53a

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

Revision: | HCFA-PM-95-3 (MB) MAY 1995

Citation

42 CFR 433.36(c) 1902(a)(18) and 1917(a) and (b) of the Act

State/Territory: Nevada

4.17 (Cont'd)

(b) Adjustment or Recoveries

The State complies with the requirements of section 1917(b) of the Act and regulations at 42 CFR 433.36(h)-(i).

Adjustments or recoveries for Medicaid claims correctly paid are as follows:

(1) For permanently institutionalized individuals, adjustments or recoveries are made from the individual's estate or upon sale of the property subject to a lien imposed because of medical assistance paid on behalf of the individual for services provided in a nursing facility, ICF/MR, or other medical institution.

_X Adjustments or recoveries are made for all other medical assistance paid on behalf of the individual.

(2) X The State determines "permanent institutional status" of individuals under the age of 55 other than those with respect to whom it imposes liens on real property under (ss)1917(a)(1)(B) (even if it does not impose those liens).

(3) For any individual who received medical assistance at age 55 or older, adjustments or recoveries of payments are made from the individual's estate for nursing facility services, and related hospital and prescription drug services.

_X In addition to adjustment or recovery of payments for services listed above, payments are adjusted or recovered for other services under the State Plan as listed below:

All other Medicaid services currently covered under Nevada's State Plan for recipients age 55 and over, except for Medicare cast sharing as identified in Section 4.17(b)(3- Continued).

TN No.10-011 Supersedes TN No. 95-011

Approval Date: MAR 0 9 201] Effective Date: October 1, 2010

Page 53a-1

Revision: HCFA-PM-95-3 (MB) May 1995

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State/Territory: Nevada 4.17 (b) Adjustments or Recoveries

(3) (Continued) Limitations on Estate Recovery — Medicare Cost Sharing:

i. Medical assistance for Medicare cost sharing is protected from estate recovery for the following categories of dual eligibles: QMB, SLMB, QI, QDWI, QMB+, SLMB+. This protection extends to medical assistance for four Medicare cost sharing benefits: (Part A and B premiums, deductibles, coinsurance, co-payments) with dates of service on or after January 1, 2010. The date of service for deductibles, coinsurance, and co- payments is the date the request for payment is received by the State Medicaid Agency. The date of service for premiums is the date the State Medicaid Agency paid the premium.

ii. In addition to being a qualified dual eligible the individual must also be age 55 or over. The above protection from estate recovery for Medicare cost sharing benefits (premiums, deductibles, coinsurance,

co-payments) applies to approved mandatory (i.e., | nursing facility, home and community-based services, | and related prescription drugs and hospital services) | as well as optional Medicaid services identified in the | State plan, which are applicable to the categories of duals referenced above.

TN No. 10-011 Approval Date: MAR_0 9 2011Effective Date: October 1, 2010 Supersedes TN No. NEW

DEPARTMENT OF HEALTH AND HUMAN SERVICES HEALTH CARE FINANCING ADMINISTRATION

FORM APPROVED OMB NO. 0938-0193

TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL

FOR: HEALTH CARE FINANCING ADMINISTRATION

1. TRANSMITTAL NUMBER: 10-011

2. STATE NEVADA

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

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

4. PROPOSED EFFECTIVE DATE October 1, 2010

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

(7 NEW STATE PLAN

[-] AMENDMENT TO BE CONSIDERED AS NEW PLAN

{] AMENDMENT

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

6. FEDERAL STATUTE/REGULATION CITATION: Section 1917(b)(1)(B)(ii) of the Social Security Act (42 U.S.C. 1396p

(b)()(B)Gi))

7. FEDERAL BUDGET IMPACT: a. FFY 2046 20(( $0 b. FFY 264+ 2012 $0

8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:

Section 4.17 (b) page 53a-1 and 53a

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

Section 4.17 (b) page 33a S3a

10. SUBJECT OF AMENDMENT:

MIPPA Section 115 requires states to exempt Medicare cost-sharing benefits paid under the Medicare Savings programs from estate

recovery.

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

fi 7 4,

[] OTHER, AS SPECIFIED: The Governor’s Office does not wish to review the State Plan Amendment.

12.8 ATE AGENCY OFFICIAL:

16. RETURN TO:

13. TYPED NAME: Michael J. Willden

14, TITLE: Director, Department of Health and Human Services

15, DATE SUBMITTED: _DEC * 8 2010

Marta Stagliano, Chief, Compliance DHCFP/Medicaid

1100 East William Street, Suite 101 Carson City, NV 89701

_FOR REGIONAL OFFICE USE ONLY

17. DATE RECEIVED:

18. DATE APPROVED:

MAR 0 9 2h

December 28, 2010

me ELAN APPROVED — ONE COPY ATTACHED

19. EFFECTIVE DATE OF

20. SIGNATURE OF REGIONAL OFFICIAL:

21. TYPED NAME:

23. REMARKS:

22- TITLE

ales eek ond Ades

Pen and \ne chanaes made to Voxes 4, gand A.

FORM HCFA-179 (07-92)

SERVICY oe SEES,

RS %y y i SO DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 6 { %, Region IX Uy, ‘aaa Division of Medicaid & Children’s Health Operations

90 Seventh Street, Suite 5-300 (SW) San Francisco, CA 94103-6706

OCT 20 2011

Michael J. Willden, Director

Department of Health and Human Services

4126 Technology Way, Suite 100 re Carson City, NV 89706

Dear Mr. Willden:

Enclosed is an approved copy of Nevada State Plan Amendment (SPA) 11-009. This SPA was submitted to my office on July 26, 2011 requesting to amend Attachment 4.19-B, Page 2 to update the rate methodology for durable medical equipment (DME), prosthetics, orthotics, and disposable supplies to reflect a 0.7% rate reduction.

The approval is effective August 1, 2011. Attached is a copy of Attachment 4.19-B, Page 2 to be incorporated into your State Plan.

If you have any questions, please contact Brian Zolynas by phone at (415) 744-3601 or by email at Brian.Zolynas @cms.hhs.gov.

Sincerely,

Gloria Nagle, Ph.D., MPA Associate Regional Administrator Division of Medicaid & Children’s Health Operations

Enclosure

ce: Charles Duarte, Administrator, DHCFP Marta Stagliano, Chief, Compliance, DHCFP Michele Bowser, CMS Center for Medicaid & State Operations (two copies)

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State __ Nevada Attachment 4.19-B Page 2 7. Home Health Care Services:

a. Home health care services include the following services and items:

1. physical therapy — 1 unit per 15 minutes,

2. occupational therapy — 1 unit per 15 minutes,

3. speech therapy — 1 unit per 15 minutes,

4. family planning education ~ 1 unit per visit,

5. skilled nursing services (RN/LPN visits) 1 unit per 60 minutes or 1 unit per 15 minutes for brief visits or 1 unit per 15 minutes for extended visits (after 1st hour),

6. home health aide services — 1 unit per 60 minutes or 1 unit per 30 minutes for extended visits (after 1* hour),

7. durable medical equipment, prosthetics, orthotics, an¢d =“

8. disposable medical supplies.

b. Reimbursements for Home Health Care services, listed above in a.1. through a.6, provided by Home Health Agencies (HHA) are the lower of a) billed charges, or b) a fixed fee schedule which includes the rate for each of the home health services and a rate for “mileage” as an add- on. The agency’s rates were set as of July 1, 2000 and are effective for services on or after July 1, 2000.

A pediatric enhancement for services listed above in a.1, 2, 3, and 5 is effective for services on or after July 1, 2009.

c. Durable Medical Equipment, Prosthetics and Orthotics

1. Reimbursement for purchase of Durable Medical Equipment, Prosthetics and Orthotics is the lower of: a) usual and customary charge, or b) a fixed fee schedule.

2. Reimbursement for rental of Durable Medical Equipment, Prosthetics and Orthotics is the lower of: a) usual and customary charge, or b) a fixed fee schedule.

The agency’s rates were set as of August 1, 2011 and are effective for services on or after August 1, 2011.

d. Disposable supplies:

1. Ifa supply item is billed through point of sale (POS), using a National Drug Code (NDC)

; number, reimbursement is the lower of: a) usual and customary charge, or b) gross amount due or b) 90% of Average Wholesale Price (AWP) as indicated on the current listing provided by the First Data Bank plus a handling fee.

2. All other supplies billed outside POS, using Healthcare Common Procedure Coding System (HCPCS) codes and/or Current Procedural. Terminology (CPT) codes are reimbursed the lower of: a) billed charge, or b) fixed fee schedule. The Agency’s rates were set as of August 1, 2011 and are effective for services on or after August 1, 2011.

TN No. 11-009 Approval Date: OCT 2 0 2011 Effective Date: August 1, 2011 Supersedes

TN No. 09-008

DEPARTMENT OF HEALTH AND HUMAN SERVICES HEALTH CARE FINANCING ADMlNISTRATJON I. TRANSMlTTAL NUMBER: FORM APPROVED OMB NO. 0938-0193 TRANSMITTAL AND NOTICE OF APPROVAL OF 11-009 2. STATE NEVADA STATE PLAN MATERIAL FOR: HEALTH CARE FINANCING ADMINISTRATION TO: REGIONAL ADMINISTRATOR HEALTH CARE FINANCING ADMINISTRATION DEPARTMENT OF HEALTH AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL (Check One): 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDIC.A.ID) 4. PROPOSED EFFECTIVE DATE August 1, 2011 0 NEW ST ATE PLAN 0 AMENDMENT TO BE CONSIDERED AS NEW PLAN lEi AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT 'Se arate Tran$mittal or each amendment) 6. FEDERAL STATUTE/REGULATION CITATION: 7. FEDERAL BUDGET IMPACT: 42 CFR 440 a. FFY 2011 $(67,313) b. FFY 2012 $ 71,751) 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: 9. PAGE N\,JMBE~ PF .THE SUPERSEDED PLAN SECTION OR ATTACHMENT (ij Applicable): Attachment 4.19B pg. 2 10. SUBJECT OF AMENDMENT: Update the rate effective dates and reduces rates by 0.7% for DME. 11. GOVERNOR'S REVIEW (Check One): 0 GOVERNOR'S OFFJCE REPORTED NO COMMENT 0 COMMENTS OF GOVERNOR'S OFFICE ENCLOSED 0 NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL Attachment 4.19B pg. 2 lEi OTHER, AS SPECIFIED: The Governor's Office does not wish to review the State Plan Amendment. 16. RETURN TO: Marta Stagliano, Chief~ Compliance DHCFP/Medicaid -----.....,.;--:----------------------1 1100 East William Street, Suite 101 Director De artment of Health and Ruman Services Carson City, NV 89701 15. DATE SUBMITTED: JUL 2 6 lQH =ORM HCFA-179 (07-92)

od BEALT 9

SERVI ope SEIS, Ly

SF s d DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services en, Region IX ‘aaa Division of Medicaid & Children’s Health Operations

90 Seventh Street, Suite 5-300 (SW) San Francisco, CA 94103-6706

FEB 28 2012

Michael J. Willden, Director

Department of Health and Human Services

4126 Technology Way, Suite 100 : yg, Carson City, NV 89706

Dear Mr. Willden:

On February 28, 2012, CMS approved Nevada State Plan Amendment (SPA) 11-014. This SPA removes reference to reimbursement utilizing Average Wholesale Price and changes to utilizing Wholesale Acquisition Cost for both medical supplies billed through Point-of-Sale and outpatient pharmaceuticals on Attachment 4.19-B, Pages 2-3. This SPA is effective October 13, 2011.

Enclosed are the approved CMS Form 179 and the approved Attachment 4.19-B, Pages 2-3 for incorporation into the Nevada State Plan.

If you have any questions, please contact Brian Zolynas by phone at (415) 744-3601 or by email at Brian.Zolynas @cms.hhs.gov.

Sincerely,

Gloria Nagle, Ph.D., MPA Associate Regional Administrator

Division of Medicaid & Children’s Health Operations Enclosure ce: Charles Duarte, Administrator, DHCFP

Marta Stagliano, Chief, Compliance, DHCFP Lisa Ferrandi, CMCS Division of Pharmacy

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State__ Nevada Attachment 4.19-B Page 2

7. Home Health Care Services:

a. Home health care services include the following services and items:

physical therapy — 1 unit per 15 minutes,

occupational therapy — 1 unit per 15 minutes,

speech therapy — 1 unit per 15 minutes,

family planning education — 1 unit per visit,

skilled nursing services (RN/LPN visits) 1 unit per 60 minutes or 1 unit per 15 minutes for brief visits or 1 unit per 15 minutes for extended visits (after 1st hour),

home health aide services — 1 unit per 60 minutes or 1 unit per’30 minutes for extended visits (after 1 hour),

7. durablé medical equipment, prosthetics, orthotics, and

8. disposable medical supplies.

wPynr

a

b. Reimbursements for Home Health Care services, listed above in a.1. through a.6, provided by Home Health Agencies (HHA) are the lower of a) billed charges, or b) a fixed fee schedule which includes the rate for each of the home health services and a rate for “mileage” as an add-on. The agency’s rates were set as of July 1, 2000 and are effective for services on or after July 1, 2000.

A pediatric enhancement for services listed above in a.1, 2, 3, and 5 is effective for services on or after July 1, 2009.

c. Durable Medical Equipment, Prosthetics and Orthotics

1. Reimbursement for purchase of Durable Medical Equipment, Prosthetics and Orthotics is the lower of: a) usual and customary charge, or b) a fixed fee schedule.

2. Reimbursement for rental of Durable Medical Equipment, Prosthetics and Orthotics is the lower of: a) usual and customary charge, or b) a fixed fee schedule.

The agency’s rates were set as of August 1, 2011 and are effective for services on or after August 1, 2011.

d. Disposable supplies:

1. Ifa supply item is billed through point of sale (POS), using a National Drug Code (NDC) number, reimbursement is the lower of: a) usual and customary charge, or b) gross amount due orc) Wholesale Acquisition Cost (WAC) + 8% as indicated on the current national drug data base utilized in Point-of-Sale plus a handling fee. For drugs without a WAC acquisition cost will be reimbursed plus a handling fee.

2. All other supplies billed outside POS, using Healthcare Common Procedure Coding System (HCPCS) codes and/or Current Procedural Terminology (CPT) codes are reimbursed the lower of: a) billed charge, or b) fixed fee schedule. The Agency’s rates were set as of August 1, 2011 and are effective for services on or after August 1, 2011.

TN No. 11-014 Approval Date: FED a 2017 Effective Date: October 13, 2011 Supersedes TN No. 11-009

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State __ Nevada Attachment 4.19-B Page 3 12, a Nevada Medicaid will meet all reporting and provision of information requirements of section

1927(b)(2) and the requirements of subsections (d) and (g) of section 1927.

The State assures that the State will not provide reimbursement for an innovator multi-source drug, subject to the Federal Upper Limits (42 CFR 447.332(a)), if, under applicable State law, a less expensive non-innovator multi-source drug could have been dispensed.

1. Payment for multi-source drugs shall be the lowest of (a) Federal Upper Limit (FUL) as established by the Centers for Medicare and Medicaid ‘Services (CMS) for listed multi- source drugs plus a dispensing fee; (b) State Maximum Allowable Cost (MAC) plus dispensing fee; (c) Estimated Acquisition Cost (EAC) plus a dispensing fee; (d) the pharmacist's usual and customary charge; (e) Department of Justice pricing less 15% plus dispensing fee or (f) billed charge.

2. Payment for covered drugs other than multi-source drugs subject to the Federal Upper Limits shall not exceed the lower of (a) EAC plus a dispensing fee; (b) the pharmacist's usual and customary charge to the general public; or (c) providers actual charge to Medicaid agency.

3. Estimated Acquisition Cost (EAC) is defined by Nevada Medicaid as Wholesale Acquisition Cost (WAC) + 2% as indicated on the current national drug data base utilized in Point-of-Sale. For drugs without a WAC acquisition, cost will be reimbursed.

4. The FUL for multi-source drugs for which an upper limit has been set does not apply if'a physician certifies in his or her own handwriting that a specific brand is medically necessary for a particular recipient, and the statement "brand medically necessary" appears on the face of the prescription. :

5. A generic drug may be considered for MAC pricing if there are 2 or more therapeutically equivalent, multi-source, non-innovator drugs with a significant cost difference. The SMAC will be based on drug status (including non-rebateable, rebateable, obsolete, therapeutic equivalency ratings) marketplace availability and cost. The obsolete drug status will be taken into account to ensure that the MAC pricing is not influenced by the prices listed for obsolete drugs. The SMAC will be based on drug prices obtained from a nationally recognized comprehensive data file maintained by a vendor under contract with the Department.

6. The State's dispensing fees are defined as (a) those given to outpatient retail pharmacists at a rate of $4.76 per prescription; (b) those given to Home Infusion Therapy providers for intravenous antibiotic therapeutic classes at $22.40 per day. All other pharmaceuticals given by Home Infusion Therapy providers receive dispensing fees in accordance with retail pharmacists; (c) those given to pharmacists for intravenous antibiotic therapeutic classes in a nursing facility at $16.80 per day. All other pharmaceuticals given by Long Term Care pharmacists receive dispensing fees in accordance with retail pharmacists.

7. There is no co-payment requirement on medications for beneficiaries. TN No. 11-014 Approval Date:__ FEB 2&8 2012 Effective Date: October 13, 2011

Supersedes TNNo. 04-018

DEPARTMENT OF HEALTH AND HUMAN SERVICES HEALTH CARE FINANCING ADMINISTRATION TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL FOR: HEALTH CARE FINANCING ADMINISTRATION TO: REGIONAL ADMINISTRATOR HEALTH CARE FINANCING ADMINISTRATION DEPARTMENT Of HEALTH AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL (Check One): FORM APPROVED OMB NO, 0938·0193 l. T.R.ANSMI!T ALNUMBER: u~oi4 2. STATE NEVADA 3. PROGRAM IDENTJfICATION: 'l'ITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) 4. PROPOSED EFFECTIVE DATE Oetober 13, 2011 __Q NEW STATE PLAN 0 AMENDMENT TO BE CONSIDERED AS NEW PLAN 181 AMENDMENT COMPLETE 13LOCI<S 6 THRU 1 o IF nns IS AN AMENDMENT · e arate Transmittal or each amendment 6. FEDERAL STATUTE/REGULATION CITATION: 7. FEDERAL BUDGET IMPACT: a. :FFY 20.12 $Budget Neutral 42CFR 440 b. FFY 2013 . " $Budget Neutral If SPA not approved State will not have a drug data benchmark. 8. PAGE NUMBER OF THE PLAN SECTION OR Art ACHMENT: 9. PAGE NUMBER. OF THE SUPERSEDED PLAN SECTION Attachment 4.19-B, Pages 2 and 3 10. SUBJECT OF AMENDMENT: Pharmacy Wholesale Acquisition Cost Benchmark 11. GOVERNOR'S REVIEW (Check One): 0 GOVERNOR'S OFFICE REPORTED NO COMMENT 0 COMMENTS OF.GOVERNOR1S OFFICE ENCLOSED 0 NO REPLY RECEIVED WITHIN' 45 DAYS OF SUBMlTTAL ( OR ATTACHNIENT (If Applicable): .Attathment4.19-B.Pages 2 and.3 0 OTHER, AS SPECIFIED: The Govemor~s Office does not wish to review the State Plan Amendment. l\fa.rtaStatWano;. ~et; COD)r>.lijUl.ce D)ICFP/Medicaid ~~~~;..;.;;...-"-'----------'----------1 1.100 EastWilli•m Street, $-..ite :101 Carson. City, NV 89701 IS.DATE SUBMITTED: NOV 3 0 2011 FORM HCFA~l79 (07.,.92)

Table of Contents State/Territory Name: Nevada State Plan Amendment (SPA) #: NV-13-0023-MM5 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Superseding Pages Notice 4) Approved SPA Pages

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

San Francisco Regional Office

90 Seventh Street, Suite 5-300 (5W)

San Francisco, CA 94103-6706

CENTERS FOR MEDICARE & MEDICAID SERVICES DIVISION OF MEDICAID & CHILDREN’S HEALTH OPERATIONS

MAY 3 0 2014

Michael J. Willden, Director

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

Carson City, NV 89706

Dear Mr. Willden:

Enclosed is an approved copy of Nevada State Plan Amendment (SPA) 13-0023-MMS. This SPA was submitted to the Centers for Medicare and Medicaid Services (CMS) on October 9, 2013 requesting to add a description of the Medicaid eligibility residency requirements to the State Plan in accordance with the Affordable Care Act.

