment, are subject to utilization management criteria. 6.2.23.

Hospice care (Section 2110(a)(23)) Inpatient covered for up to six months; subsequent periods may be approved in 30-day blocs. Hospice may also include routine or continuous home care, respite care, counseling, appliances, supplies and pharmaceuticals. 6.2.24.

Any other medical, diagnostic, screening, preventive, restorative, remedial, therapeutic, or rehabilitative services. (See instructions) (Section 2110(a)(24)) Annual vision screening exam and glasses, hearing exams, medically necessary transplants as required under the title XIX EPSDT program. 6.2.25.

Premiums for private health care insurance coverage (Section 2110(a)(25)) 6.2.26.

Medical transportation (Section 2110(a)(26)) Hospital and emergency room transport are covered. Medically necessary transportation is also covered on either public or private carriers. 6.2.27.

Enabling services (such as transportation, translation, and outreach services (See instructions) (Section 2110(a)(27)) 6.2.28.

Any other health care services or items specified by the Secretary and not included under this section (Section 2110(a)(28))

Benefits are subject to prior authorization and/or other utilization review controls as established by the plan, except for emergency services. For areas not covered by an MCO, a fee for service benefit is provided with the same State Plan benefit package.

6.3 The state assures that, with respect to pre-existing medical conditions, one of the following two statements applies to its plan: (42CFR 457.480)

6.3.1.

The state shall not permit the imposition of any pre-existing medical condition exclusion for covered services (Section 2102(b)(1)(B)(ii)); OR

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Approval Date: 33 6.3.2.

The state contracts with a group health plan or group health insurance coverage, or contracts with a group health plan to provide family coverage under a waiver (see Section 6.4.2. of the template). Pre-existing medical conditions are permitted to the extent allowed by HIPAA/ERISA (Section 2103(f)). Please describe: Previously 8.6

6.4. Additional Purchase Options. If the state wishes to provide services under the plan through cost effective alternatives or the purchase of family coverage, it must request the appropriate option. To be approved, the state must address the following: (Section 2105(c)(2) and (3)) (42 CFR 457.1005 and 457.1010)

6.4.1.

Cost Effective Coverage. Payment may be made to a state in excess of the 10% limitation on use of funds for payments for: 1) other child health assistance for targeted low-income children; 2) expenditures for health services initiatives under the plan for improving the health of children (including targeted low-income children and other low-income children); 3) expenditures for outreach activities as provided in section 2102(c)(1) under the plan; and 4) other reasonable costs incurred by the state to administer the plan, if it demonstrates the following (42CFR 457.1005(a)):

6.4.1.1. Coverage provided to targeted low-income children through such expenditures must meet the coverage requirements above; Describe the coverage provided by the alternative delivery system. The state may cross reference section 6.2.1 - 6.2.28. (Section 2105(c)(2)(B)(i)) (42CFR 457.1005(b))

6.4.1.2. The cost of such coverage must not be greater, on an average per child basis, than the cost of coverage that would otherwise be provided for the coverage described above; Describe the cost of such coverage on an average per child basis. (Section 2105(c)(2)(B)(ii)) (42CFR 457.1005(b))

6.4.1.3. The coverage must be provided through the use of a community-based health delivery system, such as through contracts with health centers receiving funds under section 330 of the Public Health Service Act or with hospitals such as those that receive disproportionate share payment adjustments under section 1886(c)(5)(F) or 1923 of the Social Security Act. Describe the

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Approval Date: 34 community-based delivery system. (Section 2105(c)(2)(B)(iii)) (42CFR 457.1005(a))

6.4.2.

Purchase of Family Coverage. Describe the plan to purchase family coverage. Payment may be made to a state for the purpose of family coverage under a group health plan or health insurance coverage that includes coverage of targeted low- income children, if it demonstrates the following: (Section 2105(c)(3)) (42CFR 457.1010)

6.4.2.1. Purchase of family coverage is cost-effective relative to the amounts that the state would have paid to obtain comparable coverage only of the targeted low-income children involved; and (Describe the associated costs for purchasing the family coverage relative to the coverage for the low income children.) (Section 2105(c)(3)(A)) (42CFR 457.1010(a)) 6.4.2.2. The state assures that the family coverage would not otherwise substitute for health insurance coverage that would be provided to such children but for the purchase of family coverage. (Section 2105(c)(3)(B)) (42CFR 457.1010(b)) 6.4.2.3. The state assures that the coverage for the family otherwise meets title XXI requirements. (42CFR 457.1010(c))

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Section 7. Quality and Appropriateness of Care

Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan, and continue on to Section 8.

7.1. Describe the methods (including external and internal monitoring) used to assure the quality and appropriateness of care, particularly with respect to well-baby care, well-child care, and immunizations provided under the plan. (2102(a)(7)(A)) (42CFR 457.495(a))

The DHCFP performs the same readiness review process, less those issues which are specific to Medicaid, prior to allowing the MCO contractor to deliver services under the Nevada Check Up program.

Overall program monitoring to assure quality and appropriateness of care will be performed on an ongoing basis by the following activities:

1) Review and analysis of encounter and financial data; 2) Review of participant and provider complaints and grievances filed with the State Insurance and/or Health Division; 3) The compilation, review and investigation, where warranted, of consumer satisfaction data; and 4) Establishment of quality and performance measures for well baby care, well child care, and immunization monitored through encounter data and chart review.

Contract monitoring is performed through the following actions:

1) Annual quality and operational review of each contractor; 2) Identical encounter data reporting (in form, format, and periodicity) as required under the Medicaid Managed Care program (to the extent that such services are program benefits under the contract); 3) Review of the contractors and contract data by an External Quality Review Organization (EQRO); 4) Generation of Health Plan Employer Data and Information Set (HEDIS) reporting, depending on program benefits under the contract, with the same periodicity, form and format as under the Medicaid Managed Care program; 5) Performing on-site review, if problems of a material nature arise; 6) Performance of a yearly member satisfaction survey by DHCFP and/or the MCO contractors with review, analysis and follow-up (as required) by the State.

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7) Complaints filed by enrolled participants with the MCO plans. Participating plans are contractually required to report complaints on a quarterly basis. These reports are shared with enrolled participants who request the information. In addition, DHCFP will track the information on the number and type of complaints filed by participants enrolled in a plan. Complaint information is used by DHCFP to identify plan performance needing improvement and to form the basis of future performance standards.

8) DHCFP works with the state’s two health insurance industry regulatory entities (i.e., the Division of Insurance and the Health Division) to ensure all publicly available data on health plan performance is known to DHCFP.

Will the state utilize any of the following tools to assure quality? (Check all that apply and describe the activities for any categories utilized.) 7.1.1.

Quality standards The state utilizes quality standards for the Nevada Check Up program identical to those currently used under the Medicaid Managed Care Program.

The following clinical areas of concern are monitored:

1. Comprehensive Well Baby and Well Child Periodic Health Screening

Standard Well Baby/Well Child screenings comprise a comprehensive health and developmental history, unclothed physical exam, and vision, dental, and hearing evaluations with follow-up. When indicated appropriate diagnostic and treatment services must be provided. Periodic screening will be completed on behalf of all eligible children between the ages of 0 through 18, according to the most current HEDIS guidelines.

An interperiodic screening is one which is provided at medically necessary intervals to determine the existence of physical or mental illnesses or conditions of concern, or to follow up on previously diagnosed health problems. Such screening exams must be provided at the request of a parent, guardian, health, or educational professional.

2. Childhood Immunizations

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Standard Age appropriate immunizations will be documented in the medical record unless documentation is provided of exemption due to State law. Age appropriate immunizations required by the State are those recommended by a recognized medical academy and/or required by the Centers for Medicare and Medicaid Services (CMS) The MCO is responsible for implementing the most recent immunization schedule as endorsed by the American Academy of Pediatrics and the Nevada Health Division.

3. Family Planning

Standard Family planning services are provided to Nevada Check Up eligible children, both male and female, of child bearing age.

4. Dental Services

Standard Dental services (including medically necessary orthodontia, if prior authorized) are provided to Nevada Check Up eligible participants.

5. Medical Record Standards

Standard The MCO must maintain medical records in accordance with Standard XII of the “Guidelines for Internal Quality Assurance Programs” as set forth in the CMS Medicaid guidelines.

6. Appointment Standards

Standard 90% of appointments must meet time criteria (both for waiting and for number of days between request and appointment).

7.1.2.

Performance measurement Performance measurements for each of the Quality Standards noted in 7.1.1 are similar to or the same as those currently utilized in the Medicaid Managed Care program.

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1. Comprehensive Well Baby and Well Child Periodic and Interperiodic Health Assessments - Periodic screening

A. Measurement 1) 80% of Nevada Check Up eligible children who are enrolled for 12 months must have an age appropriate periodic screening. HMO or MCO compliance is monitored by a quarterly evaluation of encounter data and, if indicated, liquidated damages will be calculated based on the initial annual review; that is, twelve (12) months of the contract year.

Liquidated Damage: (number of required Periodic screenings not completed) x (Periodic screening fee) = liquidated damage.

2) Annually, a chart sample of Nevada Check Up eligible children will be reviewed. During chart review, areas of critical concern are age appropriate developmental, dental, vision and hearing screenings with follow-up when indicated by diagnostic and treatment activities and/or referrals. The timely scheduling and completion of interperiodic screening upon request, accompanied by necessary follow-up activities, will be assessed during the chart review. Corrective action: If chart reviews suggest poor quality of medical care and/or inadequate follow up activities and treatment, DHCFP may direct the MCO to conduct a study of particular areas of concern. In cases of immediate concern, a simultaneous referral to the Division of Insurance and the Health Division may be initiated for further examination of appropriateness and quality of care within the existing scope of each agency.

B. Method Encounter data, chart review, analysis of number and nature of complaint reports, and participant/guardian surveys are analyzed and evaluated.

C. Frequency DHCFP will generate quarterly reports from encounter data with an annual cumulative report. An annual on-site review

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with an emphasis on chart review will be conducted by DHCFP and/or an EQRO. Chart review may be conducted more often than annually, if indicated by encounter data, complaints, etc.

2. Childhood Immunizations

A. Measurement Documentation showing 90% of Nevada Check Up eligible non-exempt participants, ages 0 through 2 are appropriately immunized. Documentation showing 95% of Nevada Check Up eligible non-exempt participants, ages 3 through 18 are appropriately immunized. Nevada Check Up clients must have been enrolled for 12 months before compliance with required percentages is calculated. For tracking purposes in managed care, each immunization (vaccine) will include two encounter codes. One code will indicate administration of a specific vaccine; the second code will indicate a history of receiving a specific immunization.

An action plan will be required from the MCO if compliance is less than 90% for children ages 0 through 2 and/or less than 95 % for those who are ages 3 through 18.

B. Method Encounter data, chart review, and analysis of number and nature of complaints reported.

C. Frequency DHCFP generates quarterly reports from encounter data with an annual cumulative report. An annual review is conducted by DHCFP and/or an EQRO.

3. Family Planning

A. Measurement 80% of eligible participants of child bearing age receive age appropriate education and services regarding family planning. A chart sample of participants who are enrolled for at least 6 months will be reviewed for compliance. At a minimum, documentation indicating that family planning information was offered or provided must be evident in the

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participant’s record. An action plan is required if the percent of compliance is less than 80%.

B. Method Encounter data, chart review and verification of service from participants whose records were reviewed will be evaluated; analysis of number and nature of complaints reported, and participant/parent/ guardian surveys will be analyzed and evaluated.

C. Frequency DHCFP will generate quarterly reports and an annual cumulative report utilizing encounter data submitted by the MCO. DHCFP will conduct an annual review. If the reviewed sample does not meet the minimum percentage criteria, follow-up will be conducted by DHCFP staff.

4. Dental Services

A. Measurement 20 percent of Nevada Check Up participants, ages 3 to 5, who have been enrolled at least twelve (12) months will receive at least one oral health screening, referral and follow-up for necessary diagnostic and preventive services; and, 50 percent of participants, ages 5 to 18, who have been enrolled for twelve (12) months will receive at least one dental visit in the reporting year.

B. Method Encounter data, chart review and verification of service from participants whose records were reviewed will be evaluated. An analysis of the number and nature of complaints reported, with the participant/parent/guardian surveys will be analyzed and evaluated.

C. Frequency DHCFP will generate quarterly reports and an annual cumulative report utilizing encounter data submitted by the MCO. DHCFP will conduct an annual review. If the reviewed sample does not meet the minimum percentage criteria, follow-up will be conducted by DHCFP and/or EQRO staff.

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5. Appointment standards

A. Measurement

1) Appointments with primary care providers (PCP):

The MCO shall have procedures in place that ensure:

(a) Same day primary care provider appointments for symptoms which are of sudden or severe onset but which do not require emergency room service are available; (b) Urgent care PCP appointments are available within two calendar days; and, (c) Routine care PCP appointments are available within two weeks. This two-week standard does not apply to regularly scheduled visits to monitor a chronic medical condition, if the schedule calls for visits more frequently than once every two weeks.

2) Specialty appointments

For specialty referrals to physicians, therapist and other diagnostic and treatment health care providers the MCO shall provide:

(a) Same day appointments within twenty-four hours of referrals as in 1) (a) above; (b) Urgent care appointments within three calendar days of referral; and, (c) Routine appointments within two weeks

3) Dental Appointments

(a) Initial appointment to a dentist is available within four weeks; (b) Follow up appointments according to a plan of care within two weeks; (c) Urgent care appointments within one week; and (d) Emergency care (severe tooth ache, loss of tooth) within 24 hours.

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4) Office Waiting Times

The MCO plans shall monitor and ensure that a participant’s waiting time at the PCP or specialist’s office is not more than one hour from the scheduled appointment time, except when the provider is unavailable due to an emergency. Office waiting times may be delayed when they “work in” urgent cases, when a serious problem is found, or when the patient had an unknown need that requires more services or education than was described at the time the appointment was made. A Plan of Correction (POC) will be required if the 90% Standard is not met. a. Method DHCFP and/or an EQRO will validate this annually by means of on-site observations, chart reviews, enrollee satisfaction surveys, review of grievances, and interviews with enrollees.

b. Frequency DHCFP and/or the EQRO will conduct reviews of available data at least annually.

6. Medical Records Standards

A. Measurement Of the 16 elements of medical record keeping, nine are critical and must be present in each record. The critical items for medical record keeping are as follows: 1) patient identification information; 2) personal/biographical data; 3) entry date; 4) provider identification; 5) legibility; 6) allergies; 7) immunizations; 8) medication information; and 9) identification of current problems.

A sample of the MCO’s Nevada Check Up participants’ medical records will be reviewed: 90% of records reviewed must contain medical record keeping and patient visit data items indicated as critical. An action plan will be required if the percent of standard is less than 90%.

B. Method

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Medical records will be reviewed.

C. Frequency Record reviews will be conducted annually by DHCFP and /or an EQRO. If the reviewed sample does not meet the minimum criteria, a corrective action plan will be required from the MCO and follow-up will be done by the DHCFP staff.

(Please note that the specific standards may be altered as a result of contract negotiations.)

7.1.3.

Information strategies A new one-step application and enrollment process is being developed and was implemented as of July 2003. At the time of application completion, the head of household must choose a health plan from information provided on the application. Nevada Check Up eligibility specialists enters the MCO or fee-for-service information while determining eligibility.

Nevada Check Up enrolled families receive a handbook from their chosen health plan which describes the benefits provided to enrollees under the program. These materials also describe enrollee rights and responsibilities and the specific steps to file a complaint.

DHCFP will collect information from the health plans on a quarterly and annual basis. This reporting provides information on enrollment, demographics, ethnic characteristics, outreach efforts, use of medical and dental services, enrollee grievance information, and data on financial expenditures. Information is used by DHCFP to document performance and assure adequate program accountability.

The Division, MCO and/or the External Quality Review Organization (EQRO) will conduct yearly consumer satisfaction surveys no more than three months after the end of the first year of the contract and every year thereafter. This data is compiled and analyzed. Where areas of concern exist, an audit will be performed and if the area of concern is valid, the MCO will be required to produce a plan of correction as is currently required under the

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Medicaid Managed Care program.

7.1.4.

Quality improvement strategies Quality improvement strategies, with which the MCO contractor must comply, are as follows:

1) Requirements for written policies and procedures regarding prior authorization standards and criteria, and for periodic review and updating of said policies and procedures; 2) Policies and procedures regarding utilization review activities, including reports to state agencies on methods from reviewing, and follow-up activities required based on the outcome of the review activities; 3) Establishment (including requirements) of a quality assurance program designed to direct, evaluate and monitor the effectiveness of health care services provided to its enrollees. The program must include, as defined in the Nevada Statutes, without limitation: a) A method for analyzing the outcomes of health care services; b) Peer review; c) A system to collect and maintain information related to the health care services provided to enrollees; d) Recommendations for remedial actions; and e) Written guidelines that set forth the procedures for remedial action when problems related to quality of care are identified. 4) Corrective action plans will be required as indicated above, where quality standards, consumer satisfaction surveys or performance measurements are below those stated standards; 5) In severe or blatant cases of non-compliance, the Division will assess liquidated damages for not meeting performance measures.

7.2. Describe the methods used, including monitoring, to assure: (2102(a)(7)(B)) (42CFR 457.495)

7.2.1 Access to well-baby care, well-child care, well-adolescent care and childhood and adolescent immunizations. (Section 2102(a)(7)) (42CFR 457.495(a))

Refer to Section 7.1.1., item 1. & 2. Section 7.1.2., item 1. & 2.

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All Nevada Check Up participants are encouraged to seek well-baby and well-child care. The MCO contracts contain standards for well-baby and well-child visits at not less than the national baseline average, along with the immunizations recommended in section 7.1.1., number 2. The contract standards include establishing, maintaining, and reporting on records of these visits and immunizations. They are also required to send out reminder notices to families that a well-child check or immunization is due. FFS providers are expected to comply with the American Academy of Pediatrics periodicity schedule for well-baby and well-child care purposes.

The Medicaid Managed Care contract requires that HEDIS measurements be used to evaluate an MCO’s performance. The MCO’s HEDIS immunization measurement rates must be comparable to the HEDIS National Medicaid average. The contract includes provision for development of corrective action plans if performance is not adequate.

7.2.2 Access to covered services, including emergency services as defined in 42 CFR 457.10. (Section 2102(a)(7)) 42CFR 457.495(b))

Emergency Services: The MCOs cannot require participants to seek prior authorization for services in a medical or behavioral health emergency. MCOs must inform their enrollees that access to covered emergency services is not restricted and that if the participant experiences a medical or behavioral health emergency, he/she may obtain services from a non- plan physician or other qualified provider without penalty. However, health plans may deny payment for such a visit should the visit be determined as a non-emergency using a prudent lay person standard. The health plan may require members to obtain prior authorization for any recommended or requested follow-up care pursuant to the emergency.

7.2.3 Appropriate and timely procedures to monitor and treat enrollees with chronic, complex, or serious medical conditions, including access to an adequate number of visits to specialists experienced in treating the specific medical condition and access to out-of-network providers when the network is not adequate for the enrollee’s medical condition. (Section 2102(a)(7)) (42CFR 457.495(c)) Refer to Section 7.1.1., item 6. and Section 7.1.2., item 5.

Service Accessibility: The MCO must take measures to ensure compliance with the access standards. DHCFP monitors MCO performance and will take action if problems are identified. Access to care analyses will be based on the results of participant

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satisfaction surveys participant complaint data, and appointment scheduling. The number of participants enrolled will be used to determine the adequacy of the MCO’s panel of PCPs and specialists.

The contract with managed care providers requires that their Enrollee Services Departments assist enrollees in obtaining out-of-area and out-of- network care. The children in Nevada Check Up’s fee-for-service component are free to seek services from any Medicaid provider in the state. Out-of-state and out-of-network providers will be accepted if they are willing to abide by the terms of Nevada Check Up claims payment rates and processes. The participants enrolled in fee-for-service have more direct access to specialists and out-of-state providers in that their care is directed by their primary care physicians who will often make referrals for the participants. The Medicaid district offices will also assist Nevada Check Up families with access to care.

Twenty-four (24) Hour Coverage: The MCO must provide health care coverage to its members, twenty-four (24) hours a day and seven (7) days a week. The MCO must instruct their enrollees how to obtain services after business hours and on weekends.

Telephone Access: The MCO may require their PCPs to have primary responsibility for serving as after hours “on-call” telephone resources to members with medical problems. Whether or not the plan assigns primary responsibility for after hours telephone access to a PCP, it must have a twenty-four (24) hour toll free telephone number for members to call, which must be answered by a live person.

Days to Appointment: The MCO must abide by the following appointment standards:

• Urgent medical or behavioral problems within 24 hours; • Non-urgent “sick visits” within 48 hours, as clinically indicated; • Routine, non-urgent or preventive care visits within two weeks: and • In-plan, non-urgent mental health or substance abuse visits within two weeks.

7.2.4 Decisions related to the prior authorization of health services are completed in accordance with state law or, in accordance with the medical needs of the patient, within 14 days after the receipt of a request for services. (Section 2102(a)(7)) (42CFR 457.495(d))

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State licensed MCOs are the principal health plan providers for enrollees who reside in areas served by managed care. Under Nevada Revised Statute 695C, these entities are subject to oversight and regulation by the Division of Insurance (DOI). The DOI is primarily responsible for monitoring initial capitalization and financial solvency. The Health Division is charged with monitoring quality of care and assuring the availability of and accessibility to health services. Requests for prior authorization are within the purview of this section. The MCOs are allowed a maximum of 14 days from the date of receipt of the request to provide an answer. In accordance with Title 42CFR 457.495(d)(1), there is allowance for an additional 14 days if the participant requests an extension or if the health care provider determines additional information is needed. Nevada Check Up fee-for-service prior authorization requests are processed by the fiscal agent and are completed in the same manner and time frames as are required for Medicaid.

To obtain licensure, certain requirements regarding availability and access must be satisfied by an MCO. These requirements are:

• Coverage for basic health services, including emergency services; • Provisions for access to primary care physician for each subscriber; • Evidence of arrangements for the ten most commonly used specialists; • Policies on obtaining referrals for specialty care; • Physician and provider network capacities.

Many of these requirements are evaluated: initially upon licensure; upon request for service area expansion; and periodically through complaint and grievance monitoring; and on-site visits by both Divisions.

To participate in the Nevada Check Up program, MCOs must establish and maintain provider networks with sufficient number of providers in each contracted geographic service area. The MCOs’ networks must contain all provider types necessary to provide to its enrollees a continuum of services which includes primary and preventive care and includes the diagnosis, management and treatment of a variety of diseases and conditions, as well as specialized care to handle complex health problems. The MCO must include the provider types necessary to furnish the prepaid benefit package, including: hospitals; physicians (primary care and specialists); mental health and substance abuse providers; nursing homes; and pharmacies. If an MCO is unable to

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provide the medically necessary covered service within its provider network, it must allow the participant to obtain the service through an out-of-network provider. The MCO must facilitate the referral to an out- of-network provider on behalf of the enrollee and must reimburse the out-of-network provider at not less than the Medicaid FFS rate for the covered service. MCOs shall not include in their networks any medical provider who has been sanctioned by Medicare or Medicaid.

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Section 8. Cost Sharing and Payment (Section 2103(e))

Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan, and continue on to Section 9.

8.1. Is cost-sharing imposed on any of the children covered under the plan? (42CFR 457.505)

8.1.1.

YES 8.1.2.

NO, skip to question 8.8.

8.2. Describe the amount of cost-sharing, any sliding scale based on income, the group or groups of enrollees that may be subject to the charge and the service for which the charge is imposed or time period for the charge, as appropriate. (Section 2103(e)(1)(A)) (42CFR 457.505(a), 457.510(b) &(c), 457.515(a)&(c))

8.2.1. Premiums: A quarterly premium is charged per family based on gross income, except for American Indians who are members of federally recognized Tribes and Alaska Natives, who are exempt from premiums. Starting April 1, 2008, families whose incomes are at or above 176% of FPL, the premium is $80 per quarter ($320 per year). For families whose incomes are at or above 151% FPL but at or below 175% FPL, the premium is $50 per quarter ($200 per year). For families whose incomes are at or above 36% FPL up to 150% FPL, the premium will be $25 per quarter ($100 per year) and these families are offered the option of paying their premium monthly, rather than quarterly. For families whose incomes are below 36% FPL, the premium is zero. These enrollees are either Medicaid referrals or have assets that would preclude their enrollment in Medicaid.

Families whose incomes are at or below 150% FPL are notified on the premium notice that Nevada Check Up premiums may be paid on a monthly basis.

8.2.2. Deductibles: There are no deductibles. 8.2.3. Coinsurance or copayments: There is no coinsurance. 8.2.4. Other:

8.3. Describe how the public will be notified, including the public schedule, of this cost sharing (including the cumulative maximum) and changes to these amounts and any differences based on income. (Section 2103(e)((1)(B)) (42CFR 457.505(b))

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The cost sharing information is explained to potential enrollees through the application, which includes a chart of income eligibility and premium payment amounts on its cover. If changes are necessary to the cost sharing requirements of Nevada Check Up, all current enrollees are notified by letter of the changes and effective dates. Public hearings are held to allow the public to comment on any proposed changes to cost sharing in Nevada Check Up.

8.4. The state assures that it has made the following findings with respect to the cost sharing in its plan: (Section 2103(e))

8.4.1.

Cost-sharing does not favor children from higher income families over lower income families. (Section 2103(e)(1)(B)) (42CFR 457.530) 8.4.2.

No cost-sharing applies to well-baby and well-child care, including age-appropriate immunizations. (Section 2103(e)(2)) (42CFR 457.520) 8.4.3

No additional cost-sharing applies to the costs of emergency medical services delivered outside the network. (Section 2103(e)(1)(A)) (42CFR 457.515(f))

8.5. Describe how the state will ensure that the annual aggregate cost-sharing for a family does not exceed 5 percent of such family’s income for the length of the child’s eligibility period in the State. Include a description of the procedures that do not primarily rely on a refund given by the state for overpayment by an enrollee: (Section 2103(e)(3)(B)) (42CFR 457.560(b) and 457.505(e))

The cost sharing requirements are set at very low levels so it is extremely unlikely that any families over 150% of FPL could approach the 5 percent cap. For a family of two at 150% of FPL, the 5 percent cap is $994 ($19,898 x .05); the total Nevada Check Up annual premiums are $100. For a family of two at 166% of FPL, the 5 percent cap is $1,101 ($22,020 x .05); the total Nevada Check Up annual premiums are $200. For a family of two at 200% of FPL, the 5 percent cap is $1,327 ($26,531 x .05); the total Nevada Check Up annual premiums are $320.

To further illustrate how low Nevada Check Up’s premium amounts are, a family of two with income of $13,265 is at 100% FPL and, if eligible for enrollment in Nevada Check Up, would pay $100 each year in premiums, less than 1% of their income. The maximum allowed for SCHIP cost sharing in this case is $663 per year. At the extreme low level (36% FPL) of those charged premium fees, the 5% cap equals $239 annually and Nevada Check Up premium totals $100.

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The State does not impose any other co-payment or deductible.

8.6. Describe the procedures the state will use to ensure American Indian (as defined by the Indian Health Care Improvement Act of 1976) and Alaska Native children will be excluded from cost-sharing. (Section 2103(b)(3)(D)) (42CFR 457.535)

The instructional section of the application states that premiums are waived for any household with an American Indian or Alaska Native child. Additionally, the application includes an ethnicity question and through self declaration, the family indicates each child’s ethnicity. This information is utilized to derive the premium notices. The Nevada Check Up database includes an edit to set the premium amount to zero if an American Indian or Alaska Native child is in the household.

8.7. Please provide a description of the consequences for an enrollee or applicant who does not pay a charge. (42CFR 457.570 and 457.505(c))

The applications will be processed and those found eligible are enrolled subject to a full enrollment limitation. If the applicant fails to pay the premium fee, the child(ren) are disenrolled after 30 days. American Indians who are members of federally recognized Tribes and Alaska Natives are exempt from paying premiums.

8.7.1 Please provide an assurance that the following disenrollment protections are being applied:

State has established a process that gives enrollees reasonable notice of and an opportunity to pay past due premiums, copayments, coinsurance, deductibles or similar fees prior to disenrollment. (42CFR 457.570(a)) • Participating families are always given 30 days written notice of any action that will result in their disenrollment from Nevada Check Up.

The disenrollment process affords the enrollee an opportunity to show that the enrollee’s family income has declined prior to disenrollment for non-payment of cost-sharing charges. (42CFR 457.570(b)) • Families who receive notices of impending disenrollment are encouraged to respond with documentation that will assist eligibility staff to modify their premium and allow their continued enrollment in Nevada Check Up.

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In the instance mentioned above, that the state will facilitate enrolling the child in Medicaid or adjust the child’s cost-sharing category as appropriate. (42CFR 457.570(b)) • Nevada Check Up denies enrollment and refers all children to Medicaid who appear to be Medicaid eligible at the time of application. Families who are Medicaid eligible must apply for Medicaid and cooperate with the Medicaid eligibility process. These families are not considered for enrollment in Nevada Check Up until any Medicaid questions have been resolved and/or their circumstances change with the result that they are no longer Medicaid eligible. Cost sharing is always adjusted based on family income.

The state provides the enrollee with an opportunity for an impartial review to address disenrollment from the program. (42CFR 457.570(c)) • Nevada Check Up letters always include information on how to request a review of any decision that impacts the family’s enrollment.

8.8. The state assures that it has made the following findings with respect to the payment aspects of its plan: (Section 2103(e))

8.8.1.

No Federal funds will be used toward state matching requirements. (Section 2105(c)(4)) (42CFR 457.220) • DHCFP ensures that no Federal funds accounts for in any way to make them appear as if they were part of a state match.

8.8.2.

No cost-sharing (including premiums, deductibles, copays, coinsurance and all other types) will be used toward state matching requirements. (Section 2105(c)(5) (42CFR 457.224) (Previously 8.4.5) • Cost sharing funds received by Nevada Check Up are used only to defray administrative costs of the program.

8.8.3.

No funds under this title will be used for coverage if a private insurer would have been obligated to provide such assistance except for a provision limiting this obligation because the child is eligible under the this title. (Section 2105(c)(6)(A)) (42CFR

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457.626(a)(1)) • Nevada Check Up does not provide insurance to families who have private insurance or have access to affordable private insurance.

8.8.4.

Income and resource standards and methodologies for determining Medicaid eligibility are not more restrictive than those applied as of June 1, 1997. (Section 2105(d)(1)) (42CFR 457.622(b)(5)) • Medicaid eligibility is determined by NSWD eligibility specialists and is in compliance with Federal standards.

8.8.5.

No funds provided under this title or coverage funded by this title will include coverage of abortion except if necessary to save the life of the mother or if the pregnancy is the result of an act of rape or incest. (Section 2105)(c)(7)(B)) (42CFR 457.475) • DHCFP assures that abortion coverage is only that which complies with the rules set forth in the citations listed above.

8.8.6.

No funds provided under this title will be used to pay for any abortion or to assist in the purchase, in whole or in part, for coverage that includes abortion (except as described above). (Section 2105)(c)(7)(A)) (42CFR 457.475) • DHCFP assures that abortion coverage is only that which complies with the rules set forth in the citations listed above.

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Section 9. Strategic Objectives and Performance Goals and Plan Administration (Section 2107)

9.1. Describe strategic objectives for increasing the extent of creditable health coverage among targeted low-income children and other low-income children: (Section 2107(a)(2)) (42CFR 457.710(b)) The strategic objectives for the Nevada Check Up program are to: 1. Increase the availability of comprehensive low cost health coverage for children at or below 200% FPL, and not eligible for Medicaid. 2. Provide an application and enrollment process which is easy for targeted low income families to understand and use. 3. Improve accessibility to dental providers for children enrolled in Nevada Check Up. 4. Through the administration of the Covering Kids and Families grant, assure the participation of community-based organizations in outreach and education activities. 5. Assure a high degree of participant satisfaction with the Nevada Check Up program.

9.2. Specify one or more performance goals for each strategic objective identified: (Section 2107(a)(3)) (42CFR 457.710(c)) The following performance goals and measures will be used to evaluate the program’s effectiveness: 1.1 Increase the percentage of children enrolled in Nevada Check Up by 5% annually, thus decreasing overall uninsured child rates in Nevada. 1.2 Process applications and enroll Nevada Check Up applicants within 30 days from the date the application is received. 2.1 Provide timely application completion assistance through dial up telephone support in both English and Spanish. 2.2 Simplify the Nevada Check Up application from a two-step to a one-step process. 2.3 Create and implement an annual quality improvement review of the Nevada Check Up business processes. 3. Achieve year to year improvements in the percentage of targeted low income children that have had a visit with a dental provider during the year. 4.1 Achieve effective outreach and education activities by community-based organizations in collaboration with Covering Kids and Families. 4.2 Achieve annual increases in the number of outreach and education activities for Nevada Check Up provided by community-based organizations in collaboration with Covering Kids and Families.