The approval is effective January 1, 2014. Attached are copies of the following pages to be incorporated into a separate section at the back of Nevada’s State Plan:

e S88, Pages S88-1 to S88-4 e Superseding Pages of State Plan Material

If you have any questions, please contact Brian Zolynas by phone at (415) 744-3601 or by email at Brian.Zolynas@cms.hhs.gov .

Sincerely,

Gloria Nagle, Ph.D., MPA Associate Regional Administrator Division of Medicaid & Children’s Health Operations

Enclosure

ce: Laurie Squartsoff, Administrator, DHCFP Marta Stagliano, Chief, Compliance, DHCFP

Medicaid State Plan Eligibility: Summary Page (CMS 179)

State/Territory name: Nevada

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-13-0023

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

Federal Statute/Regulation Citation

42 CFR 435.403 Federal Budget Impact Federal Fiscal Year Amount First Year 2014 $0.00 Second Year 2015 $0.00

Subject of Amendment New template being used as required for implementation of the Affordable Care Act. There are no changes to the state residency rules.

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

Comments of Governor's office received Describe:

No reply received within 45 days of submittal

Other, as specified Describe: The Governor's office does not wish to review the State Plan Amendment.

Signature of State Agency Official Submitted By: Robyn Heddy Last Revision Date: May 21, 2014 Submit Date: Oct 9, 2013

SUPERSEDING PAGES OF

STATE PLAN MATERIAL TRANSMITTAL NUMBER: STATE: 13-0023-MM5 Nevada PAGE NUMBER OF THE PLAN SECTION OR PAGE NUMBER OF THE SUPERSEDED PLAN SECTION ATTACHMENT: OR ATTACHMENT (If Applicable): S88 Non-Financial Eligibility- State Residency (None superseded, new pages) Section 2, Page 13, Item 2.3 Section 2, Page 13, Item 2.3, TN 87-08 Attachment 2.6-A, Page 3, Item 4 Attachment 2.6-A, Page 3, Item 4, TN 13-0025- MM

13

Revision: HCFA-PM-87-4

(BPD)

OMB No.: 0938-0193

MARCH 1987

State: Nevada

TN No. 13-0023-MM5 Approval Date: May 30, 2014 Effective Date: January 1, 2014 Supersedes

TN No. 87-08

Revision: HCFA-PM-91-4 (BPD) ATTACHMENT 2.6-A August 1991

Page 3 OMB No.: 0938- State: NEVADA

Citation Condition or Requirement

Reserved

TN No. 13-0023-MM5 Supersedes Approval Date: May 30, 2014 Effective Date: January 1, 2014 TN No. 13-0025-MM

CcCmMs. Medicaid Eligibility

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

42 CFR 435.403

State Residency

w The state provides Medicaid to otherwise eligible residents of the state, including residents who are absent from the state under certain conditions.

Individuals are considered to be residents of the state under the following conditions:

a Non-institutionalized individuals age 21 and over, or under age 21, capable of indicating intent and who are emancipated or married, if the individual is living in the state and:

[| Intends to reside in the state, including without a fixed address, or [| Entered the state with a job commitment or seeking employment, whether or not currently employed.

ia Individuals age 21 and over, not living in an institution, who are not capable of indicating intent, are residents of the state in which they live.

{M Non-institutionalized individuals under 21 not described above and non IV-E beneficiary children: [i] Residing in the state, with or without a fixed address, or

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

cl Individuals living in institutions, as defined in 42 CFR 435.1010, including foster care homes, who became incapable of indicating intent before age 21 and individuals under age 21 who are not emancipated or married:

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

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

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

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

Individuals who have been placed in an out-of-state institution, including foster care homes, by an agency of the state.

Any other institutionalized individual age 21 or over when living in the state with the intent to reside there, and not placed in the institution by another state.

™ @ & &

IV-E eligible children living in the state, or

Transmittal Number: 13-0023-MM5 Approval Date: MAY 3 0 24 Effective Date: January 1, 2014 Nevada 88-1

Page | of 4

(EMS Medicaid Eligibility

SASL,

[MH] Otherwise meet the requirements of 42 CFR 435.403.

Transmittal Number: 13-0023-MM5 Approval Date: MAY 3 0 9014 Effective Date: January 1, 2014 Nevada $88-2

Page 2 of 4

Medicaid Eligibility

Meet the criteria specified in an interstate agreement.

@ Yes

C No

[lf The state has interstate agreements with the following selected states:

|

—X) Alabama KK] Alaska Arizona Arkansas &] California Colorado Connecticut [X] Delaware District of Columbia Florida Georgia Hawaii

Idaho

Illinois Indiana Iowa Kansas Kentucky Louisiana KK] Maine Maryland Massachusetts Michigan ] Minnesota Mississippi

Missouri

Montana Nebraska

(7) Nevada

New Hampshire New Jersey New Mexico (1 New York

[X] North Carolina North Dakota Ohio Oklahoma

EX] Oregon

Pennsylvania

Rhode Island

South Carolina

KX xk &

South Dakota

Tennessee

xX

Xx

Texas

Xi

Utah

Vermont

xX &

Virginia

Xx

Washington

Xl

West Virginia

Xl

Wisconsin

[] Wyoming

The interstate agreement contains a procedure for providing Medicaid to individuals pending resolution of their residency

status and criteria for resolving disputed residency of individuals who (select all that apply):

Are IV-E eligible

(() Are in the state only for the purpose of attending schoo!

[7] Are out of the state only for the purpose of attending school

(£] Retain addresses in both states

(1) Other type of individual

The state has a policy related to individuals in the state only to attend school.

C Yes

[M_ Otherwise meet the criteria of resident, but who may be temporarily absent from the state.

@ No

The state has a definition of temporary absence, including treatment of individuals who attend school in another state.

Yes (© No

Transmittal Number: 13-0023-MM5

Nevada

Approval Date: MAY 3 0 2014 Effective Date: January 1, 2014 $88-3

Page 3 of 4

Medicaid Eligibility

Provide a description of the definition:

Nevada residency continues when a client is temporarily absent IF he/she intends to return to Nevada when the purpose of the absence has been accomplished, unless the individuals gains Medicaid eligibility in another state.

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

Transmittal Number: 13-0023-MMS5 Approvat bate: WAY 3 0 2014 Effective Date: January 1, 2014 Nevada S$88-4

Page 4 of 4

Table of Contents

State/Territory Name: Nevada

State Plan Amendment (SPA) #: NV-13-0024-MM

This file contains the following documents in the order listed:

1) Approval Letter

2) Summary Form (with 179-like data) 3) Superseding Pages Notice

4) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services San Francisco Regional Office 90 Seventh Street, Suite 5-300 (SW) San Francisco, CA 94103-6706 ~;;;:::::- -; •• ::.-::;:;;:;;c:... _. -- ~- ~ ~> (CMS CENTERS FOR MEDICARE & MEDICAID SERVICES DIVISION OF MEDICAID & CHILDREN'S HEALTH OPERATIONS Michael J. Willden, Director Department of Health and Human Services 4126 Technology Way, Suite 100 Carson City, NV 89706 Dear Mr. Willden: APR 2 3 2014 Enclosed is an approved copy ofNevada's State Plan Amendment (SPA) 13-0024-MM, which was submitted to CMS on October 9, 2013. SPA 13-0024-MM incorporates MAGI-based eligibility groups into Nevada's Medicaid State Plan in accordance with the Affordable Care Act. The effective date ofthe SPA is January 1, 2014. Enclosed is a copy of the new State Plan pages to be incorporated within a separate section at the back of Nevada's approved State Plan: • S14, Pages S14-1 to S14-8 • S25, Pages S25-1 to S25-3 • S28, Pages S28-l to S28-2 • S30, Pages S30-1 to S30-5 • S33, Page S33-1 • S50, Page S50-1 • S51, Page S51-1 • S52, Pages S52-1 to S52-5 • S53, Page S53-1 • S54, Page S54-1 • S55, Page S55-1 • S57, Pages S57-1 to S57-2 • S59, Page S59-1 • Attachment 1: Modified Adjusted Gross Income (MAGI) Conversion Plan • Superseding Pages of State Plan Material

Mr. Willden - Page 2 If you have any questions, please contact Brian Zolynas by phone at (415) 744-3601 or by email at Brian.Zolynas@cms.hhs.gov. Enclosure Sincerely,

Gloria Nagle, Ph.D., MPA Associate Regional Administrator Division of Medicaid & Children's Health Operations cc: Laurie Squartsoff, Administrator, DHCFP Marta Stagliano, Chief, Compliance, DHCFP

Medicaid State Plan Eligibility: Summary Page (CMS 179) State/Territory name: Nevada 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-13-0024 Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation 1902(e)(l4)(E) Federal Budget Impact Federal Fiscal Year First Year 2014 Second Year 2015 Subject of Amendment Amount $151967974.00 $214883710.00 The fiscal impact was determined using a projected caseload and a projected per member per month cost (cost per eligible). Caseload was projected based on age ranges, the percent of population in different FPL categories, the uninsured rate for each FPL category, and the employment ratio (employment divided by population). The cost per eligible was projected based on actual historic cost per eligible for those categories of eligibility currently covered (children and pregnant women). The parent/caretaker category cost per month was calculated by our actuary that certifies our MCO capitated rates. The actuary used claims experience for like populations and information gathered from other states. Defines the AFDC income limits used by the state to convert net income eligibility thresholds to equivelent modified adjusted gross income thresholds. Governor's Office Review Governor's office reported no comment Comments of Governor's office received Describe: No reply received within 45 days of submittal ;o Other, as specified Describe: The Governor's office does not wish to review the State Plan Amendment. Signature of State Agency Official Submitted By: Last Revision Date: Submit Date: Robyn Heddy Apr 18,2014 Oct 9, 2013

SUPERSEDING PAGES OF STATE PLAN MATERIAL TRANSMITTAL NUMBER: STATE: 13-0024-MM Nevada Pages or sections of pages being superseded by 825, 828, S30, 851, S52, S53, 857, and 814 and related pages or sections of pages being deleted as obsolete State Plan Section Complete Pages Removed Partial Pages Removed Page 1 Page 2, A.2.b Page 3 Page 2, A.2.c Page 3a Page 2a, A.3 Page 4 Page 5, A.10 Page 4a Page 9c, 8.1 remove Attachment 2.2-A Page 12 "Caretaker Page 13 relatives" and Page 13a "Pregnant women" Page 14 Page 20, 8.14 Page 14a Page 21 Page 23 Page 23c Supplement 1 to Attachment Page 1 2.2-A Page 3b Page 1, A.2.a(i) and Page lla (iii) Page 19 Page 6 related to Page 19a AFDC recipients, Page 19b pregnant women, Attachment 2.6-A Page 21 infants, and children Page 7, 1. a (1) and (2) Page 12, C.l.e(2) Page 18, C.S.e Page 25, C.11.a(3) Supplement 1 to Attachment Pages 1-4 2,6-A Supplement 2 to Attachment 2.6-A Pages 1-5 Supplement Sa to Page 1 Page la.1, related Attachment 2.6-A Page la to AFDC-related groups Supplement Bb to Page 2, Remove Attachment 2.6-A references to 1

resource tests for pregnant women, children and children in custody of. public agency Supplement 12 to Page 2, 3, 3a Attachment 2.6-A Addendum 2

Attachment 1: Modified Adjusted Gross Income (MAGI) Conversion Plan Modified Adjusted Gross Income (MAGI) Conversion Plan This MAGI Conversion Plan is being submitted to CMS by Nevada as required by Section 1902(e)(14)(E) of the Social Security Act on AprillO, 2014, which requires each state to submit for approval the income eligibility thresholds for Medicaid and the Children's Health Insurance Program (CHIP) proposed to be established using modified adjusted gross income (MAGI). As described in the December 28,2012 State Health Officials' Letter on Modified Adjusted Gross Income (MAGI) income conversion, states can choose among three options to convert net standards for Medicaid and CHIP to MAGI equivalent standards. 1 The purpose of the MAGI Conversion Plan is to provide CMS with information about each state's MAGI conversion methodology, as well as the data used and results of conversion. CMS will be reviewing the submitted materials and notifying the State with their approval or disapproval by April 24, 2014. Eligibility and FMAP claiming conversions. States are required to submit information about their conversion methodology, data and results for income conversions related to eligibility and those required for FMAP claiming in accordance with CMS' FMAP rule. For additional information about the FMAP rule, please see: https://s3.amazonaws.com/public-inspection.federalregister.gov/2013- 07599.pdf. Note about Income Eligibility Conversions and State Plan Amendments: Converted income standards will be used to set maximum MAGI-equivalent standards for adults in 2014 and will be used as the actual income standard in effect for children through October 2019. States will use the state plan amendment (SPA) process to identify the minimum and maximum MAGI-equivalent standards and to select the state's MAGI-based income standard for each eligibility group to which MAGI will apply in 2014. For adults for whom the Maintenance of Effort requirement expires in 2014, the selected income standard in the SPA will be anywhere between the minimum and the maximum derived through the income conversion process. Please indicate the MAGI conversion method chosen by your state and follow the appropriate directions: D Option la- Standardized Methodology with SIPP data, no state data adjustments for time-limited disregards Attach Excel spreadsheet with finalized SIPP results of eligibility and FMAP conversions to this cover page and submit to incomeconversion(a!cms.hhs.gov. D Option lb- Standardized Methodology with SIPP data, with state data adjustments for time-limited disregards. Please follow instructions below and submit to incomeconversion@cms.hhs.gov 0 Option 2- Standardized Methodology with State data Please follow the instructions below and submit this plan to incomeconversion@cms.hhs.gov. 1 SHO letter available at http://www.medicaid.gov/Fedcrai-Policy-Guidance/downloads/SHO 12003.pdf Transmittal Number: 13-0024-MM Nevada Approval Date: April 23, 2014 Attachment 1-1 Effective Date: January 1, 2014

Attachment 1: Modified Adjusted Gross Income (MAGI) Conversion Plan X Option 3- State proposed Alternative Method Please follow the instructions below and submit this plan to incomeconversion@cms.hhs.gov. Part 1 - Conversions for Eligibility Part 2 - Conversions for FMAP Claiming and TB Group Pages to Due Date Pages to Due Date Complete Complete Option 1a: Page 1 May 31,2013 Page 1 Fall2013 Standardized Methodology, no adjustments Option 1b Pages 1 and 3 May 31,2013 Pages 1 and 14 Fall2013 Standardized Methodology, state adjustments for time limited disregards Standardized Page 4-11 April30, 2013* Pages 15-18 Fa112013 Methodology with State Data Alternative Page 4-13 April30, 2013* Pages 15-18 Fall2013 Methodology *Eligibility conversion plans are due April 30, 2013, or within 15 days of receiving SIPP results, whichever is later. Transmittal Number: 13-0024-MM Nevada Approval Date: April 23, 2014 Attachment 1-2 Effective Date: January 1, 2014

Attachment 1: Modified Adjusted Gross Income (MAGI) Conversion Plan Option lb -- Standardized Methodology with SIPP data, with state adjustments for time limited disregards Eligibility Conversions Please provide information about the state-specific weighting strategy and relevant conversions for groups with time limited disregards in the table below. Eligibility group: Please list each eligibility group (e.g., 1931 parents/caretaker relatives) where your state applied its own weight for time-limited disregards. Time-Limited weight: Please list, for each relevant eligibility group, the weight your state applied for the conversion. For example, if you determined that 15% of enrollees received time-limited disregards in a given category and applied that as your weight, you would simply list 15%. Data Used to Derive weight: Please describe, for each relevant eligibility group, the data used to calculate the time-limited weight, e.g. "state data for all1931 enrolled individuals in March of 2012." Application of Weight: Please show the formula used to apply the weight, e.g., if standard with time-limited disregard is 100 and without time-limited disregard is 75 and weight is .15, the formula would be (100 x .85) + (75 x .15) = _79 ____ _ Converted standard: Please fill in the converted standard for each eligibility group. This will be the weighted average of the applicant (e.g., standard including time-limited disregards) and beneficiary calculations you originally received from CMS, applying the time-limited weight to the applicant conversion. Eligibilitl! Groue Transmittal Number: 13-0024-MM Nevada Time-limited Data Used to Weight Derive Weight Approval Date: April23, 2014 Attachment 1-3 Aeelication of Converted Weight Standard Effective Date: January 1, 2014

Attachment 1: Modified Adjusted Gross Income (MAGI) Conversion Plan Options 2 and 3 -- Standardized Methodology with State Data Method and Alternative Method: Please provide a state contact who can answer questions about the conversion plan, data, and methods: Name: Nova Murray Title: Project Manager _____________ _ E-mail:_Nova.murray@dhcfp.nv.gov Phone:_775-684-0553 _________ _ Supplemental Information: In addition to the information provided in the attached MAGI Conversion Plan, during the review and approval process, CMS may determine that supplemental information regarding the income conversion results is necessary. If CMS determines that a supplemental review of these results is necessary, your state may be required to submit: • Descriptive statistics of the data used. Such descriptive statistics could include for each eligibility group converted with state data: o Net income statistics and disregard statistics for the full population or sample and for the population used in conversion (e.g., the 25% band) including: Total N, Mean Net Income, Standard Deviation of Mean Net Income, Median Net Income, and Number of individuals with Positive Net Income • Data files used for conversion • Annotated programming code used in the analysis Transmittal Number: 13-0024-MM Nevada PART 1: ELIGIBILITY CONVERSIONS- TABLE 1- DUE APRIL 30, 2013 For States Using Approval Date: April23, 2014 Attachment 1-4 Effective Date: January 1, 2014

Attachment 1: Modified Adjusted Gross Income (MAGI) Conversion Plan Standardized Methodology with State Data Or Alternative Method Please fill out Table 1 below to provide CMS with information about how state data were used for MAGI income conversion. All cells in rows for eligibility groups that do not have a converted income standard in your state (for example, if your state does not cover independent foster care adolescents or does not apply an income standard to this group) should be marked "N/A." Instructions for Table 1: SIPP results used: Your state may have used SIPP results for converting some groups. For conversions based on SIPP, please mark yes in the first column of Table 1 and provide the converted standard from those results. Please list the group below (e.g., pregnant women) and an explanation of why the SIPP results are being used for this eligibility group (e.g., data unavailable). Also, for groups that have time-limited disregards, if the state chooses to provide its own weighting, please provide the state-specific weighting strategy that was used to derive the converted standard. The explanation of the weighting strategy should include the percent assumed to have time limited disregards and the data on which this calculation was based (e.g., 1S%: based on analysis of state data for those enrolled in the 1931 group in CY 2012). Attach additional pages if necessary. Note that for groups that need to be converted both for eligibility and FMAP purposes (e.g,. childless adults) the same income conversion method/data source (i.e., SIPP or state data) must be used. Parents/Caretaker Relatives 1931- Nevada is using SIPP conversion for this group. Nevada was unable to extract income data for this group to apply the alternative method. For all conversions using state data, please provide the following information: Time period-Specify the time period of data that was used, for example, June 2011-May 2012. If a time period other than 12 months was used, please explain why below and summarize the methods used to determine that the time period is unbiased. Attach additional pages if necessary: Pregnant women- Nevada used the entire eligibility data extract for the month of April 2010 to replicate data similar to SlPP for comparison purposes. A year of data for these groups can be obtained to verity the results can be duplicated: however, the state would like tentative approval of the method prior to utilizing valuable state resources to obtain the data. Children age I to 5- Nevada used the entire eligibility data extract for the month of April 20 I 0 to replicate data similar to SJPP for comparison purposes. A year of data for these groups can be obtained to verity the results can be duplicated: however, the state would like tentative approval of the method prior to utilizing valuable state resources to obtain the data. Children age 6-18- Nevada used the entire eligibility data extract for the month of April2010 to replicate data similar to SlPP for comparison purposes. A year of data for these groups can be obtained to verity the results can be duplicated: however, the state would like tentative approval of the method prior to utilizing valuable state resources to obtain the data. Transmittal Number: 13-0024-MM Nevada Approval Date: April23, 2014 Attachment 1-5 Effective Date: January 1, 2014

Attachment 1: Modified Adjusted Gross Income (MAGI) Conversion Plan Sampling: Please mark this column yes or no. If yes (in other words, the analysis did not include all records in the eligibility group), please provide a detailed explanation below of the sampling approach that was used (i.e., simple random sample, stratified sample, etc.). Please also provide information about the total population and the number of records sampled. Attach additional pages if necessary. Pregnant women- Nevada used the entire data extract for the month of April 2010. The total record included all family members; however only 4,348 individuals were eligible in the sample month. The data was then sorted to view only the eligible members with any income in the sample month. (From any source/type) The sample was sorted again to view only eligible members with a total gross income that exceeded the allowable poverty level in the sample month. It is our contention that only persons with income above the maximum poverty level in the sample month benefited from the disregard. Persons with income below the allowable standard for the benefit month would have been eligible regardless of receipt of the disregard. There were 268 pregnant women above the 133% net income limit for the sample month. The average income for the eligibility determination for this group was 159% FPL. Of the 268 pregnant women, 94 exceeded the average of the group. Children under agel- Data for this group was not used as is not reflective of the State's budget methodology. In most instances, children under the age of 1 are deemed newborns. This group does not benefit from the disregard as the eligibility is tied to the pregnant mother. Children age l to 5- Nevada used the entire data extract for the month of April20 I 0. The total record included all family members; however of the 59.142 children 1-18 the actual number of children 1-5 is not currently available. The data was then sorted to view only the eligible members with any income in the sample month. (From any source/type) The sample was sorted again to view only eligible members with a total gross income that exceeded the allowable poverty level in the sample month. It is our contention that only persons with income above the poverty level in the sample month benefited from the disregard. Persons with income below the allowable standard for the benefit month would have been eligible regardless of receipt of the disregard. There were 1,505 children 1-5 above the 133% net income limit for the sample month. The average income for the eligibility determination for this group was 159% FPL. Of the 1,505 children, 483 exceeded the average of the group. Children age 6-18- Nevada used the entire data extract for the month of April2010. The total record included all family members: however of the 59,142 children 1-18 the actual number of children 6-18 is not currently available. The data was then sorted to view only the eligible members with any income in the sample month. (From any source/type) The sample was then sorted to view only eligible members with a total gross income that exceeded the allowable poverty level in the sample month. It is our contention that only persons with income above the poverty level in the sample month benefited from the disregard. Persons with income below the allowable standard for the benefit month would have been eligible regardless of receipt of the disregard. There were 4,071 children 6-18 above the 100% net income limit for the sample month. The average income for the eligibility determination for this group was 122% FPL. Ofthe 4,071 children, only 1,344 exceeded the average ofthe group. Combined pregnant women, infants and children 1-5- Nevada is reguesting to combine pregnant women, infants and children 1-5 up to the infant converted standard reflected in Table I. Transmittal Number: 13-0024-MM Nevada Approval Date: April 23, 2014 Attachment 1-6 Effective Date: January 1, 2014

Attachment 1: Modified Adjusted Gross Income (MAGI) Conversion Plan Net income standard- Please fill in the net standard that was converted for each eligibility group. This should reflect the bolded standard from the eligibility template that you developed with CMS. For conversions that were based on fixed dollar thresholds, please specify the net standard for each family size. You may use fewer or more family sizes than indicated in Table 1. For 1115 demonstrations, please enter a row for each MAGI-included 1115 demonstration group, specifying whether it is Medicaid or S- CHIP. Income band used in conversion-This column should reflect the net standard minus 25 percentage points of FPL. For example, if the net standard was 120% FPL, the income band used in conversion would be 95% FPL to 120% FPL. For standards at or below 25% FPL, the income band will include all records-e.g., for a net standard of 18% FPL, the income band used in conversion should be 0-18% FPL. For conversions of fixed dollar thresholds, please specify the income band (expressed as a percentage of FPL) for each family size. 2 For states using an alternative method, this column should only be filled out if it is applicable (e.g., if the marginal approach was used). Converted standard -Please fill in the converted standard. Fixed dollar standards should be given in dollars for each family size. Special note for premium payment groups: If your state charges premiums for any eligibility group, please indicate which method you selected below and attach a separate sheet showing the MAGI Conversion Plan information requested (time period, net income standard, income band used in conversion, and the converted standard) for each income level used to determine premium payments. Premium conversion method: Premiums may be converted either using the Standardized MAGI Conversion Methodology; or, using a ratio of the converted standard for the group to the net standard for the group for which premiums are charged. For example, if your state charges premiums for people between 150% and 300% FPL and the standard for 300% of FPL converted to 309%, you would multiple the remaining levels by 1.03 (309/300). Please indicate which approach was used and provide upper income net and converted standards if you applied the ratio method: 0 Standardized method 0 Ratio Method Upper income level, net standard 2 See page 15 of How States Can Implement the Standardized Modified Adjusted Gross Income (MAGI) Conversion Methodology from State Medicaid and CHIP Data for more information on converting fixed dollar standards to FPL. http://aspe.hhs.gov/health/reports/2013/MAGIHowTo/rb.cfm. Transmittal Number: 13-0024-MM Nevada Approval Date: April 23, 2014 Attachment 1-7 Effective Date: January 1, 2014

Attachment 1: Modified Adjusted Gross Income (MAGI) Conversion Plan Upper income level, converted standard Coverage Category Parents and other caretaker relatives (mandatory under Section 1931) Parents and other caretaker relatives (optional under 1902(a)(IO)(A)(ii)(l) Pregnant women, full benefits Transmittal Number: 13-0024-MM Nevada SIPP Time Results Period used (Yes/No) Yes N/A N/A No 4/2010 Table 1 Sampling Net Income (yes/no) Standard %FPL N/A or Fixed dollar standards Family size I __ 253 --- 2 318 -- --- 3 383 --- 4 _448 --- 5 513 --- 6 578 -- --- 7_643 ___ Add-on for additional family members if relevant 65 -- NA % FPL N/A or Fixed dollar standards Family size I 2 3 4 5 6 7 Add-on for additional family members if relevant ___ No 133% Approval Date: April 23, 2014 Attachment 1-8 Income band used in Converted conversion Standard (Alternative Method states to fill out only if applicable) %FPL %FPL or N/A % FPL by Family size (for or groups with fixed dollar Fixed dollar standards standards} Family size 1 I 319 --- 2 2_407 3 3 495 4 4 582 5 5 670 6 6 758 I 7 7 846 Add-on for additional Add-on for additional family members if family members if relevant ___ relevant 88 - %FPL_N/A %FPL N/A - or or % FPL by Familv size (for Fixed dollar standards groups with fixed dollar Family size standards} 1 I 2 2 3 3 4 4 5 5 6 6 7 7 Add-on for additional Add-on for additional family members if family members if relevant relevant 134%-377% 160% Effective Date: January 1, 2014

Attachment 1: Modified Adjusted Gross Income (MAGI) Conversion Plan Coverage Category Pregnant women, pregnancy only coverage Children under age I Children ages I to 5 Children ages 6 to 18 M-CHIP optional targeted low- income children Optional reasonable classifications of individuals under age 21 State adoption assistance Independent foster care adolescents Familv _IJ!anning services Other Medicaid section 1115 demonstration (e.g., childless adults). Insert more rows if needed. Separate CHIP State plan • Children Separate CHIP State plan • Pregnant Women option Separate CHIP State plan • Unborn child option Other S-CHIP section 1115 demonstration (e.g., pregnant women). Insert more rows if needed. Transmittal Number: 13-0024-MM Nevada SIPP Time Results Period used (Yes/No) N/A N/A No 4/2010 No 4/2010 No 4/2010 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A No N/A N/A N/A N/A N/A N/A N/A Sampling Net Income (yes/no) Standard N/A N/A No 133% No 133% No 100% N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A No 200% N/A N/A N/A N/A N/A N/A Approval Date: April23, 2014 Attachment 1-9 Income band used in Converted conversion Standard (Alternative Method states to fill out only if applicable) N/A N/A N/A Derived from 160% Pregnant mom result 134%-382% all data 160% 101%-339% all data 122% N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A 200% N/A N/A N/A N/A N/A N/A ---- Effective Date: January 1, 2014

Attachment 1: Modified Adjusted Gross Income (MAGI) Conversion Plan Coverage Category SIPP Time Sampling Net Income Income band used in Converted Results Period (yes/no) Standard conversion Standard used (Alternative Method (Yes/No) states to fill out only if aQJ!Iicablel AFDC payment standard Yes Fixed dollar standards % FPL by family size Fixed dollar standards 511/1988 Family size I Family size I _210 ___ 2 I 229 - --- 2 - 270 3 2_296 3_330 4 3 363 4 390 5 4 430 5_450 6 5_496 6_510 7 6_563 7 570 Add-on for additional 7_630 Add-on for additional family members if Add-on for additional family members if relevant ___ fumily members if relevant_60 - relevant 67 - AFDC payment standard Yes Fixed dollar standards % FPL by family size Fixed dollar standards 7/16/1996 Family size I Family size 1_229 ___ 2 I 255 --- 2_288 3 2 323 3_348 4 3 392 4 408 5 4 461 5_468 6 5 _530 6_ 527 7 6 597 7 587 Add-on for additional 7_666 Add-on for additional fam1ly members if Add-on for additional family members if relevant family members if --- relevant 60 relevant 69 - - Pre-CHIP Medicaid as of3/31/97 N/A N/A N/A <age 1 <age 1 <age I 1-5 1-5 1-5 6-13 6-13 6-13 14-18 14-18 14-18 Premium Payment Determination: Please indicate whether the Standardized MAGI Conversion methodology was used or a ratio of the converted standard at the upper ranges of the eligibility threshold was used. N/ A I I Transmittal Number: 13-0024-MM Nevada Approval Date: April 23, 2014 Attachment 1-1 0 Effective Date: January 1, 2014

Attachment 1: Modified Adjusted Gross Income (MAGI) Conversion Plan PART 1: ELIGIBILITY CONVERSIONS Option 3-- Alternative Method, additional information Please provide a summary of the alternative method and data source or sources used for income conversion, including how the method differs from the Standardized MAGI Conversion Methodology specified in the December 28, 2012 State Health Officials' Letter on Modified Adjusted Gross Income (MAGI) Income Conversion. Please include equations showing how the method is applied mathematically and a description of how fixed dollar standards were converted, if relevant. Attach additional pages if necessary. The data does not use a set 25% FPL range per the Standardized process as it is decided that the disregard is only beneficial for recipients that would otherwise lose eligibility without the use of the disregard. All recipients must be eligible using only the 20% standard income disregard to become eligible for the program. In conversation with CMS it was determined that the time limited, multi tier disregards would not be used in the calculation using SIPP. The actual State alternative method used, included all disregards in the sample month for recipients above the FPL for the coverage group. The state methodology indentified all eligible individuals in the month of 4/2010 who were receiving and benefitting from the disregard. The average of these household's FPL was used to determine the average household income for this eligibility group when disregards are applied. Please provide a description below of how your method meets the criteria specified in the December 28, 2012 State Health Officials' Letter on Modified Adjusted Gross Income (MAGI) Conversion: unbiased, accuracy, precision, and data quality. Attach additional pages if necessary. More detailed information about these criteria is available in the ASPE issue brief Modified Adjusted Gross Income {MAGI) Income Conversion Methodologies. 3 Unbiased: Across all eligibility categories, the method does not systematically increase or decrease the number of eligible individuals within a given eligibility group or systematically increase or decrease the costs to states. 3 See http :ijwww. s ha dac.org/fi les/2.% 20ASP E%20Brief%20-%20MAG I %201 nco me %20Conversion% 20Method ologies% 20/ March% 202013). pdf. Transmittal Number: 13-0024-MM Nevada Approval Date: April 23, 2014 Attachment 1-11 Effective Date: January 1, 2014

Attachment 1: Modified Adjusted Gross Income (MAGI) Conversion Plan The State used a secondary methodology by applying a 20% increase to the highest FPL allowable for each household size. The 20% increase was added to the income limit for the family size and converted back to FPL. Using this method the eligibility group at the 133% FPL income limit equated to 159% and the eligibility group at the 100% FPL limit equated to 120% oft he FPL. In conclusion, this method arrived at nearly the same conclusion as the State Alternative method used in the summary under Part 1, option three. Accuracy: To the extent possible, the method minimizes changes in eligibility status by minimizing losses and gains in eligibility for a given category of coverage. The percentage of the population used represents the population that received a benefit as a result of the disregard. The calculation was determined using 9.2% of the eligible population for the given month, however the adjusted income limit is applied to the entire population without a weighted factoring applied. This minimizes the number of individuals that would lose eligibility under the new converted limit. There were no considerations taken for the changes in countable income, household determination or that Nevada is under the Sneede vs. Kizer provisions which creates smaller effective household sizes when there is child income in the household. These changes will create increases in our caseload. Precision: The converted standard must be stable and repeatable. In other words, if the methodology to arrive at the converted standard were repeated, it would arrive at the same result. For example, if a sampling methodology is used, the sample size must be large enough to ensure that the conversion method, if calculated on another sample, would in general yield the same converted standard. The data should be stable and repeatable. The State can pull the same data for another time period if necessary to test precision if required. As stated previously, an additional comparison to actual income limits was evaluated by adding the disregard amount (20%) to the highest income level for each household size and converted back to FPL which resulted in the same conversion figure. Data quality: The data used are representative of the income and disregards of the population so as not to bias the converted standard due to poor data quality. The data was reviewed to ensure there were no duplicates. The program rules and system limitations do not allow persons to be eligible in more than one program in the same month. The sample used does not create bias in the agency's favor and appears to actually allow for bias in the client's favor. The data extract used only individuals above the eligibility limits that existed for the time period. In developing the data set, the State chose to exclude all individuals who Transmittal Number: 13-0024-MM Nevada Approval Date: April 23, 2014 Attachment 1-12 Effective Date: January 1, 2014

Attachment 1: Modified Adjusted Gross Income (MAGI) Conversion Plan were eligible regardless of the application of the disregard. Therefore, the individuals that might create bias at the lower income levels were previously excluded. In the data set used, the individuals with the lower FPL actually are most representative of the population benefiting from the disregard; however, the state included all individuals at the highest end of the FPL range even though a small number of individuals included could be considered statistically invalid. Transmittal Number: 13-0024-MM Nevada Approval Date: April 23, 2014 Attachment 1-13 Effective Date: January 1, 2014

Attachment 1: Modified Adjusted Gross Income (MAGI) Conversion Plan Option lb --Standardized Methodology with SIPP data, with state adjustments for time limited disregards Eligibility Conversions Please provide information about the state-specific weighting strategy and relevant conversions for groups with time limited disregards in the table below. Eligibility group: Please list each eligibility group (e.g., 1931 parents/caretaker relatives) where your state applied its own weight for time-limited disregards. Time-Limited weight: Please list, for each relevant eligibility group, the weight your state applied for the conversion. For example, if you determined that 15% of enrollees received time-limited disregards in a given category and applied that as your weight, you would simply list 15%. Data Used to Derive weight: Please describe, for each relevant eligibility group, the data used to calculate the time-limited weight, e.g. "state data for all1931 enrolled individuals in March of 2012." Application of Weight: Please show the formula used to apply the weight, e.g., if standard with time-limited disregard is 100 and without time-limited disregard is 75 and weight is .15, the formula would be (100 x .85) + (75 x .15) = __ 79 ____ _ Converted standard: Please fill in the converted standard for each eligibility group. This will be the weighted average of the applicant (e.g., standard including time-limited disregards) and beneficiary calculations you originally received from CMS, applying the time- limited weight to the applicant conversion. Eligibilit~ Group Transmittal Number: 13-0024-MM Nevada Time-limited Weight Data Used to Derive Weight Approval Date: April23, 2014 Attachment 1-14 Application of Weight Converted Standard Effective Date: January 1, 2014

Medicaid Eligibility Enter the AFDC Standards below. All states must enter: MAGI-equivalent AFDC Payment Standard in Effect As of May I, 1988 and AFDC Payment Standard in Effect As of July 16, 1996 Entry of other standards is optional. The standard is as follows: (i' Statewide standard (' Standard varies by region (' Standard varies by living arrangement (' Standard varies in some other way 229 296 363 430 496 563 '+' 7 {>\}\\~' "'''i';,':' 1 .. } 8 ~"'* "~ 697 ~~ Additional incremental amount (i' Yes (' No Increment amount $ ~..16_7 __ __.j The dollar amounts increase automatically each year (' Yes (i' No OMB Control Number 0938-1148 OMB Page I of8

Medicaid Eligibility (i' Statewide standard (' Standard varies by region (' Standard varies by living arrangement (' Standard varies in some other way 229 288 348 408 5 468 6 527 587 647 The dollar amounts increase automatically each year (' Yes (i' No The standard is as follows: (i' Statewide standard (' Standard varies by region (' Standard varies by living arrangement (' Standard varies in some other way (i' Yes (' No Increment amount $ Ll6_o __ ___, 4 Page 2 of8