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4.3 Increase school-based outreach programs in the State of Nevada, resulting in an increase in the number of Nevada Check Up applications submitted that are directly attributable to school-based outreach activities. 5. Achieve a high degree of satisfaction with parents and guardians of Nevada Check Up participants as measured by an annual survey.

9.3. Describe how performance under the plan will be measured through objective, independently verifiable means and compared against performance goals in order to determine the state’s performance, taking into account suggested performance indicators as specified below or other indicators the state develops: (Section 2107(a)(4)(A),(B)) (42CFR 457.710(d))

Check the applicable suggested performance measurements listed below that the state plans to use: (Section 2107(a)(4)) 9.3.1.

The increase in the percentage of Medicaid-eligible children enrolled in Medicaid. 9.3.2.

The reduction in the percentage of uninsured children. 9.3.3.

The increase in the percentage of children with a usual source of care. 9.3.4.

The extent to which outcome measures show progress on one or more of the health problems identified by the state. 9.3.5.

HEDIS Measurement Set relevant to children and adolescents younger than 19. 9.3.6.

Other child appropriate measurement set. List or describe the set used. 9.3.7.

If not utilizing the entire HEDIS Measurement Set, specify which measures will be collected, such as: 9.3.7.1. Immunizations 9.3.7.2. Well childcare 9.3.7.3. Adolescent well visits 9.3.7.4. Satisfaction with care 9.3.7.5. Mental health 9.3.7.6. Dental care 9.3.7.7. Other, please list: 9.3.8.

Performance measures for special targeted populations.

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9.4.

The state assures it will collect all data, maintain records and furnish reports to the Secretary at the times and in the standardized format that the Secretary requires. (Section 2107(b)(1)) (42CFR 457.720)

9.5.

The state assures it will comply with the annual assessment and evaluation required under Section 10. Briefly describe the state’s plan for these annual assessments and reports. (Section 2107(b)(2)) (42CFR 457.750) The state’s plan for the assessments and reports will include an annual update of a survey on insurance coverage for children in Nevada. This survey will initially be used to determine the extent of coverage and related crowd-out issues, but will be designed to allow for additional questions on health status, access to care and other issues as appropriate.

The state will also perform surveys of families on the program regarding access to care, grievance resolution and overall satisfaction. HEDIS reporting will be evaluated for quality of health coverage.

The information will be compiled by state staff and will address each of the performance goals included in Section 9.2. Variances will be addressed and evaluated to determine policies to improve the performance of the program. Also, performance goals will be reevaluated and changes made as appropriate.

9.6.

The state assures it will provide the Secretary with access to any records or information relating to the plan for purposes of review of audit. (Section 2107(b)(3)) (42CFR 457.720)

9.7.

The state assures that, in developing performance measures, it will modify those measures to meet national requirements when such requirements are developed. (42CFR 457.710(e))

9.8. The state assures, to the extent they apply, that the following provisions of the Social Security Act will apply under Title XXI, to the same extent they apply to a state under Title XIX: (Section 2107(e)) (42CFR 457.135)

9.8.1.

Section 1902(a)(4)(C) (relating to conflict of interest standards) 9.8.2.

Paragraphs (2), (16) and (17) of Section 1903(i) (relating to limitations on payment) 9.8.3.

Section 1903(w) (relating to limitations on provider donations and taxes)

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9.8.4.

Section 1132 (relating to periods within which claims must be filed)

9.9. Describe the process used by the state to accomplish involvement of the public in the design and implementation of the plan and the method for insuring ongoing public involvement. (Section 2107(c)) (42CFR 457.120(a) and (b)) Public input on the design and implementation of the plan has been accomplished through various means:

a) The Department of Human Resources prepared a four-page outline designed as a program framework. The outline was used to solicit public comment at four public hearings held throughout the state:

October 22, 1997 in Las Vegas

December 4, 1997 in Fallon

December 5, 1997 in Reno

December 10, 1997 in Las Vegas b) The Legislative Committee on Health Care is a standing committee of Nevada’s Legislature. The Committee held monthly meetings for a period of time after October 1997, at which the Nevada Check Up program was discussed. In addition to six legislators, approximately 25 other interested parties were also represented including: • State agencies • County agencies • Hospitals • Labor unions • Health Maintenance Organizations (HMOs) • Physicians and other health professionals • Federally Qualified Health Centers (FQHC) • Native American Advocacy Groups • American Association of Retired Persons • Legal Services Statewide Advocacy Office • Children’s Advocacy groups The recommendations of the legislative body as well as the comments from the public and private sectors were taken into consideration in the drafting of the State Plan. Once available for distribution, copies of the State Plan were mailed to all persons who requested a copy in writing; and to all interested person and entities who participated in the initial public hearing process previously described. The state plan is also available through the Internet on the DHCFP/Nevada Check Up website.

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In order to ensure ongoing involvement with the public, Nevada Check Up works closely with other public agencies and the Covering Kids and Families (CKF) Coalition. The Coalition monitors the progress of two local outreach projects in Northern and Southern Nevada, and rural outreach activities targeted at sustaining the CKF goals of outreach, coordination and simplification. Coalition members are recruited from a broad segment of the community and their mission is to promote awareness of children’s health care coverage through the SCHIP and Medicaid programs.

Nevada Check Up notifies all applicants and participants of changes to the program in writing. Program modifications relating to enrollment levels, eligibility criteria and/or cost sharing require public hearings. The public hearings are widely advertised as to date, time, location and subject matter.

9.9.1 Describe the process used by the state to ensure interaction with Indian Tribes and organizations in the state on the development and implementation of the procedures required in 42 CFR 457.125. (Section 2107(c)) (42CFR 457.120(c)) Representatives of Indian tribal organizations and advocacy groups are members of the Statewide Covering Kids Coalition, which conducts meetings and also includes representatives from Medicaid and Nevada Check Up.

Nevada Check Up participates in Native American Advisory Council meetings, as required by state law, to provide information to the council and to receive advice about the effectiveness of certain marketing and training activities. Nevada Check Up has conducted training in application completion, along with the necessary inclusion of required documentation, for Tribal Clinic staff. This training allows the clinics to help their patients complete a Nevada Check Up application and attach the required documents before it is submitted to the state. This training has reduced the number of applications placed in pending status because of missing information.

Nevada Check Up staff attends and participates in quarterly Inter-Tribal Council meetings and other events.

9.9.2 For an amendment relating to eligibility or benefits (including cost sharing and enrollment procedures), please describe how and when prior public notice was provided as required in §457.65(b) through (d).\

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Public notice is provided pursuant to NRS 422.2368. Public hearing was provided for the sections related to adding back services per legislative directive effective July 1, 2009. Appropriate publishing and postings were completed on June 12, 2009 and the hearing was conducted on July 14, 2009 so that anyone interested could comment.

For updates effective September 1, 2008, public notice is provided pursuant to NRS 422.2368. Public hearing was provided for the changes to established coverage in this State Plan on August 26, 2008. Appropriate publishing and postings were completed on July 25, 2008 and the hearing was conducted to solicit feedback.

Public notice is provided pursuant to NRS 422.2368. Public hearing was provided for the sections related to the premium increase in this State Plan on March 11, 2008. Appropriate publishing and postings were completed on February 5, 2008 and the hearing was conducted so that anyone interested could comment.

For the proposal to eliminate provisional enrollment, public notice was provided pursuant to NRS 422.2368. The public hearing was conducted on July 13, 2004. Appropriate publishing and postings were completed in timely fashion and the hearings were conducted in a manner that encouraged interested parties to express their opinions.

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9.10. Provide a one year projected budget. A suggested financial form for the budget is attached. The budget must describe: (Section 2107(d)) (42CFR 457.140) • Planned use of funds, including -- - Projected amount to be spent on health services; - Projected amount to be spent on administrative costs, such as outreach, child health initiatives, and evaluation; and - Assumptions on which the budget is based, including cost per child and expected enrollment. • Projected sources of non-Federal plan expenditures, including any requirements for cost-sharing by enrollees. A suggested financial form for the budget is attached. The budget must describe: • Planned use of funds, including: 1. Projected amount to be spent on health services. 2. Projected amount to be spent on administrative costs, such as: outreach, child health initiatives, an evaluation; and 3. Assumptions on which the budget is based, including cost per child and expected enrollment. • Projected sources of non-federal plan expenditures, including any requirements for cost sharing by enrollees.

• In July 2004, Nevada Check Up discontinued the practice of provisional enrollment. Although the actual impact is unknown, it appears to be budget neutral.

The budget for the Nevada Check Up program is included below for Federal Fiscal Years (FFY) 2003 and 2004. The amounts represent the maximum funding that is being committed to the program, even though full enrollment may not be achieved. Actual cost may be significantly lower. The state’s share of funding comes through appropriations from the State General Fund.

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CHIP Budget Template STATE:___NEVADA__________ FFY Budget Budget Increase/ decrease For Requested SPA New Budget with SPA Budget Increase/ decrease Federal Fiscal Year FFY 2010 FFY 2010 FFY 2010 State's enhanced FMAP rate 65.11/34.89 65.11/34.89 65.11/34.89 Benefit Costs

Insurance payments $ 00 $ 00 $ 00 Managed care $ 26,877,248 $ 732,553 $ 27,609,801 per member/per month rate

Fee for Service $ 9,242,250 $ 264,765 $ 9,507,015 Total Benefit Costs $ 36,119,498 $ 997,318 $ 37,116,816 (Offsetting beneficiary cost sharing payments) $ (1,813,687) $ $ (1,813,687) Net Benefit Costs $ 34,305,811 $ 997,318 $ 35,303,129

Administration Costs

Personnel $ 1,409,728 $ $ 1,409,728 General administration $ 546,388 $ $ 546,388 Contractors/Brokers $ 00 $ 00 $ 00 Claims Processing $ 00 $ 00 $ 00 Outreach/marketing costs $ 00 $ 00 $ 00 Other $ 00 $ 00 $ 00 Total Administration Costs $ 1,956,117 $ $ 1,956,117 10% Administrative Cap (Net Benefit Costs /9) $ 3,811,756 $ $ 3,922,569

Federal Share $ 23,610,141 $ 649,354 $ 24,259,495 State Share $12,651,786 $ 347,964 $ 12,999,750 TOTAL COSTS OF APPROVED CHIP PLAN $36,261,927 $ 997,318 $ 37,259,245 Source of State Funds: _____________________

FFY projected numbers based on State Fiscal Year (SFY) 2008 actual numbers and SFY 2009 budgeted numbers.

FFY 2008 Actual Average Monthly Enrollment: 27,981 FFY 2008 Actual Average Annual Benefit Child per Child: $1,397 FFY 2009 Projected Average Monthly Enrollment 25,000 FFY 2008 Projected Average Annual Benefit Cost per Child: $1,658

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FFY 2009 projected savings are SFY 2009 budget projection for capping dental at $600, eliminating orthodontia, and eliminating non-medical vision care: $698,966.00.

SFY 2010 projected cost for adding back orthodontia, EPSDT, non-medical vision and removal of dental cap is ($997, 318.00) per SFY.

SFY 2008-2009 BUDGETED ENROLLMENT (Note 2.) ACTUAL ENROLLMENT BUDGET VS. ACTUAL ENROLLMENT GROWTH RATE BUDGETED GROWTH RATE ACTUAL SFY 2008

July 29,723 29,728 -5 -9.13% -0.57% August 29,699 29,969 -270 -0.08% 0.81% September 29,851 30,204 -353 0.51% 0.78% October 29,686 29,919 -233 -0.55% -0.94% November 29,757 30,184 -427 0.24% 0.89% December 30,005 29,456 549 0.83% -2.41% January 30,213 29,178 1,035 0.69% -0.94% February 30,459 28,896 1,563 0.81% -0.97% March 30,572 28,751 1,821 0.37% -0.50% April 30,974 28,158 2,816 1.31% -2.06% May 31,128 27,625 3,503 0.50% -1.89% June 31,306 26,832 4,474 0.57% -2.87% MONTHLY AVERAGE 30,281 29,075 Annual Growth Rate -4.45% -2.54%

SFY 2009

July 26,593 25,998 595 -15.05% 3.11% August 26,357 25,889 468 -0.89% -0.42% September 25,032 24,881 151 -5.03% -3.89% October 25,000 24140 860 -0.13% -2.98% November 25,000 23893 1,107 0.00% -1.02% December 25,000 23356 1,644 0.00% -2.25% January 25,000 22888 2,112 0.00% -2.00% February 25,000 22525 2,475 0.00% -1.59% March 25,000 22527 2,473 0.00% 0.01% April 25,000 22437 2,563 0.00% -0.40% May 25,000 22562 2,438 0.00% 0.56% June 25,000 22444 2,555 0.00% -0.52% MONTHLY AVERAGE 25,248 23,628 Annual Growth Rate - -16.62%

-18.73%

SFY 2010

July 22,737 22,101 636 9.05% 1.53% August 22,937 21,999 938 .88% -0.46% September 23,187

0.00%

October 23,487

0.00%

November 23,837

0.00%

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December 24,237

0.00%

January 24,687

0.00%

February 25,187

0.00%

March 25,737

0.00%

April 26,337

0.00%

May 26,987

0.00%

June 27,677

0.00%

MONTHLY AVERAGE 24,753

Annual Growth Rate 0.00%

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Section 10. Annual Reports and Evaluations (Section 2108)

10.1. Annual Reports. The state assures that it will assess the operation of the state plan under this Title in each fiscal year, including: (Section 2108(a)(1),(2)) (42CFR 457.750)

10.1.1.

The progress made in reducing the number of uncovered low- income children and report to the Secretary by January 1 following the end of the fiscal year on the result of the assessment, and

10.2.

The state assures it will comply with future reporting requirements as they are developed. (42CFR 457.710(e))

10.3.

The state assures that it will comply with all applicable Federal laws and regulations, including but not limited to Federal grant requirements and Federal reporting requirements. 10.3D.

Specify that the State agrees to submit yearly the approved dental benefit package and to submit quarterly the required information on dental providers in the state to the Human Resources and Services Administration for posting on the Insure Kids Now! website. Nevada met the August 4, 2009 deadline for posting of both the dental package and dental provider information. The provider list updates will be sent the first of the month following a quarter.

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Section 11. Program Integrity (Section 2101(a))

Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan, and continue to Section 12.

11.1.

The state assures that services are provided in an effective and efficient manner through free and open competition or through basing rates on other public and private rates that are actuarially sound. (Section 2101(a)) (42CFR 457.940(b))

11.2. The state assures, to the extent they apply, that the following provisions of the Social Security Act will apply under Title XXI, to the same extent they apply to a state under Title XIX: (Section 2107(e)) (42CFR 457.935(b)) The items below were moved from section 9.8. (Previously items 9.8.6. - 9.8.9) 11.2.1.

42 CFR Part 455 Subpart B (relating to disclosure of information by providers and fiscal agents) 11.2.2.

Section 1124 (relating to disclosure of ownership and related information) 11.2.3.

Section 1126 (relating to disclosure of information about certain convicted individuals) 11.2.4.

Section 1128A (relating to civil monetary penalties) 11.2.5.

Section 1128B (relating to criminal penalties for certain additional charges) 11.2.6.

Section 1128E (relating to the National health care fraud and abuse data collection program)

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Section 12. Applicant and Enrollee Protections (Sections 2101(a))

Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan.

12.1. Eligibility and Enrollment Matters

Please describe the review process for eligibility and enrollment matters that complies with 42 CFR 457.1120.

Enrollees and applicants are informed of program eligibility requirements at the time of application and re-enrollment. In addition, they are assured of and informed about timely processing of application requirements. They are informed of their right to request a review for the following adverse actions: • Denial of eligibility; • Failure to make a timely determination of eligibility; • Suspension or termination of enrollment, including disenrollment for failure to pay cost sharing.

Enrollees and applicants are provided a written notice of decision explaining any adverse actions regarding eligibility and enrollment and have the right to request a review, followed by a state fair hearing, regarding such action. In addition, they have the right to request services continue pending the outcome of the review and hearing process. The agency will continue services if the enrollee requests a review and/or hearing in writing within 10 days of the notice date.

A review and/or hearing will not be granted if the sole issue is a change in the State Plan, federal or state law, requiring automatic change in eligibility, or a change in the health benefits package that affects all applicants or enrollees, or a group of applicants or enrollees without regard to their individual circumstances.

The applicant or enrollee may be granted an opportunity for a review and a fair hearing, if a written request for such is submitted within 30 days after the date of the notice of the decision. The review is conducted by a Reviewing Officer (RO) who is the Chief of Medicaid and Nevada Check Up Services or his/her designee. The RO must be an impartial party who has not been involved in the investigation or initial determination of the adverse action in question. The RO sets the review in a timely manner, based on the need for a standard review, or submitted justification from the health plan or physician for an expedited review. Enrollees or applicants may represent themselves or have a representative(s) of their choosing participate in the review process, which may be conducted in person or

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by telephone. Enrollees have the right to review their files and other applicable information relevant to the review of the decision.

The RO prepares a written decision based on documentation in the case file and any supporting documentation or statements provided during the review process. The RO then provides the written decision in a timely manner as per the standard or expedited review mandates.

The written decision includes the date of the review, the findings of fact, any conclusions of law, the decision whether to affirm the adverse action, and the enrollee’s or applicant’s right to request a state fair hearing pursuant to state statute.

If the applicant requests a hearing, the request for hearing is referred to the DHCFP Hearings and Policy Unit, which will notify the Department of Administration (DOA) to schedule the fair hearing. In providing a fair hearing through DOA, the conduct of such is pursuant to Medicaid Services Manual Chapter 3100.

12.2. Health Services Matters

Please describe the review process for health services matters that comply with 42 CFR 457.1120. Participants are assured of their opportunity for an external review of the following adverse actions:

• Delay, denial, reduction, suspension or termination of a health services, in whole or in part, including a determination about the type or level of services; and • Failure to approve, furnish, or provide payment for health services in a timely manner.

Participants are provided a written notice of decision explaining any adverse actions regarding health services matters and have the right to specifically request an external review, followed by a state fair hearing, regarding such action. In addition, they have the right to have services continue pending the outcome of the review and/or hearing.

A review and/or hearing will not be granted if the sole issue is a change in the State Plan, federal or state law requiring automatic change in eligibility, or a change in the health benefits package that affects all applicants or enrollees, or a

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group of applicants or participants without regard to their individual circumstances.

The applicant or participant may be granted an opportunity for a review and a fair hearing if a written request for such is submitted within 30 days after the date of the notice of the decision. The review is conducted by a Reviewing Officer (RO) who is the Chief of Medicaid and Nevada Check Up Services or his/her designee. The RO must be an impartial party who has not been involved in the investigation or initial determination of the adverse action in question. The RO sets the review in a timely manner, based on the need for a standard review or submitted justification from the health plan or physician for an expedited review. Participants may represent themselves or have a representative(s) of their choosing participate in the review process, which may be conducted in person or by telephone. Participants have the right to review their files and other applicable information relevant to the review of the decision. If the participant requests an external review, the request for review is forwarded to the Hearings and Policy Unit and is scheduled in a timely manner by the unit supervisor or his/her designee.

The RO, or Hearings Supervisor, prepares a written decision based on documentation in the case file and any supporting documentation or statements provided during the review process. The RO, or Hearings Supervisor, then provides the written decision in a timely manner in accordance with the standard or expedited review mandates. The written decision includes the date of the review, the findings of fact, any conclusions of law, the decision whether to affirm the adverse action, and the enrollee’s right to request a state fair hearing pursuant to state statute.

The request for hearing is referred to the DHCFP Hearings Unit, which will notify the Department of Administration (DOA) to schedule the hearing requested. In providing a fair hearing through DOA, the conduct of such a hearing is pursuant to Medicaid Services Manuel Chapter 3100. 12.3. Premium Assistance Programs

If providing coverage through a group health plan that does not meet the requirements of 42 CFR 457.1120, please describe how the state will assure that applicants and enrollees have the option to obtain health benefits coverage other than through the group health plan at initial enrollment and at each redetermination of eligibility.

Not applicable.

NEVADA TITLE XXI PROGRAM FACT SHEET

1 Name of Plan:

Nevada Check Up

Date Plan Submitted:

March 11, 1998 Date Plan Approved:

August 13, 1998 Effective Date:

October 1, 1998

Date Amendment #1 Submitted: May 4, 2000 Date Amendment #1 Approved: September 22, 2000 Date Amendment #1 Effective: May 4, 2000

Date Amendment #2 Submitted: November 26, 2001 Date Amendment #2 Approved: February 7, 2002 Date Amendment #2 Effective: October 1, 2001

Date Amendment #3 Submitted: November 27, 2002 Date Amendment #3 Approved: December 11, 2002 Date Amendment #3 Effective: September 28, 2002

Date Amendment #4 Submitted: October 23, 2003 Date Amendment #4 Approved: April 2, 2004 Date Amendment #4 Effective: October 1, 2003

Date Amendment #5 Submitted: May 12, 2004 Date Amendment #5 Approved: September 14, 2004 Date Amendment #5 Effective: September 1, 2004

Date Amendment #6 Submitted: March 11, 2008 Date Amendment #6 Approved: September 8, 2008

Date Amendment #6 Effective: April 1, 2008

Date Amendment #7 Submitted: September 26, 2008 Date Amendment #7 Approved: May 6, 2009 Date Amendment #7 Effective: September 1, 2008

Date Amendment #8 Submitted: September 30, 2009 Date Amendment #8 Approved: February 24, 2010

Date Amendment #8 Effective: July 1, 2009

Background

• Nevada created a separate child health program that provides coverage to children ages 0 up to 19 with family income at or below 200 percent of the Federal poverty level (FPL).

NEVADA TITLE XXI PROGRAM FACT SHEET

2 • Nevada's current Medicaid program covers children up to age 6 in families with income up to 133 percent of the FPL; children from age 6 through 13 in families with income up to 100 percent of the FPL; and, children age 14 through 18 in families with income up to 33 percent of the FPL. Children in families with income below 100 percent of the FPL may qualify for Nevada’s CHIP program because of an asset test in Nevada’s Medicaid program.

Amendments

• The first amendment waived cost sharing for children who are American Indians or Alaska Natives and are members of federally recognized Tribes. The first amendment also removed the six-month residency requirement. In addition, the amendment modified the redetermination process so that a child is eligible for the program for one year from the date of enrollment, provided they continue to meet eligibility criteria. Prior to implementing this new policy, the eligibility of all enrollees in the program was redetermined at the same time each year, regardless of the date of the enrollment.

• The second amendment was submitted on November 26, 2001 to eliminate unemployment compensation from being counted as income when determining eligibility. This amendment provided an increase of 1,700 eligible enrollees into Nevada's CHIP program.

• The third amendment was submitted on November 27, 2002 to include unemployment compensation as income when determining eligibility. The third amendment also updates and amends the CHIP State plan to indicate the State’s compliance with the final CHIP regulations.

• The fourth amendment was submitted on October 23, 2003 to increase quarterly premiums for families with income at or above 36 percent of the FPL. This amendment also updates the State’s description of the CHIP enrollment process, which allows children to be enrolled before the first quarter’s premium is paid.

• The fifth amendment was submitted on May 12, 2004 to eliminate provisional enrollment. This amendment also updates the State's description of the CHIP screening and enrollment process, which includes the addition of an electronic Medicaid screening tool.

• The sixth amendment was submitted on March 11, 2008 to increase quarterly premiums for children in families from 36 percent of the FPL up to 200 percent of the FPL, grant the authority to implement an enrollment cap, and specify that managed care is mandatory when it is available in a county for children enrolled in the State’s CHIP.

NEVADA TITLE XXI PROGRAM FACT SHEET

3 • The seventh amendment was submitted on September 26, 2008 to eliminate coverage of non-medical vision services and orthodontia services; implement a $600.00 annual benefit limit for dental care; update the State’s procedure regarding enrollment of newborns in CHIP; and update the State Plan to specify the policy differences between Nevada’s title XIX and title XXI program with the approval of this SPA.

• The eight amendment was submitted on September 30, 2009 to reinstate coverage of non medical vision services, EPSDT and orthodontia services; eliminates the $600 annual benefit limit for dental care; replaces the language that allows the State to contract with one managed care entity with the requirement of a choice of at least two plans where MCO enrollment is mandatory.

Children Covered Under the Program

• The State reported that 33,981 children were ever enrolled in the program during Federal fiscal year 2009.

Administration

• Nevada Check Up is administered by the Department of Health and Human Services.

Health Care Delivery System

• Approximately 72 percent of all children enrolled in Nevada Check Up receive their medical care through managed care organizations (MCOs). For the geographic areas not covered by an MCO, fee-for-service coverage is offered with the same benefit package.

Benefit Package

• Nevada Check Up provides services similar to those provided under Nevada’s Medicaid program. Coverage includes the full EPSDT benefit that the State has extended to the entire Medicaid population. Services not provided under managed care are provided under fee-for-service.

Cost Sharing

• For families with incomes from 36 up to 150 percent of the FPL, the premium is $25 per quarter. Families in this group are given the choice of paying premiums on a monthly or quarterly basis.

• For families with incomes above 150 up to 175 percent of the FPL, the premium is $50 per quarter.

NEVADA TITLE XXI PROGRAM FACT SHEET

4

• For families with incomes above 175 percent of the FPL, the premium is $80 per quarter.

• Written notice is provided to families when the quarterly premium is 30 days past due; 30 additional days will be allowed to receive payment. Consequently, a 60 day grace period is allowed prior to disenrollment for failure to pay the quarterly premium.

Crowd-Out Strategy

• The application includes questions about access to health care coverage, both public and private, which must be answered before the child is enrolled in the program. The State conducts random checks by contacting employers for verification of health insurance coverage.

• A child is ineligible for the program if they had coverage six months prior to application. The six-month waiting period is waived if the applicant provides evidence that the loss of insurance was due to actions outside their control (e.g., their employer discontinues health benefits).

Outreach Activities

• The State has simplified the application, which is available statewide through schools, child care facilities, family resource centers, social service agencies, and other locations where eligible children and/or their parents frequent. The program's toll-free number is listed on the application as well as on posters and marketing brochures.

• The State informs all 26 sovereign Tribal governments on changes concerning CHIP through its various subcommittees and advisory groups.

Coordination between CHIP and Medicaid

• The Nevada Check Up application functions as an application for Nevada Check Up and as a screening tool for Medicaid eligibility. Nevada Check Up screens all initial applications and redeterminations for Medicaid through an electronic screening tool that determines whether a child may be eligible for Medicaid.

• For children who appear eligible for Medicaid and who have also indicated on the application that they would like to be considered for Medicaid, the application is referred to the Medicaid Agency.

Financial Information

NEVADA TITLE XXI PROGRAM FACT SHEET

5

FFY 2010 CHIP Allotment: $65,134,621 FFY 2010 Enhanced Federal Matching Rate: 65.11%

Last Updated: February 24, 2010

_____________________________________________________________________________

Table of Contents

State/Territory Name: Nevada

State Plan Amendment (SPA) #: NV-13-0001

This file contains the following documents in the order listed:

1) Approval Letter 2) SPA Summary Form 3) Approved SPA Pages

The complete title XXI state plan for Nevada consists of the most recent state plan posted on Medicaid.gov under CHIP and State Plan Amendments. The link is provided below. The following approved templates are in addition to, or replace sections of the state’s posted current state plan. The attached approval letter(s) explain how these templates fit into that state plan. Link to state title XXI state plans and amendments: http://medicaid.gov/chip/state-program-information/chip- state-program-information.html

DEPARTMENT OF HEALTH & HUMAN SERVICES

Centers for Medicare & Medicaid Services “Cf. M gp

7500 Security Boulevard, Mail Stop: $2-26-12 Baltimore, Maryland 21244-1850 SeuTan oe Memcn 8 Car Sane

Children and Adults Health Programs Group

AUG 1 2 2016

Michael J. Willden, Director

Department of Health and Human Services 4126 Technology Way, Suite 100

Carson City, NV 89706

Dear Mr. Willden:

Iam pleased to inform you that the Centers for Medicare & Medicaid Services has approved your title XXI Children’s Health Insurance Program (CHIP) state plan amendment (SPA) number NV-13-0001, submitted on December 16, 2013, with additional information provided on August 1, 2014. This SPA is related to Modified Adjusted Gross Income (MAGI) Eligibility and has an effective date of January 1, 2014.

In SPA number NV-13-0001, page CS15 provides assurance that the state will apply methodologies based on MAGI for all separate CHIP covered groups. Page CS7 indicates that, using the approved MAGI conversion plan income thresholds, the state will cover targeted low- income children. 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.

Your title XXI project officer is Ms. Joyce Jordan. She is available to answer questions concerning these amendments and other CHIP-related issues. Ms. Jordan’s contact information is as follows:

Centers for Medicare & Medicaid Services Center for Medicaid and CHIP Services Mail Stop: S2-01-16

7500 Security Boulevard

Baltimore, MD 21244-1850

Telephone: (410) 786-3413

Facsimile: (410) 786-5882

E-mail: Joyce.Jordan@cms.hhs.gov

Official communications regarding program matters should be sent simultaneously to Ms. Jordan and to Ms. Hye Sun Lee, Acting Associate Regional Administrator (ARA) in our San Francisco Regional Office. Ms. Lee’s address is:

Page 2 — Mr. Michael Willden

Centers for Medicare & Medicaid Services 90 7th Street, Suite 5-300 (5W) San Francisco, California 94103-6706

Congratulations on the approval. We look forward to continuing to work with you and your staff toward the approval of your remaining MAGI Eligibility SPA. If you have additional questions, please contact Ms. Kelly Whitener, Director, Division of State Coverage Programs at (410) 786- 0719.

Sincerely,

Eliot Fishman Director

Enclosures

ce: Ms. Hye Sun Lee, Acting ARA, CMS Region IX, San Francisco

logged in as TONIABROWN(CMS CO Staff) read only mode application rev p01 Children's Health Insurance Program Eligibility NV.0609.R00.00 - Jan 01, 2014 Home Logout Finder Save Validate Print Help Control Panel General Information File Management Tribal Input Summary State/Territory name: Nevada State Funds: $ Federal Funds: $ Submitted By: Malinda Southard Last Revision Date: Jul 3, 2014 Submit Date: Dec 16, 2013 Children's Health Insurance Program Eligibility: Summary Page Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. NV-13-0001 Type of SPA: MAGI Eligibility & Methods XXI Medicaid Expansion Establish 2101(f) Group Eligibility Processing Non-Financial Eligibility Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation 2102(b)(1)(B)(v) of the SSA and 42 CFR 457.310, 315 and 320, 2(b)(1)(B)(v) of the SSA and Federal Budget Impact This SPA has a budget impact. Total budget impact: Subject of Amendment Please provide a brief summary of SPA changes. Character Count:227 out of 2000 CS7 Seperate CHIP program covers children 0-6 with income between 160-200% and children 6-19 with income between 133-200% FPL. CS15 MAGI Income methodologies are used in determining eligibility for children in the CHIP program. Signature of State Agency Official Page 1 of 2 Children's Health Insurance Program Eligibility: CMS 179 05/28/2015 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

FAQs | Site Map | Contact | Medicaid.gov | CMS.gov Page 2 of 2 Children's Health Insurance Program Eligibility: CMS 179 05/28/2015 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

CHIP Eligibility

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

2102(bN1)(B\(v) of the SSA and 42 CFR 457.310, 315 and 320

wi Targeted Low-Income Children - Uninsured children under age 19 whose household income is within standards established by the state.

[The CHIP Agency operates this covered group in accordance with the following provisions: Age

Must be under age 19. Income Standards

Income standards are applied statewide. | Yes

Are there any exceptions, e.g. populations in a county which may qualify under either a statewide income

. No standard or a county income standard?

Statewide Income Standards

Begin with lowest age range first.

Please note that the lower bound for CHIP eligibility should be the highest standard used for Medicaid poverty- level children for the same age group or groups entered here.

From Age To Age Above (% FPL) Up to & including (% FPL} +: jlo 6 160 200 x lo 19 133 200 x

Age ranges may overlap. If there is an overlap, provide an explanation. Include the age ranges for cach income standard that has overlapping ages and the reason for having different income standards.