Medicaid Eligibility Additional incremental amount Household size Standard ($) (i' Yes r No ·''1 1 255 N • Increment amount 2 323 ~ 3 392 ~· ~,..! 4 461 c•c•IJ X! . ·~ ~\s~ 5 530 I~ I·~; 6 597 X '\d-o m' ~:," ,; 7 666 .)(·· ..• j 8 735 X.. The dollar amounts increase automatically each year r Yes (i' No (i' Statewide standard C Standard varies by region C Standard varies by living arrangement C Standard varies in some other way Transmittal Number: 13-0024-MM Nevada Approval Date: April23, 2014 S14-3 $ 169 I Effective Date: January 1, 2014 Page 3 of8

Medicaid Eligibility Additional incremental amount Household size Standard ($) (i' Yes r No ~;' < ~- I 459 :X' Increment amount ', "'· .+ 2 579 I~ ' ::~ ~·;'<;' ,·¢~'"" + 3 699 x 4 819 :X! '+' ~ 5 939 .x 'lfi 6 1,059 X -'-"·"<-·~t ,+ 7 1,179 X +'~ 8 1,299 ,,,,;q1!1 X: The dollar amounts increase automatically each year (i' Yes r No The basis of the increase is (i' CPI-U ('Other basis Name: I The annual increase occurs in the month and day indicated: Every Month : IJuly The standard is as follows: (i' Statewide standard (' Standard varies by region I Day :II (' Standard varies by living arrangement (' Standard varies in some other way Transmittal Number: 13-0024-MM Nevada Approval Date: April23, 2014 S14-4 I $ 1120 I I Effective Date: January 1, 2014 Page 4 of8

Medicaid Eligibility Additional incremental amount Household size Standard ($) (i' Yes r No I. 1 253 X Increment amount ~ c ,, + 2 318 x. £:', :/1:' '+ 3 383 ,, .4. ' --~ 4 448 x~ 5 513 ~ *% 6 578 'X, ;_y( t 7 643 il '*'' 8 708 XI '1 The dollar amounts increase automatically each year r Yes (i' No standard is as follows: (i' Statewide standard (" Standard varies by region (" Standard varies by living arrangement (" Standard varies in some other way Transmittal Number: 13-0024-MM Nevada Approval Date: April23, 2014 S14-5 $ 165 I Effective Date: January 1, 2014 Page5of8

Medicaid Eligibility Additional incremental amount Household size Standard ($) .; I 319 Jtt '+" 2 407 X "'"' f+ 3 495 X '+, 4 582 IX: - 5 670 •'~~ ;,._ 6 758 ~ ;+, 7 846 X ~, 8 934 lx The dollar amounts increase automatically each year ("Yes (i' No The standard is as follows: (i' Statewide standard (" Standard varies by region (" Standard varies by living arrangement (" Standard varies in some other way (i' Yes (" No Increment amount Transmittal Number: 13-0024-MM Nevada Approval Date: April 23, 2014 S14-6 $188 I Effective Date: January 1, 2014 Page 6 of8

Medicaid Eligibility Additional incremental amount Household size Standard ($) (i' Yes r No ;;"f I 253 ! Increment amount fi'""~''" i* ,'''"'''' 2 318 'X ,., 3 383 X ~ ,,,,,, 4 448 ''X ·. '" I;;.J~ • 5 513 ' t' ' 6 578 I! ??~'}("'' c'}f<1ii"' + 7 643 X li18 708 ll ""'··""" The dollar amounts increase automatically each year r Yes (i' No The standard is as follows: (i' Statewide standard (' Standard varies by region (' Standard varies by living arrangement (' Standard varies in some other way Transmittal Number: 13-0024-MM Nevada Approval Date: April23, 2014 814-7 $ 165 I Effective Date: January 1, 2014 Page 7 of8

Medicaid Eligibility Additional incremental amount Household size Standard ($) (i' Yes (" No + 319 :x Increment amount $ LI8_8 ______ _.J ~t· 2 407 -! ~-------------+----------~~ 3 495 582 670 758 846 934 The dollar amounts increase automatically each year (" Yes (i' No PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. Transmittal Number: 13-0024-MM Nevada Approval Date: April23, 2014 814-8 Effective Date: January 1, 2014 Page 8 of8

~ f!.~~s --.. -- Medicaid Eligibility CFR 435.110 1902(a)( I O)(A)(i)(I) 193l(b)and(d) OMB Control Number 0938-1148 OMB date: 10/31/2014 [!I Parents and Other Caretaker Relatives- Parents and other caretaker relatives of dependent children with household income at or • below a standard established by the state. [Z] The state attests that it operates this eligibility group in accordance with the following provisions: [!I Individuals qualifying under this eligibility group must meet the following criteria: [!I Are parents or other caretaker relatives (defined at 42 CFR 435.4), including pregnant women, of dependent children (defined at 42 CFR 435.4) under age 18. Spouses of parents and other caretaker relatives are also included. The state elects the following options: This eligibility group includes individuals who are parents or other caretakers of children who are 18 years old, 1Z! provided the children are full-time students in a secondary school or the equivalent level of vocational or technical training. 1Z! Options relating to the definition of caretaker relative (select any that apply): IZ! The definition of caretaker relative includes the domestic partner of the parent or other caretaker relative, even after the partnership is terminated. Definition of domestic partner: Individuals who have registered a valid domestic partnership through the Office ofthe Secretary of State in the State ofNevada. IZ! The definition of caretaker relative includes other relatives of the child based on blood (including those of half-blood), adoption or marriage. Description of other relatives: D The definition of caretaker relative includes any adult with whom the child is living and who assumes primary responsibility for the dependent child's care. IZ! Options relating to the definition of dependent child (select the one that applies): The state elects to eliminate the requirement that a dependent child must be deprived of parental support or (i care by reason of the death, physical or mental incapacity, or absence from the home or unemployment of at least one parent. { The child must be deprived of parental support or ca~e, but a less restrictive standard is used to measure Transmittal Number11~-00~mnt of the parent;..~W~tfSJt ~££r~~Vl1%~~8\\ts ): Effective Date: January 1, 2014 Page 1 of3

Medicaid Eligibility ~ Have household income at or below the standard established by the state. ~ MAGI-based income methodologies are used in calculating household income. Please refer as necessary to S I 0 MAGI- Based Income Methodologies, completed by the state. ~ Income standard used for this group ~ Minimum income standard The minimum income standard used for this group is the state's AFDC payment standard in effect as of May I, 1988, converted to MAGI-equivalent amounts by household size. The standard is described in S 14 AFDC Income Standards. 0 The state certifies that it has submitted and received approval for its converted May I, 1988 AFDC payment standard. ~ Maximum income standard The state certifies that it has submitted and received approval for its converted income standard(s) for parents and 0 other caretaker relatives to MAGI-equivalent standards and the determination of the maximum income standard to be used for parents and other caretaker relatives under this eligibility group. 'illX''' m·jiti;j(ttatbmeut: is sullfilttec,Jiiii •. The state's maximum income standard for this eligibility group is: (i' The state's effective income level for section 1931 families under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent ofFPL or amounts by household size. (' The state's effective income level for section 1931 families under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent ofFPL or amounts by household size. The state's effective income level for any population of parents/caretaker relatives under a Medicaid 1115 (' demonstration as of March 23,2010, converted to a MAGI-equivalent percent ofFPL or amounts by household size. The state's effective income level for any population of parents/caretaker relatives under a Medicaid 1115 (' demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL or amounts by household size. Enter the amount of the maximum income standard: Transmittal Number: 13-0024-MM Nevada Approval Date: April23, 2014 S25-2 Effective Date: January 1, 2014 Page 2 of3

Medicaid Eligibility r A percentage of the federal poverty level: D% (' The state's AFDC payment standard in effect as of July 16, 1996, converted to a MAGI-equivalent standard. The standard is described in Sl4 AFDC Income Standards. The state's AFDC payment standard in effect as of July 16, 1996, increased by no more than the percentage (' increase in the Consumer Price Index for urban consumers (CPI-U) since such date, converted to a MAGI- equivalent standard. The standard is described in S 14 AFDC Income Standards. (i' The state's TANF payment standard, converted to a MAGI-equivalent standard. The standard is described in Sl4 AFDC Income Standards. (' Other dollar amount [!] Income standard chosen: Indicate the state's income standard used for this eligibility group: (i' The minimum income standard (' The maximum income standard The state's AFDC payment standard in effect as of July 16, 1996, increased by no more than the percentage (' increase in the Consumer Price Index for urban consumers (CPI-U) since such date. The standard is described in S 14 AFDC Income Standards. (' Another income standard in-between the minimum and maximum standards allowed (!] There is no resource test for this eligibility group. (!] Presumptive Eligibility The state covers individuals under this group when determined presumptively eligible by a qualified entity. The state assures it also covers individuals under the Pregnant Women ( 42 CFR 435. 116) and/or Infants and Children under Age 19 ( 42 CFR 435.118) eligibility groups when determined presumptively eligible. (' Yes (i' No PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. Transmittal Number: 13-0024-MM Nevada Approval Date: April 23, 2014 825-3 Effective Date: January 1, 2014 Page 3 of3

Medicaid Eligibility OMB Control Number 0938-1148 OMB date: 10/31/2014 CFR435.116 1902(a)(l O)(A)(i)(III) and (IV) 1902(a)(IO)(A)(ii)(I), (IV) and (IX) 193l(b)and(d) 1920 ~ Pregnant Women- Women who are pregnant or post-partum, with household income at or below a standard established by the state. IZl The state attests that it operates this eligibility group in accordance with the following provisions: ~ Individuals qualifying under this eligibility group must be pregnant or post-partum, as defined in 42 CFR 435.4. Pregnant women in the last trimester of their pregnancy without dependent children are eligible for full benefits under this group in accordance with section 193 I of the Act, if they meet the income standard for state plan Parents and Other Caretaker Relatives at 42 CFR 435.110. (i Yes r No ~MAGI-based income methodologies are used in calculating household income. Please refer as necessary to S I 0 MAGI-Based • Income Methodologies, completed by the state. ~ Income standard used for this group ~ Minimum income standard (Once entered and approved by CMS, the minimum income standard cannot be changed.) The state had an income standard higher than 133% FPL established as of December 19, 1989 for determining eligibility for pregnant women, or as of July I, 1989, had authorizing legislation to do so. rYes (i' No The minimum income standard for this eligibility group is 133% FPL. ~ Maximum income standard The state certifies that it has submitted and received approval for its converted income standard(s) for pregnant !Zl women to MAGI-equivalent standards and the determination of the maximum income standard to be used for pregnant women under this eligibility group. The state's maximum income standard for this eligibility group is: The state's highest effective income level for coverage of pregnant women under sections 1931 (low-income families), l902(a)( l O)(A)(i)(Ill) (qualified pregnant women), 1902(a)( I O)(A)(i)(IV) (mandatory poverty level- r related pregnant women), 1902(a)( I O)(A)(ii)(IX) (optional poverty level-related pregnant women), 1902(a)( 10) (A)(ii)(l) (pregnant women who meet AFDC financial eligibility criteria) and 1902(a)( lO)(A)(ii)(lV) (institutionalized pregnant women) in effect under the Medicaid state plan as of March 23, 20 I 0, con vetted to a MAGI-equivalent percent of FPL. Transmittal Number: 13-0024-MM Nevada Approval Date: April 23, 2014 528-1 Effective Date: January 1. 2014 Page I of2

~Ms _,. __ _ Medicaid Eligibility The state's highest effective income level for coverage of pregnant women under sections 1931 (low-income families), l902(a)( l O)(A)(i)(III) (qualified pregnant women), 1902(a)(l O)(A)(i)(IV) (mandatory poverty level- r related pregnant women), 1902(a)( I O)(A)(ii)(IX) (optional poverty level-related pregnant women), !902(a)( I 0) (A)(ii)(I) (pregnant women who meet AFDC financial eligibility criteria) and 1902(a)( I O)(A)(ii)(IV) (institutionalized pregnant women) in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. r The state's effective income level for any population of pregnant women under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. r The state's effective income level for any population of pregnant women under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. ~ 185%FPL ~ Income standard chosen Indicate the state's income standard used for this eligibility group: r The minimum income standard r The maximum income standard ~· Another income standard in-between the minimum and maximum standards allowed. The amount of the income standard for this eligibility group is:~ % FPL ~ There is no resource test for this eligibility group. ~Benefits for individuals in this eligibility group consist of the following: ~ All pregnant women eligible under this group receive full Medicaid coverage under this state plan. r Pregnant women whose income exceeds the income limit specified below for full coverage of pregnant women receive only pregnancy-related services. ~ Presumptive Eligibility The state covers ambulatory prenatal care for individuals under this group when determined presumptively eligible by a qualified entity. rYes ~No PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. Transmittal Number: 13-0024-MM Nevada Approval Date: April23, 2014 828-2 Effective Date: January 1, 2014 Page 2 of2

Medicaid Eligibility OMB Control Number 0938-1148 CFR435.118 1902(a)(lO)(A)(i)(III), (IV), (VI) and (VII) 1902(a)( 1 O)(A)(ii)(IV) and (IX) 1931(b)and(d) OMB [!] Infants and Children under Age 19- Infants and children under age 19 with household income at or below standards established by the state based on age group. 0 The state attests that it operates this eligibility group in accordance with the following provisions: [!] Children qualifying under this eligibility group must meet the following criteria: [!] Are under age 19 [!] Have household income at or below the standard established by the state. [!] MAGI-based income methodologies are used in calculating household income. Please refer as necessary to S I 0 MAGI- Based Income Methodologies, completed by the state. [!] Income standard used for infants under age one [!] Minimum income standard The state had an income standard higher than 133% FPL established as of December 19, 1989 for determining eligibility for infants under age one, or as of July I, 1989, had authorizing legislation to do so. C Yes (i No The minimum income standard for infants under age one is 133% FPL. [!] Maximum income standard The state certifies that it has submitted and received approval for its converted income standard(s) for infants 0 under age one to MAGI-equivalent standards and the determination of the maximum income standard to be used for infants under age one. The state's maximum income standard for this age group is: The state's highest effective income level for coverage of infants under age one under sections 193 I (low-income families), 1902(a)(IO)(A)(i)(III) (qualified children), 1902(a)(IO)(A)(i)(IV) (mandatory poverty level-related C infants), 1902(a)(IO)(A)(ii)(IX) (optional poverty level-related infants) and 1902(a)(IO)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 20 I 0, converted to a MAGI- equivalent percent of FPL. Transmittal Number: 13-0024-MM Nevada Approval Date: April 23, 2014 830-1 Effective Date: January 1, 2014 Page I of 5

Medicaid Eligibility The state's highest effective income level for coverage of infants under age one under sections 1931 (low-income families), 1902(a)( I O)(A)(i)(III) (qualified children), 1902(a)( I O)(A)(i)(IV) (mandatory poverty level-related (' infants), 1902(a)(IO)(A)(ii)(IX) (optional poverty level-related infants) and 1902(a)(IO)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. (' The state's effective income level for any population of infants under age one under a Medicaid 1115 demonstration as of March 23,2010, converted to a MAGI-equivalent percent ofFPL. (' The state's effective income level for any population of infants under age one under a Medicaid I I 15 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. (i 185% FPL ~ Income standard chosen The state's income standard used for infants under age one is: (' The maximum income standard If not chosen as the maximum income standard, the state's highest effective income level for coverage of infants under age one under sections 1931 (low-income families), 1902(a)(IO)(A)(i)(lll) (qualified children), 1902(a)(IO) (i (A)(i)(TV) (mandatory poverty level-related infants), 1902(a)(IO)(A)(ii)(IX) (optional poverty level-related infants) and 1902(a)( IO)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 20 I 0, converted to a MAGI-equivalent percent of FPL. If higher than the highest effective income level for this age group under the state plan as of March 23, 20 I 0, and if not chosen as the maximum income standard, the state's highest effective income level for coverage of infants (' under age one under sections 193 I (low-income families), 1902(a)( I O)(A)(i)(lll) (qualified children), 1902(a)(l 0) (A)(i)(TV) (mandatory poverty level-related infants), 1902(a)( I O)(A)(ii)(JX) (optional poverty level-related infants) and 1902(a)(l O)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of December 3 I, 2013, converted to a MAGI-equivalent percent of FPL. If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's effective income level for any population of infants (' under age one under a Medicaid III5 demonstration as of March 23,2010, converted to a MAGI-equivalent percent of FPL. Ifhigher than the highest effective income level for this age group under the state plan as of March 23,2010, and if not chosen as the maximum income standard, the state's effective income I eve I for any population of infants (' under age one under a Medicaid I I 15 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. (' Another income standard in-between the minimum and maximum standards allowed, provided it is higher than the effective income standard for this age group in the state plan as of March 23, 20 I 0. The amount of the income standard for infants under one is: ~ % FPL ~ Income standard for children age one through age five, inclusive T fil1 Minimum in.corne.standard ran simi ar Numoer: 1 J-UUl4-MM NevadA Approval Date: April 23, 2014 830-2 Effective Date: January 1, 2014 Page 2 of5

Medicaid Eligibility The minimum income standard used for this age group is 133% FPL. ~ Maximum income standard The state certifies that it has submitted and received approval for its converted income standard(s) for children [{] age one through five to MAGI-equivalent standards and the determination of the maximum income standard to be used for children age one through five. MJ,tfacbment is S'JJUtitte~~::; I The state's maximum income standard for children age one through five is: The state's highest effective income level for coverage of children age one through five under sections 193 1 (low- (i' income families), 1902(a)( l O)(A)(i)(III) (qualified children), 1902(a)( I O)(A)(i)(VI) (mandatory poverty level- related children age one through five), and 1902(a)( I O)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of March 23,2010, converted to a MAGI-equivalent percent ofFPL. The state's highest effective income level for coverage of children age one through five under sections 193 1 (low- (' income families), l 902(a)( I O)(A)(i)(III) (qualified children), 1902(a)( I O)(A)(i)(Vl) (mandatory poverty level- related children age one through five), and 1902(a)( I O)(A)(ii)(lV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAG !-equivalent percent of FPL. (' The state's effective income level for any population of children age one through five under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. (' The state's effective income level for any population of children age one through five under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. Enter the amount of the maximum income standard: ~ % FPL ~ Income standard chosen The state's income standard used for children age one through five is: (i' The maximum income standard If not chosen as the maximum income standard, the state's highest effective income level for coverage of children age one through five under sections 1931 (low-income families), 1902(a)( I O)(A)(i)(Ill) (qualified children), (' 1902(a)(IO)(A)(i)(VI) (mandatory poverty level-related children age one through five), and 1902(a)(JO)(A)(ii) (IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 20 I 0, converted to a MAGI-equivalent percent of FPL. Ifhigher than the highest effective income level forth is age group under the state plan as of March 23, 20 I 0, and if not chosen as the maximum income standard, the state's highest effective income level for coverage of children (' age one through five under sections 1931 (low-income families), 1902(a)( I O)(A)(i)(lll) (qualified children), 1902(a)(IO)(A)(i)(VI) (mandatory poverty level-related children age one through five), and l902(a)(l O)(A)(ii) (IV) (institutionalized children), in effect under the Medicaid state plan as of December 3 1, 2013, converted to a MAGI-equivalent percent of FPL. Transmittal Number: 13-0024-MM Nevada Approval Date: April23, 2014 830-3 Effective Date: January 1, 2014 Page 3 of 5

Medicaid Eligibility If higher than the highest effective income level for this age group under the state plan as of March 23, 20 I 0, and (' if not chosen as the maximum income standard, the state's effective income level for any population of children age one through five under a Medicaid 1115 demonstration as of March 23, 20 I 0, converted to a MAGI- equivalent percent of FPL. If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and (' if not chosen as the maximum income standard, the state's effective income I eve I for any population of children age one through five under a Medicaid 1115 demonstration as of December 3 L 2013, converted to a MAG!- equivalent percent of FPL. (' Another income standard in-between the minimum and maximum standards allowed, provided it is higher than the effective income standard for this age group in the state plan as of March 23, 20 I 0. ~ Income standard for children age six through age eighteen, inclusive ~ Minimum income standard The minimum income standard used for this age group is 133% FPL. ~ Maximum income standard The state certifies that it has submitted and received approval for its converted income standard(s) for children age IZJ six through eighteen to MAGI-equivalent standards and the determination of the maximum income standard to be used for children age six through age eighteen. The state's maximum income standard for children age six through eighteen is: The state's highest effective income level for coverage of children age six through eighteen under sections 1931 (' (low-income families), 1902(a)(IO)(A)(i)(lll) (qualified children), 1902(a)(IO)(A)(i)(VII) (mandatory poverty level-related children age six through eighteen) and 1902(a)( I O)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 20 I 0, converted to a MAG !-equivalent percent of FPL. The state's highest effective income level for coverage of children age six through eighteen under sections 1931 (' (low-income families), 1902(a)( I O)(A)(i)(III) (qualified children), 1902(a)( I O)(A)(i)(VII) (mandatory poverty level-related children age six through eighteen) and 1902(a)( 1 O)(A)(ii)(JV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent ofFPL. (' The state's effective income level for any population of children age six through eighteen under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAG !-equivalent percent of FPL. (' The state's effective income level for any population of children age six through eighteen under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. (i' 133% FPL ~ Income standard chosen The state's income standard used for children age six through eighteen is: Nevada 830-4 Page 4 of5

Medicaid Eligibility (i The maximum income standard If not chosen as the maximum income standard, the state's highest effective income level for coverage of children age six through eighteen under sections 1931 (low-income families), 1902(a)( I O)(A)(i)(III) (qualified children), (" 1902(a)(l O)(A)(i)(VII) (mandatory poverty level-related children age six through eighteen) and 1902(a)( 1 O)(A) (ii)(1V) (institutionalized children), in effect under the Medicaid state plan as of March 23,2010. converted to a MAGI-equivalent percent of FPL If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's highest effective income level for coverage of children (" age six through eighteen under sections 1931 (low-income families), 1902(a)( I O)(A)(i)(III) (qualified children), 1902(a)(l O)(A)(i)(VII) (mandatory poverty level-related children age six through eighteen) and 1902(a)( 1 O)(A) (ii)(1V) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent ofFPL If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and r if not chosen as the maximum income standard, the state's effective income level for any population of children age six through eighteen under a Medicaid 1115 demonstration as of March 23, 20 I 0, converted to a MAG!- equivalent percent of FPL lfhigher than the highest effective income level for this age group under the state plan as of March 23, 20 I 0, and r if not chosen as the maximum income standard, the state's effective income level for any population of children age six through eighteen under a Medicaid 1115 demonstration as of December 3 I, 20 13, converted to a MAG!- equivalent percent of FPL (" Another income standard in-between the minimum and maximum standards allowed, provided it is higher than the effective income standard for this age group in the state plan as of March 23, 20 I 0. ~ There is no resource test for this eligibility group. ~ Presumptive Eligibility The state covers children \\·hen determined presumptively eligible by a qualified entity. (" Yes (i' No PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. Transmittal Number: 13-0024-MM Nevada Approval Date: April 23, 2014 830-5 Effective Date: January 1, 2014 Page 5 of 5

CFR435.150 1902(a)(IO)(A)(i)(IX) Medicaid Eligibility OMB Control Number 0938-1148 OMB date: 10/31/2014 ~ Former Foster Care Children - Individuals under the age of 26, not otherwise mandatorily eligible, who were on Medicaid and in foster care when they turned age 18 or aged out of foster care. 0 The state attests that it operates this eligibility group under the following provisions: ~ Individuals qualifying under this eligibility group must meet the following criteria: ~ Are under age 26. ~ Are not otherwise eligible for and enrolled for mandatory coverage under the state plan, except that eligibility under this group takes precedence over eligibility under the Adult Group. Were in foster care under the responsibility of the state or Tribe and were enrolled in Medicaid under the state's state ~plan or 1115 demonstration when they turned 18 or at the time of aging out of that state's or Tribe's foster care program. The state elects to cover children who were in foster care and on Medicaid in fill)'_ state at the time they turned 18 or aged out of the foster care system. ('Yes (i' No The state covers individuals under this group when determined presumptively eligible by a qualified entity. The state assures it also covers individuals under the Pregnant Women ( 42 CFR 435. I 16) and/or Infants and Children under Age 19 ( 42 CFR 435.118) eligibility groups when determined presumptively eligible. ('Yes (i' No PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this forn1, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. Transmittal Number: 13-0024-MM Nevada Approval Date: April23, 2014 833-1 Effective Date: January 1, 2014 Page I of 1

1902(a)(l O)(A)(ii)(XX) 1902(hh) CFR 435.218 Medicaid Eligibility Individuals above 133% FPL- The state elects to cover individuals under 65, not otherwise mandatorily or optionally eligible, with income above 133% FPL and at or below a standard established by the state and in accordance with provisions described at 42 CFR435.218. (' Yes {i No PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. Transmittal Number: 13-0024-MM Nevada Approval Date: April 23, 2014 S50-1 Effective Date: January 1, 2014 Page I of I

CFR 435.220 1902(a)( I O)(A)(ii)(l) Medicaid Eligibility OMB Control Number 0938-1148 OMB Ex ·ration date: 10/31/2014 Optional Coverage of Parents and Other Caretaker Relatives- The state elects to cover individuals qualifying as parents or other caretaker relatives who are not mandatorily eligible and who have income at or below a standard established by the state and in accordance with provisions described at 42 CFR 435.220. ("' Yes (i' No PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. Transmittal Number: 13-0024-MM Nevada Approval Date: April 23, 2014 S51-1 Effective Date: January 1, 2014 Page I of I

Medicaid Eligibility 1-"'~:aMJHable Classification of Individuals under Age 21 - The state elects to cover one or more reasonable classifications of individuals age 21 who are not mandatorily eligible and who have income at or below a standard established by the state and in accordance provisions described at 42 CFR 435.222. (i' Yes (" No 0 The state attests that it operates this eligibility group in accordance with the following provisions: ~ Individuals qualifying under this eligibility group must qualify under a reasonable classification by meeting the following criteria: ~ Be under age 21, or a lower age, as defined within the reasonable classification. ~ Have household income at or below the standard established by the state, if the state has an income standard for the • reasonable classification. ~ Not be eligible and enrolled for mandatory coverage under the state plan. ~ MAGI-based income methodologies are used in calculating household income. Please refer as necessary to S I 0 MAGI- Based Income Methodologies, completed by the state. The state covered at least one reasonable classification under this eligibility group under its Medicaid state plan as of December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 3 L 2013, with income standards higher (including disregarding all income) than the current mandatory income standards for the individual's age. (i' Yes (" No The state also covered at least one reasonable classification under this group in the Medicaid state plan as of March 23, 20 I 0 with income standards higher (including disregarding all income) than the current mandatory income standards for the individual's age. (i' Yes (" No Reasonable Classifications Covered in the Medicaid State Plan as of March 23, 20 I 0 The state attaches the approved pages from the Medicaid state plan as of March 23, 20 I 0 to indicate the age 0 groups, reasonable classifications, and income standards used at that time for this eligibility group. Current Coverage of All Children under a Specified Age Transmittal Number: 13-0024-MM Nevada Approval Date: April23, 2014 852-1 Effective Date: January 1, 2014 Page 1 of5

Medicaid Eligibility The state covers all children under a specified age limit, equal to or higher than the age limit and/or income standard used in the Medicaid state plan as of March 23, 2010, provided the income standard is higher than the current mandatory income standard for the individual's age. The age limit and/or income standard used must be no higher than any age limit and/or income standard covered in the Medicaid state plan as of December 3 I, 20 I 3 or under a Medicaid 1 I I 5 Demonstration as of March 23, 20 I 0 or December 3 L 2013. Higher income standards may include the disregard of all income. (' Yes (i' No Current Coverage of Reasonable Classifications Covered in the Medicaid State Plan as of March 23, 20 I 0 The state covers reasonable classifications of children previously covered in the Medicaid state plan as of March 23, 2010, with income standards higher than the current mandatory income standard for the age group. Age I im its and income standards are equal to or higher than the Medicaid state plan as of March 23, 2010, but no higher than any age limit and/or income standard for this classification covered in the Medicaid state plan as of December 3 I. 20 I 3 or under a Medicaid I I I5 Demonstration as of March 23, 20 I 0 or December 3 I, 20 I 3. Higher income standards may include the disregard of all income. (i' Yes (' No Indicate the reasonable classifications of children that were covered in the state plan in effect as of March 23. 20 I 0 with income standards higher than the mandatory standards used for the child's age, using age limits and income standards that are not more restrictive than used in the state plan as of as March 23, 2010 and are not less restrictive than used in the Medicaid state plan as of December 3 I, 2013 or under a Medicaid I I I 5 Demonstration as of March 23, 20 I 0 or December 3 I, 20 I 3. Current Coverage of Reasonable Classifications Covered in the Medicaid State Plan as of March 23. 20 I 0 ~ Individuals for whom public agencies are assuming full or partial financial responsibility. ~ Individuals placed in foster care homes by public agencies Indicate the age which applies: (' Under age 2 I (' Under age 20 (i' Under age I 9 (' Under age I 8 D Individuals placed in foster care homes by private. non-profit agencies ~ Individuals placed in private institutions by public agencies Indicate the age which applies: ('Under age 21 ('Under age 20 (i' Under age 19 ('Under age I8 D Individuals placed in private institutions by private, non-profit agencies D Individuals in adoptions subsidized in full or part by a public agency D Individuals in nursing facilities, if nursing facility services are provided under this plan D Individuals receiving active treatment as inpatients in psychiatric facilities or programs, if such services are provided under this plan Page 2 of 5

Medicaid Eligibility ~ Other reasonable classifications Name of classification Individuals for whom public agencies are assuming full or partial financial responsibility. Description Who are placed in psychiatric facilities Age Limit Under age 19 Enter the income standard used for these classifications. The income standard must be higher than the mandatory standard for the child's age. It may be no lower than the income standard used in the state plan as of March 23, 2010 and no higher than the highest standard used in the Medicaid state plan as of December 3 L 2013 or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 3 L 2013. =-------~~--------~~----------------~--------~ ";i]ll:ti~"!s:;~re above is'iornplete to vie*the income standards form,) ~~~~~~~~ ~ Income standard used ~ Minimum income standard The minimum income standard for this classification of children must exceed the lowest income standard chosen for children under this age under the Infants and Children under Age 19 eligibility group. ~ Maximum income standard No income test was used (all income was disregarded) for this classification either in the Medicaid state plan as of December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 20 I 0 or December 31, 2013. (i' Yes (' No ~ No income test was used (all income was disregarded) for this classification under: (check all that apply) ~ The Medicaid state plan as of March 23, 20 I 0. ~ The Medicaid state plan as of December 31, 2013. D A Medicaid 1115 Demonstration as of March 23, 20 I 0. 0 A Medicaid 1115 Demonstration as of December 31, 2013. The state's maximum standard for this classification of children is no income test (all income is disregarded). ~ Income standard chosen Individuals qualify under this classification under the following income standard: This classification does not use an income test (all income is disregarded). Transmittal Number: 13-0024-MM Nevada Approval Date: April23, 2014 S52-3 Effective Date: January 1, 2014 Page 3 of 5

Medicaid Eligibility [!] Income standard used [!] Minimum income standard The minimum income standard for this classification of children must exceed the lowest income standard chosen for children under this age under the Infants and Children under Age 19 eligibility group. [!] Maximum income standard No income test was used (all income was disregarded) for this classification either in the Medicaid state plan as of December 31, 2013, or under a Medicaid II 15 Demonstration as of March 23, 20 l 0 or December 31, 2013. (i Yes (' No [!] No income test was used (all income was disregarded) for this classification under: (check all that apply) rgj The Medicaid state plan as of March 23, 2010. rgj The Medicaid state plan as of December 3 I, 20 13. 0 A Medicaid 1115 Demonstration as of March 23, 2010. 0 A Medicaid 1115 Demonstration as of December 31.2013. The state's maximum standard for this classification of children is no income test (all income is disregarded). [!] Income standard chosen Individuals qualify under this classification under the following income standard: This classification does not use an income test (all income is disregarded). [!] Income standard used [!] Minimum income standard The minimum income standard for this classification of children must exceed the lowest income standard chosen for children under this age under the Infants and Children under Age 19 eligibility group. [!] Maximum income standard No income test was used (all income was disregarded) for this classification either in the Medicaid state plan as of December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 20 I 0 or December 31,2013. (i Yes (' No Page 4 of 5

Medicaid Eligibility ~ No income test was used (all income was disregarded) for this classification under: (check all that apply) 1ZJ The Medicaid state plan as of March 23, 20 I 0. IZJ The Medicaid state plan as of December 3 I, 20 13. D A Medicaid 1115 Demonstration as of March 23, 2010. D A Medicaid 1115 Demonstration as of December 3 I, 20 13. The state's maximum standard for this classification of children is no income test (all income is disregarded). ~ Income standard chosen Individuals qualify under this classification under the following income standard: This classification does not use an income test (all income is disregarded). Other Reasonable Classifications Previously Covered The state covers reasonable classifications of children not covered in the Medicaid state plan as of March 23,2010, but covered under the Medicaid state plan as of December 3 I, 20 13 or under a Medicaid 11 15 Demonstration as of March 23, 20 I 0 or December 31, 2013 with an income standard higher than the current mandatory income standard for the age group. (' Yes (i' No Additional new age groups or reasonable classifications covered If the state has not elected to cover the Adult Group ( 42 CFR 435 .119), it may elect to cover additional new age groups or reasonable classifications that have not been covered previously. If the state covers the Adult Group, this additional option is not available, as the standard for the new age groups or classifications is lower than that used for mandatory coverage. The state does not cover the Adult Group and elects the option to include in this eligibility group additional age groups or reasonable classifications that have not been covered previously in the state plan or under a Medicaid 1115 Demonstration. Any additional age groups or reasonable classifications not previously covered are restricted to the AFDC income standard from July 16, 1996, not converted to a MAGI-equivalent standard. (' Yes (i' No ~ There is no resource test for this eligibility group. PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard. Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. Transmittal Number: 13-0024-MM Approval Date: April23, 2014 Effective Date: January 1, 2014 Nevada 852-5 Page 5 of 5

Medicaid Eligibility OMB Control Number 0938-1148 OMB date: 10/31/2014 42 CFR 435.227 1902(a)( I O)(A)(ii)(VIII) Children with Non IV-E Adoption Assistance- The state elects to cover children with special needs for whom there is a non IV-E adoption assistance agreement in effect with a state, who were eligible for Medicaid, or who had income at or below a standard established by the state and in accordance with provisions described at 42 CFR 435.227. ~ Yes (' No [Z] The state attests that it operates this eligibility group in accordance with the following provisions: ~ Individuals qualifying under this eligibility group must meet the following criteria: ~ The state adoption agency has determined that they cannot be placed without Medicaid coverage because of special needs for medical or rehabilitative care; ~ Are under the following age (see the Guidance for restrictions on the selection of an age): (' Under age 21 C Under age 20 ~ Under age 19 (' Under age 18 ~ MAGI-based income methodologies are used in calculating household income. Please refer as necessary to S 10 MAGI- Based Income Methodologies, completed by the state. The state covered this eligibility group in the Medicaid state plan as of December 31, 2013, or under a Medicaid 1115 Demonstration as ofMarch 23,2010 or December 31,2013. ~-Yes (' No The state also covered this eligibility group in the Medicaid state plan as of March 23, 20 I 0. ~ Yes (' No ~ Individuals qualify under this eligibility group if they were eligible under the state's approved state plan prior to • the execution of the adoption agreement. The state used an income standard or disregarded all income for this eligibility group either in the Medicaid state plan as of March 23, 20 I 0 or December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 20 I 0 or December 3 I, 20 13. (' Yes ~ No ~ There is no resource test for this eligibility group. PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, MiMk~l!t81 ~rOh&!t;.rOOlXe, Maryland 21 A~~rdJIJ~ate: April 23, 2014 Effective Date: January 1, 2014 Nevada 853-1 Page I of I

1902(a)( I O)(A)(ii)(XIV) CFR 435.229 and 435.4 1905(u)(2)(B) Medicaid Eligibility OMB Control Number 0938-1148 Optional Targeted Low Income Children - The state elects to cover uninsured children who meet the definition of optional targeted low income children at 42 CFR 435.4, who have household income at or below a standard established by the state and in accordance with provisions described at 42 CFR 435.229. (' Yes (i' No PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. Transmittal Number: 13-0024-MM Nevada Approval Date: April 23, 2014 554-1 Effective Date: January 1, 2014 Page I of I

1902(a)( I O)(A)(ii)(Xll) 1902(z) Medicaid Eligibility OMB Control Number 0938-1148 OMB ration date: 10/31/2014 Individuals with Tuberculosis -The state elects to cover individuals infected with tuberculosis who have income at or below a standard established by the state, limited to tuberculosis-related services. (' Yes (i' No PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. Transmittal Number: 13-0024-MM Nevada Approval Date: April23, 2014 855-1 Effective Date: January 1, 2014 Page I of I

Medicaid Eligibility OMB Control Number 0938-1148 0 MB ration date: I 0/3 I /20 14 CFR 435.226 1902(a)( I O)(A)(ii)(XVII) Independent Foster Care Adolescents- The state elects to cover individuals under an age specified by the state, less than age 21, who were in state-sponsored foster care on their 18th birthday and who meet the income standard established by the state and in accordance with the provisions described at 42 CFR 435.226. (i' Yes ("' No [Z] The state attests that it operates this eligibility group in accordance with the following provisions: ~ Individuals qualifying under this eligibility group must meet the following criteria: ~ Are under the following age (i' Under age 21 ("'Under age 20 ("' Under age 19 ~ Were in foster care under the responsibility of a state on their 18th birthday. ~ Are not eligible and enrolled for mandatory coverage under the Medicaid state plan. ~ Have household income at or below a standard established by the state. ~ MAGI-based income methodologies are used in calculating household income. Please refer as necessary to S I 0 MAGI- Based Income Methodologies, completed by the state. The state covered this eligibility group under its Medicaid state plan as of December 31, 2013, or under a Medicaid 1115 demonstration as of March 23, 2010 or December 31, 2013. (i' Yes ("' No The state also covered this eligibility group in the Medicaid state plan as of March 23, 20 I 0. (i' Yes ("' No The state covers children under this eligibility group, as follows (selection may not be more restrictive than the coverage in the Medicaid state plan as of March 23, 20 I 0 until October I, 2019, nor more liberal than the most ~ liberal coverage in the Medicaid state plan as of December 3 I, 2013, or under a Medicaid I I 15 demonstration as of March 23, 2010 or December 31, 20 13): (i' All children under the age selected C A reasonable classification of children under the age selected: ~ Income standard used for this eligibility group ~ Minimum income standard The minimum income standard for this classification of children is the AFDC payment standard in effect as of July 16, 1996, not converted to MAGI-equivalent. This standard is described in S 14 AFDC Income Standards. Transmittal Number: 13-0024-MM Nevada Approval Date: April 23, 2014 S57-1 Effective Date: January 1, 2014 Page I of2