Special Program for Children with Disabilities

PRA Disclosure Statement

AUG 12 2014

SPA# NV-13-0001 Approval Date: Effective Date: January 1, 2014

Page | of 2

coms CHIP Eligibility

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 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, 7300 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore. Maryland 21244-1850.

V.20130709

AUG 12 2014

SPA# NV-13-0001 Approval Date: Effective Date: January 1, 2014 Page 2 of 2

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

CHIP Eligibility

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

The CHIP Agency will apply Modified Adjusted Gross Income methodologies for all separate CHIP covered groups, as described below, and consistent with 42 CFR 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 each of the children she is expected to deliver.

In determining family size for the eligibility determination of the other individuals in a household that includes a pregnant woman: @ The pregnant woman is counted just as herself. C The pregnant woman is counted just as herself, plus one. C The pregnant woman is counted as herself. plus the number of children she is expected to deliver. Financial eligibility is determined consistent with the following provisions: When determining eligibility for new applicants, financial eligibility is based on current monthly income and family size. When determining eligibility for current beneficiaries, financial eligibility is based on: @ Current monthly household income and family size. C Projected annual household income 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: {X] Include a prorated portion of the 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 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.

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.

10

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.

i detachment is submited,

PRA Disclosure Statement

SPA# NV-13-0001 Approval Date: AUG 1 2 2014 Effective Date: January 1, 2014 Page 1 of 2

cmMs CHIP Eligibility

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

AUG 12 2014

SPA# NV-13-0001 Approval Date: Effective Date: January 1, 2014

Page 2 of 2

_____________________________________________________________________________

Table of Contents

State/Territory Name: Nevada

State Plan Amendment (SPA) #: NV-13-0002

This file contains the following documents in the order listed:

1) Approval Letter 2) SPA Summary Form 3) Approved SPA Pages

The complete title XXI state plan for Nevada consists of the most recent state plan posted on Medicaid.gov under CHIP and State Plan Amendments. The link is provided below. The following approved templates are in addition to, or replace sections of the state’s posted current state plan. The attached approval letter(s) explain how these templates fit into that state plan. Link to state title XXI state plans and amendments: http://medicaid.gov/chip/state-program-information/chip- state-program-information.html

DEPARTMENT OF HEALTH & HUMAN SERVICES

Centers for Medicare & Medicaid Services (CMs

7500 Security Boulevard, Mail Stop: S2-26-12 CM Ss (CENTERS FOR MEDICARE & MEDICAID SERVICES

Baltimore, Maryland 21244-1850

CENTER FOR MEDICAID & CHIP SERVICES

Children and Adults Health Programs Group

MAR 14 2014

Michael J. Willden, Director

Department of Health and Human Services 4126 Technology Way, Suite 100

Carson City, NV 89706

Dear Mr. Willden:

I am pleased to inform you that the Centers for Medicare & Medicaid Services has approved your title XXI Children’s Health Insurance Program (CHIP) state plan amendment (SPA) number NV-13-0002 submitted on December 16, 2013, and related Modified Adjusted Gross Income (MAGI) Eligibility with an effective date of January 1, 2014.

SPA number NV-13-0002 describes the state’s plan to provide coverage in its separate CHIP, for children subject to section 2101(f) of the Affordable Care Act, 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 CS14 is attached, and should be incorporated within a separate subsection under Section 4.1 of Nevada’s approved CHIP state plan.

Your title XXI project officer is Ms. Joyce Jordan. She is available to answer questions concerning these amendments and other CHIP-related issues. Ms. Jordan’s contact information is as follows:

Centers for Medicare & Medicaid Services Center for Medicaid and CHIP Services Mail Stop: $2-01-16

7500 Security Boulevard

Baltimore, MD 21244-1850

Telephone: (410) 786-3413

Facsimile: (410) 786-5882

E-mail: Joyce.Jordan@cms.hhs.gov

Official communications regarding program matters should be sent simultaneously to Ms. Jordan and to Ms. Gloria Nagle, Associate Regional Administrator (ARA) in our San Francisco Regional Office. Ms. Nagle’s address is:

Centers for Medicare & Medicaid Services 90 7th Street, Suite 5-300 (5W) San Francisco, California 94103-6706

Page 2 — Mr. Michael Willden

Congratulations on the approval. We look forward to continuing to work with you and your staff toward the approval of your remaining MAGI Eligibility SPAs. If you have additional questions, please contact Ms. Linda Nablo, Director, Division of State Coverage Programs at (410) 786-5143.

Sincerely,

Eliot Fishman Director

Enclosure

ce: Ms. Gloria Nagle, ARA, CMS Region VIII, San Francisco

logged in as TONIABROWN(CMS CO Staff) read only mode application rev p01 Children's Health Insurance Program Eligibility NV.0610.R00.00 - Jan 01, 2014 Home Logout Finder Save Validate Print Help Control Panel General Information File Management Tribal Input Summary State/Territory name: Nevada State Funds: $ Federal Funds: $ Submitted By: Robyn Heddy Last Revision Date: Mar 7, 2014 Submit Date: Dec 16, 2013 Children's Health Insurance Program Eligibility: Summary Page Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. NV-13-0002 Type of SPA: MAGI Eligibility & Methods XXI Medicaid Expansion Establish 2101(f) Group Eligibility Processing Non-Financial Eligibility Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation Section 2101(f) of the ACA and 42 CFR 457.310(d) Federal Budget Impact This SPA has a budget impact. Total budget impact: Subject of Amendment Please provide a brief summary of SPA changes. Character Count:225 out of 2000 CS14 Children ineligible for Medicaid as a result of elimination of income disregards. The CHIP agency provides coverage for these children for 12 months. These children will be provided the same benefits as the CHIP program. Signature of State Agency Official Page 1 of 2 Children's Health Insurance Program Eligibility: CMS 179 05/28/2015 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

FAQs | Site Map | Contact | Medicaid.gov | CMS.gov Page 2 of 2 Children's Health Insurance Program Eligibility: CMS 179 05/28/2015 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

CHIP Eligibility

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

Section 2101(f) of the ACA and 42 CFR 457.310(d)

[lj 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:

oO The state has received approval from CMS to maintain Medicaid eligibility for children who would otherwise be subject to Section 210 1(f) such that no child in the state will be subject to this pro vision.

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 c overage 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(f) of the Affordable Care Act:

The state has demonstrated and CMS has agreed that all children qualifying for section 210 1(f) protection will qualify for the state’s existing separate CHIP.

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 a 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 therefore covered in the separate CHIP.

200 % 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 applie d to the family income as determined by MAGI methodology.

C: Other.

Describe the benefits pro vided to this population:

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

© Other (consistent with Sectio n 2103 of the SSA and 42 CFR 457 Subpart D).

Describe premiums and cost sharing required of this population:

Cost sharing is the same as for children in the Medicaid program.

SPA# NV-13-0002 Approval Date:, MAR L 4 2014 Effective Date: January 1, 2014 Page | of 2

CHIP Eligibility

@ Premiums and cost sharing are the same as for targeted low-income children in the state's separate CHIP. CONo premiums, copayments, deductibles, coinsurance or other cost sharing is required.

(Other premiums and/or cost-sharing requirements (consistent with Section 2103(e) of the SSA and 42 CFR 457 Subpart E).

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 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# NV-13-0002 Approval Date: MAR 1 4 2014 Effective Date: January 1, 2014 Page 2 of 2

_____________________________________________________________________________

Table of Contents

State/Territory Name: Nevada

State Plan Amendment (SPA) #: NV-13-0003

This file contains the following documents in the order listed:

1) Approval Letter 2) SPA Summary Form 3) Approved SPA Pages

The complete title XXI state plan for Nevada consists of the most recent state plan posted on Medicaid.gov under CHIP and State Plan Amendments. The link is provided below. The following approved templates are in addition to, or replace sections of the state’s posted current state plan. The attached approval letter(s) explain how these templates fit into that state plan. Link to state title XXI state plans and amendments: http://medicaid.gov/chip/state-program-information/chip- state-program-information.html

DEPARTMENT OF HEALTH & HUMAN SERVICES

Centers for Medicare & Medicaid Services (CMs

7500 Security Boulevard, Mail Stop: S2-26-12 CM Ss (CENTERS FOR MEDICARE & MEDICAID SERVICES

Baltimore, Maryland 21244-1850

CENTER FOR MEDICAID & CHIP SERVICES

Children and Adults Health Programs Group

MAY 2 1 2014

Michael J. Willden, Director

Department of Health and Human Services 4126 Technology Way, Suite 100

Carson City, NV 89706

Dear Mr. Willden:

I am pleased to inform you that the Centers for Medicare & Medicaid Services has approved your title XXI Children’s Health Insurance Program (CHIP) state plan amendment (SPA) number NV-13-0003 submitted on December 16, 2013, with additional information provided on May 13, 2014. This SPA relates to the Modified Adjusted Gross Income (MAGI) Eligibility and has an effective date of January 1, 2014.

The SPA number NV-13-0003 converts the state’s existing income eligibility standards to MAGI-equivalent standards, by age group, for children covered in its title XXJ-funded Medicaid program. A copy of the approved state plan page (CS3) is attached, and should be incorporated into the state’s approved CHIP state plan. This page supersedes the current Medicaid expansion Section (4.0) of the current CHIP state plan.

Your title XXI project officer is Ms. Joyce Jordan. She is available to answer questions concerning these amendments and other CHIP-related issues. Ms. Jordan’s contact information is as follows:

Centers for Medicare & Medicaid Services Center for Medicaid and CHIP Services Mail Stop: S2-01-16

7500 Security Boulevard

Baltimore, MD 21244-1850

Telephone: (410) 786-3413

Facsimile: (410) 786-5882

E-mail: Joyce. Jordan@cms.hhs.gov

Official communications regarding program matters should be sent simultaneously to Ms. Jordan and to Ms. Gloria Nagle, Associate Regional Administrator (ARA) in our San Francisco Regional Office. Ms. Nagle’s address is:

Page 2 — Mr. Michael Willden

Centers for Medicare & Medicaid Services 90 7th Street, Suite 5-300 (SW) San Francisco, California 94103-6706

Congratulations on the approval. We look forward to continuing to work with you and your staff toward the approval of your remaining MAGI Eligibility SPAs. If you have additional questions, please contact Ms. Barbara K. Richards, Acting Director, Division of State Coverage Programs at (410) 786-5920.

Sincerely,

Eliot Fishman Director

Enclosure

ce: Ms. Gloria Nagle, ARA, CMS Region VIII, San Francisco

logged in as TONIABROWN(CMS CO Staff) read only mode application rev p01 Children's Health Insurance Program Eligibility NV.0611.R00.00 - Jan 01, 2014 Home Logout Finder Save Validate Print Help Control Panel General Information File Management Tribal Input Summary State/Territory name: Nevada State Funds: $ Federal Funds: $ Submitted By: Robyn Heddy Last Revision Date: May 13, 2014 Submit Date: Dec 16, 2013 Children's Health Insurance Program Eligibility: Summary Page Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. NV-13-0003 Type of SPA: MAGI Eligibility & Methods XXI Medicaid Expansion Establish 2101(f) Group Eligibility Processing Non-Financial Eligibility Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation 42 CFR 457.320(a)(2) and (3) Federal Budget Impact This SPA has a budget impact. Total budget impact: Subject of Amendment Please provide a brief summary of SPA changes. Character Count:85 out of 2000 CS3 Medicaid expansion program covers children 6-19 with income between 123-133% FPL. Signature of State Agency Official Page 1 of 2 Children's Health Insurance Program Eligibility: CMS 179 05/28/2015 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

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CHIP Eligibility

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

42 CFR 457,320(a)(2) and (3)

Income eligibility for children under the Medicaid Expansion is determined in accordance with the following income standards: There should be no overlaps or gaps for the ages entered.

Age and Household Income Ranges

From Age To Age Above (% FPL) Up to & including (% FPL)

||6 19 122 133

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.

MAY 2 4 2018

SPA# NV-13-0003 Approval Date: Effective Date: January 1, 2014

Page | of |

_____________________________________________________________________________

Table of Contents

State/Territory Name: Nevada

State Plan Amendment (SPA) #: NV-13-0004

This file contains the following documents in the order listed:

1) Approval Letter 2) SPA Summary Form 3) Approved SPA Pages 4) Additional Attachments that are part of the state plan

The complete title XXI state plan for Nevada consists of the most recent state plan posted on Medicaid.gov under CHIP and State Plan Amendments. The link is provided below. The following approved templates are in addition to, or replace sections of the state’s posted current state plan. The attached approval letter(s) explain how these templates fit into that state plan. Link to state title XXI state plans and amendments: http://medicaid.gov/Medicaid-CHIP-Program-Information/By- Topics/Childrens-Health-Insurance-Program-CHIP/CHIP-State-Program-Information.html

DEPARTMENT OF HEALTH & HUMAN SERVICES - Centers for Medicare & Medicaid Services Cc M Ss 7500 Security Boulevard, Mail Stop: S2-26-12

Baltimore, Maryland 21244-1850 NTER FOR MEDICAID & CHIP SERVIC

‘CENTER FOR MEDICAID & CHIP SERVICES

Children and Adults Health Programs Group

MAY 0 7 2015

Ms. Nova Murray

Division of Health Care Financing and Policy 1000 East William Street, Suite 200

Carson City, NV 89701

Dear Ms. Murray:

I am pleased to inform you that the Centers for Medicare & Medicaid Services (CMS) has approved Nevada’s Children’s Health Insurance Program (CHIP) state plan amendment (SPA), NV-13-0004 submitted on December 16, 2013. This SPA incorporates the Modified Adjusted Gross Income (MAGI)-based eligibility process requirements in accordance with the Affordable Care Act and implementing regulations. The effective date of this SPA is October 1, 2013.

The approval of SPA NV-13-0004 includes full approval of the state’s alternative paper application. The state is using an interim alternative single streamlined online application. By ‘August 31, 2015, the state will implement a revised alternative single streamlined online application that addresses CMS concerns outlined in the companion letter issued with this SPA approval.

Enclosed is a copy of the following state plan pages and attachments to be incorporated within a separate section at the end of Nevada’s approved state plan:

Template CS24 — Separate Child Health Insurance Program Attachment 1 — Statement of use with respect to the alternative single streamlined online application ;

e Attachment 2 — Alternative single streamlined paper application

This approval and the enclosures supercede the following sections of the current CHIP state plan:

e Section 4.3: Single Streamlined Application Screen and Enroll Process e Section 4.4: Renewals, Screening by Other Insurance Affordability Programs

The CMS appreciates the significant amount of work your staff dedicated to preparing this State Plan Amendment. Your title XXI project officer is Ms. Joyce Jordan. She is available to answer questions concerning this amendment and other CHIP-related issues.

Page 2 — Ms. Nova Murray Ms. Jordan’s contact information is as follows:

Centers for Medicare & Medicaid Services Center for Medicaid & CHIP Services Mail Stop: S2-01-16

7500 Security Blvd.

Baltimore, MD 21244-1850

Telephone: (410) 786-3413

Facsimile: (410) 786-5882

E-mail: Joyce.Jordan@cms.hhs.gov

Official communications regarding program matters should be sent simultaneously to Ms. Jordan and Ms. Hye Sun Lee, Acting Associate Regional Administrator, in our San Francisco Regional Office. Ms. Lee’s address is:

Ms. Hye Sun Lee

Centers for Medicare and Medicaid Services Office of the Regional Administrator

90-7" Street, Suite 5-300

San Francisco, CA 94103-6706

If you have additional questions, please contact Ms. Kelly Whitener, Director, Division of State Coverage Programs at 410-786-0719.

We look forward to continuing to work with you and your staff.

Sincerely,

Director Enclosure

ce: Hye Sun Lee, Acting ARA, CMS San Francisco Region

DEPARTMENT OF HEALTH & HUMAN SERVICES

Centers for Medicare & Medicaid Services Cc M Ss 7500 Security Boulevard, Mail Stop: $2-26-12

CENTERS FOR MEDICARE & MEDICAID SERVICES:

Baltimore, Mary! land 21244-1850 ~ CENTER FOR MEDICAID & CHIP SERVICES

Children and Adults Health Programs Group

MAY 0 7 2015

Ms. Nova Murray

Division of Health Care Financing and Policy 1000 East William Street, Suite 200

Carson City, NV 89701

Dear Ms. Murray:

This letter is being sent as a companion to the Centers for Medicare & Medicaid Services (CMS) approval of Nevada’s Children’s Health Insurance Program (CHIP) state plan amendment (SPA), NV-13-0004, which was submitted to CMS on December 16, 2013. Our review of this submission included a review of the alternative single streamlined paper and online applications developed by the state.

Until August 31, 2015, the state will use an interim alternative single streamlined online application. The interim alternative online application needs to be revised to reflect the following changes.

Date by which changes

Necessary changes: will be completed:

1. The state will add a solution concerning residency and August 31, 2015 citizenship along with the permanent solution concerning suppression of the PDF verification form that displays at the end of the process.

2. The state will add a permanent solution to modify the income | August 31, 2015 type table and move the child support disclaimer.

3. The state will add a permanent solution to modify the August 31, 2015 household determination sequence and add ESI information.

Page 2 — Ms. Nova Murray

Please submit the revised alternative single streamlined online application to CMS for review no later than July 31, 2015 to ensure approval by August 31, 2015. We continue to be available to provide technical assistance. If you have any questions about your application, please contact Ms. Victoria Collins at Victoria.Collins@cms.hhs.gov or (410) 786-2167. We look forward to continuing to work with you and your staff.

Sincerely,

Kelly Whitener Director Division of State Coverage Programs

ce: Ms. Hye Sun Lee, Acting ARA, CMS San Francisco Region

logged in as TONIABROWN(CMS CO Staff) read only mode application rev p01 Children's Health Insurance Program Eligibility NV.0613.R00.00 - Oct 01, 2013 Home Logout Finder Save Validate Print Help Control Panel General Information File Management Tribal Input Summary State/Territory name: Nevada State Funds: $ Federal Funds: $ Submitted By: Robyn Heddy Last Revision Date: Jun 2, 2015 Submit Date: Dec 16, 2013 Children's Health Insurance Program Eligibility: Summary Page Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. NV-13-0004 Type of SPA: MAGI Eligibility & Methods XXI Medicaid Expansion Establish 2101(f) Group Eligibility Processing Non-Financial Eligibility Proposed Effective Date 10/01/2013 (mm/dd/yyyy) Federal Statute/Regulation Citation 2102(b)(3) & 2107(e)(1)(O) of the SSA and 42 CFR 457, subpart C Federal Budget Impact This SPA has a budget impact. Total budget impact: Subject of Amendment Please provide a brief summary of SPA changes. Character Count:27 out of 2000 CS24 Eligibility Processing Signature of State Agency Official Page 1 of 2 Children's Health Insurance Program Eligibility: CMS 179 06/23/2015 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

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CHIP Eligibility

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

2102(b)(3) & 2107(e\(1)(O) of the SSA and 42 CFR 457, subpart C

The CHIP Agency meets all of the requirements of 42 CFR 457, subpart C for application processing, eligibility screening and enrollment.

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:

oO The single, streamlined application 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 and approved by the Secretary in accordance with ' section 1413(b)(1)(B) of the Affordable Care Act.

An alternative application used to apply for multiple human service programs approved by the Secretary, provided that the agency makes readily available the single or alternative application used only for insurance affordability programs to individuals seeking assistance only through such programs.

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 CFR 457.340(a), by telephone, via mail, in person and other commonly available electronic means.

The agency accepts applications in the following other electronic means.

[RX] Other electronic means:

Name of method Description

acsimile Will be considered an original document

Screen and Enroll Process

The CHIP Agency has coordinated eligibility and enrollment screening procedures in place that are applied at time of initial application, periodic redeterminations, and follow-up eligibility determinations. The procedures ensure that only targeted low-

Pa income children are provided CHIP coverage and that enrollment is facilitated for applicants found to be potentially eligible for other insurance affordability programs.

Procedures include:

SPA# NV-13-0004 Approval Date: MAY 0 7 2015 Effective Date: October 1, 2013

Page | of 2

CHIP Eligibility

Screening of application to identify all individuals eligible or potentially eligible for CHIP or other insurance affordability Cy programs; and

rl Income eligibility test, with calculation of household income consistent with 42 CFR 457.315 for individuals identified as potentially eligible for Medicaid or other insurance affordability programs based on household income; and

im Screening process for individuals who may qualify for Medicaid on a basis other than having household income at or below the applicable MAGI standard, based on information in the single streamlined application.

The CHIP agency has entered into an arrangement with the Exchange to make eligibility determinations for advanced

premium tax credits in accordance with section 1943(b)(2) of the SSA. No

Redetermination Processing

Redeterminations of eligibility for individuals whose financial eligibility is based on the applicable modified adjusted gross income standard are performed as follows, consistent with 42 CFR 457.343:

[HM] Once every 12 months.

ml 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.

Screening by Other Insurance Affordability Programs

The CHIP Agency provides assurance that it has adopted procedures to accept and process electronic accounts of individuals screened as potentially eligible for CHIP by other insurance affordability programs in accordance with the requirements of 42 CFR 457.348(b) and to determine eligibility in accordance with 42 CFR 457.340 in the same manner as if the application had been submitted directly to, and processed by the state.

The CHIP Agency elects the option to accept CHIP eligibility decisions made by the Exchange or other agencies administering

oO insurance affordability programs as provided in 42 CFR 457.348 and to furnish CHIP in accordance with requirements of 42 CFR 457.340 to the same extent and in the same manner as if the applicant had been determined by the state to be eligible for CHIP.

The CHIP Agency has entered into an agreement with agencies administering other insurance affordability programs to fulfill the requirements of 457.348(b) and will provide this agreement to the Secretary upon request.

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.

V.20130709

MAY 07 2015

SPA# NV-13-0004 Approval Date: Effective Date: October 1, 2013 Page 2 of 2

USE OF THE ALTERNATIVE SINGLE STREAMLINED APPLICATION

C1 Paper Application

Online Application

TRANSMITTAL NUMBER:

NV-13-0004 _

STATE:

Nevada

Through August 30, 2015, the state is using an interim alternative single streamlined application. After August 30, 2015, the state will use a revised alternative single streamlined application. The revised application will address the issues outlined in the CMS letter, which was issued with the approval of this state plan amendment, concerning the state’s application. The revised application will be incorporated by reference into the state plan.

MAY 0 7 2015

Application for Health Insurance

You can use this application to:

«Apply for free or low-cost insurance from Medicaid or Nevada Check-Up. o You can apply for and receive Medicaid, even if you already have insurance.

= If you or your family members are determined to be ineligible for Medicaid or Nevada Check-Up, you may still qualify for help paying for health insurance from the federal government. A referral will be sent to Nevada Health Link. For additional information, visit their website at www.nevadahealthlink.com or call 855-768-5465.

Access your benefits faster.

Apply Did you know that you can apply, enroll and start using your health benefits sooner by Online submitting your application online?

« Takes about 45 minutes for a typical household

« Follow the prompts and, when finished, click “SUBMIT” * Once you create an account, you can check the status of your benefits online.

Go to: www.dwss.nv.gov

Get assistance with your application.

P l You can get personalized assistance completing your application at one of the Division’s ersona district offices or a Family Resource Center.

Assistance To find a location nearest your home:

Call 1-800-992-0900 (voice) or 1-800-326-6888 (TTY) or visit www.dwss.nv.gov

Fill out the attached paper application.

A handwritten, paper application is an option for those who must use paper.

By « Follow the instructions and complete ALL areas that apply to you and your family. Mail ¢ Submit your application to the local Welfare Office or mail to: _DWSS

PO Box 15400

Las Vegas, NV 89114

First Name: Middle Name: Last Name: Suffix Date of Birth

Home Address: Apartment Number:

City: State: Zip Code:

Mailing Address: (if different than home address) Apartment Number: City: State: Zip Code: Daytime Phone # Ext. Secondary Phone # Ext.

Currently, all notifications are sent in paper format. In the future, if available, would you like to receive information by:

Email: O Yes O No Email address:

Preferred language (if not English): 0 Spanish O Other: Interpreter needed? O Yes O No

Household Information

Your income and family size help us decide what programs you qualify for. With this information, we can make sure everyone gets the most coverage possible.

Who needs to be included on this application:

¢ your spouse, if married

e your children who live with you

¢ your partner who lives with you (but only if you have children together who need health insurance) ¢ anyone you include on your federal tax return, whether they live with you or not

e Ifyou don't file a tax return, remember to still add family members who live with you.

Anyone else who lives with you will need to file their own application if they want insurance. You don't need to file taxes to apply for health insurance.

Complete the Additional Member pages for each person in your family. Start with yourself. If you have more than 2 people in your family, you will need to make a copy of the 'Additional Member' pages and complete.

We need Social Security Numbers (SSNs) for everyone applying for health insurance that has one. An SSN is optional for people not applying for insurance, but providing one can speed up the application process. Please ensure the name is listed the same as it is displayed on your Social Security Card.

American Indians or Alaska Natives (AI/AN) who enroll in Medicaid, Nevada Check-Up and the Silver State Health Insurance Exchange can also get services from the Indian Health Services, tribal health programs or urban Indian health programs.

If you or your family members are American Indian or Alaska Native, you may not have to pay premiums or cost sharing and may get special monthly enrollment periods. We will ask additional questions to make sure you and your family get the most help possible.

Need help with your application? 2960-EG (9/14) Call 1-800-992-0900 (voice) or 1-800-326-6888 (TTY) or visit us online at www.dwss.nv.gov Page 2 of 14

os } Relationship to you? SELF

First Name, MI, Last Name & Suffix Marital Status

Social Security Number (OPTIONAL) Date of Birth

Pregnant? © Yes O No

Due Date:

If yes, how many babies are expected:

O Yes Ifyes, answer questions | - 3 O No = Ifno, skip to question 3

Note: You can still apply for health insurance even if you don't file a federal tax return. 1. Do you expect to file a joint return with a spouse/partner? 0 Yes 0 No If yes, name of spouse/partner:

2. Will you claim any dependents on your tax return? O Yes O No If yes, list name(s) of dependents:

3. Are you being claimed as a dependent on someone else's tax return? © Yes O No If yes, please list the name of the tax filer:

How are you related to the tax filer?

O Yes _ Ifyes, answer all the questions below. C1No = If no, skip to the income questions. Note: Marking 'Yes' means you will be evaluated for federally funded medical assistance.

Social Security Number - REQUIRED if not listed above | If you are a child, under the age of 19, do you have

access to public employee coverage? 0 Yes O No

Are you a U.S. citizen? O Yes O No Have you lived in the U.S. since 1996? 0 Yes O No

If not a U.S. citizen, do you have eligible immigration status? O Yes O No

: soe : Type: ID Number: If yes, provide the following information: yp

Are you, your spouse, domestic partner or your parent (if you are a minor) an honorably discharged veteran or active duty member of the military? O Yes O No

Are you a full-time student? O Yes O No

Are you an American Indian or Alaskan Native? OO Yes O No

If yes, what tribe?

If under age 26, have you ever been in foster care? O Yes ONo _ Ifyes, what state? Did you receive health care through a state Medicaid

9 Age when you left the program? program? Yes UO No

Are you the parent or primary caretaker relative of any child(ren), under the age of 19, in the household? O Yes ONo If yes, who?

Do you have medical bills for the past three months that you need help with? O Yes O No

If yes, what months?

Need help with your application? 2960-EG (9/14) Call 1-800-992-0900 (voice) or 1-800-326-6888 (TTY) or visit us online at www.dwss.nv.gov Page 3 of 14

Are you legally blind or permanently disabled? O Yes O No

Are you receiving Supplemental Security Income (SS)? 0 Yes O No

Do you need help with activities of daily living through personal assistance services or a medical facility? O Yes O No

Job and I

In the past 3 months, did you: Change jobs Stop working O Work fewer hours CO None of these

Employer Name: (if self-employed, write 'SELF') Average hours worked each week Employer Address: Employer Phone Number:

Cc) City: State: Zip Code:

Gross wages/tips per pay period: How often are you paid? O Weekly O Every 2 weeks $ O1 Semi-Monthly O Monthly O Annually

If self-employed, please answer the following questions: Type of work:

How much net income (profits once expenses are paid) will you recei

this month? $

Note: You don't need to tell us about child support or veteran's disability payments. Certain money received may or may not be counted for Medicaid and Nevada Check-Up. Let us know if any money received is considered tribal income.

oO None Tribal Income? oO Unemployment $ How often?

O Retirement $ How often?

O Pensions $ How often?

O Social Security (RSDI) Benefits $ How often?

O_Interest/Dividends $ How often? O Yes O No oO Annuities $ How often? O Yes O No Oo Rental or Royalty Income $ How often? O Yes O No OO Capital Gains $ How often? O Yes O No O Farming or Fishing Income $ How often? O Yes O No oOo Alimony $ How often?

O Scholarships & Grants $ How often? . O Yes O No O Cash Advances $ How often?

to Gambling Winnings $ How often?

Other $ How often? ———————_ 0 Yes O No Need help with your application? 2960-EG (9/14)

Call 1-800-992-0900 (voice) or 1-800-326-6888 (TTY) or visit us online at www.dwss.nv.gov Page 4 of 14

If you pay for certain things that can be deducted on a federal income tax return, telling us about them could reduce your countable income. Note: You shouldn't include a cost that you already considered in your answer to net self-employment.

O Educator expenses $ How often? O Health savings account $ How often? 0 Moving expenses $ How often? Oo Alimony $ How often? oO IRA deductions $ How often?

Business expenses of reservists, O performing artists, and fee-basis $ How often? government officials

Penalty paid on early withdrawal of $

oO savings How often? CO Student loan interest $ How often? Tuition and fees $ How often? O Domestic production activities $ How often?

If the income you listed on this page is not steady from month to month, please tell us what you expect the yearly income to be. For example, some people expect their income to change because they only work some months of the year. If you do not expect a change to your monthly income, skip this question.

Total annual income expected this year: $ Total annual income expected next year: $

Are you Hispanic, Latino or of Spanish origin? (optional) O Yes O No If Hispanic/Latino (check all that apply - optional):

O Mexican O Mexican American O PuertoRican O Cuban OChicano/a O Other Race (optional) - check all that apply

oO White O Filipino oO Native Hawaiian O Black or African American O Japanese oO Guamanian or Chamorro oO American Indian or Alaska Native CO Korean o Samoan o. Asian Indian O Vietnamese oO Other Pacific Islander O Chinese O Other Asian O Other Need help with your application? 2960-EG (9/14)

Call 1-800-992-0900 (voice) or 1-800-326-6888 (TTY) or visit us online at www.dwss.nv.gov Page 5 of 14

Relationship to you?

Marital Status

First Name, MI, Last Name & Suffix If married, do they live with their spouse?

O Yes O No

Social Security Number (OPTIONAL) Date of Birth Pregnant? O Yes 0 No Sex Due Date: 0 Male If yes, how many babies are expected: 0 Female

O Yes Ifyes, answer questions | - 3 ONo = Ifno, skip to question 3.

Note: They can still apply for health insurance even if they don't file a federal tax return. 1. Do they expect to file a joint return with a spouse/partner? O Yes O No If yes, name of spouse/partner:

2. Will they claim any dependents on their tax return? O Yes O No If yes, list name(s) of dependents:

3. Are they being claimed as a dependent on someone else's tax return? © Yes O No If yes, please list the name of the tax filer: How are they related to the tax filer?

O Yes If yes, answer all the questions below. ONo = If no, skip to the income questions. Note: Marking 'Yes' means they will be evaluated for federally funded medical assistance.

Social Security Number - REQUIRED if not listed above | If they are a child, under the age of 19, do they have

access to public employee coverage? 0 Yes O No

Are they a USS. citizen? O Yes O No Have they lived in the U.S. since 1996? 0 Yes O No

If not a U.S. citizen, do they have eligible immigration status? O Yes O No

: se : Type: ID Number: If yes, provide the following information: yp

Are they, their spouse or their parent (if they are a minor) an honorably discharged veteran or active duty member of the military? O Yes O No

Are they a full-time student? 0 Yes O No

Are they an American Indian or Alaskan Native? O Yes O No

If yes, what tribe?

If under age 26, have they ever been in foster care? O Yes O1No If yes, what state? Did they receive health care through a state Medicaid

program? O Yes O No

Age when they left the program?

Are they a parent or primary caretaker relative of any child(ren), under the age of 19, in the household? O Yes ONo If yes, who?

Do they have medical bills for the past three months that they need help with? O Yes O No

If yes, what months?