Medicaid Eligibility ~ Maximum income standard No income test was used (all income was disregarded) for this eligibility group either in the Medicaid state plan as of March 23, 2010 or December 3 1, 2013. or under a Medicaid 1115 Demonstration as ofMarch 23,2010 or December 31,2013. (i' Yes (' No ~ No income test was used (all income was disregarded) for this eligibility group under (check all that apply): 1Zl The Medicaid state plan as of March 23, 2010. 1Z1 The Medicaid state plan as of December 31,2013. D A Medicaid 1115 demonstration as of March 23,2010. D A Medicaid 1115 demonstration as of December 31, 2013. The state's maximum standard for this eligibility group is no income test (all income is disregarded). ~ Income standard chosen Individuals qualify under this eligibility group under the following income standard: This eligibility group does not use an income test (all income is disregarded). ~ There is no resource test for this eligibility group. PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. Transmittal Number: 13-0024-MM Nevada Approval Date: April 23, 2014 857-2 Effective Date: January 1, 2014 Page 2 of2

Medicaid Eligibility OMB Control Number 0938-1148 OMB ll""Jl'F':,W,r- Individuals Eligible for Family Planning Services- The state elects to cover individuals who are not pregnant, and have household income at or below a standard established by the state, whose coverage is limited to family planning and related services and in accordance with provisions described at 42 CFR 435.214. (" Yes (i' No PRA Disclosure Statement According to the Pape1work Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. Transmittal Number: 13-0024-MM Nevada Approval Date: April 23, 2014 S59-1 Effective Date: January 1, 2014 Page l of l

Table of Contents

State/Territory Name: Nevada State Plan Amendment (SPA) #: NV 13-0025 MM

This file contains the following documents in the order listed:

1) Approval Letter

2) Summary Form (with 179-like data) 3) Superseding Pages Notice

4) Approved SPA Pages

5) Additional Attachments

ene aaa

“CM

CENTERS FOR MEDICARE & MEDICAID SERVICES

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

San Francisco Regional Office

90 Seventh Street, Suite 5-300 (5W)

San Francisco, CA 94103-6706

DIVISION OF MEDICAID & CHILDREN’S HEALTH OPERATIONS

Michael J. Willden, Director DEC 19 2013 Department of Health and Human Services

4126 Technology Way, Suite 100

Carson City, NV 89706

Dear Mr. Willden:

Enclosed is an approved copy of Nevada State Plan Amendment (SPA) 13-0025-MM. This SPA was submitted to CMS on October 9, 2013 requesting to add a description of the provisions concerning citizen and non-citizen Medicaid eligibility to the State Plan in accordance with the Affordable Care

Act.

The approval is effective January 1, 2014. Attached are copies of the following pages to be incorporated into a separate section at the back of Nevada’s State Plan:

e $89, Pages 1-3 In addition, the following new pages should replace the existing approved pages in the State Plan: e Attachment 2.6-A, Pages 2 and 3

If you have any questions, please contact Brian Zolynas by phone at (415) 744-3601 or by email at Brian.Zolynas@cms.hhs.gov .

Sincerely,

/s/ Gloria Nagle, Ph.D., MPA Associate Regional Administrator Division of Medicaid & Children’s Health Operations Enclosure

ce: Laurie Squartsoff, Administrator, DHCFP Marta Stagliano, Chief, Compliance, DHCFP

Medicaid State Plan Eligibility; Summary Page (CMS 179)

State/Territory name: Nevada Transmittal Number: Please enter the Transmititt Number (¢ TN) in the. format ST- YY- 0000 where ST= the state abbreviation, V YY = the last two digits of

NV-13- 0025

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

Federal Statute/Regulation Citation epee _ es 1902 (a)(46)(B); 8 U.S.C. 1611, 1612, 1613, and 1641; "1903(v)(2),(3) and (4); 42 CFR 435.4; 42 CFR 435.406

Federal Budget Impact Federal Fiscal Year Amount First Year 2014 $0.00 Subject of Amendment

New template required for implementation of the Affordable Care Act.

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

(© Comments of Governor's office received Describe:

©) No reply received within 45 days of submittal

© Other, as specified Describe: The Governor's office does not wish to review the State Plan Amendment.

Signature of State Agency Official Submitted By: Robyn Heddy Last Revision Date: Dec 5, 2013 Submit Date: Oct 9, 2013

SUPERSEDING PAGES OF

STATE PLAN MATERIAL TRANSMITTAL NUMBER: STATE: 13-0025 MM Nevada

PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:

S89 Non-Financial Eligibility- Citizenship and Non-citizen Eligibility Attachment 2.6-A: Page 2, Item 3, subparagraphs (a)-(c)

Attachment 2.6-A, Page 3, Item 3, subparagraphs (d)-(e)

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

(None superseded, new pages)

Attachment 2.6-A: Page 2, Item 3, subparagraphs (a)-(c), TN 91- 22

Attachment 2.6-A, Page 3, Item 3, subparagraphs (d)-(e), TN 91- 22

Revision: HCFA-PM-91-4TC (BPD) ATTACHMENT 2.6-A

August 1991 Page 2 OMB No.: 0938-

State: NEVADA

Citation Condition or Requirement

b. For the medically needy, meets the non-financial eligibility conditions of 42 CFR Part 435.

1905(p) of the c. For financially eligible qualified Medicare Act beneficiaries covered under section 1902 (a) (10) (E) (i) of the Act, meets the non-financial criteria of section 1905(p) of

“the Act. 1905(s) of the d. For financially eligible qualified disabled and Act working individuals covered under section

1902(a) (10) (E) (ii) of the Act, meets the non-financial criteria of section 1905(s).

TN No. 13-0025-MM

Supersedes Approval Date DEC ] 9 2013 Effective Date 1/1/2014

TN No. 91-22

Revision: HCFA-PM-91-4 (BPD) ATTACHMENT 2.6-A August 1991 Page 3 OMB No.: 0938- State: NEVADA

Citation Condition or Requirement

42 CFR 435.403 4. Is a resident of the State, regardless of whether 1902(b) of the or not the individual maintains the residence Act permanently or maintains it at a fixed address. N/A State has interstate residency agreement with the following States: .

N/A State has open agreement (s).

N/A Not applicable; no residency requirement.

TN No. 13-0025-MM

Supersedes Approval Date DEC 1 9 2013 Effective Date_1/1/2014

TN No. 91-22

Cccms Medicaid Eligibility

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

1902(a)(46)(B) 8 U.S.C. 1611, 1612, 1613, and 1641 * 11903(v)(2),(3) and (4) 42 CFR 435.4 42 CFR 435.406 . a 42 CFR 435.956

Citizenship and Non-Citizen Eligibility

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

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

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

Who have declared themselves to be citizens or nationals of the United States, or an individual having satisfactory im immigration status, during a reasonable opportunity period pending verification of their citizenship, nationality or

satisfactory immigration status consistent with requirements of 1903(x), 1137(d), 1902(ee) of the SSA and 42 CFR 435.406, and 956.

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

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

@Yes (No

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

@yYes (No The date benefits are furnished is: e The date of application containing the declaration of citizenship or immigration status. C The date the reasonable opportunity notice is sent.

( Other date, as described:

Transmittal Number: NV-13-0025-MM Approval Date: DEC 1 9 201 SL rectve Date: January 1, 2014 Nevada $89-1

Page | of 3

Medicaid Eligibility

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

@yYes C©No

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

C Yes @No

Ir An individual is considered to be lawfully residing in the United States if he or she is lawfully present and otherwise meets the eligibility requirements in the state plan.

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

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

3. Is a non-citizen who has been paroled into the United States in accordance with 8 U.S.C. 1182(d)(5) for less than 1 year, except for an individual paroled for prosecution, for deferred inspection or pending removal proceedings;

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

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

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

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

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

{@) Granted an administrative stay of removal under 8 CFR 241;

{@) Beneficiary of approved visa petition who has a pending application for adjustment of status;

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

[Mf] Has been granted employment authorization; or

[ll] Is under the age of 14 and has had an application pending for at least 180 days; 6. Has been granted withholding of removal under the Convention Against Torture; 7. Is a child who has a pending application for Special Immigrant Juvenile status as described in 8 U.S.C. 1101(a)(27)(J); 8. Is lawfully present in American Samoa under the immigration laws of American Samoa; or

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

Transmittal Number: NV-13-0025-MM Approval Date: Effective Date: January 1, 2014 Nevada $89-2 DEC 1 9 2013

Page 2 of 3

Medicaid Eligibility

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

(1) Other

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

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

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

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

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

Transmittal Number: NV-13-0025-MM Approval Date: DEC 1 9 201 Bective Date: January 1, 2014 $89-3

Nevada Page 3 of 3

Table of Contents State/Territory Name: Nevada State Plan Amendment (SPA) #: NV-13-0026-MM This file contains the following documents in the order listed: 1) Single Streamlined Application Approval 2) Single Streamlined Application Pages 3) SPA Approval Letter 4) Additional Companion letter 5) CMS 179 Form/Summary Form (with 179-like data) 6) Superseding Pages Notice 7) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services San Francisco Regional Office 90 Seventh Street, Suite 5-300 (5W) San Francisco, CA 94103-6706

Division of Medicaid & Children’s Health Operations

August 22, 2014

Laurie Squartsoff, Administator Department of Health and Human Services Division of Health Care Financing and Policy 1100 East William Street, Suite 101 Carson City, NV 89710

Dear Ms. Squartsoff:

On June 6, 2014, the Centers for Medicare & Medicaid Services (CMS) approved Nevada’s State Plan Amendment (SPA) 13-0026-MM with an effective date of October 1, 2013. This SPA included approval for the State to use an interim alternative single streamlined paper application until September 30, 2014.

The CMS has reviewed the changes submitted with respect to Nevada’s alternative single streamlined paper application. The revised application addresses the concerns outlined in the companion letter that was issued with the SPA approval. This letter serves as official approval of Nevada’s alternative single streamlined paper application.

Enclosed is a copy of the approved alternative single streamlined paper application. Please incorporate these pages into the State Plan following the attachment to S94 entitled “Use of the Alternative Single Streamlined Application.”

If you have any additional questions or require any further assistance, please contact Brian Zolynas at (415) 744-3601 or Brian.Zolynas@cms.hhs.gov.

Sincerely,

/s/

Hye Sun Lee Acting Associate Regional Administrator Division of Medicaid and Children’s Health Operations

Enclosure

Application for Health Insurance

Apply Online

Access your benefits faster.

Did you know that you can apply, enroll and start using your health benefits sooner by 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

Personal Assistance Get assistance with your application.

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

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

By Mail Fill out the attached paper application.

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

• Follow the instructions and complete ALL areas that apply to you and your family. • Submit your application to the local Welfare Office or mail to: DWSS

PO Box 15400

Las Vegas, NV 89114

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. Transmittal Number: 13-0026-MM Nevada Approval Date: August 22, 2014 Paper Single Streamlined Application 1 Effective Date: October 1, 2014

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

Contact Information (We will need to contact an adult member of the family.) First Name: Middle Name: Last Name: Suffix Date of Birth

Home Address:

Apartment Number:

City:

State:

Zip Code:

If you don't have a permanent address, you still need to give a valid mailing address. 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: □ Yes □ No Email address: _____________________________________________ Preferred language (if not English): □ Spanish □ Other: _____________ Interpreter needed? □ Yes □ 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  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  If you 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. Transmittal Number: 13-0026-MM Nevada Approval Date: August 22, 2014 Paper Single Streamlined Application 2 Effective Date: October 1, 2014

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 Head of Household Information First Name, MI, Last Name & Suffix Marital Status If married, do you live with your spouse?

□ Yes □ No Relationship to you? SELF Social Security Number (OPTIONAL) Date of Birth Pregnant? □ Yes □ No Sex _______ - ______ - __________ ___/___/_____ Due Date: _______________________ □ Male If yes, how many babies are expected: _________ □ Female Do you plan to file a federal income tax return NEXT YEAR? □ Yes If yes, answer questions 1 - 3 □ No If no, 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? □ Yes □ No

If yes, name of spouse/partner: ______________________________________________________ 2. Will you claim any dependents on your tax return? □ Yes □ No

If yes, list name(s) of dependents: ____________________________________________________ 3. Are you being claimed as a dependent on someone else's tax return? □ Yes □ No

If yes, please list the name of the tax filer: ______________________________________________

How are you related to the tax filer? ___________________________________________________ Are you applying for Medicaid, Nevada Check-Up or assistance with your health insurance premiums (Advanced Premium Tax Credit - APTC)? □ Yes If yes, answer all the questions below. □ No 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? □ Yes □ No Are you a U.S. citizen? □ Yes □ No Have you lived in the U.S. since 1996? □ Yes □ No If not a U.S. citizen, do you have eligible immigration status? □ Yes □ No If yes, provide the following information: Type: ID Number:

________________ ____________

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? □ Yes □ No Are you a full-time student? □ Yes □ No Are you an American Indian or Alaskan Native? □ Yes □ No

If yes, what tribe? ___________________________________________________________

If under age 26, have you ever been in foster care? □ Yes □ No If yes, what state? ___________________ Age when you left the program? ______________ Did you receive health care through a state Medicaid program?

□ Yes □ No Are you the parent or primary caretaker relative of any child(ren), under the age of 19, in the household? □ Yes □ No If yes, who? _____________________________________________________________ Do you have medical bills for the past three months that you need help with? □ Yes □ No

If yes, what months? ________________________________________________

Transmittal Number: 13-0026-MM Nevada Approval Date: August 22, 2014 Paper Single Streamlined Application 3 Effective Date: October 1, 2014

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 Head of Household Information continued: Are you legally blind or permanently disabled? □ Yes □ No Are you receiving Supplemental Security Income (SSI)? □ Yes □ No Do you need help with activities of daily living through personal assistance services or a medical facility? □ Yes □ No Current Job and Income Information

□ Not employed - Skip to 'Other Income' section CURRENT JOB: In the past 3 months, did you: □ Change jobs □ Stop working □ Work fewer hours □ None of these Employer Name: (if self-employed, write 'SELF')

Average hours worked each week Employer Address:

Employer Phone Number: ( ) City:

State:

Zip Code: Gross wages/tips per pay period: How often are you paid? □ Weekly □ Every 2 weeks $

□ Semi-Monthly □ Monthly □ Annually If self-employed, please answer the following questions: Type of work: _____________________________________________________________________________ How much net income (profits once expenses are paid) will you receive this month? $ ____________________ OTHER INCOME: Check all that apply and give amount and how often you receive it.

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.

□ None

Tribal Income? □ Unemployment $ ___________ How often? ____________

□ Retirement $ ___________ How often? ____________

□ Pensions $ ___________ How often? ____________

□ Social Security (RSDI) Benefits $ ___________ How often? ____________

□ Interest/Dividends $ ___________ How often? ____________ □ Yes □ No □ Annuities $ ___________ How often? ____________ □ Yes □ No □ Rental or Royalty Income $ ___________ How often? ____________ □ Yes □ No □ Capital Gains $ ___________ How often? ____________ □ Yes □ No □ Farming or Fishing Income $ ___________ How often? ____________ □ Yes □ No □ Alimony $ ___________ How often? ____________

□ Scholarships & Grants $ ___________ How often? ____________ □ Yes □ No □ Cash Advances $ ___________ How often? ____________

□ Gambling Winnings $ ___________ How often? ____________

□ Other $ ___________ How often? ____________

□ Yes □ No

Transmittal Number: 13-0026-MM Nevada Approval Date: August 22, 2014 Paper Single Streamlined Application 4 Effective Date: October 1, 2014

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

Head of Household Information continued: DEDUCTIONS (Only list deductions reported on the IRS form 1040): Check all that apply and give amount and how often. 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. □ Educator expenses $ __________ How often? ____________

□ Health savings account $ __________ How often? ____________

□ Moving expenses $ __________ How often? ____________

□ Alimony $ __________ How often? ____________

□ IRA deductions $ __________ How often? ____________

□ Business expenses of reservists, performing artists, and fee-basis government officials $ __________ How often? ____________ □ Penalty paid on early withdrawal of savings $ __________ How often? ____________

□ Student loan interest $ __________ How often? ____________

□ Tuition and fees $ __________ How often? ____________

□ Domestic production activities $ __________ How often? ____________ YEARLY INCOME: 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: $ __________

RACE / ETHNICITY Are you Hispanic, Latino or of Spanish origin? (optional) □ Yes □ No If Hispanic/Latino (check all that apply - optional): □ Mexican □ Mexican American □ Puerto Rican □ Cuban □ Chicano/a □ Other Race (optional) - check all that apply □ White □Filipino □ Native Hawaiian □ Black or African American □Japanese □ Guamanian or Chamorro □ American Indian or Alaska Native □Korean □ Samoan □ Asian Indian □Vietnamese □ Other Pacific Islander □ Chinese □Other Asian □ Other

Transmittal Number: 13-0026-MM Nevada Approval Date: August 22, 2014 Paper Single Streamlined Application 5 Effective Date: October 1, 2014

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 Additional Member Information (If you have more than two people to include, make a copy of the Additional Member section and complete.) First Name, MI, Last Name & Suffix Marital Status If married, do they live with their spouse?

□ Yes □ No Relationship to you?

Social Security Number (OPTIONAL) Date of Birth Pregnant? □ Yes □ No Sex _______ - ______ - __________ ___/___/_____ Due Date: _______________________ □ Male If yes, how many babies are expected: _________ □ Female Do they plan to file a federal income tax return NEXT YEAR? □ Yes If yes, answer questions 1 - 3 □ No If no, 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? □ Yes □ No

If yes, name of spouse/partner: ______________________________________________________ 2. Will they claim any dependents on their tax return? □ Yes □ No

If yes, list name(s) of dependents: ____________________________________________________ 3. Are they being claimed as a dependent on someone else's tax return? □ Yes □ No

If yes, please list the name of the tax filer: ______________________________________________

How are they related to the tax filer? ___________________________________________________ Are they applying for Medicaid, Nevada Check-Up or assistance with their health insurance premiums (Advanced Premium Tax Credit - APTC)? □ Yes If yes, answer all the questions below. □ No 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? □ Yes □ No Are they a U.S. citizen? □ Yes □ No Have they lived in the U.S. since 1996? □ Yes □ No If not a U.S. citizen, do they have eligible immigration status? □ Yes □ No If yes, provide the following information: Type: ID Number:

________________ ____________

Are they, their spouse or their parent (if they are a minor) an honorably discharged veteran or active duty member of the military? □ Yes □ No Are they a full-time student? □ Yes □ No Are they an American Indian or Alaskan Native? □ Yes □ No

If yes, what tribe? If under age 26, have they ever been in foster care? □ Yes □ No If yes, what state? ___________________ Age when they left the program? ______________ Did they receive health care through a state Medicaid program?