Need help with your application? 2960-EG (9/14) Call 1-800-992-0900 (voice) or 1-800-326-6888 (TTY) or visit us online at www.dwss.nv.gov Page 6 of 14

hubs

Are they legally blind or permanently disabled? O Yes O No

Are they receiving Supplemental Security Income (SSI)? O Yes O No

Do they need help with activities of daily living through personal assistance services or a medical facility? O Yes O No

Current Job and Income Information O Not employed - Skip to ‘Other Income' section

In the past 3 months, did they: 1 Change jobs Stop working O Work fewerhours O None of these

Employer Name: (if self-employed, write 'SELF') Average hours worked each week Employer Address: Employer Phone Number:

a) City: State: . Zip Code:

Gross wages/tips per pay period: How often are they paid? © Weekly O Every 2 weeks

$ O Semi-Monthly O Monthly O Annually If self-employed, please answer the following questions: Type of work:

How much net income (profits once expenses are paid) will they receive this month? $

Note: They don't need to tell us about child support or veteran's disability payments. Certain money received may or may not be counted for Medicaid and Nevada Check-Up. Let us know if any money received is considered tribal income.

oO None Tribal Income? O Unemployment $ How often?

O Retirement $ How often?

O Pensions $ How often?

O Social Security (RSDI) Benefits $ How often?

O_ Interest/Dividends $ How often? O Yes O No oO Annuities $ How often? O Yes O No O Rental or Royalty Income $ How often? O Yes O No O Capital Gains $ How often? O Yes O No O Farming or Fishing Income $ How often? O Yes O No oO Alimony $ How often?

O Scholarships & Grants $ How often? O Yes O No Ol Cash Advances $ How often?

O Gambling Winnings $ How often?

O Other $ How often? O Yes O No Need help with your application? 2960-EG (9/14)

Call 1-800-992-0900 (voice) or 1-800-326-6888 (TTY) or visit us online at www.dwss.nv.gov Page 7 of 14

If they pay for certain things that can be deducted on a federal income tax return, telling us about them could reduce their countable income. Note: Do not include a cost they already considered in their answer to net self- employment.

OO ~=©Educator expenses $ How often? O Health savings account $ How often? CO Moving expenses $ How often? Oo Alimony $ How often? oO IRA deductions $ How often?

Business expenses of reservists, O performing artists, and fee-basis $ How often? government officials

Penalty paid on early withdrawal of $

go . How often? savings

Student loan interest $ How often?

(1 Tuition and fees $ How often?

O =©Domestic production activities $ How often?

income to be. For example, some people expect their income to change because they only work some months of the year. If they do not expect a change to their monthly income, skip this question.

Total annual income expected this year: $ Total annual income expected next year: $

Are they Hispanic, Latino or of Spanish origin? (optional) O Yes O No

If Hispanic/Latino (check all that apply - optional): O Mexican O Mexican American O PuertoRican O Cuban O Chicano/a O Other Race (optional) - check all that apply

oO White oO Filipino oO. Native Hawaiian o Black or African American O Japanese oO Guamanian or Chamorro oO American Indian or Alaska Native O Korean oO Samoan o Asian Indian O Vietnamese CO = _ Other Pacific Islander oO Chinese O Other Asian oO Other Need help with your application? 2960-EG (9/14)

Call 1-800-992-0900 (voice) or 1-800-326-6888 (TTY) or visit us online at www.dwss.nv.gov Page 8 of 14

Answer the following questions for everyone who is applying for help to pay for health insurance.

Is anyone offered health coverage from a job?

O Yes If yes, answer the following questions O No Ifno, skip to ‘Other Health Insurance’

We need to know about any health coverage you could get through a job. You can use this form to get information from the employer about health coverage this job offers. If there is more than one job, copy this

page.

Employee Name: Employee Social Security Number Employer Name: Employer Identification Number Employer Phone Number (EIN) ( ) - Employer Address: City State ZIP Code Who can we contact about employee health Phone Number: Email Address: coverage at this job? ( ) -

Is the employee currently eligible for coverage offered by this employer? O Yes If yes, will this job offer coverage NEXT year? O Yes O No

O No Ifthe employee is NOT currently eligible, will they be eligible in the NEXT 3 months? O Yes O No If yes, provide date: /_/

Who in the employee's family will the health plan cover? © Spouse O Domestic Partner O Dependent(s)

Who does this plan offer coverage to? (If you need more space, attach another sheet of paper)

go Enrolled Now cg Plans to drop coverage

cg Plans to Enroll Date: / / StartDate: / / ss} G_~—sC Will become eligible

go Not Enrolled StartDate: //

oOo Enrolled Now cg Plans to drop coverage

Plans to Enroll Date: / / StartDate: = / /_ Ss | Gg Will become eligible

og Not Enrolled StartDate: / /

o Enrolled Now cg Plans to drop coverage

o Plans to Enroll Date: / / StartDate: / / ss | Gg Will become eligible

go Not Enrolled StartDate: //

Need help with your application? 2960-EG (9/14)

Call 1-800-992-0900 (voice) or 1-800-326-6888 (TTY) or visit us online at www.dwss.nv.gov Page 9 of 14

Does the employer offer a health plan that meets the minimum value standard*? OO Yes O No

For the lowest-cost plan that meets the minimum value standard* offered only to the employee (don’t include family plans):

If the employer has wellness programs, provide the premium that the employee would pay if he/she received the maximum discount for any tobacco cessation programs, and did not receive any other discounts based on wellness programs.

a. How much would the employee have to pay in premiums for this plan? $ b. How often? O Weekly O Every2 weeks 1 Twiceamonth 0 Onceamonth O Quarterly O Yearly

What change will the employer make for the new plan year (if known)? O Employer won’t offer health coverage

C1 Employer will start offering health coverage to employees or change the premium for the lowest-cost plan available only to the employee that meets the minimum value standard. * (Premium should reflect the discount for wellness programs.)

a. How much would the employee have to pay in premiums for this plan? $

b. How often? O Weekly O Every2weeks O Twiceamonth (1 Onceamonth O Quarterly O1 Yearly c. 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.)

Does anyone have other health insurance, including Veterans, Medicaid/Nevada Check-Up, Medicare, COBRA, Private, or other Retiree Health Plan? O Yes O No

If yes, provide the following information

To make it easier to determine my eligibility for help paying for health coverage in future years, J agree to allow Nevada Health Link to use my income data, including information from tax returns, for the next 5 years (the maximum number of years allowed). The Nevada Health Link will send me a notice, let me make changes, and I can opt out at any time.

I give permission for tax return access at renewal time for the next:

O Yes Ifyes, how many years? O0Years O 1 Year 0 2 Years O 3 Years 0 4 Years O 5 Years O No Do not renew my eligibility for help paying for health insurance

Need help with your application? 2960-EG (9/14) Call 1-800-992-0900 (voice) or 1-800-326-6888 (TTY) or visit us online at www.dwss.nv.gov Page 10 of 14

Do you want to name someone as your authorized representative? O Yes O No Ifno, skip this section.

Name of Authorized Representative

Phone Number

( ) -

Address City

State ZIP Code

By signing, you allow this person to sign your application, to get official information about this application and

to act for you on all future matters with this agency.

Your Signature

Medicaid recipients who are 55 years or older or inpatients of a medical facility may be responsible for repayment of Medicaid expenses paid for them. Recovery of these payments made from the Medicaid Program would be pursued from the estate of the recipient after their death or after the death of their surviving spouse.

(See Form 6160-AF, Program Operation.)

Initial

erstand the fo owing is an eligibility requirement to receive Medicaid benefits:

1) If anyone on this application receives Medicaid benefits, | give the Medicaid agency the right to pursue and get any money from other health insurance, insurance, legal settlements, and any other third party

that may be liable for the medical services paid by Medicaid; and

2) I give the Medicaid agency the right to pursue and get child and medical support from a spouse or a

parent; and

3) I agree my household members will cooperate with the Medicaid agency to obtain any money from insurance companies, legal settlements and third parties and will give DHHS notice of any settlements or

legal action.

Initial

How did you hear about these programs? Check ONLY one: oO Covering Kids & Families oO School oO WIC im Clinic oO Other:

Following federal law, discrimination is not permitted on the basis of race, color, national origin, sex, age, sexual

oO oO

Tribal Resources

Friend / Family

orientation, gender identity or disability. You can file a complaint of discrimination by visiting http://www.hhs.gov/ocr/office/file; or you may write: HHS, Director, Office for Civil Rights, Room 506-F, 200 Independence Ave, S.W. Washington, D.C. 20201; or call (202) 619-0403 (voice) or (202) 619-3257(TTY).

Need help with your application? Call 1-800-992-0900 (voice) or 1-800-326-6888 (TTY) or visit us online at www.dwss.nv.gov

2960-EG (9/14) Page 11 of 14

(Please check one) O Yes O No

If you do not check either box, you will be considered to have decided not to register to vote at this time.

The National Voter Registration Act provides you with the opportunity to register to vote at this location. If you would like help in filling out a voter registration application form, we will help you. The decision whether to seek or accept help is yours. You may fill out the application form in private.

IMPORTANT NOTICE: Applying to register or declining to register to vote WILL NOT AFFECT the amount of assistance you will be provided by this agency.

/_

Your Signature Date

CONFIDENTIALITY: Whether you decide to register to vote or not, your decision will remain confidential.

IF YOU BELIEVE SOMEONE HAS INTERFERED with your right to register or to decline to register to vote, or your right to choose your own political party or other political preference, you may file a complaint with the Office of the Secretary of State, Capitol Complex, Carson City, Nevada 89701.

ue By signing this application, you are authorizing the Department of Health and Human Services to mak investigations concerning you, other members of your household and/or your child(ren)'s legal or natural parent(s) that may be necessary to determine eligibility for benefits you or your household receives under programs administered by the DWSS and Nevada Health Link. Information provided to the agency may be verified or investigated by federal, state and local officials including quality control staff.

You must cooperate in the investigation or your benefits may be denied or terminated. If you knowingly make a statement which is false or misleading; provide documents that have been altered; or conceal or withhold information that is necessary for the agency to make an accurate determination of the benefits for which you are eligible your benefits may be denied, terminated or reduced. If you receive benefits for which you are not entitled, you must repay the agency for all money, services, and benefits you were not entitled to receive. You may also be disqualified from receiving future benefits and be criminally prosecuted or penalized according to state and federal law.

Initial

If you think we made a mistake, or have not acted timely on your application you can appeal. That means you can ask us to look at your case again. You must request an appeal in writing within 90 days of the date of the notice. The notice will tell you how to appeal. You may appoint a representative to act for you in the appeals process. Contact us, and we can help you with your appeal.

Initial

I know that I must tell the program I'll be enrolled in if information I listed on this application changes. I know I | can make changes by calling customer service and that J must report by the fifth (5") of the following month. I understand that a change in my information could affect my eligibility for member(s) of my household.

Initial

Need help with your application? 2960-EG (9/14) Call 1-800-992-0900 (voice) or 1-800-326-6888 (TTY) or visit us online at www.dwss.nv.gov Page 12 of 14

I hereby authorize and consent to the release of all information concerning me or my household members to the Department of Health and Human Services by the holder of the information such as, but not limited to, wage information, information made confidential by law, as well as patient information privileged under NRS 49.225, or any other provision of law. I hereby release the holder of the information from liability, if any, resulting from the release (disclosure) of the required information.

If I am 60 years of age or older, I hereby consent to the disclosure of my identity and waive my right as an older person to have my identity kept confidential. I hereby release the holder of information from liability, if any, resulting from the disclosure of the required information.

Your Signature Date

I know I'll be required to cooperate with the agency to collect medical support and establish paternity from an absent parent. If I think that cooperating to collect medical support will harm me or my children, I can tell the agency and I may not have to cooperate.

Initial

Does any child on this application have a parent living outside of the home? O Yes O No

Is anyone applying for health insurance on this application incarcerated (detained or jailed)? O Yes O No

If yes, write the name of the person incarcerated here:

O Check here if this person is pending disposition of charges.

We keep your information private as required by law. Your answers on this application will only be used to determine eligibility for health coverage or help paying for coverage. Nevada Health Link, Division of Welfare and Supportive Services and the Department of Health and Human Services will check your eligibility using our electronic databases and the databases of other federal agencies. If the information does not match, we may ask you to send us proof. We won't ask any questions about your medical history. Household members who don't want coverage won't be asked questions about citizenship or immigration status.

IMPORTANT: As part of the application process, we may need to retrieve your information from the Internal Revenue Service (IRS), Social Security, the Department of Homeland Security and/or a consumer reporting agency.

We need this information to check your eligibility for coverage and help paying for coverage if you want it and to give you the best service possible. We may also check your information at a later time to make sure your information is up to date. We'll notify you if we find something has changed.

I understand my information will be used and retrieved from data sources for this application. I have consent for all people I will list on the application that allows their information to be retrieved and used from the above- mentioned data sources.

Initial

Need help with your application? 2960-EG (9/14) Call 1-800-992-0900 (voice) or 1-800-326-6888 (TTY) or visit us online at www.dwss.nv.gov Page 13 of 14

amilies who live in urban Washoe County or urban Clark County are covered by a managed care organization (MCO). You are being asked to choose one of the following health plans. If you do not indicate a health plan preference on your application, we will choose a plan for you. Your choice of health plan does not guarantee acceptance into the Nevada Medicaid or Nevada Check Up program. We might not honor your choice of plans if you or any family members have been enrolled in one of our current managed care organizations. Once enrolled, families will receive a member handbook explaining the health plan benefits and can contact the numbers below for information regarding the health plans.

Amerigroup: 1-800-600-4441 Health Plan of Nevada: 1-800-962-8074 www.amerigroup.com www.healthplanofnevada.com

Please choose a health plan:

NOTE: If you do not choose a health plan preference, we will choose a plan for you.

For families living in the fee-for-service benefit area, services may be obtained from any Nevada Medicaid provider. If you need assistance in locating a provider, please call your local Medicaid district office:

Carson City Reno Las Vegas Elko 775) 684-3651 775) 687-1900 702) 668-4200 775) 753-1191

e I'm signing this application under penalty of perjury, which means I've provided true answers to all of the questions to the best of my knowledge. I know that I may be subject to penalties under federal law if I

intentionally provide false or untrue information.

e I swear I have honestly reported the citizenship status of myself and anyone I am applying for.

/ /

Signature or Mark of Applicant Date f/f]

Signature or Mark of Spouse/Partner (Second Parent of Children) Date

Witness: (Use if applicant cannot read or write or is blind.) The information in this application has been read to the applicant and I have witnessed the above signature.

Signature of Witness Date

Submit your application to the local Welfare | Did you remember to: Office or, mail your application to: v Tell us about everyone in your family & household, even if they don't need insurance?

PO BOX 15400 v . : Las Vegas, NV 89114 Ask your employer about any job-related insurance?

v_ Sign this application?

Need help with your application? 2960-EG (9/14) Call 1-800-992-0900 (voice) or 1-800-326-6888 (TTY) or visit us online at www.dwss.nv.gov Page 14 of 14

_____________________________________________________________________________

Table of Contents

State/Territory Name: Nevada

State Plan Amendment (SPA) #: NV-13-0005

This file contains the following documents in the order listed:

1) Approval Letter 2) SPA Summary Form 3) Approved SPA Pages

The complete title XXI state plan for Nevada consists of the most recent state plan posted on Medicaid.gov under CHIP and State Plan Amendments. The link is provided below. The following approved templates are in addition to, or replace sections of the state’s posted current state plan. The attached approval letter(s) explain how these templates fit into that state plan. Link to state title XXI state plans and amendments: http://medicaid.gov/chip/state-program-information/chip- state-program-information.html

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services (CMs 7500 Security Boulevard, Mail Stop: $2-26-12 CM Ss

Baltimore, Maryland 21244-1850 CENTER FOR MEDICAID & CHIP SERVICES

Children and Adults Health Programs Group

MAY 15 2014

Michael J. Willden, Director

Department of Health and Human Services 4126 Technology Way, Suite 100

Carson City, NV 89706

Dear Mr. Willden:

I am pleased to inform you that the Centers for Medicare & Medicaid Services has approved your title XXI Children’s Health Insurance Program (CHIP) state plan amendment (SPA) number NV-13-0005 submitted on December 16, 2013, with additional information provided on May 5, 2014. This SPA relates to the Modified Adjusted Gross Income (MAGI) Eligibility and has an effective date of January 1, 2014.

The SPA number NV-13-0005 is approved to clarify the state’s non-financial eligibility policies on residency, citizenship, social security numbers, substitution of coverage, non-payment of premiums, continuous eligibility, and presumptive eligibility. Copies of the approved state plan pages are attached and these approved pages supersede sections of Nevada’s current state plan as detailed below:

New State Plan Page Impact on Current State Plan Section CS17: Non-Financial Eligibility — Section 4.1.5 Residency CS18: Non-Financial Eligibility — Section 4.1.0; 4.1-LR; 4.1.1-LR Citizenship CS19: Non-Financial Eligibility —Social | Section 4.1.9.1 Security Number C820: Non-Financial Eligibility — Section 4.4.4 Substitution of Coverage CS21: Non-Financial Eligibility - Non- Section 8.7 Payment of Premiums CS27: General Eligibility - Continuous Section 4.1.8 Eligibility CS28: General Eligibility - Presumptive | Section 4.3.2 Eligibility for Children

Page 2 — Mr. Michael Willden

Your title XXI project officer is Ms. Joyce Jordan. She is available to answer questions concerning these amendments and other CHIP-related issues. Ms. Jordan’s contact information is as follows:

Centers for Medicare & Medicaid Services Center for Medicaid and CHIP Services Mail Stop: $2-01-16

7500 Security Boulevard

Baltimore, MD 21244-1850

Telephone: (410) 786-3413

Facsimile: (410) 786-5882

E-mail: Joyce.Jordan@cms.hhs.gov

Official communications regarding program matters should be sent simultaneously to Ms. Jordan and to Ms. Gloria Nagle, Associate Regional Administrator (ARA) in our San Francisco Regional Office. Ms. Nagle’s address is:

Centers for Medicare & Medicaid Services 90 7th Street, Suite 5-300 (SW) San Francisco, California 94103-6706

Congratulations on the approval. We look forward to continuing to work with you and your staff toward the approval of your remaining MAGI Eligibility SPAs. If you have additional questions, please contact Ms. Barbara K. Richards, Acting Director, Division of State Coverage Programs at (410) 786-5920.

Sincerely, 10t Fishman Director Enclosure cc:

Ms. Gloria Nagle, ARA, CMS Region VIIII, San Francisco

logged in as TONIABROWN(CMS CO Staff) read only mode application rev p01 Children's Health Insurance Program Eligibility NV.0612.R00.00 - Jan 01, 2014 Home Logout Finder Save Validate Print Help Control Panel General Information File Management Tribal Input Summary State/Territory name: Nevada State Funds: $ Federal Funds: $ Submitted By: Robyn Heddy Children's Health Insurance Program Eligibility: Summary Page Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. NV-13-0005 Type of SPA: MAGI Eligibility & Methods XXI Medicaid Expansion Establish 2101(f) Group Eligibility Processing Non-Financial Eligibility Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation 42 CFR 457.320, 42 CFR 457.340(b), 457.310(b)(2) and (b)(3), 457.320(a)(9) and 2110(b)(1) Federal Budget Impact This SPA has a budget impact. Total budget impact: Please attach a revised CHIP budget. Document Subject of Amendment Please provide a brief summary of SPA changes. Character Count:302 out of 2000 Non financial eligiblity rules are outlined in; CS17 Residency, CS18 Citizenship,CS19 SSN, CS20 Substitution of coverage, CS21 Non Payment of Premiums, CS28 Presumptive eligibility for children. The CHIP agency made minor changes to non-payment of premiums and aligned new policies to ACA requirements. Signature of State Agency Official Page 1 of 2 Children's Health Insurance Program Eligibility: CMS 179 05/28/2015 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

Last Revision Date: May 5, 2014 Submit Date: Dec 16, 2013 FAQs | Site Map | Contact | Medicaid.gov | CMS.gov Page 2 of 2 Children's Health Insurance Program Eligibility: CMS 179 05/28/2015 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

ccms. CHIP Eligibility

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

42 CFR 457.320

Residency The CHIP Agency provides CHIP to otherwise eligible residents of the state, including residents who are absent from the state under

certain conditions. A child is considered to be a resident of the state under the following conditions:

rl A non-institutionalized child. if capable of indicating intent and who is emancipated or married, if the child is living in the state and:

1, Intends to reside in the state, including without a fixed address, or

2. Has entered the state with a job commitment or seeking employment. whether or not currently employed. [ia] A non-institutionalized child not described above and a child who is not a ward of the state:

1. Residing in the state, with or without a fixed address, or

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

wl An institutionalized child. who is not a ward of the state, if the state is the state of residence of the child's custodial parent or caretaker at the time of placement. or

[i] A child who is a ward of the state regardless of where the child lives. or

A child physically located in the state when there is a dispute with one or more states as to the child's actual state of

(a

If the state covers pregnant women, a pregnant woman is considered to be a resident under the following conditions:

residence.

{@] A non-institutionalized pregnant woman who is living in the state and: |. Intends to reside in the state, including without a fixed address, or if incapable of indicating intent, is living in the state. or 2. Entered with a job commitment or seeking employment, whether or not currently employed.

a An institutionalized pregnant woman placed in an out-of-state-institution, as defined in 42 CFR 435.1010, including foster care homes. by an agency of the state. or

ry An institutionalized pregnant woman residing in an in-state-institution. as defined in 42 CFR 435.1010. whether or not the individual established residency in the state prior to entering the institution, or

[ia] A pregnant woman physically located in the state when there is a dispute with one or more states as to the pregnant woman's actual state of residence.

The state has in place related to the residency of children and pregnant women (if covered by the state):

MAY 15 20% Effective Date: January 1, 2014

Page | of 2

SPA# NV-13-0005 Approval Date:

(CMs. CHIP Eligibility

One or more interstate agreement(s). No

A policy related to individuals in the state only for educational purposes. No

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

MAY 15 2014

SPA# NV-13-0005 Approval Date: Effective Date: January 1, 2014 Page 2 of 2

cems. CHIP Eligibility

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

Sections 2105(c)(9) and 2107(e)(1)(J) of the SSA and 42 CFR 457.320(b)(6), (c) and (d)

Citizenship

The CHIP Agency provides CHIP eligibility to otherwise eligible citizens and nationals of the United States and certain non-citizens, [7] including the time period during which they are provided with reasonable opportunity to submit verification of their citizenship, national status or satisfactory immigration status.

{| The CHIP Agency provides eligibility under the Plan to otherwise eligible individuals: Who are citizens or nationals of the United States; or

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); or

Who have declared themselves to be citizens or nationals of the United States, or an individual having satisfactory immigration status, during a reasonable opportunity period pending verification of their citizenship, nationality, or satisfactory immigration status consistent with requirements of 1903(x), 1137(d), and 1902(ee) of the Act, and 42 CFR 435.406, 407, 956 and 457.380.

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 Yes verification process.

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 ed by the individual. No

The CHIP Agency elects the option to provide CHIP coverage to otherwise eligible children up to age 19, lawfully residing

in the United States, as provided in Section 2107(e)(1)(J) of the SSA (Section 214 of CHIPRA 2009. P.L. 111-3). No

The CHIP Agency elects the option to provide CHIP coverage to otherwise eligible pregnant women, lawfully residing in the United States, as provided in Section 214 of CHIPRA 2009, P.L. 111-3. The state may not select this option unless the state also elects to cover lawfully residing children. A state may not select this option unless the state also covers Targeted Low- Income Pregnant Women.

No

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995. no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 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# NV-13-0005 Approval Date: MAY { 3 2014

Effective Date: January 1, 2014 Page | of |

CHIP Eligibility

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

42 CFR 457.340(b)

Social Security Number

As a condition of eligibility, the CHIP Agency must require individuals who have a social security number or are eligible for one as determined by the Social Security Administration, to furnish their social security number, or numbers if they have more than one number.

The CHIP Agency requires individuals, as a condition of eligibility, to furnish their social security number(s), with the following exceptions:

Individuals refusing to obtain a social security number (SSN) because of well established religious objections. or Individuals who are not eligible for an SSN, or

Individuals who are issued an SSN only for a valid non-work purpose.

r The CHIP Agency assists individuals. who are required to provide their SSN, to apply for or obtain an SSN from the Social Security Administration if the individual does not have or forgot their SSN.

[@] The CHIP Agency informs individuals required to provide their SSN: By what statutory authority the number is solicited; and How the state will use the SSN.

The CHIP Agency provides assurance that it will verify each SSN furnished by an applicant or beneficiary with the Social Security Administration, not deny or delay services to an otherwise eligible applicant pending issuance or verification of the individual's SSN by the Social Security Administration and that the state's utilization of the SSNs is consistent with sections 205 and 1137 of the Social Security Act and the Privacy Act of 1974.

The state may request non-applicant household members to voluntarily provide their SSN, if the state meets the requirements below.

The state requests non-applicant household members to voluntarily provide their

SSN. es

When requesting an SSN for non-applicant household members, the state assures that:

rr At the time such SSN is requested. the state informs the non-applicant that this information is voluntary and provides information regarding how the SSN will be used; and

ry The state only uses the SSN for determination of eligibility for CHIP or other insurance affordability programs. or for a purpose directly connected with the administration of the state plan.

PRA Disclosure Statement

SPA# NV-13-0005 Approval Date: MAY 1 5 2016 Effective Date: January 1, 2014

Page | of 2

CHIP Eligibility

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 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. [f 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# NV-13-0005 Approval Date: MAY 1 3 2016 Effective Date: January 1, 2014 Page 2 of 2

CHIP Eligibility

MEISE NEN ha SOD MINI

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

457.310(b)(2) and (b)\3), 457.320(a\9) and 21 10(b)(1)(C) of the SSA

Substitution of Coverage

wl The CHIP Agency provides assurance that it has methods and policies in place to prevent the substitution of group health coverage or other commercial health insurance with public funded coverage. These policies include:

[ Substitution of coverage prevention strategy:

Name of policy Description

Monitor Substitution The Division will identify the percentage of enrollees who dropped group health insurance without good cause, in order to enroll in NCU, by generating an annual report and comparing the number of individuals under age 19 that were denied due to other | x insurance, reapplied and were enrolled in NCU, who a no longer report other insurance within a six month time frame. If substitution exceeds 10%, the Division will work with CMS create a strategy to reduce substitution.

A waiting period during which an individual is ineligible due to having dropped group health coverage.

([) If the state covers pregnant women, the waiting period does not apply to pregnant women.

If the state elects to offer dental only supplemental coverage. the following assurances apply:

oO The other coverage exclusion does not apply to children who are otherwise eligible for dental only supplemental coverage as ““ provided in section 2110(b)(5) of the SSA.

(7 The waiting period does not apply to children eligible for dental only supplemental coverage.

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.

V.20130718

MAY 15 2016

SPA# NV-13-0005 Approval Date: Effective Date: January 1, 2014

Page | of |

coms CHIP Eligibility

OMB Control Number: 0938-1148 0/31/2014

xpiration date

42 CFR 457.570

Non-Payment of Premiums

Does the state impose premiums or enrollment fees? Yes Can non-payment of premiums or enrollment fees result in loss of CHIP eligibility? Yes Does the state have a premium lock out period? Yes

Please describe the lock-out period:

The participant will receive a Quarterly Invoice. If the premium remains unpaid after 60 days a disenrollment will occur. Once a disenrollment has occurred. the lock-out period will commence at the beginning of that month. If the premium balance is paid at any time during the 90 day lock-out period, the child/ren will be re-enrolled without a new application. If the participant pays the past due balance after the 90 day lock-out is complete. a new application will be required. If all other eligibility criteria are met and the lock-out period has been satisfied, a child/re will not be denied eligibility, even if a past due balance exists. The child/ren will be enrolled and the debt balance will be moved to a separate account (lock-out category) and will be forwarded to DHCFP for initiation of the debt collection process.

What is the length of the time premium lock-out period? Select a length of time:

C One month

C Two months

@ 90 days

C Other (not to exceed 90 days)

Are there exceptions to the required lock-out period? No

[YZ] The state assures that: It does not require the collection of past due premiums or enrollment fees as a condition of eligibility for enrollment once the lock-out period has expired; and

It provides enrollees with an opportunity for an impartial review to address disenrollment from the program in accordance with section 457.1130(a}(3): and .

The child will be reenrolled in CHIP during the lock-out period upon payment of past due premiums or enrollment fees.

PRA Disclosure Statement

MAY 15 2014

SPA# NV-13-0005 Approval Date: Effective Date: January 1, 2014

Page | of 2

ccMs CHIP Eligibility

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

V.20130709

MAY 15 2016

SPA# NV-13-0005 Approval Date: Effective Date: January 1, 2014 Page 2 of 2

ccems. CHIP Eligibility

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

2105(a)(4)(A) of the SSA and 42 CFR 457.342 and 435.926

The CHIP Agency may provide that children who have been determined eligible under the state plan shall remain eligible. regardless of any changes in the family’s circumstances, during a continuous eligibility period up to 12 months, or until the time the child reaches an age specified by the state (not to exceed age 19), whichever is earlier.

The CHIP Agency elects to provide continuous eligibility to children under this provision. |Yes

@ For children up to age 19

C For children up to age

The continuous eligibility period begins on the effective date of the child's most recent determination or redetermination of eligibility, and ends:

[i] Atthe end ofthe |12 months continuous eligibility period.

Exceptions to the continuous eligibility period: [ii] The child attains the age specified by the state Agency or age 19. [B] The child or child's representative requests voluntary disenrollment. [i] The child is no longer a resident of the state.

rl The Agency determines that eligibility was erroneously granted at the most recent determination or renewal of eligibility because of Agency error or fraud, abuse, or perjury attributed to child or child's representative.

[HB] The child dies. [i] There is a failure to pay required premiums or enrollment fees on behalf of a child, as provided for in the state plan.

Other

Describe

Enrolled in Medicaid

| Incarcerated in a penal institution

Does not resolve citizenship requirements during reasonable opportunity period

Ward of the State

Enrolled in Minimum Essential Coverage xX

SPA# NV-13-0005 Approval Date: MAY t 5 2014 Effective Date: January 1, 2014

Page | of 2

coms CHIP Eligibility

ee Loss of Contact +

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 C Jearance Officer, Mail Stop C4-26-05, Baltimore. Maryland 21244-1850.

V.20130717

SPA# NV-13-0005 Approval Date: MAY 1 5 2014 Effective Date: January 1, 2014 Page 2 of 2

Cems. CHIP Eligibility

OMB Control Number: 0938-1148

42 CFR 457.355 and 435.1102. 2107(e)(1)(L) and 1920A of the SSA

The CHIP Agency covers children when determined presumptively eligible by a qualified entity. |No

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

V.20130709

MAY 15 2014

SPA# NV-13-0005 Approval Date: Effective Date: January 1, 2014

Page | of |

_____________________________________________________________________________ Table of Contents State/Territory Name: Nevada State Plan Amendment (SPA) #: NV-16-0012-A This file contains the following documents in the order listed: 1) Approval Letter 2) State Plan Pages The complete title XXI state plan for Nevada consists of the most recent state plan posted on Medicaid.gov under CHIP and State Plan Amendments. The link is provided below. The following pages are in addition to, or replace sections of the state’s posted current state plan. The attached approval letter(s) explain how these pages fit into that state plan. Link to state title XXI state plans and amendments: http://medicaid.gov/Medicaid-CHIP-Program-Information/By- Topics/Childrens-Health-Insurance-Program-CHIP/CHIP-State-Program-Information.html

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

7500 Security Boulevard, Mail Stop $2-26-12 Baltimore, MD 21244-1850

a

MSs

CENTERS FOR MEDICARE & MEDICAID SERVICES ‘CENTER FOR MEDICAID & CHIP SERVICES

.

NOV 2 3 2016

Marta Jensen

Acting Administrator

Division of Health Care Financing and Policy Nevada Department of Health and Human Services 1100 East William Street, Suite 101

Carson City, NV 89710

Dear Ms. Jensen:

I am writing to inform you that the Centers for Medicare & Medicaid Services (CMS) has approved your title XXI Children’s Health Insurance Program (CHIP) state plan amendment (SPA) number NV-16-012-A submitted on September 12, 2016. The SPA has an effective date of October 1, 2016.