□ Yes □ No Are they a parent or primary caretaker relative of any child(ren), under the age of 19, in the household? □ Yes □ No If yes, who? _____________________________________________________________ Do they have medical bills for the past three months that they need help with? □ Yes □ No

If yes, what months? Transmittal Number: 13-0026-MM Nevada Approval Date: August 22, 2014 Paper Single Streamlined Application 6 Effective Date: October 1, 2014

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 Additional Member Information continued: Are they legally blind or permanently disabled? □ Yes □ No Are they receiving Supplemental Security Income (SSI)? □ Yes □ No Do they need help with activities of daily living through personal assistance services or a medical facility? □ Yes □ No Current Job and Income Information

□ Not employed - Skip to 'Other Income' section CURRENT JOB: In the past 3 months, did they: □ Change jobs □ Stop working □ Work fewer hours □ None of these Employer Name: (if self-employed, write 'SELF') Average hours worked each week

Employer Address:

Employer Phone Number: ( ) City:

State:

Zip Code: Gross wages/tips per pay period: How often are they paid? □ Weekly □ Every 2 weeks $

□ Semi-Monthly □ Monthly □ 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? $ ____________________ OTHER INCOME: Check all that apply and give amount and how often they receive it.

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.

□ None

Tribal Income? □ Unemployment $ ___________ How often? ____________

□ Retirement $ ___________ How often? ____________

□ Pensions $ ___________ How often? ____________

□ Social Security (RSDI) Benefits $ ___________ How often? ____________

□ Interest/Dividends $ ___________ How often? ____________ □ Yes □ No □ Annuities $ ___________ How often? ____________ □ Yes □ No □ Rental or Royalty Income $ ___________ How often? ____________ □ Yes □ No □ Capital Gains $ ___________ How often? ____________ □ Yes □ No □ Farming or Fishing Income $ ___________ How often? ____________ □ Yes □ No □ Alimony $ ___________ How often? ____________

□ Scholarships & Grants $ ___________ How often? ____________ □ Yes □ No □ Cash Advances $ ___________ How often? ____________

□ Gambling Winnings $ ___________ How often? ____________

□ Other $ ___________ How often? ____________ □ Yes □ No

Transmittal Number: 13-0026-MM Nevada Approval Date: August 22, 2014 Paper Single Streamlined Application 7 Effective Date: October 1, 2014

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 Additional Member Information continued: DEDUCTIONS (Only list deductions reported on the IRS form 1040): Check all that apply and give amount and how often. 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. □ Educator expenses $ __________ How often? ____________

□ Health savings account $ __________ How often? ____________

□ Moving expenses $ __________ How often? ____________

□ Alimony $ __________ How often? ____________

□ IRA deductions $ __________ How often? ____________

□ Business expenses of reservists, performing artists, and fee-basis government officials $ __________ How often? ____________ □ Penalty paid on early withdrawal of savings $ __________ How often? ____________

□ Student loan interest $ __________ How often? ____________

□ Tuition and fees $ __________ How often? ____________

□ Domestic production activities $ __________ How often? ____________ YEARLY INCOME: If the income listed on this page is not steady from month to month, please tell us what they expect their yearly 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: $ __________

RACE / ETHNICITY Are they Hispanic, Latino or of Spanish origin? (optional) □ Yes □ No If Hispanic/Latino (check all that apply - optional):

□ Mexican □ Mexican American □ Puerto Rican □ Cuban □ Chicano/a □ Other Race (optional) - check all that apply □ White □Filipino □ Native Hawaiian □ Black or African American □Japanese □ Guamanian or Chamorro □ American Indian or Alaska Native □Korean □ Samoan □ Asian Indian □Vietnamese □ Other Pacific Islander □ Chinese □Other Asian □ Other

Transmittal Number: 13-0026-MM Nevada Approval Date: August 22, 2014 Paper Single Streamlined Application 8 Effective Date: October 1, 2014

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

HEALTH INSURANCE INFORMATION Answer the following questions for everyone who is applying for help to pay for health insurance. INSURANCE FROM JOBS: (This includes coverage from someone else's job, such as a parent, domestic partner or spouse, and includes private employer plans as well as TRICARE, federal or state employee plans and Peace Corps.) Is anyone offered health coverage from a job? □ Yes If yes, answer the following questions □ No If no, 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 (EIN) Employer Phone Number ( ______ ) ______- ________ Employer Address:

City State ZIP Code Who can we contact about employee health coverage at this job?

Phone Number:

( ______ ) ______- _______ Email Address: Is the employee currently eligible for coverage offered by this employer? □ Yes If yes, will this job offer coverage NEXT year? □ Yes □ No □ No If the employee is NOT currently eligible, will they be eligible in the NEXT 3 months? □ Yes □ No

If yes, provide date: ___/___/_____ Who in the employee's family will the health plan cover? □ Spouse □ Domestic Partner □ Dependent(s) Who does this plan offer coverage to? (If you need more space, attach another sheet of paper) Person Name (First Name, MI, Last Name) Enrolled now, plans to enroll, or not enrolled Changes you plan to make next year

□ Enrolled Now □ Plans to drop coverage □ Plans to Enroll

Date: ___/___/_____

Start Date: ___/___/_____ □ Will become eligible □ Not Enrolled

Start Date: ___/___/_____

□ Enrolled Now □ Plans to drop coverage □ Plans to Enroll

Date: ___/___/_____

Start Date: ___/___/_____ □ Will become eligible □ Not Enrolled

Start Date: ___/___/_____

□ Enrolled Now □ Plans to drop coverage □ Plans to Enroll

Date: ___/___/_____

Start Date: ___/___/_____ □ Will become eligible □ Not Enrolled

Start Date: ___/___/_____

Transmittal Number: 13-0026-MM Nevada Approval Date: August 22, 2014 Paper Single Streamlined Application 9 Effective Date: October 1, 2014

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 INSURANCE FROM JOBS (continued): Does the employer offer a health plan that meets the minimum value standard*? □ Yes □ 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? □ Weekly □ Every 2 weeks □ Twice a month □ Once a month □ Quarterly □ Yearly

What change will the employer make for the new plan year (if known)? □ Employer won’t offer health coverage □ Employer will start offering health coverage to employees or change the premium for the lowest-cost plan available only to the employee that meets the minimum value standard. * (Premium should reflect the discount for wellness programs.)

a. How much would the employee have to pay in premiums for this plan? $ _______________ b. How often? □ Weekly □ Every 2 weeks □ Twice a month □ Once a month □ Quarterly □ 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.) OTHER HEALTH INSURANCE INFORMATION Does anyone have other health insurance, including Veterans, Medicaid/Nevada Check-Up, Medicare, COBRA, Private, or other Retiree Health Plan? □ Yes □ No If yes, provide the following information: Who has other health insurance? What type do they have? Name of Plan Policy Number Name:

Name:

OTHER INFORMATION Renewal of Coverage (for APTC households only) To make it easier to determine my eligibility for help paying for health coverage in future years, I 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:

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

Transmittal Number: 13-0026-MM Nevada Approval Date: August 22, 2014 Paper Single Streamlined Application 10 Effective Date: October 1, 2014

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 11 of 14

Authorized Representative You can give a trusted friend or partner permission to talk about this application with us, see your information and act for you on matters related to this application. This person is called an "authorized representative." Do you want to name someone as your authorized representative? □ Yes □ No If no, 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

Date Medicaid Estate Recovery Program 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 __________ Third Party Liability I understand the following is an eligibility requirement to receive Medicaid benefits:

1) If anyone on this application receives Medicaid benefits, I 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 __________ Referral Information: How did you hear about these programs? Check ONLY one: □ Covering Kids & Families

□ School

□ Tribal Resources □ WIC

□ Clinic

□ Friend / Family □ Other: ____________________________

Non-Discrimination Following federal law, discrimination is not permitted on the basis of race, color, national origin, sex, age, sexual 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).

Transmittal Number: 13-0026-MM Nevada Approval Date: August 22, 2014 Paper Single Streamlined Application 11 Effective Date: October 1, 2014

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

IF YOU ARE NOT REGISTERED TO VOTE WHERE YOU LIVE NOW, WOULD YOU LIKE TO REGISTER TO VOTE HERE TODAY? (Please check one) □ Yes □ 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.

Reviews and Investigations By signing this application, you are authorizing the Department of Health and Human Services to make 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 __________ Your Rights 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 __________ Your Responsibilities 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 I must report by the fifth (5th) of the following month. I understand that a change in my information could affect my eligibility for member(s) of my household.

Initial __________ Transmittal Number: 13-0026-MM Nevada Approval Date: August 22, 2014 Paper Single Streamlined Application 12 Effective Date: October 1, 2014

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 Release of Information 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 Cooperation with Child Support Enforcement 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? □ Yes □ No

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

If yes, write the name of the person incarcerated here: ___________________________ □ Check here if this person is pending disposition of charges.

Privacy Policy 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 __________

Transmittal Number: 13-0026-MM Nevada Approval Date: August 22, 2014 Paper Single Streamlined Application 13 Effective Date: October 1, 2014

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

Health Plan Selection (this section applies to Medicaid and Nevada Check-Up households only and does not apply if eligible for APTC): Families 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 Please read and sign this application.  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.

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

____/____/_____ Signature or Mark of Applicant

Date

____/____/_____ 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 Mail Your Completed Application. Submit your application to the local Welfare Office or, mail your application to:

PO BOX 15400 Las Vegas, NV 89114 Did you remember to:  Tell us about everyone in your family & household, even if they don't need insurance?

 Ask your employer about any job-related insurance?

 Sign this application?

Transmittal Number: 13-0026-MM Nevada Approval Date: August 22, 2014 Paper Single Streamlined Application 14 Effective Date: October 1, 2014

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

San Francisco Regional Office

90 Seventh Street, Suite 5-300 (5W)

San Francisco, CA 94103-6706

es

CMS

CENTERS FOR MEDICARE & MEDICAID SERVICES DIVISION OF MEDICAID & CHILDREN’S HEALTH OPERATIONS

JUN 06 2014

Michael J. Willden, Director

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

Carson City, NV 89706

Dear Mr. Willden:

Enclosed is an approved copy of Nevada’s State Plan Amendment (SPA) 13-0026-MM, which was submitted to the Centers for Medicare & Medicaid Services (CMS) on October 9, 2013. SPA 13- 0026-MM incorporates the MAGI-based eligibility process requirements, including the single streamlined application, into Nevada’s state plan in accordance with the Affordable Care Act.

The effective date of this SPA is October 1, 2013.

The approval of 13-0026-MM includes full approval of your state’s alternative paper application used to apply for multiple human service programs. Until September 30, 2014, the state will use interim alternative single streamlined paper and online applications. By September 30, 2014, the state will implement revised alternative paper and online applications that addresses CMS concerns outlined in the companion letter issued with this SPA approval.

Enclosed is a copy of the following $94 state plan pages and attachments to be incorporated within a separate section at the end of Nevada’s approved state plan:

S94, pages S94-1, $94-2 Attachment 1 — Nevada’s alternative paper application used to apply for multiple human service programs ;

e Attachment 2 — Statement of use with respect to the alternative single streamlined online application

e Attachment 3 — Statement of use with respect to the alternative single streamlined paper application

In addition, enclosed is a summary of state plan pages which are superseded by SPA 13-0026-MM, which should also be incorporated into a separate section in the front of the state plan.

e Superseding Pages of State Plan Material, 13-0026-MM

Mr. Willden — Page 2

CMS appreciates the significant amount of work your staff dedicated to preparing this State Plan Amendment. If you have any questions concerning this SPA, please contact Brian Zolynas by phone at (415) 744-3601 or by email at Brian.Zolynas@cms.hhs.gov.

Sincerely,

Gloria Nagle, Ph.D., MPA Associate Regional Administrator Division of Medicaid & Children’s Health Operations

Enclosures

ce: Laurie Squartsoff, Administrator, DHCFP Marta Stagliano, Chief, Compliance, DHCFP

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

San Francisco Regional Office

90 Seventh Street, Suite 5-300 (5W)

San Francisco, CA 94103-6706

CENTERS FOR MEDICARE & MEDICAID SERVICES DIVISION OF MEDICAID & CHILDREN’S HEALTH OPERATIONS

JUN 0 6 2014

Michael J. Willden, Director

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

Carson City, NV 89706

Dear Mr. Willden:

This letter is being sent as a companion to Centers for Medicare & Medicaid Services (CMS) approval of state plan amendment (SPA) 13-0026-MM, which was submitted to CMS on October 9, 2013. Our review of this submission included a review of the state’s alternative single streamlined paper and online applications and the state’s alternative paper application used to apply for multiple human service programs.

Until September 30 2014, the state will use interim alternative single streamlined paper and online applications. The interim alternative paper and online applications need to be revised to reflect the following changes.

Date by which changes

Necessary changes: will be completed:

1. The state will remove the tobacco question on the alternative | September 30, 2014 single streamlined paper application. On the alternative single streamlined online application, the state will only ask the tobacco question to individuals who appear ineligible for Medicaid/CHIP. ;

2. The state will remove the question regarding income from September 30, 2014 inheritances on both the alternative single streamlined paper and online applications.

Please submit the revised alternative single streamlined paper and online applications to CMS for review no later than September 1, 2014 to ensure approval by September 30, 2014. We continue to be available to provide technical assistance. If you have any questions about your application, please contact Dena Greenblum at Dena.Greenblum@cms.hhs.gov or (410) 786-8684. If you

Mr. Willden — Page 2

have any questions about this letter or need any additional information, please contact Brian Zolynas by phone at (415) 744-3601 or by email at Brian.Zolynas@cms.hhs. gov.

Sincerely,

Gloria Nagle, Ph.D., MPA Associate Regional Administrator Division of Medicaid & Children’s Health Operations

ce: Laurie Squartsoff, Administrator, DHCFP Marta Stagliano, Chief, Compliance, DHCFP

Medicaid State Plan Eligibility: Summary Page (CMS 179)

State/Territory name: Nevada 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.

13-0026-MM

Proposed Effective Date 10/01/2013 (mm/dd/yyyy)

Federal Statute/Regulation Citation 42 CFR 435, Subpart J and Subpart M

Federal Budget Impact

Federal Fiscal Year Amount First Year 2014 $0.00 Second Year 2015 $0.00

Subject of Amendment

Defines the application process and indicates the states election to use an alternative single streamlined application as well as an alternative application for multiple programs.

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

Comments of Governor's office received Describe:

No reply received within 45 days of submittal

Other, as specified Describe: The Governor's Office does not wish to review the State Plan Amendment.

Signature of State Agency Official Submitted By: Robyn Heddy Last Revision Date: Jun 6, 2014

Submit Date: Oct 9, 2013

SUPERSEDING PAGES OF

STATE PLAN MATERIAL TRANSMITTAL NUMBER: STATE: 13-0026-MM Nevada PAGE NUMBER OF THE PLAN SECTION OR PAGE NUMBER OF THE SUPERSEDED PLAN SECTION ATTACHMENT: OR ATTACHMENT (If Applicable):

$94 Eligibility Process, Page S94-1, S94-2 : Section 2, Page 10, section 2.1(a), 91-22

Section 2, Page 11a, section 2.1(d), 92-6

Attachment 1

Division of Welfare and Supportive Services

Application for Assistance “Working for the Welfare of ALL Nevadans”

Programs You May Apply For:

Food Assistance from the Supplemental Nutrition Assistance Program (SNAP) helps people buy food. Temporary Assistance for Needy Families (TANF) helps families with children meet their basic needs with cash assistance.

Time Frames ¢ SNAP benefits are processed within 30 days from the date of the application. If your household has little or no income, you could receive SNAP benefits within 7 days from the date of your application. SNAP benefits are paid from the date of the application. e TANF benefits are paid from the date of approval or 30 days from the date of the application, whichever is sooner. TANF applications are processed within 45 days from the application date unless there are unusual circumstances.

Denial of benefits for one program does not automatically affect the decision on another program you may be applying for.

Social Security Numbers You will be asked to provide Social Security Numbers (SSN) for all persons (including yourself) who are applying for assistance, pursuant to Title 42 USC 1320b-7. Providing or applying for a SSN is voluntary. For SNAP, any person who wants assistance but does not want to give information about his or her SSN will not be eligible for benefits. Other family or household members may still get benefits if they are otherwise eligible. For TANF, if a required household member fails or refuses to provide an SSN without good cause, the entire household will be ineligible for TANF benefits. This includes all individuals who income and needs are used to determine eligibility for the TANF program.

SSNs are used to verify your household’s income and resources and to conduct computer matching with other agencies such as the Social Security Administration, Employment Security Division, Child Support Enforcement Programs and the Internal Revenue Service. It is also used to gather workforce information, investigations, recover overpaid benefits and to ensure duplicate benefits are not received.

Citizenship/Immigration Status You will be required to provide information about the citizenship and/or immigration status for all persons (including yourself) who are applying for assistance. For SNAP, if any of these persons do not want to give us information about his/her citizenship and/or immigration status, he/she will not be eligible for benefits. Other family or household members may still receive benefits if they are otherwise eligible. For TANF, if a required household member fails or refuses to provide verification of their status, the entire household will be ineligible for TANF benefits. Qualified Non-Citizen status is verified with the United States Citizenship and Immigration Service (USCIS) for eligibility purposes. Information on non-applicants or non-qualified non-citizens will not be shared with USCIS. Non-Discrimination

“In accordance with Federal law and U.S. Department of Agriculture (USDA) and U.S. Department of Health and Human Services (HHS) policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, or disability. Under the Food Stamp Act and USDA policy, discrimination is prohibited also on the basis of religion or political beliefs.

“To file a complaint of discrimination, contact USDA or HHS. Write USDA, Director, Office of Civil Rights, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410 or call (800) 795-3272 (voice) or (202) 720-6382 (TTY). Write HHS, Director, Office for Civil Rights, Room 506-F, 200 Independence Avenue, S.W., Washington, D.C. 20201 or call (202) 619-0403 (voice) or (202) 619-3257 (TTY). USDA and HHS are equal opportunity providers and employers.”

Special Accommodations To get SNAP (food assistance) and/or TANF (cash assistance), most people have to come into the office for a face-to-face interview; you need to bring identification with you. Do you have a physical or mental condition that requires special accommodations during your interview? OVYES (JNO If YES, what do you need? (Most services are free to you.) Do you speak English? [J] YES [J NO _I£NO, what language do you speak? Do you need an interpreter for your interview? OLYES [INO (This service is free to you.)

Transmittal Number: 13-0026-MM Approval Date: June 6, 2014 Effective Date: October 1, 2013 Nevada 1

Attachment 1

Please everyone who lives in the home you, whether you consider them household members or not. If someone is pregnant please list the unborn child(ren) as household members as well. Please list the head of household first; you may choose who this individual will be. The person chosen as the head of household will be the case name. Fill out as much of the application as you can; you may ask for help if you need it.