This SPA permits Nevada to implement a new health services initiative (HSI) to integrate the Resources for the Early Advancement of Child Health (REACH) program into after school programs serving the highest risk populations of children in Nevada public schools. The implementation of this HSI supports Nevada students ages 10 through 18 with the goal of demonstrating the effectiveness of early intervention to prevent the onset of future behavioral health diagnosis by promoting social and emotional competence, student resilience, increased social-emotional competence, and improved student coping skills. The scope of services will include early intervention and preventive behavioral and mental health services.

This SPA provides funding through the HSI option at section 2105(a)(1)(D)(i) of the Social Security Act to use available title XXI administrative funding to pay for activities that protect public health, protect the health of individuals, improve or promote a state’s capacity to deliver public health services, or strengthen the human and material resources necessary to accomplish public health goals relating to improving the health of children, including targeted low-income children and other low-income children. The state shall ensure that the remaining title XXI funding, within the state’s 10 percent limit, is sufficient to continue the proper administration of the CHIP program. If such funds become less than sufficient, the state agrees to redirect title XXI funds from the support of these HSIs to the administration of the CHIP program. The state shall report annually to CMS the expenditures funded by the HSI for each federal fiscal year. CMS will work with the state to develop a simple and effective reporting process for these expenditures.

Your title XXI project officer is Mr. Patrick Edwards. He is available to answer questions concerning these amendments and other CHIP-related issues. Mr. Edwards’ contact information is as follows:

Page 2-Ms. Marta Jensen Centers for Medicare & Medicaid Services Center for Me"1.foaid and CHIP Services Mail Stop: s2.:01-15 7500 Security Boulevard Baltimore, MD 21244-1850 Telephone: (410) 786-6643 Facsimile: (410) 786-5882 E-mail: Patrick.Edwards@cms.hhs.gov Official communications regarding program matters should be sent simultaneously to Mr. Edwards and to Ms. Henrietta Sam-Louie, Associate Regional Administrator, in our San Francisco Regional Office. Ms. Hogaboom's address is: Centers for Medicare & Medicaid Services Division of Medicaid and Children's Health Operations 90 Seventh Street, Suite 5-300 (5W) San Francisco, CA 94103-6706 If you have additional questions or concerns, please contact Ms. Amy Lutzky, Acting Director, Division of State Coverage Programs, at (410) 786-0721. We look forward to continuing to work with you and your staff. l/J) Anne Marie Costello Director cc: Ms. Henrietta Sam-Louie, Associate Regional Administrator, CMS Region IX, San Francisco / Anne Marie Costello /

Effective Date: July 1, 2009October 1, 2016 Page 8 Approval Date: __November 23, 2016_ 3) Newborns – In Nevada Check Up, if a family is expecting a child, whether the adult female in the home or one of the enrolled children, Nevada Check Up must be notified within 14 days of the birth, the newborn, if eligible, will be added to the family as of its date of birth. If the notification criterion is not met, the child, if eligible, will be added the next administrative month following notification. A newborn cannot be enrolled before a family’s start date. A newborn will begin services at the same time as the other children in the family. One exception for the Checkup program is if the mother has other coverage for the newborn, and she has other children enrolled in Nevada Check Up, the newborn will be enrolled in Nevada Check Up as of the first day of the next administrative month following date of birth. In Medicaid, all children born to Medicaid-enrolled mothers are enrolled as of their date of birth. 2.2. Describe the current state efforts to provide or obtain creditable health coverage for uncovered children by addressing: (Section 2102)(a)(2) (42 CFR 457.80(b)) 2.2.1 The steps the state is currently taking to identify and enroll all uncovered children who are eligible to participate in public health insurance programs (i.e. Medicaid and state-only child health insurance): Nevada currently has several initiatives to enroll children in Medicaid and Nevada Check Up. These include outreach and referral services to the Women, Infant, and Children (WIC) centers, Federally Qualified Health Centers (FQHCs), Special Children’s Clinic (SCC)Nevada Early Intervention Programs, Baby Your Baby program (BYB), Family Resource Centers (FRCs), and the Family to Family program, Tribal Administrators, Tribal Clinics and Indian Health Services (IHS), Resources for the Early Advancement of Child Health (REACH) Program, Connecting Kids to Health Coverage, Nevada 211 and Nevada Health Link-Silver State Health Insurance Exchange. In addition, out stationed eligibility workers are in certain public hospitals and federally qualified health centers in order to provide these outreach and referral services. The descriptions of these programs are as follows: 1. The Medicaid program is administered by the Division of Health Care Financing and Policy and provides health coverage to low-income and disabled Nevada children. Nevada takes the following steps to enroll children in Medicaid: a. Nevada State Welfare District Offices located throughout the state determine a person’s eligibility for TANF, CHAP, and Medicaid. If applicants appear to be Nevada Check Up eligible, rather than Medicaid, they are appropriately referred. Out stationed sites (FQHCs, county hospitals, and local county health departments) help people apply for Medicaid or Nevada Check Up and send their applications and eligibility determination to the local Nevada

Effective Date: July 1, 2009October 1, 2016 Page 9 Approval Date: __November 23, 2016 State Welfare District Office or to the Nevada Check Up office. Local public health agencies identify low income, uninsured children through referrals from a variety of sources including: WIC, child health and immunization clinics, community health and social services agencies, and schools. 2. Women, Infants and Children (WIC) provides nutritious food to supplement the regular diet of pregnant women, infants, and children under age five who meet state income standards. Women and children under five years old qualify if the combined family income is at or below 185% of the federal poverty level. WIC staff encourages pregnant women and parents in this program to apply for Medicaid or Nevada Check Up, depending on their income level. 3. Federally Qualified Health Centers offer health care to low-income people. Nevada has three (13) federally qualified community health centers. The centers provide primary care services including care for acute and chronic illness, injuries, emergency care, diagnostic services and prescriptions. Community health centers take the following steps to enroll children in Medicaid or Nevada Check Up: 1. Provide a financial screen for each new patient or family 2. Provide information on and explanation of the program(s) for which family members may be eligible. 3. Assist with completing applications and collecting required documentation. 4. Forward applications to the determining agency and communicate with family about eligibility status. If a patient/family is not eligible for any program, the community health center will provide the health care services and will use its sliding fee scale according to family size and income to determine the fee. 4. Special Children’s Clinic Nevada Early Intervention Programs The Nevada Health Division, Special Children’s Clinic (SCC)Early Intervention Programs provides direct services to low-income children ages 0-3 under the Maternal and Child Health Block Grant (Title V). Services include well child clinic services, including developmental and physical assessments and immunizations. Children who appear to qualify for Medicaid or Nevada Check Up are encouraged to apply. 5. Baby Your Baby Program Baby Your Baby staff can provide Nevada Check Up applications and information to expectant mothers for future use in insuring their newborns. The state Title V program supports Baby Your Baby (BYB), which is a statewide multi-media bilingual campaign to promote early entry of pregnant women into prenatal care. In 2002 BYB assisted 9,768 women seeking services through the information referral line, and has assisted 111,035

Effective Date: July 1, 2009October 1, 2016 Page 10 Approval Date: _November 23, 2016_ women since the program’s inception. When appropriate, these women were referred to Medicaid and Title V prenatal care programs. 6. 5.Family Resource Centers A total of 2636 Family Resource Centers (FRCs) have been established in high risk neighborhoods throughout Nevada, and an additional two 2 are scheduled to open in the next year. The FRCs are community based centers run by not-for-profit organizations with state grants and private contributions. Their aim is to provide information about available social services including Medicaid and Nevada Check Up, and how to access those services. Sites also provide some services (e.g. child care) based on the needs of the community. Nevada Check Up staff have participated with Family Resource Centers in the coordination of health fairs. 7. 6. Community Connections/Family to2to Family Program The Family to Family program is an initiative aimed at informing new mothers of the services that are available to them and how to access such services. A total of two19 centers have been established throughout the state. These centers are community based and operate as public/private partnerships. New mothers are able to receive a home visit, get questions answered about parenting issues and services available to aid them in raising their children, including health insurance through Medicaid and Nevada Check Up. 8. 7. Tribal Administrators, Tribal Clinics, and Indian Health Services (IHS) Nevada Check Up staff attends and participates in meetings of the Native American Advisory Council, as mandated by Nevada law, in order to share information and receive advice as to the needs of the Native American tribes in Nevada. Application training and program updates are also provided by program staff. 9. Covering Kids and Families Grant (Robert Wood Johnson Foundation – RWJ) There are northern, southern and statewide coalitions whose members direct the activities of Covering Kids and Families staff and volunteers. Covering Kids and Families coordinators work with community-based organizations, schools, private businesses, and the state to promote the enrollment of children in appropriate health insurance programs. They provide applications for Medicaid and Nevada Check Up to those who appear to be eligible for public programs when no private insurance is available to them. Their employees also assist applicants in the proper completion and submission of applications. 8. Resources for the Early Advancement of Child Health (REACH) Program, through the Health Services Initiative, The Nevada Division of Health Care Financing and Policy (DHCFP) have been working on the coordination of the Rising Risk children’s behavioral health project with the Department of Education’s Office for a Safe and Respectful Learning Environment. The Office for a Safe and Respectful Learning Environment has a mission to

Effective Date: July 1, 2009October 1, 2016 Page 11 Approval Date: __November 23, 2016_ train, empower, educate, collaborate, advocate and intervene in order to ensure that every student in Nevada, regardless of any differing characteristic or interest feels fully protected physically, emotionally and socially. The office is responsible for the foundational four levels of a hierarchy of learning: physical needs, safety, belonging, and self-esteem. The Department of Education (DOE) has implemented several initiatives across the state school system, including placement of social workers in all schools and a mandated environmental scan. The environment scan is used to identify at risk schools in order to prioritize interventions and programming to these schools. The scan consists of 50 questions answered by all students in grades 5 through 12 annually focusing upon the safe and respectful learning environment issues. The administrative grant provides social workers or other licensed mental health workers in the identified targeted schools. The DHCFP is proposing the use of Health Services Initiative (HSI) funding to integrate the Resources for the Early Advancement of Child Health (REACH) program into after school programs serving the highest risk schools in Nevada that will be prioritized by the mandated environmental scan. The implementation of these innovative changes supports Nevada children in achieving a physical and emotionally safe environment by incorporating the REACH pilot project within the targeted schools. This approach will also allow the program to be scaled up or down based on available funding and the individualized schools needs. The individualized school needs will be identified per data tracking by utilizing the newly implemented statewide longitudinal data system to track outcomes and compare cohorts within the same school as well as compare to schools across the state. The HSI public health approach allows the services to be provided to all children in a targeted area regardless of payer source. The DHCFP will work with current after-school program(s) to determine capacity for providing the services within their current structure or coordinate with community providers who have the capacity to create a collaboration to provide these services. The DHCFP will be working to identify these groups to determine the best model for payment of these programs based on the community infrastructure and capacity. The HSI option allows the state to take a population health approach in partnership with the DOE assisting with supportive behavioral health and early intervention for children. HSI also provides the flexibility to pilot the rising-risk concept across various age groups with the goal of being able to demonstrate the effectiveness of early intervention. The scope of services will target early intervention services, mental health resources, and create support environments for parents focusing on formal and informal links within their communities. The collaboration between both the DOE and the DHCFP will provide teacher training, curriculum, and parental education

Effective Date: July 1, 2009October 1, 2016 Page 12 Approval Date: _November 23, 2016_ used to promote social and emotional competence, and an improvement in student resilience, increased social-emotional competence, and improved coping skills with overall health comes. 191. Connecting Kids to Health Coverage The Connecting Kids to Coverage will identify children who are eligible for Medicaid and the Children's Health Insurance Program (CHIP) and support targeted strategies needed to enroll eligible children who do not have health coverage, including application assistance and outreach. 102. Nevada 2-1-1 Nevada 2-1-1, a program of the Financial Guidance Center, is committed to helping Nevada Citizentscitizens connect with the services they need, w. Wwhether by phone or internet. The goal is to present accurate, well- organized and easy-to-find information for the state and local health and human services program. 113. Nevada Health Link- Silver State Health Insurance Exchange The state utilized Navigator Organizations, Certified Enrollment Assistant and is based on their attendance of community events, community involvement, and health care provider engagement eligibility screening. 14. Health Plans- Amerigroup & Health Plan of Nevada? 2.2.2 The steps this state is currently taking to identify and enroll all uncovered children who are eligible to participate in health insurance programs that involve a public/private partnership.

_____________________________________________________________________________ Table of Contents State/Territory Name: Nevada State Plan Amendments (SPA) #: NV-18-0008 This file contains the following documents in the order listed: 1) Approval Letter 2) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, MailStop S2-01-16 Baltimore, MD 21244-1850 Children and Adults Health Prosrams Groun rvrs ctNrfRs FoR MtDtcAtt & MtDtc_AtD stRvtcts CENTEN fOR MEDICAID & CHIP SIRVICES Suzanne Bierman Administrator Division of Health Care Financing and Policy Department of Health and Human Services I100 East'William Street, Suite 101 Carson City, NV 89710 JUN 0 6 2019 Dear Ms. Bierman Your title XXI Children's Health Insurance Program (CHIP) state plan amendment (SPA) NV- l8-0008 submitted on June 27,2018, with additional information submitted on (insert date), 2019, has been approved. Through this SPA, Nevada implements mental health parity requirements to ensure that treatment limitations applied to mental health (MH) and substance use disorder (SUD) benefits are no more restrictive than those applied to medical/surgical (M/S) benefits. This SPA has an effective date of October 2,2017 with the exception of the changes described below. Section 2103(c)(7)(A) of the Social Security Act (the Act), as implemented through regulations at 42 CFR 457.496(d)(3)-(5), requires states that provide both M/S and MH/SUD benefits to ensure that frnancial requirements and treatment limitations applied to MH/SUD benefits covered under the state child health plan are consistent with the mental health parity requirements of section2705(a) of the Public Health Service Act, in the same manner that such requirements apply to a group health plan. Nevada demonstrated compliance by providing the necessary assurances and supporting documentation that the state's application of non- quantitative treatment limitations to MH/SUD benefits are consistent with section 2103(oX7XA) of the Act. In order to comply with parity requirements, the state is updating its written policy on crisis intervention services to accurately reflect that soft limits can be exceeded if medically necessary, and updating its overall policy on assessments and therapy services to permit soft limits to be exceeded for all levels of care. These changes were effective November 16, 2017. This approval relates only to benefits provided under the CHIP state plan; Medicaid benefits will be analy zed separately. Your title XXI project officer is Ms. Jasmine Aplin. She is available to answer questions conceming this amendment and other CHlP-related issues. Her contact information is as t'ollows:

Page 2-Ms. Suzanne Bierman Centers for Medicare & Medicaid Services Center for Medicaid and CHIP Services Mail Stop: 52-01-16 7500 Security Boulevard Baltimore, MD 21244-1850 Telephone : (41 0) 7 86-81 02 E-mail: Jasmine.Aplin@cms.hhs.eov Offrcial communications regarding program matters should be sent simultaneously to Ms. Aplin and Mr. Richard Allen, Director, Division of Medicaid Field Operations West. Mr. Allen's address is: Centers for Medicare & Medicaid Services Division of Medicaid Field Operations West 90-7rh Street, Suite 5-300 San Francisco, CA 94103-6706 Ifyou have questions additional questions, please contact Amy Lutzky, Director, Division of State Coverage Programs (+10)786-0721. Sincerely, t*wßw Anne Marie Costello Director Cc: Richard Allen, Director, Division of Medicaid Field Operations West /signed Anne Marie Costello/

Section 1. General Description and Purpose of the Children’s Health Insurance Plans and the Requirements 1.1. The state will use funds provided under Title XXI primarily for (Check appropriate box) (Section 2101)(a)(1)); (42 CFR 457.70): Guidance: Check below if child health assistance shall be provided primarily through the development of a separate program that meets the requirements of Section 2101, which details coverage requirements and the other applicable requirements of Title XXI. 1.1.1. Obtaining coverage that meets the requirements for a separate child health program (Sections 2101(a)(1) and 2103); OR Guidance: Check below if child health assistance shall be provided primarily through providing expanded eligibility under the State’s Medicaid program (Title XIX). Note that if this is selected the State must also submit a corresponding Medicaid SPA to CMS for review and approval. 1.1.2. Providing expanded benefits under the State’s Medicaid plan (Title XIX) (Section 2101(a)(2)); OR Guidance: Check below if child health assistance shall be provided through a combination of both 1.1.1. and 1.1.2. (Coverage that meets the requirements of Title XXI, in conjunction with an expansion in the State’s Medicaid program). Note that if this is selected the state must also submit a corresponding Medicaid state plan amendment to CMS for review and approval. 1.1.3. A combination of both of the above. (Section 2101(a)(2)) 1.1-DS The State will provide dental-only supplemental coverage. Only States operating a separate CHIP program are eligible for this option. States choosing this option must also complete sections 4.1-DS, 4.2-DS, 6.2-DS, 8.2-DS, and 9.10 of this SPA template. (Section 2110(b)(5)) 1.2. Check to provide an assurance that expenditures for child health assistance will not be claimed prior to the time that the State has legislative authority to operate the State plan or plan amendment as approved by CMS. (42 CFR 457.40(d)) 1.3. Check to provide an assurance that the State complies with all applicable civil rights requirements, including title VI of the Civil Rights Act of 1964, title II of the Americans with Disabilities Act of 1990, section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, 45 CFR part 80, part 84, and part 91, and 28 CFR part 35. (42 CFR 457.130) Guidance: The effective date as specified below is defined as the date on which the State begins to incur costs to implement its State plan or amendment. (42 CFR 457.65) The implementation date is defined as the date the State begins to provide services; or, the date on which the State puts into practice the new policy described in the State plan or amendment. For example, in a State that has increased

eligibility, this is the date on which the State begins to provide coverage to enrollees (and not the date the State begins outreach or accepting applications). 1.4. Provide the effective (date costs begin to be incurred) and implementation (date services begin to be provided) dates for this SPA (42 CFR 457.65). A SPA may only have one effective date, but provisions within the SPA may have different implementation dates that must be after the effective date. Original Plan Effective Date: July 1, 2011 Implementation Date: September 1, 2011 SPA #18-008 Purpose of SPA: To align the CHIP SPA with the Mental Health Parity Addiction and Equity Act. Proposed effective date: October 2, 2017 Proposed implementation date: October 2, 2017 1.4- TC Tribal Consultation (Section 2107(e)(1)(C)) Describe the consultation process that occurred specifically for the development and submission of this State Plan Amendment, when it occurred and who was involved. The Department of Health and Human Services (DHHS), Tribes, Indian Health Service, Tribal and Urban Indian Organizations (I/T/U) residing within of the State of Nevada created a Tribal Consultation Process. The Tribal Consultation Process was signed and became effective March 2010. Below is a summary of the process for the Tribal Consultation Process: Purpose – The purpose of the agreement is to establish an open and meaningful consultation process between the Nevada DHHS and the Indian Tribes in the State of Nevada to facilitate better communication and collaboration between the entities. Agreement – The guiding principle of the agreement is to ensure that open and meaningful communication occurs in a timely manner for consultation between the parties regarding high-level policy changes that significantly impact Indian Tribes in the State of Nevada. Policy changes that significantly impact Indian Tribes refer to actions that have substantial Tribal implications with direct effects on one or more Indian Tribes, on relationship between the State of Nevada and Indian Tribes or on the distribution of roles on and responsibilities between the State of Nevada and Indian Tribes. A copy of the tribe-state consultation process can be requested from the Division of Health Care Financing and Policy (DHCFP). TN No: 18-008 Approval Date: _______________ Effective Date: October 2, 2017

In addition to the tribe-state consultation process set forth between DHHS, Tribes, and I/T/Us; The DHCFP will consult with all federally recognized Tribes and I/T/Us within the State of Nevada on all Medicaid state plan amendments, waiver requests, waiver renewals, demonstration project proposals and/or on all matters that relate to Medicaid and CHIP programs. a. The notification will describe the purpose of the state plan amendment, waiver request, waiver renewal, demonstration project proposal and/or on matter relating to Medicaid and CHIP programs and will include the anticipated impact on Tribal members, Tribes and/or I/T/Us. The description of the impact will not be Tribal member, Tribe and/or I/T/U specific if the impact is similar on all Tribal members, Tribes and/or I/T/Us. b. The notification will also describe a method for Tribes and/or I/T/Us to provide official written comments and questions within a time-frame that allows adequate time for State analysis, consideration of any issues that are raised and the time for discussion between the State and entities responding to the notification. c. Tribes and I/T/Us will be provided a reasonable amount of time to respond to the notification. Whereof, 30 days is considered reasonable. d. In all cases where Tribes and/or I/T/Us request in-person consultation meetings, the DHCFP will make these meetings available. e. The tribe-state consultation process allows for an expedited process for notification of policy changes due to budget cuts prior to changes being implemented. The Centers for Medicare and Medicaid Services (CMS) requires Medicaid state plan amendments, waiver requests and waiver renewals, which fall within this category to have a notification process prior to these documents being submitted to CMS. Due to this, the State is instituting an expedited process which allows for notification to the tribes of at least one-week notice prior to the changes being implemented as agreed upon in the tribe-state consultation process or two weeks prior to the submission of the state plan amendments, waiver requests and/or waiver renewals, whichever date precedes. Tribal notification for SPA 18-008 was distributed on March 28, 2018. TN No: 18-008 Approval Date: _______________ Effective Date: October 2, 2017

40 Section 6. Coverage Requirements for Children’s Health Insurance Check here if the State elects to use funds provided under Title XXI only to provide expanded eligibility under the State’s Medicaid plan and proceed to Section 7 since children covered under a Medicaid expansion program will receive all Medicaid covered services including EPSDT. 6.1. The State elects to provide the following forms of coverage to children: (Check all that apply.) (Section 2103(c)); (42 CFR 457.410(a)) Guidance: Benchmark coverage is substantially equal to the benefits coverage in a benchmark benefit package (FEHBP-equivalent coverage, State employee coverage, and/or the HMO coverage plan that has the largest insured commercial, non-Medicaid enrollment in the state). If box below is checked, either 6.1.1.1., 6.1.1.2. or 6.1.1.3. must also be checked. (Section 2103(a)(1)) 6.1.1. Benchmark coverage; (Section 2103(a)(1) and 42 CFR 457.420) Guidance: Check box below if the benchmark benefit package to be offered by the State is the standard Blue Cross/Blue Shield preferred provider option service benefit plan, as described in and offered under Section 8903(1) of Title 5, United States Code. (Section 2103(b)(1) (42 CFR 457.420(b)) 6.1.1.1. FEHBP-equivalent coverage; (Section 2103(b)(1) (42 CFR 457.420(a)) (If checked, attach copy of the plan.) Guidance: Check box below if the benchmark benefit package to be offered by the State is State employee coverage, meaning a coverage plan that is offered and generally available to State employees in the state. (Section 2103(b)(2)) 6.1.1.2. State employee coverage; (Section 2103(b)(2)) (If checked, identify the plan and attach a copy of the benefits description.) Guidance: Check box below if the benchmark benefit package to be offered by the State is offered by a health maintenance organization (as defined in Section 2791(b)(3) of the Public Health Services Act) and has the largest insured commercial, non-Medicaid enrollment of covered lives of such coverage plans offered by an HMO in the state. (Section 2103(b)(3) (42 CFR 457.420(c))) 6.1.1.3. HMO with largest insured commercial enrollment (Section 2103(b)(3)) (If checked, identify the plan and attach a copy of the benefits description.) Guidance: States choosing Benchmark-equivalent coverage must check the box below and ensure that the coverage meets the following requirements:  The coverage includes benefits for items and services within each of the categories of basic services described in 42 CFR 457.430:

41 • dental services • inpatient and outpatient hospital services, • physicians’ services, • surgical and medical services, • laboratory and x-ray services, • well-baby and well-child care, including age-appropriate immunizations, and • emergency services;  the coverage has an aggregate actuarial value that is at least actuarially equivalent to one of the benchmark benefit packages (FEHBP-equivalent coverage, State employee coverage, or coverage offered through an HMO coverage plan that has the largest insured commercial enrollment in the state); and  the coverage has an actuarial value that is equal to at least 75 percent of the actuarial value of the additional categories in such package, if offered, as described in 42 CFR 457.430: • coverage of prescription drugs, • mental health services, • vision services and • hearing services. If 6.1.2. is checked, a signed actuarial memorandum must be attached. The actuary who prepares the opinion must select and specify the standardized set and population to be used under paragraphs (b)(3) and (b)(4) of 42 CFR 457.431. The State must provide sufficient detail to explain the basis of the methodologies used to estimate the actuarial value or, if requested by CMS, to replicate the State results. The actuarial report must be prepared by an individual who is a member of the American Academy of Actuaries. This report must be prepared in accordance with the principles and standards of the American Academy of Actuaries. In preparing the report, the actuary must use generally accepted actuarial principles and methodologies, use a standardized set of utilization and price factors, use a standardized population that is representative of privately insured children of the age of children who are expected to be covered under the State child health plan, apply the same principles and factors in comparing the value of different coverage (or categories of services), without taking into account any differences in coverage based on the method of delivery or means of cost control or utilization used, and take into account the ability of a State to reduce benefits by taking into account the increase in actuarial value of benefits coverage offered under the State child health plan that results from the limitations on cost sharing under such coverage. (Section 2103(a)(2)) 6.1.2. Benchmark-equivalent coverage; (Section 2103(a)(2) and 42 CFR 457.430) Specify the coverage, including the amount, scope and duration of each service, as well as any exclusions or limitations. Attach a signed actuarial report that meets the requirements specified in 42 CFR 457.431. Guidance: A State approved under the provision below, may modify its program from time to time so long as it continues to provide coverage at least equal to the lower of the actuarial value of

42

the coverage under the program as of August 5, 1997, or one of the benchmark programs. If “existing comprehensive state-based coverage” is modified, an actuarial opinion documenting that the actuarial value of the modification is greater than the value as of August 5, 1997, or one of the benchmark plans must be attached. Also, the fiscal year 1996 State expenditures for “existing comprehensive state-based coverage” must be described in the space provided for all states. (Section 2103(a)(3))

6.1.3.

Existing Comprehensive State-Based Coverage; (Section 2103(a)(3) and 42 CFR 457.440) This option is only applicable to New York, Florida, and Pennsylvania. Attach a description of the benefits package, administration, and date of enactment. If existing comprehensive State-based coverage is modified, provide an actuarial opinion documenting that the actuarial value of the modification is greater than the value as of August 5, 1997 or one of the benchmark plans. Describe the fiscal year 1996 State expenditures for existing comprehensive state-based coverage.

Guidance: Secretary-approved coverage refers to any other health benefits coverage deemed appropriate and acceptable by the Secretary upon application by a state. (Section 2103(a)(4)) (42 CFR 457.250)

6.1.4.

Secretary-approved Coverage. (Section 2103(a)(4)) (42 CFR 457.450)

Guidance: Section 1905(r) of the Act defines EPSDT to require coverage of (1) any medically necessary screening, and diagnostic services, including vision, hearing, and dental screening and diagnostic services, consistent with a periodicity schedule based on current and reasonable medical practice standards or the health needs of an individual child to determine if a suspected condition or illness exists; and (2) all services listed in Section 1905(a) of the Act that are necessary to correct or ameliorate any defects and mental and physical illnesses or conditions discovered by the screening services, whether or not those services are covered under the Medicaid state plan. Section 1902(a)(43) of the Act requires that the State (1) provide and arrange for all necessary services, including supportive services, such as transportation, needed to receive medical care included within the scope of the EPSDT benefit and (2) inform eligible beneficiaries about the services available under the EPSDT benefit.

If the coverage provided does not meet all of the statutory requirements for EPSDT contained in Sections 1902(a)(43) and 1905(r) of the Act, do not check this box.

6.1.4.1.

Coverage of all benefits that are provided to children that is the same as the benefits provided under the Medicaid State plan, including Early Periodic Screening, Diagnostic, and Treatment (EPSDT).

6.1.4.2.

Comprehensive coverage for children under a Medicaid Section 1115 demonstration waiver.

6.1.4.3.

Coverage that the State has extended to the entire Medicaid population.

43

Guidance: Check below if the coverage offered includes benchmark coverage, as specified in §457.420, plus additional coverage. Under this option, the State must clearly demonstrate that the coverage it provides includes the same coverage as the benchmark package, and also describes the services that are being added to the benchmark package.

6.1.4.4.

Coverage that includes benchmark coverage plus additional coverage. CHIP enrollees receive coverage offered in the benchmark package and have added value benefit services through the HMO and State PEBP. 6.1.4.5.

Coverage that is the same as defined by existing comprehensive state-based coverage applicable only in New York, Pennsylvania or Florida. (under 42 CFR 457.440)

Guidance: Check below if the State is purchasing coverage through a group health plan and intends to demonstrate that the group health plan is substantially equivalent to or greater than coverage under one of the benchmark plans specified in 457.420, through the use of a benefit-by-benefit comparison of the coverage. Provide a sample of the comparison format that will be used. Under this option, if coverage for any benefit does not meet or exceed the coverage for that benefit under the benchmark, the State must provide an actuarial analysis as described in 457.431 to determine actuarial equivalence.

6.1.4.6.

Coverage under a group health plan that is substantially equivalent to or greater than benchmark coverage through a benefit by benefit comparison (Provide a sample of how the comparison will be done).

Guidance: Check below if the State elects to provide a source of coverage that is not described above. Describe the coverage that will be offered, including any benefit limitations or exclusions.

6.1.4.7.

Other. (Describe) The state elects to provide a basic set of health care benefits that are focused on primary health care needs and that contain the cost of the benefit package. Specific covered services are described in Section 2 below.

Guidance: All forms of coverage that the State elects to provide to children in its plan must be checked. The State should also describe the scope, amount and duration of services covered under its plan, as well as any exclusions or limitations. States that choose to cover unborn children under the State plan should include a separate Section 6.2 that specifies benefits for the unborn child population. (Section 2110(a)) (42 CFR, 457.490)

If the state elects to cover the new option of targeted low income pregnant women but chooses to provide a different benefit package for these pregnant women under the CHIP plan, the state must include a separate Section 6.2 describing the benefit package for pregnant women. (Section 2112)

6.2. The State elects to provide the following forms of coverage to children: (Check all that apply. If an item is checked, describe the coverage with respect to the amount, duration and scope of

44

services covered, as well as any exclusions or limitations) (Section 2110(a)) (42 CFR 457.490)

6.2.1.

Inpatient services (Section 2110(a)(1)) Inpatient services include all physician, surgical, medical, mental health, substance use disorder and other services delivered during a hospital stay. Inpatient services covered in full. 6.2.2.

Outpatient services (Section 2110(a)(2)) Outpatient services include outpatient surgery – covered in full. 6.2.3.

Physician services (Section 2110(a)(3)) Physician services include medical office visits with a physician, mid-level practitioner or specialist. Covered in full. Preventive care (well baby) and immunizations covered in full. 6.2.4.

Surgical services (Section 2110(a)(4)) Covered in full. See 6.2.1 for Inpatient Surgical Services and 6.2.2 for Outpatient Surgical Services. 6.2.5.

Clinic services (including health center services) and other ambulatory health care services. (Section 2110(a)(5)) See Section 6.2.2. 6.2.6.

Prescription drugs (Section 2110(a)(6)) Covered for inpatient and outpatient prescription drugs with no co-payment. 6.2.7.

Over-the-counter medications (Section 2110(a)(7)) Over-the-counter medications are covered when prescribed by an authorized medical provider. The participant may have up to two over-the-counter medications within a therapeutic class before a prior authorization is required. 6.2.8.

Laboratory and radiological services (Section 2110(a)(8)) Covered in full for physician-ordered services. 6.2.9.

Prenatal care and pre-pregnancy family services and supplies (Section 2110(a)(9)) Family planning and prenatal maternity care covered in full. 6.2.10.

Inpatient mental health services, other than services described in 6.2.18., but including services furnished in a state-operated mental hospital and including residential or other 24-hour therapeutically planned structural services (Section 2110(a)(10)) Services covered with continuing stay authorized by Quality Improvement Organization (QIO) like vendor. All covered treatment consistent with Medicaid Services Manual Chapter 400. 6.2.11.

Outpatient mental health services, other than services described in 6.2.19, but including services furnished in a state-operated mental hospital and including community-based services (Section 2110(a)(11) Mental health professionals are subject to the following utilization criteria: Utilization criteria is based on the Intensity of Needs Determination. A standardized mechanism to determine the intensity of services needed based upon the severity of the recipient’s condition. The intensity of needs determination is to be utilized in conjunction with the clinical judgment of the Qualified Mental Health Professional (QMHP) and/or trained Qualified Mental Health Associate (QMHA). This assessment was previously known as a level of care assessment. Currently, the DHCFP recognizes the Level of Care Utilization System (LOCUS) for adults and

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the Child and Adolescent Screening Intensity Instrument (CASII) for children and adolescents. There is no level of care assessment tool recognized by the DHCFP for children below age six, however, providers must utilize a tool comparable to the CASII and recognized as a standard of practice in determining the intensity of needs for this age group. 6.2.12.

Durable medical equipment and other medically-related or remedial devices (such as prosthetic devices, implants, eyeglasses, hearing aids, dental devices and adaptive devices) (Section 2110(a)(12)) Durable medical equipment is dispensed, on prescription signed by a physician or physician extender (APN, PA), based on medical necessity and prior authorization. There are limitations which may only be overridden by authorized approval of written, medical justification. 6.2.13.

Disposable medical supplies (Section 2110(a)(13))

Guidance: Home and community-based services may include supportive services such as home health nursing services, home health aide services, personal care, assistance with activities of daily living, chore services, day care services, respite care services, training for family members and minor modifications to the home.

6.2.14.

Home and community-based health care services (Section 2110(a)(14))

Guidance: Nursing services may include nurse practitioner services, nurse midwife services, advanced practice nurse services, private duty nursing care, pediatric nurse services and respiratory care services in a home, school or other setting.

6.2.15.

Nursing care services (Section 2110(a)(15)) Skilled nursing covered with no limitations as long as medical necessity requirements have been met. 6.2.16.

Abortion only if necessary to save the life of the mother or if the pregnancy is the result of an act of rape or incest (Section 2110(a)(16) 6.2.17.

Dental services (Section 2110(a)(17)) States updating their dental benefits must complete 6.2-DC (CHIPRA # 7, SHO # #09-012 issued October 7, 2009) Coverage for preventative, diagnostic and treatment, and other general dental services and emergency assessments. Medically necessary orthodontia is a benefit requiring prior authorization. 6.2.18.

Vision screenings and services (Section 2110(a)(24)) 6.2.19.

Hearing screenings and services (Section 2110(a)(24)) 6.2.20.

Inpatient substance abuse treatment services and residential substance abuse treatment services (Section 2110(a)(18)) Detoxification – Up to five hospital days, more if medical necessity warrants. Treatment – Up to 21 hospital days, more if medical necessity warrants. 6.2.21.

Outpatient substance abuse treatment services (Section 2110(a)(19)) The benefit is the same as 6.2.11 above. 6.2.22.

Case management services (Section 2110(a)(20)) Targeted case management services are required to be provided by the Nevada Check Up program, consistent with the Medicaid Title XIX State Plan.

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6.2.23.

Care coordination services (Section 2110(a)(21)) Care coordination services are required to be provided by the MCOs in the managed care portion of the Nevada Check Up program. Care coordination services are not currently available in the Fee-for-Service areas. 6.2.24.

Physical therapy, occupational therapy, and services for individuals with speech, hearing and language disorders (Section 2110(a)(22)) Therapy Services, including group and individual treatment, are subject to utilization management criteria. 6.2.25.

Hospice care (Section 2110(a)(23)) Inpatient covered for up to six months; subsequent periods may be approved in 30- day blocs. Hospice may also include routine or continuous home care, respite care, counseling, appliances, supplies and pharmaceuticals. Curative services are provided to NCU participants in accordance with Section 2302 of the Affordable Care Act.

Guidance: See guidance for Section 6.1.4.1 for guidance on the statutory requirements for EPSDT under Sections 1905(r) and 1902(a)(43) of the Act. If the benefit being provided does not meet the EPSDT statutory requirements, do not check the box below.

6.2.26.

EPSDT consistent with requirements of Sections 1905(r) and 1902(a)(43) of the Act

Guidance: Any other medical, diagnostic, screening, preventive, restorative, remedial, therapeutic or rehabilitative service may be provided, whether in a facility, home, school or other setting, if recognized by State law and only if the service is: 1) prescribed by or furnished by a physician or other licensed or registered practitioner within the scope of practice as prescribed by State law; 2) performed under the general supervision or at the direction of a physician; or 3) furnished by a health care facility that is operated by a State or local government or is licensed under State law and operating within the scope of the license.

6.2.27.

Any other medical, diagnostic, screening, preventive, restorative, remedial, therapeutic, or rehabilitative services. (Section 2110(a)(24)) Annual vision screening exam and glasses, hearing exams, medically necessary transplants as required under the Title XIX EPSDT program. 6.2.28.

Premiums for private health care insurance coverage (Section 2110(a)(25)) 6.2.29.

Medical transportation (Section 2110(a)(26)) Hospital and emergency room transport are covered.

Guidance: Enabling services, such as transportation, translation, and outreach services, may be offered only if designed to increase the accessibility of primary and preventive health care services for eligible low-income individuals.

6.2.30.

Enabling services (such as transportation, translation, and outreach services) (Section 2110(a)(27)) 6.2.31.

Any other health care services or items specified by the Secretary and not included under this Section (Section 2110(a)(28))

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Benefits are subject to prior authorization and/or other utilization review controls as established by the plan, except for emergency services. For areas not covered by an MCO, a Fee-for-Service benefit is provided with the same State Plan benefit package.

6.2-DC Dental Coverage (CHIPRA # 7, SHO # #09-012 issued October 7, 2009) The State will provide dental coverage to children through one of the following. Please update Sections 9.10 and 10.3-DC when electing this option. Dental services provided to children eligible for dental-only supplemental services must receive the same dental services as provided to otherwise eligible CHIP children (Section 2103(a)(5)):

6.2.1-DC State Specific Dental Benefit Package. The State assures dental services represented by the following categories of common dental terminology (CDT1) codes are included in the dental benefits: 1. Diagnostic (i.e., clinical exams, x-rays) (CDT Codes: D0100-D0999) (must follow periodicity schedule) 2. Preventive (i.e., dental prophylaxis, topical fluoride treatments, sealants) (CDT Codes: D1000-D1999) (must follow periodicity schedule) 3. Restorative (i.e., fillings, crowns) (CDT Codes: D2000-D2999) 4. Endodontic (i.e., root canals) (CDT Codes: D3000-D3999) 5. Periodontics (treatment of gum disease) (CDT Codes: D4000-D4999) 6. Prosthodontic (dentures) (CDT Codes: D5000-D5899, D5900-D5999, and D6200-D6999) 7. Oral and Maxillofacial Surgery (i.e., extractions of teeth and other oral surgical procedures) (CDT Codes: D7000-D7999) 8. Orthodontics (i.e., braces) (CDT Codes: D8000-D8999) 9. Emergency Dental Services

6.2.1.1-DC Periodicity Schedule. The State has adopted the following periodicity schedule: State-developed Medicaid-specific American Academy of Pediatric Dentistry Other Nationally recognized periodicity schedule Other (description attached)

6.2.2-DC Benchmark coverage; (Section 2103(c)(5), 42 CFR 457.410, and 42 CFR 457.420)

6.2.2.1-DC FEHBP-equivalent coverage; (Section 2103(c)(5)(C)(i)) (If checked, attach copy of the dental supplemental plan benefits description and the applicable CDT2 codes. If the State chooses to provide supplemental services, also attach a description of the services and applicable CDT codes)

6.2.2.2-DC State employee coverage; (Section 2103(c)(5)(C)(ii)) (If checked, identify the plan and attach a copy of the benefits description and the applicable

Current Dental Terminology, © 2010 American Dental Association. All rights reserved. Current Dental Terminology, © 2010 American Dental Association. All rights reserved.

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CDT codes. If the State chooses to provide supplemental services, also attach a description of the services and applicable CDT codes) 6.2.2.3-DC HMO with largest insured commercial enrollment (Section 2103(c)(5)(C)(iii)) (If checked, identify the plan and attach a copy of the benefits description and the applicable CDT codes. If the State chooses to provide supplemental services, also attach a description of the services and applicable CDT codes)

6.2-DS

Supplemental Dental Coverage- The State will provide dental coverage to children eligible for dental-only supplemental services. Children eligible for this option must receive the same dental services as provided to otherwise eligible CHIP children (Section 2110(b)(5)(C)(ii)). Please update Sections 1.1-DS, 4.1-DS, 4.2-DS, and 9.10 when electing this option.

Guidance: Under Title XXI, pre-existing condition exclusions are not allowed, with the only exception being in relation to another law in existence (HIPAA/ERISA). Indicate that the plan adheres to this requirement by checking the applicable description.

In the event that the State provides benefits through a group health plan or group health coverage or provides family coverage through a group health plan under a waiver (see Section 6.4.2.), pre-existing condition limits are allowed to the extent permitted by HIPAA/ERISA. If the State is contracting with a group health plan or provides benefits through group health coverage, describe briefly any limitations on pre-existing conditions. (Formerly 8.6.)

6.2 – MHPAEA Section 2103(c)(6)(A) of the Social Security Act requires that, to the extent that it provides both medical/surgical benefits and mental health or substance use disorder benefits, a State child health plan ensures that financial requirements and treatment limitations applicable to mental health and substance use disorder benefits comply with the mental health parity requirements of Section 2705(a) of the Public Health Service Act in the same manner that such requirements apply to a group health plan. If the state child health plan provides for delivery of services through a managed care arrangement, this requirement applies to both the state and managed care plans. These requirements are also applicable to any additional benefits provided voluntarily to the child health plan population by managed care entities and will be considered as part of CMS’s contract review process at 42 CFR 457.1201(l).

6.2.1 – MHPAEA. Before completing a parity analysis, the State must determine whether each covered benefit is a medical/surgical, mental health, or substance use disorder benefit based on a standard that is consistent with state and federal law and generally recognized independent standards of medical practice. (42 CFR 457.496(f)(1)(i))

6.2.1.1 – MHPAEA. Please choose the standard(s) the state uses to determine whether a covered benefit is a medical/surgical benefit, mental health benefit, or substance use disorder benefit. The most current version of the standard elected must be used. If different standards are used for different benefit types, please specify the benefit type(s) to which each standard is applied. If “Other” is selected, please provide a description of that standard.

International Classification of Disease (ICD)

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Diagnostic and Statistical Manual of Mental Disorders (DSM) State guidelines (Describe: ) Other (Describe: ) 6.2.1.2 – MHPAEA. Does the State provide mental health and/or substance use disorder benefits?

Yes No

Guidance: If the State does not provide any mental health or substance use disorder benefits, the mental health parity requirements do not apply ((42 CFR 457.496(f)(1)). Continue on to Section 6.3.

6.2.2 – MHPAEA. Section 2103(c)(6)(B) of the Social Security Act (the Act) provides that to the extent a State child health plan includes coverage of early and periodic screening, diagnostic, and treatment services (EPSDT) defined in Section 1905(r) of the Act and provided in accordance with Section 1902(a)(43) of the Act, the plan shall be deemed to satisfy the parity requirements of Section 2103(c)(6)(A) of the Act.

6.2.2.1 – MHPAEA. Does the State child health plan provide coverage of EPSDT? The State must provide for coverage of EPSDT benefits, consistent with Medicaid statutory requirements, as indicated in Section 6.2.26 of the State child health plan in order to answer “yes.”

Yes No

Guidance: If the State child health plan does not provide EPSDT consistent with Medicaid statutory requirements at Sections 1902(a)(43) and 1905(r) of the Act, please go to Section 6.2.3 – MHPAEA to complete the required parity analysis of the State child health plan.

If the state does provide EPSDT benefits consistent with Medicaid requirements, please continue this section to demonstrate compliance with the statutory requirements of Section 2103(c)(6)(B) of the Act and the mental health parity regulations of 42 CFR 457.496(b) related to deemed compliance. Please provide supporting documentation, such as contract language, provider manuals, and/or member handbooks describing the state’s provision of EPSDT.

6.2.2.2 – MHPAEA. EPSDT benefits are provided to the following:

All children covered under the State child health plan. A subset of children covered under the State child health plan. Please describe the different populations (if applicable) covered under the State child health plan that are provided EPSDT benefits consistent with Medicaid statutory requirements.

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Guidance: If only a subset of children is provided EPSDT benefits under the State child health plan, 42 CFR 457.496(b)(3) limits deemed compliance to those children only and Section 6.2.3 - MHPAEA must be completed as well as the required parity analysis for the other children.

6.2.2.3 – MHPAEA. To be deemed compliant with the MHPAEA parity requirements, States must provide EPSDT in accordance with Sections 1902(a)(43) and 1905(r) of the Act (42 CFR 457.496(b)). The State assures each of the following for children eligible for EPSDT under the separate State child health plan:

All screening services, including screenings for mental health and substance use disorder conditions, are provided at intervals that align with a periodicity schedule that meets reasonable standards of medical or dental practice as well as when medically necessary to determine the existence of suspected illness or conditions. (Section 1905(r))

All diagnostic services described in 1905(a) of the Act are provided as needed to diagnose suspected conditions or illnesses discovered through screening services, whether or not those services are covered under the Medicaid state plan. (Section 1905(r))

All items and services described in Section 1905(a) of the Act are provided when needed to correct or ameliorate a defect or any physical or mental illnesses and conditions discovered by the screening services, whether or not such services are covered under the Medicaid State plan. (Section 1905(r)(5))

Treatment limitations applied to services provided under the EPSDT benefit are not limited based on a monetary cap or budgetary constraints and may be exceeded as medically necessary to correct or ameliorate a medical or physical condition or illness. (Section 1905(r)(5))

Non-quantitative treatment limitations, such as definitions of medical necessity or criteria for medical necessity, are applied in an individualized manner that does not preclude coverage of any items or services necessary to correct or ameliorate any medical or physical condition or illness. (Section 1905(r)(5))

EPSDT benefits are not excluded on the basis of any condition, disorder, or diagnosis. (Section 1905(r)(5))

The provision of all requested EPSDT screening services, as well as any corrective treatments needed based on those screening services, are provided or arranged for as necessary. (Section 1902(a)(43))

All families with children eligible for the EPSDT benefit under the separate State child health plan are provided information and informed about the full range of services available to them. (Section 1902(a)(43)(A))

Guidance: For states seeking deemed compliance for their entire State child health plan population,

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please continue to Section 6.3. If not all of the covered populations are offered EPSDT, the State must conduct a parity analysis of the benefit packages provided to those populations. Please continue to 6.2.3- MHPAEA.

Mental Health Parity Analysis Requirements for States Not Providing EPSDT to All Covered Populations

Guidance: The State must complete a parity analysis for each population under the State child health plan that is not provided the EPSDT benefit consistent with the requirements 42 CFR 457.496(b). If the State provides benefits or limitations that vary within the child or pregnant woman populations, states should perform a parity analysis for each of the benefit packages. For example, if different financial requirements are applied according to a beneficiary’s income, a separate parity analysis is needed for the benefit package provided at each income level.

Please ensure that changes made to benefit limitations under the State child health plan as a result of the parity analysis are also made in Section 6.2.

6.2.3 – MHPAEA. In order to conduct the parity analysis, the State must place all medical/surgical and mental health and substance use disorder benefits covered under the State child health plan into one of four classifications: Inpatient, outpatient, emergency care, and prescription drugs. (42 CFR 457.496(d)(2)(ii); 42 CFR 457.496(d)(3)(ii)(B))

6.2.3.1 – MHPAEA. Please describe below the standard(s) used to place covered benefits into one of the four classifications.

1. For the purpose of analysis for compliance with MHPAEA, MH/SUD inpatient benefits are defined as those services provided in a hospital or institutional setting under a physician’s order for treatment for diagnostic codes listed in Chapter 5 in the most current ICD manual. For the purpose of analysis for compliance with MHPAEA, M/S inpatient benefits are defined as those services provided in a hospital or institutional setting under a physician’s order for treatment for diagnostic codes listed in all chapters of the current ICD manual, except for those diagnostic codes listed in Chapter 5.

2. For the purpose of analysis for compliance with MHPAEA, MH/SUD outpatient benefits are defined as those services provided in an outpatient, clinic, office or community setting under clinical supervision for treatment for diagnostic codes listed in Chapter 5 of the current ICD manual. For the purpose of analysis for compliance with MHPAEA, M/S outpatient benefits are defined as those services provided in an outpatient, clinic, office or community setting under medical supervision for treatment for diagnostic codes listed in all chapters of the current ICD manual, except for those diagnostic codes listed in Chapter 5.

3. For the purpose of analysis for compliance with MHPAEA, MH/SUD prescription drug benefits are defined as those medication services provided in a hospital, emergency department, or an outpatient, clinic, office or community setting under medical supervision for treatment for diagnostic codes listed in Chapter 5 of the current ICD manual.

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For the purpose of analysis for compliance with MHPAEA, M/S outpatient benefits are defined as those services provided in an outpatient, clinic, office or community setting under medical supervision for treatment for diagnostic codes listed in all chapters of the current ICD manual, except for those diagnostic codes listed in Chapter 5.

4. For the purpose of analysis for compliance with MHPAEA, MH/SUD emergency care benefits are defined as those crisis intervention services provided in an emergency department, or a behavioral health outpatient, clinic, office or community setting under clinical supervision for treatment for diagnostic codes listed in Chapter 5 of the current ICD manual.

For the purpose of analysis for compliance with MHPAEA, M/S prescription drug benefits are defined as those medication services provided in a hospital, emergency department or an outpatient, clinic, office or community setting under medical supervision for treatment for diagnostic codes listed in all chapters of the current ICD manual, except for those diagnostic codes listed in Chapter

6.2.3.1.1 – MHPAEA. The State assures that:

The State has classified all benefits covered under the State plan into one of the four classifications.

The same reasonable standards are used for determining the classification for a mental health or substance use disorder benefit as are used for determining the classification of medical/surgical benefits.

6.2.3.1.2 – MHPAEA. Does the State use sub-classifications to distinguish between office visits and other outpatient services?

Yes No

6.2.3.1.2.1 – MHPAEA. If the State uses sub-classifications to distinguish between outpatient office visits and other outpatient services, the State assures the following:

The sub-classifications are only used to distinguish office visits from other outpatient items and services and are not used to distinguish between similar services on other bases (ex: generalist vs. specialist visits).

Guidance: For purposes of this section, any reference to “classification(s)” includes sub- classification(s) in states using sub-classifications to distinguish between outpatient office visits from other outpatient services.

6.2.3.2 – MHPAEA. The State assures that:

Mental health/ substance use disorder benefits are provided in all classifications in which medical/surgical benefits are provided under the State child health plan.

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Guidance: States are not required to cover mental health or substance use disorder benefits (42 CFR 457.496(f)(2)). However, if a state does provide any mental health or substance use disorder benefits, those mental health or substance use disorder benefits must be provided in all the same classifications in which medical/surgical benefits are covered under the State child health plan (42 CFR 457.496(d)(2)(ii).

Annual and Aggregate Lifetime Dollar Limits

6.2.4 – MHPAEA. A State that provides both medical/surgical benefits and mental health and/or substance use disorder benefits must comply with parity requirements related to annual and aggregate lifetime dollar limits for benefits covered under the State child health plan. (42 CFR 457.496(c))

6.2.4.1 – MHPAEA. Please indicate whether the State applies an aggregate lifetime dollar limit and/or an annual dollar limit on any mental health or substance abuse disorder benefits covered under the State child health plan.

Aggregate lifetime dollar limit is applied Aggregate annual dollar limit is applied No dollar limit is applied Guidance: A monetary coverage limit that applies to all CHIP services provided under the State child health plan is not subject to parity requirements.

If there are no aggregate lifetime or annual dollar limits on any mental health or substance use disorder benefits, please go to section 6.2.5- MHPAEA.

6.2.4.2 – MHPAEA. Are there any medical/surgical benefits covered under the State child health plan that have either an aggregate lifetime dollar limit or an annual dollar limit? If yes, please specify what type of limits apply.

Yes (Type(s) of limit: ) No

Guidance: If no aggregate lifetime dollar limit is applied to medical/ surgical benefits, the State may not impose an aggregate lifetime dollar limit on any mental health or substance use disorder benefits. If no aggregate annual dollar limit is applied to medical/surgical benefits, the State may not impose an aggregate annual dollar limit on any mental health or substance use disorder benefits. (42 CFR 457.496(c)(1))

6.2.4.3 – MHPAEA. States applying an aggregate lifetime or annual dollar limit on medical/surgical benefits and mental health or substance use disorder benefits must determine whether the portion of the medical/surgical benefits to which the limit applies is less than one- third, at least one-third but less than two-thirds, or at least two-thirds of all medical/surgical benefits covered under the State plan (42 CFR 457.496(c)). The portion of medical/surgical benefits subject to the limit is based on the dollar amount expected to be paid for all

54

medical/surgical benefits under the State plan for the State plan year or portion of the plan year after a change in benefits that affects the applicability of the aggregate lifetime or annual dollar limits. (42 CFR 457.496(c)(3))

The State assures that it has developed a reasonable methodology to calculate the portion of covered medical/surgical benefits which are subject to the aggregate lifetime and/or annual dollar limit, as applicable.

Guidance: Please include the state’s methodology to calculate the portion of covered medical/surgical benefits which are subject to the aggregate lifetime and/or annual dollar limit and the results as an attachment to the State child health plan.

6.2.4.3.1 – MHPAEA Please indicate the portion of the total costs for medical and surgical benefits covered under the State plan which are subject to a lifetime dollar limit:

Less than 1/3 At least 1/3 and less than 2/3 At least 2/3 6.2.4.3.2 – MHPAEA Please indicate the portion of the total costs for medical and surgical benefits covered under the State plan which are subject to an annual dollar limit:

Less than 1/3 At least 1/3 and less than 2/3 At least 2/3 Guidance: If an aggregate lifetime limit is applied to less than one-third of all medical/surgical benefits, the State may not impose an aggregate lifetime limit on any mental health or substance use disorder benefits. If an annual dollar limit is applied to less than one-third of all medical surgical benefits, the State may not impose an annual dollar limit on any mental health or substance use disorder benefits (42 CFR 457.496(c)(1)). Skip to section 6.2.5-MHPAEA.

If the State applies an aggregate lifetime or annual dollar limit to at least one-third of all medical/surgical benefits, please continue below to provide the assurances related to the determination of the portion of total costs for medical/surgical benefits that are subject to either an annual or lifetime limit.

6.2.4.3.2.1 – MHPAEA If the State applies an aggregate lifetime or annual dollar limit to at least 1/3 and less than 2/3 of all medical/surgical benefits, the State assures the following (42 CFR 457.496(c)(4)(i)(B)); (42 CFR

55

457.496(c)(4)(ii)):

The State applies an aggregate lifetime or annual dollar limit on mental health or substance use disorder benefits that is no more restrictive than an average limit calculated for medical/surgical benefits.

Guidance: The state’s methodology for calculating the average limit for medical/surgical benefits must be consistent with 42 CFR 457.496(c)(4) (i)(B) and 42 CFR 457.496(c)(4)(ii). Please include the state’s methodology and results as an attachment to the State child health plan.

6.2.4.3.2.2 – MHPAEA If at least 2/3 of all medical/surgical benefits are subject to an annual or lifetime limit, the State assures either of the following (42 CFR 457.496(c)(2)(i)); (42 CFR 457.496(c)(2)(ii)):

The aggregate lifetime or annual dollar limit is applied to both medical/surgical benefits and mental health and substance use disorder benefits in a manner that does not distinguish between medical/surgical benefits and mental health and substance use disorder benefits; or

The aggregate lifetime or annual dollar limit placed on mental health and substance use disorder benefits is no more restrictive than the aggregate lifetime or annual dollar limit on medical/surgical benefits.

Quantitative Treatment Limitations

6.2.5 – MHPAEA Does the State apply quantitative treatment limitations (QTLs) on any mental health or substance use disorder benefits in any classification of benefits? If yes, specify the classification(s) of benefits in which the State applies one or more QTLs on any mental health or substance use disorder benefits.

Yes (Specify: ) No

Guidance: If the state does not apply any type of QTLs on any mental health or substance use disorder benefits in any classification, the state meets parity requirements for QTLs and should continue to Section 6.2.6 – MHPAEA. If the state does apply QTLs to any mental health or substance use disorder benefits, the state must conduct a parity analysis. Please continue.

6.2.5.1 – MHPAEA Does the State apply any type of QTL on any medical/surgical benefits?

Yes No

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Guidance: If the State does not apply QTLs on any medical/surgical benefits, the State may not impose quantitative treatment limitations on mental health or substance use disorder benefits, please go to Section 6.2.6 – MHPAEA related to non-quantitative treatment limitations.

6.2.5.2 – MHPAEA Within each classification of benefits in which the State applies a type of QTL on any mental health or substance use disorder benefits, the State must determine the portion of medical and surgical benefits in the classification which are subject to the limitation. More specifically, the State must determine the ratio of (a) the dollar amount of all payments expected to be paid under the State plan for medical and surgical benefits within a classification which are subject to the type of quantitative treatment limitation for the plan year (or portion of the plan year after a mid-year change affecting the applicability of a type of quantitative treatment limitation to any medical/surgical benefits in the class) to (b) the dollar amount expected to be paid for all medical and surgical benefits within the classification for the plan year. For purposes of this paragraph, all payments expected to be paid under the State plan includes payments expected to be made directly by the State and payments which are expected to be made by MCEs contracting with the State. (42 CFR 457.496(d)(3)(i)(C))

The State assures it has applied a reasonable methodology to determine the dollar amounts used in the ratio described above for each classification within which the State applies QTLs to mental health or substance use disorder benefits. (42 CFR 457.496(d)(3)(i)(E))

Guidance: Please include the state’s methodology and results as an attachment to the State child health plan.

6.2.5.3 – MHPAEA. For each type of QTL applied to any mental health or substance use disorder benefits within a given classification, does the State apply the same type of QTL to “substantially all” (defined as at least two-thirds) of the medical/surgical benefits within the same classification? (42 CFR 457.496(d)(3)(i)(A))

Yes No

Guidance: If the State does not apply a type of QTL to substantially all medical/surgical benefits in a given classification of benefits, the State may not impose that type of QTL on mental health or substance use disorder benefits in that classification. (42 CFR 457.496(d)(3)(i)(A))

6.2.5.3.1 – MHPAEA. For each type of QTL applied to mental health or substance use disorder benefits, the State must determine the predominant level of that type which is applied to medical/surgical benefits in the classification. The “predominant level” of a type of QTL in a classification is the level (or least restrictive of a combination of levels) that applies to more than one-half of the medical/surgical benefits in that classification, as described in 42 CFR 457.496(d)(3)(i)(B). The portion of medical/surgical benefits in a classification to which a given level of a QTL type is applied is based on the dollar amount of payments expected to be paid for medical/surgical benefits subject to that level as

57

compared to all medical/surgical benefits in the classification, as described in 42 CFR 457.496(d)(3)(i)(C). For each type of quantitative treatment limitation applied to mental health or substance use disorder benefits, the State assures:

The same reasonable methodology applied in determining the dollar amounts used to determine whether substantially all medical/surgical benefits within a classification are subject to a type of quantitative treatment limitation also is applied in determining the dollar amounts used to determine the predominant level of a type of quantitative treatment limitation applied to medical/surgical benefits within a classification. (42 CFR 457.496(d)(3)(i)(E))

The level of each type of quantitative treatment limitation applied by the State to mental health or substance use disorder benefits in any classification is no more restrictive than the predominant level of that type which is applied by the State to medical/surgical benefits within the same classification. (42 CFR 457.496(d)(2)(i))

Guidance: If there is no single level of a type of QTL that exceeds the one-half threshold, the State may combine levels within a type of QTL such that the combined levels are applied to at least half of all medical/surgical benefits within a classification; the predominant level is the least restrictive level of the levels combined to meet the one-half threshold. (42 CFR 457.496(d)(3)(i)(B)(2))

Non-Quantitative Treatment Limitations

6.2.6 – MHPAEA. The State may utilize non-quantitative treatment limitations (NQTLs) for mental health or substance use disorder benefits, but the State must ensure that those NQTLs comply with all the mental health parity requirements. (42 CFR 457.496(d)(4)); (42 CFR 457.496(d)(5))

6.2.6.1 – MHPAEA. If the State imposes any NQTLs, complete this subsection. If the State does not impose NQTLs, please go to Section 6.2.7 – -MHPAEA.

The State assures that the processes, strategies, evidentiary standards or other factors used in the application of any NQTL to mental health or substance use disorder benefits are no more stringent than the processes, strategies, evidentiary standards or other factors used in the application of NQTLs to medical/surgical benefits within the same classification.

ATTACHMENT F MHPAEA Final Report 2008 (03-22-18).pdf

ATTACHMENT G

MHPAEA-CHIP Monitoring plan (03-23-18).pdf

Guidance: Examples of NQTLs include medical management standards to limit or exclude benefits based on medical necessity, restrictions based on geographic location, provider specialty, or other criteria to limit the scope or duration of benefits and provider network design (ex: preferred

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providers vs. participating providers). Additional examples of possible NQTLs are provided in 42 CFR 457.496(d)(4)(ii). States will need to provide a summary of its NQTL analysis, as well as supporting documentation as requested.

6.2.6.2 – MHPAEA The State or MCE contracting with the State must comply with parity if they provide coverage of medical or surgical benefits furnished by out-of-network providers.

6.2.6.2.1 – MHPAEA Does the State or MCE contracting with the State provide coverage of medical or surgical benefits provided by out-of-network providers?

Yes No

Guidance: The State can answer no if the State or MCE only provides out of network services in specific circumstances, such as emergency care, or when the network is unable to provide a necessary service covered under the contract.

6.2.6.2.2 – MHPAEA. If yes, the State must provide access to out-of-network providers for mental health or substance use disorder benefits. Please assure the following:

The State attests that when determining access to out-of-network providers within a benefit classification, the processes, strategies, evidentiary standards, or other factors used to determine access to those providers for mental health/ substance use disorder benefits are comparable to and applied no more stringently than the processes, strategies, evidentiary standards or other factors used to determine access for out- of-network providers for medical/surgical benefits.

Availability of Plan Information

6.2.7 – MHPAEA. The State must provide beneficiaries, potential enrollees, and providers with information related to medical necessity criteria and denials of payment or reimbursement for mental health or substance use disorder services (42 CFR 457.496(e)) in addition to existing notice requirements at 42 CFR 457.1180.

6.2.7.1 – MHPAEA Medical necessity criteria determinations must be made available to any current or potential enrollee or contracting provider, upon request. The state attests that the following entities provide this information:

State Managed Care entities Both Other

Guidance: If other is selected, please specify the entity.

59

6.2.7.2 – MHPAEA. Reason for any denial for reimbursement or payment for mental health or substance use disorder benefits must be made available to the enrollee by the health plan or the State. The state attests that the following entities provide denial information:

State Managed Care entities Both

Other

Guidance: If other is selected, please specify the entity. 6.3. The State assures that, with respect to pre-existing medical conditions, one of the following two statements applies to its plan: (42 CFR 457.480)

6.3.1.

The State shall not permit the imposition of any pre-existing medical condition exclusion for covered services (Section 2102(b)(1)(B)(ii)); OR 6.3.2.

The State contracts with a group health plan or group health insurance coverage, or contracts with a group health plan to provide family coverage under a waiver (see Section 6.6.2. (formerly 6.4.2) of the template). Pre-existing medical conditions are permitted to the extent allowed by HIPAA/ERISA. (Formerly 8.6.) (Section 2103(f)) Describe:

Guidance: States may request two additional purchase options in Title XXI: cost effective coverage through a community-based health delivery system and for the purchase of family coverage. (Section 2105(c)(2) and (3)) (42 CFR 457.1005 and 457.1010)

6.4. Additional Purchase Options- If the State wishes to provide services under the plan through cost effective alternatives or the purchase of family coverage, it must request the appropriate option. To be approved, the State must address the following: (Section 2105(c)(2) and (3)) (42 CFR 457.1005 and 457.1010)

6.4.1.

Cost Effective Coverage – Payment may be made to a State in excess of the 10% limitation on use of funds for payments for: 1) other child health assistance for targeted low-income children; 2) expenditures for health services initiatives under the plan for improving the health of children (including targeted low-income children and other low-income children); 3) expenditures for outreach activities as provided in Section 2102(c)(1) under the plan; and 4) other reasonable costs incurred by the State to administer the plan, if it demonstrates the following (42CFR 457.1005(a)):

6.4.1.1. Coverage provided to targeted low-income children through such expenditures must meet the coverage requirements above; Describe the coverage provided by the alternative delivery system. The State may cross

60

reference Section 6.2.1 – 6.2.28. (Section 2105(c)(2)(B)(i)) (42 CFR 457.1005(b))

6.4.1.2. The cost of such coverage must not be greater, on an average per child basis, than the cost of coverage that would otherwise be provided for the coverage described above; Describe the cost of such coverage on an average per child basis. (Section 2105(c)(2)(B)(ii)) (42 CFR 457.1005(b))

Guidance: Check below if the State is requesting to provide cost-effective coverage through a community-based health delivery system. This allows the State to waive the 10 percent limitation on expenditures not used for Medicaid or health insurance assistance if coverage provided to targeted low-income children through such expenditures meets the requirements of Section 2103; the cost of such coverage is not greater, on an average per child basis, than the cost of coverage that would otherwise be provided under Section 2103; and such coverage is provided through the use of a community-based health delivery system, such as through contracts with health centers receiving funds under Section 330 of the Public Health Services Act or with hospitals such as those that receive disproportionate share payment adjustments under Section 1886(c)(5)(F) or 1923.

If the cost-effective alternative waiver is requested, the State must demonstrate that payments in excess of the 10% limitation will be used for other child health assistance for targeted low-income children; expenditures for health services initiatives under the plan for improving the health of children (including targeted low-income children and other low-income children); expenditures for outreach activities as provided in Section 2102(c)(1) under the plan; and other reasonable costs incurred by the State to administer the plan. (42 CFR, 457.1005(a))

6.4.1.3. The coverage must be provided through the use of a community-based health delivery system, such as through contracts with health centers receiving funds under Section 330 of the Public Health Service Act or with hospitals such as those that receive disproportionate share payment adjustments under Section 1886(c)(5)(F) or 1923 of the Social Security Act. Describe the community-based delivery system. (Section 2105(c)(2)(B)(iii)) (42 CFR 457.1005(a)) Guidance: Check 6.4.2. if the State is requesting to purchase family coverage. Any State requesting to purchase such coverage will need to include information that establishes to the Secretary’s satisfaction that: 1) when compared to the amount of money that would have been paid to cover only the children involved with a comparable package, the purchase of family coverage is cost effective; and 2) the purchase of family coverage is not a substitution for coverage already being provided to the child. (Section 2105(c)(3)) (42 CFR 457.1010)

6.4.2.

Purchase of Family Coverage- Describe the plan to purchase family coverage. Payment may be made to a State for the purpose of family coverage under a group health plan or health insurance coverage that includes coverage of targeted low- income children, if it demonstrates the following: (Section 2105(c)(3)) (42 CFR 457.1010)

61

6.4.2.1. Purchase of family coverage is cost-effective. The State’s cost of purchasing family coverage, including administrative expenditures, that includes coverage for the targeted low-income children involved or the family involved (as applicable) under premium assistance programs must not be greater than the cost of obtaining coverage under the State plan for all eligible targeted low-income children or families involved; and (2) The State may base its demonstration of cost effectiveness on an assessment of the cost of coverage, including administrative costs, for children or families under premium assistance programs to the cost of other CHIP coverage for these children or families, done on a case-by-case basis, or on the cost of premium assisted coverage in the aggregate.

6.4.2.2. The State assures that the family coverage would not otherwise substitute for health insurance coverage that would be provided to such children but for the purchase of family coverage. (Section 2105(c)(3)(B)) (42 CFR 457.1010(b))

6.4.2.3. The State assures that the coverage for the family otherwise meets Title XXI requirements. (42 CFR 457.1010(c))

6.4.3-PA: Additional State Options for Providing Premium Assistance (CHIPRA # 13, SHO # 10-002 issued February, 2, 2010) A State may elect to offer a premium assistance subsidy for qualified employer-sponsored coverage, as defined in Section 2105(c)(10)(B), to all targeted low- income children who are eligible for child health assistance under the plan and have access to such coverage. No subsidy shall be provided to a targeted low-income child (or the child’s parent) unless the child voluntarily elects to receive such a subsidy. (Section 2105(c)(10)(A)). Please remember to update section 9.10 when electing this option. Does the State provide this option to targeted low-income children?

Yes

No

6.4.3.1-PA Qualified Employer-Sponsored Coverage and Premium Assistance Subsidy.

6.4.3.1.1-PA Provide an assurance that the qualified employer-sponsored insurance meets the definition of qualified employer-sponsored coverage as defined in Section 2105(c)(10)(B), and that the premium assistance subsidy meets the definition of premium assistance subsidy as defined in 2105(c)(10)(C).

6.4.3.1.2-PA Describe whether the State is providing the premium assistance subsidy as reimbursement to an employee or for out-of-pocket expenditures or directly to the employee’s employer.

62

6.4.3.2-PA: Supplemental Coverage for Benefits and Cost Sharing Protections Provided under the Child Health Plan.

6.4.3.2.1-PA If the State is providing premium assistance for qualified employer- sponsored coverage, as defined in Section 2105(c)(10)(E)(i), provide an assurance that the State is providing for each targeted low-income child enrolled in such coverage, supplemental coverage consisting of all items or services that are not covered or are only partially covered, under the qualified employer-sponsored coverage consistent with 2103(a) and cost sharing protections consistent with Section 2103(e).

6.4.3.2.2-PA Describe whether these benefits are being provided through the employer or by the State providing wraparound benefits.

6.4.3.2.3-PA If the State is providing premium assistance for benchmark or benchmark-equivalent coverage, the State ensures that such group health plans or health insurance coverage offered through an employer will be certified by an actuary as coverage that is equivalent to a benchmark benefit package described in Section 2103(b) or benchmark equivalent coverage that meets the requirements of Section 2103(a)(2).

6.4.3.3-PA: Application of Waiting Period Imposed Under State Plan: States are required to apply the same waiting period to premium assistance as is applied to direct coverage for children under their CHIP State plan, as specified in Section 2105(c)(10)(F).

6.4.3.3.1-PA Provide an assurance that the waiting period for children in premium assistance is the same as for those children in direct coverage (if State has a waiting period in place for children in direct CHIP coverage).

6.4.3.4-PA: Opt-Out and Outreach, Education, and Enrollment Assistance

6.4.3.4.1-PA Describe the State’s process for ensuring parents are permitted to disenroll their child from qualified employer-sponsored coverage and to enroll in CHIP effective on the first day of any month for which the child is eligible for such assistance and in a manner that ensures continuity of coverage for the child (Section 2105(c)(10)(G)).

6.4.3.4.2-PA Describe the State’s outreach, education, and enrollment efforts related to premium assistance programs, as required under Section 2102(c)(3). How does the State inform families of the availability of premium assistance, and assist them in obtaining such subsidies? What are the specific significant resources the State intends to apply to educate employers about the availability of premium assistance subsidies under the State child health plan? (Section 2102(c))

63 6.4.3.5-PA Purchasing Pool – A State may establish an employer-family premium assistance purchasing pool and may provide a premium assistance subsidy for enrollment in coverage made available through this pool (Section 2105(c)(10)(I)). Does the State provide this option? Yes No 6.6.3.5.1-PA Describe the plan to establish an employer-family premium assistance purchasing pool. 6.6.3.5.2-PA Provide an assurance that employers who are eligible to participate: 1) have less than 250 employees; 2) have at least one employee who is a pregnant woman eligible for CHIP or a member of a family that has at least one child eligible under the State’s CHIP plan. 6.6.3.5.3-PA Provide an assurance that the State will not claim for any administrative expenditures attributable to the establishment or operation of such a pool except to the extent such payment would otherwise be permitted under this Title. 6.4.3.6-PA Notice of Availability of Premium Assistance – Describe the procedures that assure that if a State provides premium assistance subsidies under this Section, it must: 1) provide as part of the application and enrollment process, information describing the availability of premium assistance and how to elect to obtain a subsidy; and 2) establish other procedures to ensure that parents are fully informed of the choices for child health assistance or through the receipt of premium assistance subsidies (Section 2105(c)(10)(K)). 6.4.3.6.1-PA Provide an assurance that the State includes information about premium assistance on the CHIP application or enrollment form.

_____________________________________________________________________________ Table of Contents State/Territory Name: Nevada State Plan Amendments (SPA) #: NV-19-0006 This file contains the following documents in the order listed: 1) Approval Letter 2) State Plan Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES = Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop $2-01-16 « boy] ze,

Baltimore, MD 21 244-1850 CENTERS FOR MEDICARE & MEDICAID SERVICES: CENTER FOR MEDICAID & CHIP SERVICES Children and Adults Health Programs Group

AUG 2 0 2019

Suzanne Bierman

Medicaid Administrator

Division of Health Care Financing and Policy Las Vegas Medicaid District Office

1210 S. Valley View, Suite 104

Las Vegas, NV 89102

Dear Ms. Bierman:

Tam pleased to inform you that your title XXI Children’s Health Insurance Program (CHIP) state plan amendment (SPA), NV-19-0006, has been approved. NV-19-0006 demonstrates compliance with the CHIP managed care regulations at 42 CFR 457, Subpart L, for utilization of a managed care delivery system. This SPA has an effective date of July 1, 2018.

Sections 2101 (a), 2103(£)(3), 2107(b), and 2107(e) of the Social Security Act, as implemented through regulations at 42 CFR 457 Subpart L, describe the application of managed care requirements to CHIP. Nevada has provided the necessary assurances indicating that the state complies with the managed care requirements in the delivery of CHIP services and benefits covered under the state’s separate child health plan as of July 1, 2018.

This SPA approval does not substitute for CMS review of any contracts between the state and managed care entities that serve the state’s CHIP populations. All managed care contracts for CHIP populations in effect as of the state fiscal year beginning on or after July 1, 2018 must comply with the CHIP managed care regulations and be submitted for CMS review.

Your title XXI project officer is Ms. Joyce Jordan. She is available to answer questions concerning this amendment and other CHIP-related issues. Ms. Jordan’s contact information is as follows:

Centers for Medicare & Medicaid Services Center for Medicaid and CHIP Services Mail Stop: S2-01-16

7500 Security Boulevard

Baltimore, MD 21244-1850

Telephone: (410) 786-3413

E-mail: Joyce.Jordan@cms.hhs.gov

Page 2- Ms. Suzanne Bierman Official communications regarding program matters should be sent simultaneously to Ms. Jordan and to Mr. Richard Allen, Director, Division of Medicaid Field Operations West. Mr. Allen's address is: Centers for Medicare & Medicaid Services Division of Medicaid and Children's Health Operations 90 7th Street, Suite #5-300 (W) San Francisco, CA 94103-6706 If you have additional questions, please contact Arny Lutzky, Director, Division of State Coverage Programs at ( 410) 786-0721. We look forward to continuing to work with you and your staff. Sincerely, /signed Anne Marie Costello/ Aime Marie Costello Director cc: Mr. Richard Allen, Director, Division of Medicaid Field Operations West

Effective Date: August 24, 2002 Page 1 Approval Date: ___________

TABLE OF CONTENTS Nevada Title XXI State Plan

Section 1. General Description and Purpose of the State Child Health Plans and State Child Health Plan Requirements

Section 2. General Background and Description of State Approach to Child Health Coverage and Coordination

Section 3. General Methods of Delivery and Utilization Controls

Section 4. Eligibility Standards and Methodology

Section 5. Outreach

Section 6. Coverage Requirements for Children’s Health Insurance

Section 7. Quality and Appropriateness of Care

Section 8. Cost-Sharing and Payment

Section 9. Strategic Objectives and Performance Goals and Plan Administration

Section 10. Annual Reports and Evaluations

Section 11. Program Integrity

Section 12. Applicant and Enrollee Protections

Effective Date: February 1, 2018 Page 2 Approval Date: June 7, 2018 STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT STATE CHILDREN’S HEALTH INSURANCE PROGRAM

New section 2101(b) required under 4901 of the Balanced Budget Act of 1997 State/Territory: Nevada As a condition for receipt of Federal funds under Title XXI of the Social Security Act, (42 CFR 457.40(b))

_____________________________________ ___________________ Richard Whitley, MS Date Director, Department of Health and Human Services

(Signature of Governor or designee of State/Territory, Date Signed) submits the following State Child Health Plan for the State Children’s Health Program and hereby agrees to administer the program in accordance with the provisions of the State Child Health Plan, the requirements of Title XXI and XIX of the Act (as appropriate) and all applicable Federal regulations and other official issuances of the Department. The following state officials are responsible for program administration and financial oversight (42 CFR 457.40(c) Name: Suzanne Bierman Position/Title: Administrator, Division of Health Care Financing & Policy DHCFP Name: Cody Phinney Position/Title: Deputy Administrator, DHCFP Name: Budd Milazzo Position/Title: Administrative Services Officer IV, DHCFP

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 0938-0707. The time required to complete this information collection is estimated to average 160 hours (or minutes) per response, including the time to review instructions, search existing data resources, gather the data needed and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, N2-14-26, Baltimore, Maryland 21244.

TN No: 18-008 Approval Date: June 6, 2019 Effective Date: October 2, 2017

Page 3 Section 1. General Description and Purpose of the Children’s Health Insurance Plans and the Requirements

1.1. The state will use funds provided under Title XXI primarily for (Check appropriate box) (Section 2101)(a)(1)); (42 CFR 457.70):

Guidance: Check below if child health assistance shall be provided primarily through the development of a separate program that meets the requirements of Section 2101, which details coverage requirements and the other applicable requirements of Title XXI.

1.1.1. Obtaining coverage that meets the requirements for a separate child health program (Sections 2101(a)(1) and 2103); OR

Guidance: Check below if child health assistance shall be provided primarily through providing expanded eligibility under the State’s Medicaid program (Title XIX). Note that if this is selected the State must also submit a corresponding Medicaid SPA to CMS for review and approval. 1.1.2. Providing expanded benefits under the State’s Medicaid plan (Title XIX) (Section 2101(a)(2)); OR

Guidance: Check below if child health assistance shall be provided through a combination of both 1.1.1. and 1.1.2. (Coverage that meets the requirements of Title XXI, in conjunction with an expansion in the State’s Medicaid program). Note that if this is selected the state must also submit a corresponding Medicaid state plan amendment to CMS for review and approval. 1.1.3. A combination of both of the above. (Section 2101(a)(2))

1.1-DS

The State will provide dental-only supplemental coverage. Only States operating a separate CHIP program are eligible for this option. States choosing this option must also complete sections 4.1-DS, 4.2-DS, 6.2-DS, 8.2-DS and 9.10 of this SPA template. (Section 2110(b)(5))

1.2.

Check to provide an assurance that expenditures for child health assistance will not be claimed prior to the time that the State has legislative authority to operate the State plan or plan amendment as approved by CMS. (42 CFR 457.40(d))

1.3.

Check to provide an assurance that the State complies with all applicable civil rights requirements, including title VI of the Civil Rights Act of 1964, title II of the Americans with Disabilities Act of 1990, section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, 45 CFR part 80, part 84, and part 91, and 28 CFR part 35. (42 CFR 457.130)

Guidance: The effective date as specified below is defined as the date on which the State begins to incur costs to implement its State plan or amendment. (42 CFR 457.65) The implementation date is defined as the date the State begins to provide services; or, the date on which the State puts into practice the new

TN No: 18-008 Approval Date: June 6, 2019 Effective Date: October 2, 2017

Page 4 policy described in the State plan or amendment. For example, in a State that has increased eligibility, this is the date on which the State begins to provide coverage to enrollees (and not the date the State begins outreach or accepting applications).

1.4. Provide the effective (date costs begin to be incurred) and implementation (date services begin to be provided) dates for this SPA (42 CFR 457.65). A SPA may only have one effective date, but provisions within the SPA may have different implementation dates that must be after the effective date.

Original Plan Effective Date: September 1, 2008

Implementation Date: September 1, 2008

SPA #19-0006 Purpose of SPA: Compliance with the Medicaid Managed Care Final Rule

Proposed effective date: July 1, 2018

Proposed implementation date: July 1, 2018

1.4- TC Tribal Consultation (Section 2107(e)(1)(C)) Describe the consultation process that occurred specifically for the development and submission of this State Plan Amendment, when it occurred and who was involved.

A tribal consultation letter was sent to the tribes on June 19, 2019 and consultation was not requested; however, the DHCFP tribal liaison was able to add the NV CHIP SPA to the July 9, 2019 tribal consultation meeting agenda. Theresa Carsten, Chief of the Managed Care and Quality Assurance Unit provided an update on the SPA revisions and the only concern noted by members was to ensure that tribal members remained voluntarily enrolled into the managed care benefit plan.

TN No: Approval Date Effective Date June 19, 2019

Effective Date: April 1, 2008 Page 5 Approval Date: ___________ Section 2. General Background and Description of State Approach to Child Health Coverage (Section 2102 (a)(1) - (3)) and (Section 2105)(c)(7)(A) - (B))

2.1 Describe the extent to which, and manner in which, children in the state including targeted low-income children and other classes of children, by income level and other relevant factors, such as race and ethnicity and geographic location, currently have creditable health coverage (as defined in 42 CFR 457.10). To the extent feasible, make a distinction between creditable coverage under public health insurance programs and public-private partnerships (see Section 10 for annual report requirements). (42 CFR 457.80(a))

Uninsured Children Based on the State Demographer’s 2002 population estimates, the DHCFP has estimated that there are 69,000 children in Nevada who are uninsured living in families with incomes under 200% of federal poverty level. Of these, as many as 50% may be eligible for Medicaid. These numbers are based on limited and sometimes seemingly contradictory data.

For example, the U.S. Census Bureau estimates that for 1996, there were 45,000 uninsured children under 200% of federal poverty level in Nevada, but also estimated that there were 77,000 uninsured at all income levels. This would mean that less than 60% of all uninsured would be under 200% of federal poverty level. The national average is 73%. Only five other states (Alaska, Massachusetts, Vermont, Hawaii, and New Jersey) are under 60%, all of whom have significantly higher Medicaid eligibility levels than Nevada, resulting in a greater level of coverage for low-income children.

With regard to demographic data, the best information comes from a survey of the uninsured in Nevada completed in June 2000, and updated as of January 2003, by the Great Basin Primary Care Association and the State Demographer’s 2002 population estimates. The following chart reports on these findings as follows:

Effective Date: April 1, 2008 Page 6 Approval Date: ___________ Number of Uninsured Children in Nevada by Region

Age in Years

Washoe County

Clark County

Rural Counties

Totals

Less than 6

6,209

30,493

3,534

40,236

6 to 18

11,363

51,644

9,015

72,022

TOTAL

17,572

82,137

12,549

112,258

Estimates of Nevada Populations According to the current Nevada State Demographer’s data, Nevada’s total population is 2,210,650. Nevada’s children age 0-19 comprise the following races by age and sex:

Age in Years

White

Black

American Indian

Asian

Hispanic

Total

<5

103,60 1

11,157

1,594

9,563

33,471

159,386

5 to 19

298,14 8

32,108

4,587

27,521

96,325

458,689

Total

401,74 9

43,265

6,181

37,084

129,796

618,075

Effective Date: July 1, 2009 Page 7 Approval Date: ___________ Language spoken at home by Nevadans According to the 2000 Census Supplementary Survey Summary Tables, Nevada’s language spoken at home is as follows:

Nevadans Age >5 years No English at home 78% Speak English at home 81% Speak Spanish at home 5% No English at home (see breakdown at right) 19% Speak language other than 17% Don’t speak English well English or Spanish

Public Health Insurance Coverage Medicaid is Nevada’s major public health insurance program. In 1967, Nevada implemented the Medicaid program for the Aid to Families with Dependent Children (AFDC) now Temporary Assistance for Needy Families (TANF), Child Welfare, Aged, Blind, and Disabled populations, and in 1985 implemented the Child Health Assurance Program (CHAP) for pregnant women and later for pregnant women with children. Nevada is at the federal minimums for eligibility, 133% of the federal poverty level (FPL) for children up to age six and 100% of FPL for children six and older born on or after October 1, 1983. Currently, TANF and CHAP Medicaid eligible children residing in Clark County are enrolled in mandatory managed care, with the exception of disabled children and those children who reside more than 25 miles from a primary care physician (PCP) and participating hospital, pursuant to NAC 695C.160.

Nevada Check Up Nevada Check Up provides access to affordable health insurance to children in working, low-income families. The program features simplified mail-in eligibility applications and low premiums while providing a comprehensive health benefits package.

Differences between Nevada Check Up and Nevada Medicaid – There are areas where Medicaid policy and Nevada Check Up policy differ. They are:

1) Residential Treatment Centers (RTC) – In Nevada Check Up, it remains the HMO’s responsibility to provide reimbursement for all medical care (physician, optometry, laboratory, dental and x-ray services, etc.) for participants who are receiving services in an RTC. The RTC bed day rate is covered by FFS.

In Medicaid, those who are admitted to an RTC are disenrolled from the HMO and receive all Medicaid-covered services as FFS recipients.

2) Severely Emotionally Disturbed (SED)/Seriously Mentally Ill (SMI) – In Nevada Check Up, this group must receive evaluation and medically appropriate services through a FFS provider if the family resides in a FFS area. In mandatory HMO geographic areas, SED determinations don’t permit disenrollment from the HMO, so the HMOs will provide appropriate services. In Medicaid, once a diagnosis of SED or SMI is confirmed through evaluation, a recipient may elect to disenroll from the HMO and the HMO must notify the DHCFP of such election.

Effective Date: October 1, 2016 Page 9 Approval Date: November 23, 2016 3) Newborns – In Nevada Check Up, if a family is expecting a child, whether the adult female in the home or one of the enrolled children, Nevada Check Up must be notified within 14 days of the birth, the newborn, if eligible, will be added to the family as of its date of birth. If the notification criterion is not met, the child, if eligible, will be added the next administrative month following notification. A newborn cannot be enrolled before a family’s start date. A newborn will begin services at the same time as the other children in the family. One exception for the Checkup program is if the mother has other coverage for the newborn, and she has other children enrolled in Nevada Check Up, the newborn will be enrolled in Nevada Check Up as of the first day of the next administrative month following date of birth.

In Medicaid, all children born to Medicaid-enrolled mothers are enrolled as of their date of birth.

2.2. Describe the current state efforts to provide or obtain creditable health coverage for uncovered children by addressing: (Section 2102)(a)(2) (42 CFR 457.80(b))

2.2.1 The steps the state is currently taking to identify and enroll all uncovered children who are eligible to participate in public health insurance programs (i.e. Medicaid and state-only child health insurance):

Nevada currently has several initiatives to enroll children in Medicaid and Nevada Check Up. These include outreach and referral services to the Women, Infant, and Children (WIC) centers, Federally Qualified Health Centers (FQHCs), Nevada Early Intervention Programs, Family Resource Centers (FRCs), Family to Family program, Tribal Administrators, Tribal Clinics and Indian Health Services (IHS), Resources for the Early Advancement of Child Health (REACH) Program, Connecting Kids to Health Coverage, Nevada 211 and Nevada Health Link-Silver State Health Insurance Exchange. In addition, out stationed eligibility workers are in certain public hospitals and federally qualified health centers in order to provide these outreach and referral services. The descriptions of these programs are as follows:

1. The Medicaid program is administered by the Division of Health Care Financing and Policy and provides health coverage to low-income and disabled Nevada children. Nevada takes the following steps to enroll children in Medicaid:

a. Nevada State Welfare District Offices located throughout the state determine a person’s eligibility for TANF, CHAP, and Medicaid. If applicants appear to be Nevada Check Up eligible, rather than Medicaid, they are appropriately referred.

Out stationed sites (FQHCs, county hospitals, and local county health departments) help people apply for Medicaid or Nevada Check Up and send their applications and eligibility determination to the local Nevada State Welfare District Office.

Effective Date: October 1, 2016 Page 9 Approval Date: November 23, 2016 Local public health agencies identify low income, uninsured children through referrals from a variety of sources including: WIC, child health and immunization clinics, community health and social services agencies, and schools.

2. Women, Infants and Children (WIC) provides nutritious food to supplement the regular diet of pregnant women, infants, and children under age five who meet state income standards. Women and children under five years old qualify if the combined family income is at or below 185% of the federal poverty level. WIC staff encourages pregnant women and parents in this program to apply for Medicaid or Nevada Check Up, depending on their income level.

3. Federally Qualified Health Centers offer health care to low-income people. Nevada has 13 federally qualified community health centers. The centers provide primary care services including care for acute and chronic illness, injuries, emergency care, diagnostic services and prescriptions.

Community health centers take the following steps to enroll children in Medicaid or Nevada Check Up: 1. Provide a financial screen for each new patient or family 2. Provide information on and explanation of the program(s) for which family members may be eligible. 3. Assist with completing applications and collecting required documentation. 4. Forward applications to the determining agency and communicate with family about eligibility status.

If a patient/family is not eligible for any program, the community health center will provide the health care services and will use its sliding fee scale according to family size and income to determine the fee.

4. Nevada Early Intervention Programs The Nevada Early Intervention Programs provide direct services to low- income children ages 0-3 under the Maternal and Child Health Block Grant (Title V). Services include well child clinic services, including developmental and physical assessments and immunizations. Children who appear to qualify for Medicaid or Nevada Check Up are encouraged to apply.

5. Family Resource Centers A total of 26 Family Resource Centers (FRCs) have been established in high risk neighborhoods throughout Nevada, and an additional two are scheduled to open in the next year. The FRCs are community-based centers run by not-for-profit organizations with state grants and private contributions. Their aim is to provide information about available social services including Medicaid and Nevada Check Up, and how to access

Effective Date: October 1, 2016 Page 10 Approval Date: November 23, 2016 those services. Sites also provide some services (e.g. child care) based on the needs of the community. Nevada Check Up staff have participated with Family Resource Centers in the coordination of health fairs.

6. Family to Family Program The Family to Family program is an initiative aimed at informing new mothers of the services that are available to them and how to access such services. A total of two centers have been established throughout the state. These centers are community based and operate as public/private partnerships. New mothers are able to receive a home visit, get questions answered about parenting issues and services available to aid them in raising their children, including health insurance through Medicaid and Nevada Check Up.

7. Tribal Administrators, Tribal Clinics, and Indian Health Services (IHS) Nevada Check Up staff attends and participates in meetings of the Native American Advisory Council, as mandated by Nevada law, in order to share information and receive advice as to the needs of the Native American tribes in Nevada. Application training and program updates are also provided by program staff.

8. The DHCFP is proposing the use of Health Services Initiative (HSI) funding to integrate the Resources for the Early Advancement of Child Health (REACH) program into after school programs serving the highest risk schools in Nevada that will be prioritized by the mandated environmental scan. The implementation of these innovative changes supports Nevada children in achieving a physical and emotionally safe environment by incorporating the REACH pilot project within the targeted schools. This approach will also allow the program to be scaled up or down based on available funding and the individualized school’s needs. The individualized school needs will be identified per data tracking by utilizing the newly implemented statewide longitudinal data system to track outcomes and compare cohorts within the same school as well as compare to schools across the state.

The HSI public health approach allows the services to be provided to all children in a targeted area regardless of payer source. The DHCFP will work with current after-school program(s) to determine capacity for providing the services within their current structure or coordinate with community providers who have the capacity to create a collaboration to provide these services. The DHCFP will be working to identify these groups to determine the best model for payment of these programs based on the community infrastructure and capacity.

Effective Date: September 1, 2008 Page 11 Approval Date: ___________

The HSI option allows the state to take a population health approach to behavioral health and early intervention for children. HSI also provides the flexibility to pilot the rising-risk concept across children ages 10 through 18 with the goal of being able to demonstrate the effectiveness of early intervention through the use of performance measures. The scope of services will target early intervention and preventive services and mental health resources to prevent the onset of a future behavioral health diagnosis. The DHCFP provides assurance that the HSI program will not supplant or match CHIP federal funds with other federal funds, nor allow other federal funds to supplant or match CHIP federal funds.

9. Connecting Kids to Health Coverage The Connecting Kids to Coverage will identify children who are eligible for Medicaid and the Children's Health Insurance Program (CHIP) and support targeted strategies needed to enroll eligible children who do not have health coverage, including application assistance and outreach.

10. Nevada 2-1-1 Nevada 2-1-1, a program of the Financial Guidance Center, is committed to helping Nevada citizens connect with the services they need, whether by phone or internet. The goal is to present accurate, well-organized and easy-to-find information for the state and local health and human services program.

11. Nevada Health Link- Silver State Health Insurance Exchange The state utilized Navigator Organizations, Certified Enrollment Assistant and is based on their attendance of community events, community involvement, and health care provider engagement eligibility screening.

2.2.2 The steps this state is currently taking to identify and enroll all uncovered children who are eligible to participate in health insurance programs that involve a public/private partnership.

Other than the referrals received from Family Resource Centers, there are no public/private partnerships in Nevada offering health insurance to low-income children.

2.3. Describe the procedures the state uses to accomplish coordination of SCHIP with other public and private health insurance programs, sources of health benefits coverage for children, and relevant child health programs, such as Title V, that provide health care services for low-income children to increase the number of children with creditable health coverage. (Previously 4.4.5) (Section 2102)(a)(3) and 2102(c)(2) and 2102(b)(3)(E)) (42 CFR 457.80(c))

This issue is addressed in the above Section 2.2.

10 Section 3. Methods of Delivery and Utilization Controls

Check here if the State elects to use funds provided under Title XXI only to provide expanded eligibility under the State’s Medicaid plan, and continue on to Section 4 (Eligibility Standards and Methodology).

Guidance: In Section 3.1, describe all delivery methods the State will use to provide services to enrollees, including: (1) contracts with managed care organizations (MCO), prepaid inpatient health plans (PIHP), prepaid ambulatory health plans (PAHP), primary care case management entities (PCCM entities), and primary care case managers (PCCM); (2) contracts with indemnity health insurance plans; (3) fee-for-service (FFS) paid by the State to health care providers; and (4) any other arrangements for health care delivery. The State should describe any variations based upon geography and by population (including the conception to birth population). States must submit the managed care contract(s) to CMS’ Regional Office for review.

3.1. Delivery Systems (Section 2102(a)(4)) (42 CFR 457.490; Part 457, Subpart L)

3.1.1 Choice of Delivery System 3.1.1.1 Does the State use a managed care delivery system for its CHIP populations? Managed care entities include MCOs, PIHPs, PAHPs, PCCM entities and PCCMs as defined in 42 CFR 457.10. Please check the box and answer the questions below that apply to your State.

No, the State does not use a managed care delivery system for any CHIP populations.

Yes, the State uses a managed care delivery system for all CHIP populations.

Yes, the State uses a managed care delivery system; however, only some of the CHIP population is included in the managed care delivery system and some of the CHIP population is included in a fee-for-service system. If the State uses a managed care delivery system for only some of its CHIP populations and a fee-for-service system for some of its CHIP populations, please describe which populations are, and which are not, included in the State’s managed care delivery system for CHIP. States will be asked to specify which managed care entities are used by the State in its managed care delivery system below in Section 3.1.2. Chip eligible members that reside in urban Washoe or Clark counties are mandatorily enrolled into one of three contracted MCOs, and a dental PAHP. Guidance: Utilization control systems are those administrative mechanisms that are designed to ensure that enrollees receiving health care

11 services under the State plan receive only appropriate and medically necessary health care consistent with the benefit package. Examples of utilization control systems include but are not limited to: requirements for referrals to specialty care; requirements that clinicians use clinical practice guidelines; or demand management systems (e.g., use of an 800 number for after-hours and urgent care). In addition, the State should describe its plans for review, coordination, and implementation of utilization controls, addressing both procedures and State developed standards for review, in order to assure that necessary care is delivered in a cost-effective and efficient manner. (42 CFR 457.490(b)) If the State does not use a managed care delivery system for any or some of its CHIP populations, describe the methods of delivery of the child health assistance using Title XXI funds to targeted low-income children. Include a description of: • The methods for assuring delivery of the insurance products and delivery of health care services covered by such products to the enrollees, including any variations. (Section 2102(a)(4); 42 CFR 457.490(a)) • The utilization control systems designed to ensure that enrollees receiving health care services under the State plan receive only appropriate and medically necessary health care consistent with the benefit package described in the approved State plan. (Section 2102(a)(4); 42 CFR 457.490(b))

Guidance: Only States that use a managed care delivery system for all or some CHIP populations need to answer the remaining questions under Section 3 (starting with 3.1.1.2). If the State uses a managed care delivery system for only some of its CHIP population, the State’s responses to the following questions will only apply to those populations. 3.1.1.2 Do any of your CHIP populations that receive services through a managed care delivery system receive any services outside of a managed care delivery system?

No

Yes

If yes, please describe which services are carved out of your managed care delivery system and how the State provides these services to an enrollee, such as through fee-for-service. Examples of carved out services may include transportation and dental, among others. Dental services are carved out of the MCO contracts and are provided under a contract PAHP vendor. Transportation (NET), school-based child health services, intermediate care facility for individuals with intellectual disabilities, targeted case management, skilled nursing facility benefits after 45 days, swing bed stays in an acute hospital over 45 days, hospice and orthodontic services are carved

11 out of managed care and the State elects to provide these services to enrollees through fee-for-service. 3.1.2 Use of a Managed Care Delivery System for All or Some of the State’s CHIP Populations 3.1.2.1 Check each of the types of entities below that the State will contract with under its managed care delivery system, and select and/or explain the method(s) of payment that the State will use:

Managed care organization (MCO) (42 CFR 457.10)

Capitation payment risk adjusted per member per month capitation payment. Describe population served: Nevada Check Up/CHIP members residing in urban Washoe and Clark counties.

Prepaid inpatient health plan (PIHP) (42 CFR 457.10)

Capitation payment

Other (please explain) Describe population served:

Guidance: If the State uses prepaid ambulatory health plan(s) (PAHP) to exclusively provide non-emergency medical transportation (a NEMT PAHP), the State should not check the following box for that plan. Instead, complete section 3.1.3 for the NEMT PAHP.

Prepaid ambulatory health plan (PAHP) (42 CFR 457.10)

Capitation payment risk adjusted per member per month capitation payment.

Other (please explain) Describe population served:

Primary care case manager (PCCM) (individual practitioners) (42 CFR 457.10)

Case management fee

Other (please explain)

Primary care case management entity (PCCM Entity) (42 CFR 457.10)

Case management fee

Shared savings, incentive payments, and/or other financial rewards for improved quality outcomes (see 42 CFR 457.1240(f))

Other (please explain)

11

If PCCM entity is selected, please indicate which of the following function(s) the entity will provide (as described in 42 CFR 457.10), in addition to PCCM services:

Provision of intensive telephonic case management

Provision of face-to-face case management

Operation of a nurse triage advice line

Development of enrollee care plans

Execution of contracts with fee-for-service (FFS) providers in the FFS program

Oversight responsibilities for the activities of FFS providers in the FFS program

Provision of payments to FFS providers on behalf of the State

Provision of enrollee outreach and education activities

Operation of a customer service call center

Review of provider claims, utilization and/or practice patterns to conduct provider profiling and/or practice improvement

Implementation of quality improvement activities including administering enrollee satisfaction surveys or collecting data necessary for performance measurement of providers

Coordination with behavioral health systems/providers

Other (please describe)

3.1.2.2

The State assures that if its contract with an MCO, PAHP or PIHP allows the entity to use a physician incentive plan, the contract stipulates that the entity must comply with the requirements set forth in 42 CFR 422.208 and 422.210. (42 CFR 457.1201(h), cross-referencing to 42 CFR 438.3(i)) 3.1.3 Nonemergency Medical Transportation PAHPs Guidance: Only complete Section 3.1.3 if the State uses a PAHP to exclusively provide non- emergency medical transportation (a NEMT PAHP). If a NEMT PAHP is the only managed care entity for CHIP in the State, please continue to Section 4 after checking the assurance below. If the State uses a PAHP that does not exclusively provide NEMT and/or uses other managed care entities beyond a NEMT PAHP, the State will need to complete the remaining sections within Section 3.

The State assures that it complies with all requirements applicable to NEMT PAHPs, and through its contracts with such entities, requires NEMT PAHPs to comply with all applicable requirements, including the following (from 42 CFR 457.1206(b)): • All contract provisions in 42 CFR 457.1201 except those set forth in 42 CFR 457.1201(h) (related to physician incentive plans) and 42 CFR 457.1201(l) (related to mental health parity). • The information requirements in 42 CFR 457.1207 (see Section 3.5 below for more details). • The provision against provider discrimination in 42 CFR 457.1208.

11 • The State responsibility provisions in 42 CFR 457.1212 (about disenrollment), 42 CFR 457.1214 (about conflict of interest safeguards), and 42 CFR 438.62(a), as cross-referenced in 42 CFR 457.1216 (about continued services to enrollees). • The provisions on enrollee rights and protections in 42 CFR 457.1220, 457.1222, 457.1224, and 457.1226. • The PAHP standards in 42 CFR 438.206(b)(1), as cross-referenced by 42 CFR 457.1230(a) (about availability of services), 42 CFR 457.1230(d) (about coverage and authorization of services), and 42 CFR 457.1233(a), (b) and (d) (about structure and operation standards). • An enrollee's right to a State review under subpart K of 42 CFR 457. • Prohibitions against affiliations with individuals debarred or excluded by Federal agencies in 42 CFR 438.610, as cross referenced by 42 CFR 457.1285. • Requirements relating to contracts involving Indians, Indian Health Care Providers, and Indian managed care entities in 42 CFR 457.1209.

3.2. General Managed Care Contract Provisions

3.2.1

The State assures that it provides for free and open competition, to the maximum extent practical, in the bidding of all procurement contracts for coverage or other services, including external quality review organizations, in accordance with the procurement requirements of 45 CFR part 75, as applicable. (42 CFR 457.940(b); 42 CFR 457.1250(a), cross referencing to 42 CFR 438.356(e)) 3.2.2

The State assures that it will include provisions in all managed care contracts that define a sound and complete procurement contract, as required by 45 CFR part 75, as applicable. (42 CFR 457.940(c)) 3.2.3

The State assures that each MCO, PIHP, PAHP, PCCM, and PCCM entity complies with any applicable Federal and State laws that pertain to enrollee rights and ensures that its employees and contract providers observe and protect those rights (42 CFR 457.1220, cross-referencing to 42 CFR 438.100). These Federal and State laws include: Title VI of the Civil Rights Act of 1964 (45 CFR part 80), Age Discrimination Act of 1975 (45 CFR part 91), Rehabilitation Act of 1973, Title IX of the Education Amendments of 1972, Titles II and III of the Americans with Disabilities Act, and section 1557 of the Patient Protection and Affordable Care Act. 3.2.4

The State assures that it operates a Web site that provides the MCO, PIHP, PAHP, and PCCM entity contracts. (42 CFR 457.1207, cross-referencing to 42 CFR 438.10(c)(3)) 3.3 Rate Development Standards and Medical Loss Ratio 3.3.1 The State assures that its payment rates are:

Based on public or private payment rates for comparable services for comparable populations; and

12

Consistent with actuarially sound principles as defined in 42 CFR 457.10. (42 CFR 457.1203(a))

Guidance: States that checked both boxes under 3.3.1 above do not need to make the next assurance. If the state is unable to check both boxes under 3.1.1 above, the state must check the next assurance.

If the State is unable to meet the requirements under 42 CFR 457.1203(a), the State attests that it must establish higher rates because such rates are necessary to ensure sufficient provider participation or provider access or to enroll providers who demonstrate exceptional efficiency or quality in the provision of services. (42 CFR 457.1203(b)) 3.3.2

The State assures that its rates are designed to reasonably achieve a medical loss ratio standard equal to at least 85 percent for the rate year and provide for reasonable administrative costs. (42 CFR 457.1203(c)) 3.3.3

The State assures that it will provide to CMS, if requested by CMS, a description of the manner in which rates were developed in accordance with the requirements of 42 CFR 457.1203(a) through (c). (42 CFR 457.1203(d)) 3.3.4

The State assures that it annually submits to CMS a summary description of the reports pertaining to the medical loss ratio received from the MCOs, PIHPs and PAHPs. (42 CFR 457.1203(e), cross referencing to 42 CFR 438.74(a)) 3.3.5 Does the State require an MCO, PIHP or PAHP to pay remittances through the contract for not meeting the minimum MLR required by the State? (42 CFR 457.1203(e), cross referencing to 42 CFR 438.74(b)(1))

No, the State does not require any MCO, PIHP, or PAHP to pay remittances.

Yes, the State requires all MCOs, PIHPs, and PAHPs to pay remittances.

Yes, the State requires some, but not all, MCOs, PIHPs, and PAHPs to pay remittances.

If the State requests some, but not all, MCOs, PIHPs, and PAHPs to pay remittances through the contract for not meeting the minimum MLR required by the State, please describe which types of managed care entities are and are not required to pay remittances. For example, if a state requires a medical MCO to pay a remittance but not a dental PAHP, please include this information. If the answer to the assurance above is yes for any or all managed care entities, please answer the next assurance: The State assures that it if a remittance is owed by an MCO, PIHP, or PAHP to the State, the State: • Reimburses CMS for an amount equal to the Federal share of the remittance,

11 taking into account applicable differences in the Federal matching rate; and • Submits a separate report describing the methodology used to determine the State and Federal share of the remittance with the annual report provided to CMS that summarizes the reports received from the MCOs, PIHPs, and PAHPs. (42 CFR 457.1203(e), cross referencing to 42 CFR 438.74(b))

3.3.6

The State assures that each MCO, PIHP and PAHP calculates and reports the medical loss ratio in accordance with 42 CFR 438.8. (42 CFR 457.1203(f)) 3.4 Enrollment

The State assures that its contracts with MCOs, PIHPs, PAHPs, PCCMs and PCCM entities provide that the MCO, PIHP, PAHP, PCCM or PCCM entity: • Accepts individuals eligible for enrollment in the order in which they apply without restriction (unless authorized by CMS), up to the limits set under the contract (42 CFR 457.1201(d), cross-referencing to 42 CFR 438.3(d)(1)); • Will not, on the basis of health status or need for health care services, discriminate against individuals eligible to enroll (42 CFR 457.1201(d), cross-referencing to 42 CFR 438.3(d)(3)); and • Will not discriminate against individuals eligible to enroll on the basis of race, color, national origin, sex, sexual orientation, gender identity, or disability and will not use any policy or practice that has the effect of discriminating on the basis of race, color, national origin, sex, sexual orientation, gender identity or disability. (42 CFR 457.1201(d), cross-referencing to 438.3(d)(4)) 3.4.1 Enrollment Process 3.4.1.1

The State assures that it provides informational notices to potential enrollees in an MCO, PIHP, PAHP, PCCM or PCCM entity that includes the available managed care entities, explains how to select an entity, explains the implications of making or not making an active choice of an entity, explains the length of the enrollment period as well as the disenrollment policies, and complies with the information requirements in 42 CFR 457.1207 and accessibility standards established under 42 CFR 457.340. (42 CFR 457.1210(c)) 3.4.1.2

The State assures that its enrollment system gives beneficiaries already enrolled in an MCO, PIHP, PAHP, PCCM or PCCM entity priority to continue that enrollment if the MCO, PIHP, PAHP, PCCM or PCCM entity does not have the capacity to accept all those seeking enrollment under the program. (42 CFR 457.1210(b)) 3.4.1.3 Does the State use a default enrollment process to assign beneficiaries to an MCO, PIHP, PAHP, PCCM or PCCM entity? (42 CFR 457.1210(a))

Yes

No

11 If the State uses a default enrollment process, please make the following assurances:

The State assigns beneficiaries only to qualified MCOs, PIHPs, PAHPs, PCCMs, and PCCM entities that are not subject to the intermediate sanction of having suspension of all new enrollment (including default enrollment) under 42 CFR 438.702 and have capacity to enroll beneficiaries. (42 CFR 457.1210(a)(1)(i))

The State maximizes continuation of existing provider-beneficiary relationships under 42 CFR 457.1210(a)(1)(ii) or if that is not possible, distributes the beneficiaries equitably and does not arbitrarily exclude any MCO, PIHP, PAHP, PCCM or PCCM entity from being considered. (42 CFR 457.1210(a)(1)(ii), 42 CFR 457.1210(a)(1)(iii)) 3.4.2 Disenrollment 3.4.2.1

The State assures that the State will notify enrollees of their right to disenroll consistent with the requirements of 42 CFR 438.56 at least annually. (42 CFR 457.1207, cross-referencing to 42 CFR 438.10(f)(2)) 3.4.2.2

The State assures that the effective date of an approved disenrollment, regardless of the procedure followed to request the disenrollment, will be no later than the first day of the second month following the month in which the enrollee requests disenrollment or the MCO, PIHP, PAHP, PCCM or PCCM entity refers the request to the State. (42 CFR 457.1212, cross-referencing to 438.56(e)(1)) 3.4.2.3

If a beneficiary disenrolls from an MCO, PIHP, PAHP, PCCM, or PCCM entity, the State assures that the beneficiary is provided the option to enroll in another plan or receive benefits from an alternative delivery system. (Section 2103(f)(3) of the Social Security Act, incorporating section 1932(a)(4); 42 CFR 457.1212, cross referencing to 42 CFR 438.56; State Health Official Letter #09-008) 3.4.2.4 MCO, PIHP, PAHP, PCCM and PCCM Entity Requests for Disenrollment.

The State assures that contracts with MCOs, PIHPs, PAHPs, PCCMs and PCCM entities describe the reasons for which an MCO, PIHP, PAHP, PCCM and PCCM entity may request disenrollment of an enrollee, if any. (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(b)) Guidance: Reasons for disenrollment by the MCO, PIHP, PAHP, PCCM, and PCCM entity must be specified in the contract with the State. Reasons for disenrollment may not include an adverse change in the enrollee's health

11 status, or because of the enrollee's utilization of medical services, diminished mental capacity, or uncooperative or disruptive behavior resulting from his or her special needs (except when his or her continued enrollment in the MCO, PIHP, PAHP, PCCM or PCCM entity seriously impairs the entity's ability to furnish services to either this particular enrollee or other enrollees). (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(b)(2)) 3.4.2.5 Enrollee Requests for Disenrollment. Guidance: The State may also choose to limit disenrollment from the MCO, PIHP, PAHP, PCCM, or PCCM entity, except for either: 1) for cause, at any time; or 2) without cause during the latter of the 90 days after the beneficiary’s initial enrollment or the State sends the beneficiary notice of that enrollment, at least once every 12 months, upon reenrollment if the temporary loss of CHIP eligibility caused the beneficiary to miss the annual disenrollment opportunity, or when the State imposes the intermediate sanction specified in 42 CFR 438.702(a)(4). (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(c)) Does the State limit disenrollment from an MCO, PIHP, PAHP, PCCM and PCCM entity by an enrollee? (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(c))

Yes

No If the State limits disenrollment by the enrollee from an MCO, PIHP, PAHP, PCCM and PCCM entity, please make the following assurances (42 CFR 457.1212, cross- referencing to 42 CFR 438.56(c)):

The State assures that enrollees and their representatives are given written notice of disenrollment rights at least 60 days before the start of each enrollment period. (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(f)(1))

The State assures that beneficiary requests to disenroll for cause will be permitted at any time by the MCO, PIHP, PAHP, PCCM or PCCM entity. (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(c)(1) and (d)(2))

The State assures that beneficiary requests for disenrollment without cause will be permitted by the MCO, PIHP, PAHP, PCCM or PCCM entity at the following times: • During the 90 days following the date of the beneficiary's initial enrollment into the MCO, PIHP, PAHP, PCCM, or PCCM entity, or during the 90 days following the date the State sends the beneficiary notice of that enrollment, whichever is later;

11 • At least once every 12 months thereafter; • If the State plan provides for automatic reenrollment for an individual who loses CHIP eligibility for a period of 2 months or less and the temporary loss of CHIP eligibility has caused the beneficiary to miss the annual disenrollment opportunity; and • When the State imposes the intermediate sanction on the MCO, PIHP, PAHP, PCCM or PCCM entity specified in 42 CFR 438.702(a)(4). (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(c)(2)) 3.4.2.6

The State assures that the State ensures timely access to a State review for any enrollee dissatisfied with a State agency determination that there is not good cause for disenrollment. (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(f)(2)) 3.5 Information Requirements for Enrollees and Potential Enrollees 3.5.1

The State assures that it provides, or ensures its contracted MCOs, PAHPs, PIHPs, PCCMs and PCCM entities provide, all enrollment notices, informational materials, and instructional materials related to enrollees and potential enrollees in accordance with the terms of 42 CFR 457.1207, cross-referencing to 42 CFR 438.10. 3.5.2

The State assures that all required information provided to enrollees and potential enrollees are in a manner and format that may be easily understood and is readily accessible by such enrollees and potential enrollees. (42 CFR 457.1207, cross- referencing to 42 CFR 438.10(c)(1)) 3.5.3

The State assures that it operates a Web site that provides the content specified in 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(g)-(i) either directly or by linking to individual MCO, PIHP, PAHP and PCCM entity Web sites. 3.5.4

The State assures that it has developed and requires each MCO, PIHP, PAHP and PCCM entity to use: • Definitions for the terms specified under 42 CFR 438.10(c)(4)(i), and • Model enrollee handbooks, and model enrollee notices. (42 CFR 457.1207, cross-referencing to 42 CFR 438.10(c)(4))

3.5.5

If the State, MCOs, PIHPs, PAHPs, PCCMs or PCCM entities provide the information required under 42 CFR 457.1207 electronically, check this box to confirm that the State assures that it meets the requirements under 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(c)(6) for providing the material in an accessible manner. Including that: • The format is readily accessible; • The information is placed in a location on the State, MCO's, PIHP's, PAHP's or PCCM's, or PCCM entity's Web site that is prominent and readily accessible;

11 • The information is provided in an electronic form which can be electronically retained and printed; • The information is consistent with the content and language requirements in 42 CFR 438.10; and • The enrollee is informed that the information is available in paper form without charge upon request and is provided the information upon request within 5 business days. 3.5.6

The State assures that it meets the language and format requirements set forth in 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(d), including but not limited to: • Establishing a methodology that identifies the prevalent non-English languages spoken by enrollees and potential enrollees throughout the State, and in each MCO, PIHP, PAHP or PCCM entity service area; • Making oral interpretation available in all languages and written translation available in each prevalent non-English language; • Requiring each MCO, PIHP, PAHP and PCCM entity to make its written materials that are critical to obtaining services available in the prevalent non- English languages in its particular service area; • Making interpretation services available to each potential enrollee and requiring each MCO, PIHP, PAHP and PCCM entity to make those services available free of charge to each enrollee; and • Notifying potential enrollees, and requiring each MCO, PIHP, PAHP and PCCM entity to notify its enrollees:

o That oral interpretation is available for any language and written translation is available in prevalent languages; o That auxiliary aids and services are available upon request and at no cost for enrollees with disabilities; and o How to access the services in 42 CFR 457.1207, cross-referencing 42 CFR 438.10(d)(5)(i) and (ii).

3.5.7

The State assures that the State or its contracted representative provides the information specified in 42 CFR 457.1207, cross-referencing to 438.10(e)(2), and includes the information either in paper or electronic format, to all potential enrollees at the time the potential enrollee becomes eligible to enroll in a voluntary managed care program or is first required to enroll in a mandatory managed care program and within a timeframe that enables the potential enrollee to use the information to choose among the available MCOs, PIHPs, PAHPs, PCCMs and PCCM entities: • Information about the potential enrollee's right to disenroll consistent with the requirements of 42 CFR 438.56 and which explains clearly the process for exercising this disenrollment right, as well as the alternatives available to the potential enrollee based on their specific circumstance; • The basic features of managed care;

11 • Which populations are excluded from enrollment in managed care, subject to mandatory enrollment, or free to enroll voluntarily in the program; • The service area covered by each MCO, PIHP, PAHP, PCCM or PCCM entity; • Covered benefits including: o Which benefits are provided by the MCO, PIHP or PAHP; and which, if any, benefits are provided directly by the State; and o For a counseling or referral service that the MCO, PIHP or PAHP does not cover because of moral or religious objections, where and how to obtain the service; • The provider directory and formulary information required in 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(h) and (i); • Any cost-sharing for the enrollee that will be imposed by the MCO, PIHP, PAHP, PCCM or PCCM entity consistent with those set forth in the State plan; • The requirements for each MCO, PIHP or PAHP to provide adequate access to covered services, including the network adequacy standards established in 42 CFR 457.1218, cross-referencing 42 CFR 438.68; • The MCO, PIHP, PAHP, PCCM and PCCM entity's responsibilities for coordination of enrollee care; and • To the extent available, quality and performance indicators for each MCO, PIHP, PAHP and PCCM entity, including enrollee satisfaction. 3.5.8

The State assures that it will provide the information specified in 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(f) to all enrollees of MCOs, PIHPs, PAHPs and PCCM entities, including that the State must notify all enrollees of their right to disenroll consistent with the requirements of 42 CFR 438.56 at least annually. 3.5.9

The State assures that each MCO, PIHP, PAHP and PCCM entity will provide the information specified in 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(f) to all enrollees of MCOs, PIHPs, PAHPs and PCCM entities, including that: • The MCO, PIHP, PAHP and, when appropriate, the PCCM entity, must make a good faith effort to give written notice of termination of a contracted provider within the timeframe specified in 42 CFR 438.10(f), and • The MCO, PIHP, PAHP and, when appropriate, the PCCM entity must make available, upon request, any physician incentive plans in place as set forth in 42 CFR 438.3(i).

3.5.10

The State assures that each MCO, PIHP, PAHP and PCCM entity will provide enrollees of that MCO, PIHP, PAHP or PCCM entity an enrollee handbook that meets the requirements as applicable to the MCO, PIHP, PAHP and PCCM entity, specified in 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(g)(1)-(2), within a reasonable time after receiving notice of the beneficiary's enrollment, by a method consistent with 42 CFR 438.10(g)(3), and including the following items:

11 • Information that enables the enrollee to understand how to effectively use the managed care program, which, at a minimum, must include: o Benefits provided by the MCO, PIHP, PAHP or PCCM entity; o How and where to access any benefits provided by the State, including any cost sharing, and how transportation is provided; and o In the case of a counseling or referral service that the MCO, PIHP, PAHP, or PCCM entity does not cover because of moral or religious objections, the MCO, PIHP, PAHP or PCCM entity must inform enrollees that the service is not covered by the MCO, PIHP, PAHP, or PCCM entity and how they can obtain information from the State about how to access these services; • The amount, duration, and scope of benefits available under the contract in sufficient detail to ensure that enrollees understand the benefits to which they are entitled; • Procedures for obtaining benefits, including any requirements for service authorizations and/or referrals for specialty care and for other benefits not furnished by the enrollee's primary care provider; • The extent to which, and how, after-hours and emergency coverage are provided, including: o What constitutes an emergency medical condition and emergency services; o The fact that prior authorization is not required for emergency services; and o The fact that, subject to the provisions of this section, the enrollee has a right to use any hospital or other setting for emergency care; • Any restrictions on the enrollee's freedom of choice among network providers; • The extent to which, and how, enrollees may obtain benefits, including family planning services and supplies from out-of-network providers; • Cost sharing, if any is imposed under the State plan; • Enrollee rights and responsibilities, including the elements specified in 42 CFR §438.100; • The process of selecting and changing the enrollee's primary care provider; • Grievance, appeal, and review procedures and timeframes, consistent with 42 CFR 457.1260, in a State-developed or State-approved description, including: o The right to file grievances and appeals; o The requirements and timeframes for filing a grievance or appeal; o The availability of assistance in the filing process; and o The right to request a State review after the MCO, PIHP or PAHP has made a determination on an enrollee's appeal which is adverse to the enrollee; • How to access auxiliary aids and services, including additional information in alternative formats or languages; • The toll-free telephone number for member services, medical management, and any other unit providing services directly to enrollees; and

11 • Information on how to report suspected fraud or abuse. 3.5.11

The State assures that each MCO, PIHP, PAHP and PCCM entity will give each enrollee notice of any change that the State defines as significant in the information specified in the enrollee handbook at least 30 days before the intended effective date of the change. (42 CFR 457.1207, cross-referencing to 42 CFR 438.10(g)(4)) 3.5.12

The State assures that each MCO, PIHP, PAHP and when appropriate, PCCM entity, will make available a provider directory for the MCO’s, PIHP’s, PAHP’s or PCCM entity’s network providers, including for physicians (including specialists), hospitals, pharmacies, and behavioral health providers, that includes information as specified in 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(h)(1)-(2) and (4). 3.5.13

The State assures that each MCO, PIHP, PAHP and when appropriate, PCCM entity, will update any information included in a paper provider directory at least monthly and in an electronic provider directory as specified in 42 CFR 438.10(h)(3). (42 CFR 457.1207, cross-referencing to 42 CFR 438.10(h)(3)) 3.5.14

The State assures that each MCO, PIHP, PAHP and when appropriate, PCCM entity, will make available the MCO’s, PIHP’s, PAHP’s or PCCM entity’s formulary that meets the requirements specified in 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(i), including: • Which medications are covered (both generic and name brand); and • What tier each medication is on. 3.5.15

The State assures that each MCO, PIHP, PAHP, PCCM and PCCM entity follows the requirements for marketing activities under 42 CFR 457.1224, cross-referencing to 42 CFR 438.104 (except 42 CFR 438.104(c)). Guidance: Requirements for marketing activities include, but are not limited to, that the MCO, PIHP, PAHP, PCCM, or PCCM entity does not distribute any marketing materials without first obtaining State approval; distributes the materials to its entire service areas as indicated in the contract; does not seek to influence enrollment in conjunction with the sale or offering of any private insurance; and does not, directly or indirectly, engage in door-to-door, telephone, email, texting, or other cold-call marketing activities. (42 CFR 104(b)) Guidance: Only States with MCOs, PIHPs or PAHPs need to answer the remaining assurances in Section 3.5 (3.5.16 through 3.5.18). 3.5.16

The State assures that each MCO, PIHP and PAHP protects communications between providers and enrollees under 42 CFR 457.1222, cross-referencing to 42 CFR 438.102. 3.5.17

The State assures that MCOs, PIHP, and PAHPs have arrangements and procedures that prohibit the MCO, PIHP and PAHP from conducting any unsolicited personal

11 contact with a potential enrollee by an employee or agent of the MCO, PAHP or PIHP for the purpose of influencing the individual to enroll with the entity. (42 CFR 457.1280(b)(2)) Guidance: States should also complete Section 3.9, which includes additional provisions about the notice procedures for grievances and appeals. 3.5.18

The State assures that each contracted MCO, PIHP, and PAHP comply with the notice requirements specified for grievances and appeals in accordance with the terms of 42 CFR 438, Subpart F, except that the terms of 42 CFR 438.420 do not apply and that references to reviews should be read to refer to reviews as described in 42 CFR 457, Subpart K. (42 CFR 457.1260)

3.6 Benefits and Services Guidance: The State should also complete Section 3.10 (Program Integrity). 3.6.1

The State assures that MCO, PIHP, PAHP PCCM entity, and PCCM contracts involving Indians, Indian health care providers, and Indian managed care entities comply with the requirements of 42 CFR 438.14. (42 CFR 457.1209) 3.6.2

The State assures that all services covered under the State plan are available and accessible to enrollees. (42 CFR 457.1230(a), cross-referencing to 42 CFR 438.206) 3.6.3

The State assures that it: • Publishes the State’s network adequacy standards developed in accordance with 42 CFR 457.1218, cross-referencing 42 CFR 438.68(b)(1) on the Web site required by 42 CFR 438.10; • Makes available, upon request, the State’s network adequacy standards at no cost to enrollees with disabilities in alternate formats or through the provision of auxiliary aids and services. (42 CFR 457.1218, cross- referencing 42 CFR 438.68(e)) Guidance: Only States with MCOs, PIHPs or PAHPs need to complete the remaining assurances in Section 3.6 (3.6.4 through 3.6.20. 3.6.4

The State assures that each MCO, PAHP and PIHP meet the State’s network adequacy standards. (42 CFR 457.1218, cross-referencing 42 CFR 438.68; 42 CFR 457.1230(a), cross-referencing to 42 CFR 438.206) 3.6.5

The State assures that each MCO, PIHP, and PAHP includes within its network of credentialed providers: • A sufficient number of providers to provide adequate access to all services covered under the contract for all enrollees, including those with limited

11 English proficiency or physical or mental disabilities; • Women’s health specialists to provide direct access to covered care necessary to provide women’s routine and preventative health care services for female enrollees; and • Family planning providers to ensure timely access to covered services. (42 CFR 457.1230(a), cross-referencing to 42 CFR 438.206(b) 3.6.6

The State assures that each contract under 42 CFR 457.1201 permits an enrollee to choose his or her network provider. (42 CFR 457.1201(j), cross-referencing 42 CFR 438.3(l)) 3.6.7

The State assures that each MCO, PIHP, and PAHP provides for a second opinion from a network provider or arranges for the enrollee to obtain one outside the network, at no cost. (42 CFR 457.1230(a), cross-referencing to 42 CFR 438.206(b)(3)) 3.6.8

The State assures that each MCO, PIHP, and PAHP ensures that providers, in furnishing services to enrollees, provide timely access to care and services, including by: • Requiring the contract to adequately and timely cover out-of-network services if the provider network is unable to provide necessary services covered under the contract to a particular enrollee and at a cost to the enrollee that is no greater than if the services were furnished within the network; • Requiring the MCO, PIHP and PAHP meet and its network providers to meet State standards for timely access to care and services, taking into account the urgency of the need for services; • Ensuring that the hours of operation for a network provider are no less than the hours of operation offered to commercial enrollees or comparable to Medicaid or CHIP Fee-For-Service, if the provider serves only Medicaid or CHIP enrollees; • Ensuring that the MCO, PIHP and PAHP makes available services include in the contract on 24 hours a day, 7 days a week basis when medically necessary; • Establishing mechanisms to ensure compliance by network providers; • Monitoring network providers regularly to determine compliance; • Taking corrective action if there is a failure to comply by a network provider. (42 CFR 457.1230(a), cross-referencing to 42 CFR 438.206(b)(4) and (5) and (c)) 3.6.9

The State assures that each MCO, PIHP and PAHP has the capacity to serve the expected enrollment in its service area in accordance with the State's standards for access to care. (42 CFR 457.1230(b), cross-referencing to 42 CFR 438.207) 3.6.10

The State assures that each MCO, PIHP and PAHP will be required to submit documentation to the State, at the time of entering into a contract with the State, on an annual basis, and at any time there has been a significant change to the MCO,

11 PIHP or PAHP’s operations that would affect the adequacy of capacity and services, to demonstrate that each MCO, PIHP and PAHP for the anticipated number of enrollees for the service area: • Offers an appropriate range of preventative, primary care and specialty services; and • Maintains a provider network that is sufficient in number, mix, and geographic distribution. (42 CFR 457.1230, cross-referencing to 42 CFR 438.207(b)) 3.6.11

Except that 42 CFR 438.210(a)(5) does not apply to CHIP, the State assures that its contracts with each MCO, PIHP or PAHP comply with the coverage of services requirements under 42 CFR 438.210, including: • Identifying, defining, and specifying the amount, duration, and scope of each service that the MCO, PIHP or PAHP is required to offer; and • Permitting an MCO, PIHP or PAHP to place appropriate limits on a service. (42 CFR 457.1230(d), cross referencing to 42 CFR 438.210(a) except that 438.210(a)(5) does not apply to CHIP contracts) 3.6.12

Except that 438.210(b)(2)(iii) does not apply to CHIP, the State assures that its contracts with each MCO, PIHP or PAHP comply with the authorization of services requirements under 42 CFR 438.210, including that: • The MCO, PIHP or PAHP and its subcontractors have in place and follow written policies and procedures; • The MCO, PIHP or PAHP have in place mechanisms to ensure consistent application of review criteria and consult with the requesting provider when appropriate; and • Any decision to deny a service authorization request or to authorize a service in an amount, duration, or scope that is less than requested be made by an individual with appropriate expertise in addressing the enrollee’s medical, or behavioral health needs. (42 CFR 457.1230(d), cross referencing to 42 CFR 438.210(b), except that 438.210(b)(2)(iii) does not apply to CHIP contracts) 3.6.13

The State assures that its contracts with each MCO, PIHP or PAHP require each MCO, PIHP or PAHP to notify the requesting provider and given written notice to the enrollee of any adverse benefit determination to deny a service authorization request, or to authorize a service in an amount, duration, or scope that is less than requested. (42 CFR 457.1230(d), cross-referencing to 42 CFR 438.210(c)) 3.6.14

The State assures that its contracts with each MCO, PIHP or PAHP provide that compensation to individuals or entities that conduct utilization management activities is not structured so as to provide incentives for the individual or entity to deny, limit, or discontinue medically necessary services to any enrollee. (42 CFR 457.1230(d), cross-referencing to 42 CFR 438.210(e))

11 3.6.15

The State assures that it has a transition of care policy that meets the requirements of 438.62(b)(1) and requires that each contracted MCO, PIHP and PAHP implements the policy. (42 CFR 457.1216, cross-referencing to 42 CFR 438.62) 3.6.16