Social State or Security Country Number of Birth

Date of Birth

Relation to

Last Name First Name You

Middle Initial Modifier Jr. Sr. Gender Age Marital Status ** US. Citizen Y/N *Race/Ethnicity Last Grade Completed Month/Year Completed FOOD TANF NONE

SELF

OVO |O;O;O oO,O OVO OO ;O;O\O OVO/O;O OOO

Are there additional people in your home? [] YES [] NO If“YES”, list them on a separate sheet of paper.

Race - Please check one of the boxes that best describes your household - () Hispanic/Latino or 1] Non-Hispanic or Latino

*Ethnicity (Optional) - Please choose one of the following ethnicity codes for each household member: A-Asian; B-Black or African American; I- American Indian or Alaska Native; J-American Indian or Alaska Native and White; L-Asian and White; M-Black or African American and White; N- American Indian or Alaska Native and Black or African American; U-Native Hawaiian or Other Pacific Islander; W-White; Z-2 or more combinations not listed above.

**Marital Status ~ Please choose one of the following marital status codes for each household member: D-Divorced; L-Legally Separated; M-Married; N-Never Married; P-Separated; W-Widowed

Home Address (Give Directions if you do not have an address.) City State Zip Code Mailing Address (If different from your home address.) City State Zip Code Home Phone Cell/Message/Daytime Phone E-mail Address

If you are applying for Food Assistance, please answer questions 1 through 6 about your household. A Food

Assistance household includes all people who live and share food with you. Based on your answers below, you may

qualify for expedited service. You may complete, sign and submit the first page in order to start the application

process.

1. Do you usually buy, prepare and eat with others you live with? CU YES [JNO If “NO”, list who buys their food separately

List the total gross amount of money your household received or expects to receive this month. How much do all persons have in cash, checking and savings accounts?

How much is your current monthly cost for housing (rent/mortgage) and utilities.

Are you or any person(s) in your household a migrant or seasonal farm worker? LJ YES L[]NO Have you or any person in your household received TANF, Food Assistance or Indian Commodities

in Nevada or any other state? CIYES [JNO If “YES”, Who? What Benefits?

ANARwWN Aw

Where? Last month and year benefits were received / 1 certify under penalty of perjury, my answers are correct and complete to the best of my knowledge and ability. I swear I have honestly reported the citizenship of myself and anyone I am applying for.

Your Signature Date FOR OFFICE USE ONLY — EXPEDITED SERVICE SCREENING: HOUSEHOLD ELIGIBLE FOR EXPEDITED SERVICE? (J YES [] NO Expedited service screener signature: DATE: Transmittal Number: 13-0026-MM Approval Date: June 6, 2014 Effective Date: October 1, 2013 Nevada 2

Attachment 1

. Do you want someone other than yourself, age 18 or older, to apply for benefits or act on your behalf?

rT YES [_]No

If “YES” Who? Age? Telephone # (__) Address 8. Incase of emergency, who would you like us to contact? . Name Relationship

Telephon _ Addr

9. Do you plan to continue living in evada? If “NO”, Explain:

(MM/YYYY)

[_] ves [No

10. List the most recent date you started living in Nevada. / 11. Are you or any person(s) in your household a member of an American Indian or Alaskan Native Tribe? If “YES,” Who? What Tribe? 12. Are you or any person(s) in your household currently disqualified for an Intentional Program Violation (IPV)? If “YES”, Who? What State? .

(yes [] No

13. Have you or any person(s) in your household been convicted of a felony drug offense on or after August 22, 1996? If “YES”, Who? When? Where?

[_] YEs [] No

14, Are you or any person(s) in your household currently participating in or have participated in a Drug Addiction or Alcohol Treatment Program? If “YES”, Who? Date Entered / / Date Completed Facility Name: Facility Address

Clyes [)Nno a)

15. Are you or any person(s) in your household currently wanted by Law Enforcement? If “YES”, Who? Why?

16. Are you or any person(s) in your household pregnant? f “YES” Who?

Expected Due Date? / /

: Are you or any person(s) in your household blind, disabled or unable to work due to illness or injury? If “YES”, Who? When did this condition begin? / / What is the disability?

18. Are you or any person(s) in your household NOT a U.S. Citizen?

LJ] yes L]No

LJYEes []No

(MM/DD/YYYY)

LJyes []No

If “YES” Who? Alien Registration # When did this person enter the United States? / / If “YES” Who? Alien Registration #

(MM/DD/YYYY)

When did this person enter the United States?

19. Are you or any person(s) in your household between the ages of 7 and 11 or over 16 attending school? If “YES” Who? . School Name?

al ”” Who? _ School Name?

20. Are you or any person(s) in your household currently working, including self-employment?

| ]yeEs []No

If “YES”, Who is employed? Hourly Wage? $ Hours worked per week? How often are they paid? Tips paid per month? $ Start Date? / Employer’s Name? Employer’s Telephone Employer’s Address? Transmittal Number: 13-0026-MM Approval Date: June 6, 2014 Effective Date: October 1, 2013

Nevada 3

Attachment 1

If “YES”, for additional household members

Who is employed? Hourly Wage? $ Hours worked per week? How often are they paid? Tips paid per month? $ Start Date? / / Employer’s Name? Employer’s Telephone? Employer’s Address? If more than two persons are currently working, please attach an additional sheet of paper. 21. Have you or any persons(s) in your household had a job that ended in the last three months? L] YES [_]NO Who was employed? Hourly Wage? $ Hours worked per week? How often where they paid? Tips received per month? § $ Employer’s Name? Start Date? / L When did the job end? / / Employer’s Address Employer’s Telephone? C_) -

Reason for leaving? [[] Quit L] Fired [] Leave of Absence [_] Applied Worker’s Compensation [| Other If “YES” for additional household members:

Who was employed? Hourly Wage? $ Hours worked per week?

How often where they paid? Tips received per month? $

Employer’s Name? Start Date? / / When did the job end? / / Employer’s Address Employer’s Telephone? C_) -

Reason for leaving? [[] Quit L] Fired [] Leave of Absence [] Applied Worker’s Compensation [] Other 22. Are you or any person(s) in your household currently registered with or working for a Temporary Employment

Service/Agency? LJ YEs | NO If “YES”, Who? Which Service/Agency?

23. Are you or any person(s) in your household currently on strike? LJ YES Cl NO If “YES”, Who?

24. Do you or any person(s) in your household work in exchange for food, shelter or something else? im YES LJ NO If “YES”, Who? What do they receive for their work? What is the value of this exchange? When did this begin?

. Please check the “YES” box for each of the types of the unearned income you or any person(s) in your household receives or has applied for. If you do not check the “yes” box for any of the unearned income below you are acknowledging neither you or any person(s) in your household have any unearned or other income.

SOURCE Person Applied/Receiving . Gross amount Per

Alimony

Boarder/Roomer Income

Child Support (Voluntary or Court Ordered) Contributions/Gifts

Educational Assistance/Student Loans Foster Care

General Assistance

Insurance Settlements Interest/Dividends

Loans

Military Allotment

Mining Claims

Pan Handling

Pensions/Retirement

Property Rentals

Railroad Retirement

Royalties

Social Security Benefits (RSDI)

dooqgandoooecooodccKd §

18 | 8 | a8 | 8 | 28 | 8 8 | 68 18) 18 | 168 108 18 18 |

Transmittal Number: 13-0026-MM Approval Date: June 6, 2014 Effective Date: October 1, 2013 Nevada 4

Attachment 1

Strike Benefits

Subsidized Housing

Supplemental Security Income (SSI)

Supported Living Arrangement (SLA)

TANF Assistance

Trust Income

Unemployment Insurance

Utility Allowance/Rebate Check

Veteran’s Benefits

Gambling Winnings

OOOO oOooO

Worker’s Compensation or Temporary

Disability

neither you or any person(s) in your household have any resources:

| 26. If you do not have any income, please explain how you are paying your bills and buying persona

Pt | P| |G | [P| 4 1 1D

27. Please mark the “YES” box for each types of resources you or any person(s) in your household has, even if jointly owned with someone outside the household. If you do not check the “YES” box for any of the resources below you are acknowledging

ms for your household?

Transmittal Number: 13-0026-MM Nevada

Approval Date: June 6, 2014 5

BANK ACCOUNTS ACCOUNT n NUMBER a TYPE OF ACCOUNT OWNER(S) NAME OF BANK VALUE (Please list the last 4 numbers only) CI | Savings Account $ CO | Checking Account $ (] | Credit Union Account $ C1 | Minor Savings $ C1 _| Business Account $ oO Christmas Club $ Account oO Educational Savings $ Account OO | Patient Trust Fund $ oO Individual Indian $ Money Account LIFE INSURANCE/TRUSTS/BURIALS POLICY OR AC @ | TYPE OF ACCOUNT OWNER(S) NAME OF COMPANY FACE VALUE NUMBER (lease ™ OR BANK list the last 4 numbers only) (0 | Life Insurance $ Icsv$ C1 | Available Trusts $ 0 _| Unavailable Trusts $ CJ | Burial Funds/Plans $ /csv$ BF | Life Estates a

Effective Date: October 1, 2013

Attachment 1

NVESTMENT & RETIREMENT ACCOUNTS

TYPE OF ACCOUNT

OWNER(S)

COMPANY

Savings Bonds

Stocks or Bonds

NAME OF BANK OR

VALUE

ACCOUNT NUMBER (Please list the last 4 numbers only)

Certificates of Deposit

Individual Retirement Accounts (IRA)

Keogh Account

(401K)

O} O | 0 |OjOjC) Yes

Annuities

PERSONAL PROPERTY

TYPE OF PROPERTY

OWNER(S)

LOCATION

CONTENTS OR TYPE OF

RESOURCE

CURRENT OR MARKET VALUE

Safe Deposit Box

Livestock

Land Mineral Rights

Mining Claims

Business Equipment/ Inventory

O | 0 /OWOjOIC} Yes

Houses/Land or Buildings

Is this property currently

for sale?(_] Yes [] No

A PARIS

MISCELLANEOUS

TYPE OF RESOURCE

OWNER(S)

CURRENT VALUE

Promissory Notes

Cash on Hand

$ $

O}OlO} yes

Other: (please list)

$

. Do you or any person(s) in your household own,

28. Are any of the resources in question 27 designated as money for burial? If “YES” Which resources?

or are they buying, a car, motorcycle, trailer, truck, camper, boat, motorcycle,

L]yEs []No

Who was the resource transferred to? Why was the resource transferred?

ATV, etc.? (Please include any vehicles that are not currently working.) CL] YES in NO If “YES”, Please complete the information below. OWNER TYPE OF YEAR, MAKE & IS THE VEHICLE FAIR MARKET AMOUNT VEHICLE MODEL REGISTERED VALUE OWED LJ YES L]NO $ $ Ll yEs [] NO $ $ L] YES [] NO $ $ 30. Have you or any person(s) in your household sold, traded or given away any money, vehicles, property or other resources, or closed any bank accounts in the last 3 months? 4 YES L] NO If “YES”, Who? What resource was transferred? When? / (MM/YYYY) What was the value of this resource when it was transferred? $

Relationship to you?

Transmittal Number: 13-0026-MM

Nevada

Approval Date: June 6, 2014 6

Effective Date: October 1, 2013

Attachment 1

31. Please choose which of the following housing costs that you or any person(s) in your household pays.

RENT (1 MORTGAGE/RELATED EXPENSES [CL] NONE 32. If you are renting your home, how much is the monthly rent? (Including space/lot rent) $ 33. What is your landlord’s Name? Landlord’s Telephone Number (_) - 34. What is your landlord’s address? 35. Is your rent subsidized by any agency? im YES [_]NO 36. If “YES,” by which agency? How much is subsidized? $ 37. If you are buying your home, please complete the areas with the current expenses: Mortgage Amount (including second) $ How Often Paid? Taxes (if paid separately) $ How Often Paid? Homeowners Insurance (if paid separately) $ How Often Paid? Association Fees (if paid separately) $ How Often Paid? Lot/Space Rent $ How Often Paid? 38. Does anyone outside the home pay any of your rent or mortgage expenses? : LJ YES LJ NO If “YES”, Who? Telephone How Much? $ How Often? 39. Are you or any person(s) in your household responsible for paying any utility expenses? L_] YES NO If “YES”, does this utility expense include costs for heating or cooling? im YES CL NO If “NO”, please choose the utilities your household is responsible for paying: Electricity | [1] Wood | [] Water | [J Sewer | J] Other | [1] Natural Gas | []] Propane | []} Garbage | []| Telephone | []

. Does anyone outside your household pay a portion of your utility expenses? | YES O NO elephone __ How Much? $ How Often?

. Do you or any person(s) in your household pay court ordered Child Support to someone outside the household? L | NO

If “YES”, Who? How much do they pay per month? $e

42. Do you or any person(s) in your household pay child care or for the care of a disabled adult? LI YES LJ NO If “YES”, Who? For Whom? How much per month?

$

43. Does any agency or anyone outside your home pay a portion of your daycare costs? im YES C] NO If “YES,” Who? How much per month? $

44. Does anyone age 60 or over, or any person(s) who is disabled have out-of-pocket medical expenses including costs for Medicare or medical insurance? LJ yes [No If “YES”, Who? How much per month? $

45. Does anyone outside the household pay for any of these medical expenses? L}yEs L]No If“YES”, Who? How much i

46. Have you or anyone in your household been injured or in an accident in the last 12 months? LJyes [_]No If “YES”, Who? . When? 47. Is there a pending lawsuit because of the injury or accident? L]Jyes []No

If “YES”, What is the attorney’s name? Attorney’s Address 48. Have you or anyone in your household received or expect to receive an insurance reimbursement, payment or

legal settlement? Ll YES O NO If “YES”, Who? When? How Much $ From Where?

49. Is the father/mother of the child(ren) you are applying for : (Check one) [_] living somewhere else [_] disabled or L] deceased 50. If anyone in your home is pregnant, is the father of the unborn in the home? im YES CL] NO If “YES”, Who is thefather? Complete the following form with information about the absent parent of your child(ren) who is not living with you (including

the parent of an unborn child). If there is more than one possible parent, complete a form for each one. Please provide as much information as possible.

*Please make copies or request additional copies of this page for additional parents.

Transmittal Number: 13-0026-MM Approval Date: June 6, 2014 Effective Date: October 1, 2013 Nevada 7

Attachment 1

STATE OF NEVADA DEPARTMENT OF HEALTH AND HUMAN SERVICES DIVISION OF WELFARE AND SUPPORTIVE SERVICES

NON-CUSTODIAL PARENT (NCP) FORM

When applying for TANF the law requires you to cooperate with Child Support Enforcement (CSE) to establish paternity to get child support owed to you and/or any child(ren) that you are applying for. This may include genetic testing. If the test proves the person you named is not the father, you may be required to pay the cost of the test. You are also responsible for providing all available information requested by the CSE Program such as certified copies of divorce decrees and/or support orders, birth certificates and photographs of the absent parent.

The CSE Program locates absent parents and/or sources of income and assets, establishes and enforces financial support, reviews and adjusts existing child support orders, and collects and distributes financial payments.

The CSE Program has sole discretion in determining which legal remedies are used in pursuing support and cannot guarantee success. CSE may request assistance of another state, and thereby, be subject to the laws of that state. CSE does not provide services involving custody or visitation. CSE may close your case when your case meets closure rules established by federal and state regulation.

The CSE Program represents the State of Nevada when providing services and no attorney-client privilege exists. CSE is authorized to endorse and cash payments made payable to you for support payments and may collect past-due support by intercepting an IRS tax refund or other federal payment. If a tax intercept occurs, the CSE Program has the authority to hold a joint tax refund for a period of six (6) months before distributing the funds. No interest is paid on the held funds. Funds collected from a tax intercept are applied first to pay off any past-due support assigned to the State of Nevada. A nonrefundable fee is deducted by the federal government of any tax or federal payment intercepted by the CSE Program.

Good cause for not cooperating in pursuing child support or paternity may be allowed. If you do not cooperate with CSE and good cause has not been determined, your household will be ineligible for TANF. Good cause for not cooperating will be considered if you request it in writing. Examples of good cause are as follows:

e@ The child was conceived as a result of rape or incest.

e Legal proceedings for adoption of the child are pending before a court.

e You are being assisted by a public or licensed private social service agency to decide whether to keep or relinquish the child for adoption (no longer than three (3) months).

e Your cooperation in establishing paternity or securing support will result in physical or emotional harm to yourself or the child(ren).

You must provide your case manager with verification within twenty (20) days after claiming good cause. You will receive written notification of the good cause decision. If you are found to have good cause for not cooperating, CSE will NOT attempt to establish paternity or collect child support.

(] YES, I wish to claim good cause. (1 NO, Iam not claiming good cause at this time.

Signature

You must report changes whenever a name change occurs; you have a new address or telephone number for home or work; you hire a private attorney or collection agency; another child support or paternity legal action is filed; you file for divorce; you receive support payments directly from the absent parent; you have a new address, telephone number, employment for the absent parent; a child(ren) no longer lives with you; a child(ren) is still in high school after age 18; a child(ren) becomes disabled before age 18; a child(ren) comes to live with you or you birth another child; a child marries, is adopted, joins the armed forces or is declared an adult by court order.

You are responsible for repayment of support amounts received in error, including payments from an IRS tax refund, which are adjusted by the IRS. If you fail to enter into a repayment agreement with the CSE Program, the outstanding balance may be reported to a credit reporting agency and money collected on your behalf by the CSE Program may be withheld for repayment. Additionally, legal action may be initiated against you.

Transmittal Number: 13-0026-MM Approval Date: June 6, 2014 Effective Date: October 1, 2013 Nevada 8

Attachment 1

NEVADA STATE DIVISION OF WELFARE AND SUPPORTIVE SERVICES NON-CUSTODIAL PARENT (NCP) FORM Complete one form for each parent who does not live with the child(ren) for whom you are requesting assistance. For example, if you have two children and each have a different father / mother, you need to complete two forms. If you are not the parent of the child(ren) you are requesting assistance for, you need to complete one form for the absent mother and one form for the absent father. Do not leave any question blank. Write or type unknown or N/A (not applicable) for any question that does not apply or you do not know the answer.

YOUR NAME: YOUR SSN: YOUR DOB: YOUR RELATIONSHIP TO THE CHILD(REN):

Have you or the children received public If YES, where? (City, State)

assistance in the past? O Yes [JNO

Fill in whatever you know about the Non-Custodial Parent. If you do not know the answer to the question, write unknown or NIA.

LAST NAME: FIRST NAME: MIDDLE INITIAL: MODIFIER (Jr., Sr., etc.):

ADDRESS:

CITY: STATE: ZIP:

SOCIAL SECURITY NUMBER: TELEPHONE / CELL PHONE:

DATE OF BIRTH: BIRTH CITY AND STATE:

IF DECEASED, DATE OF DEATH: IF DECEASED, PLACE OF DEATH:

DATE LAST SEEN OR CONTACTED: IS HE OR SHE DISABLED? O1 yes [JNO

RACE: SEX: HAIR COLOR: EYE COLOR: WEIGHT: HEIGHT:

AT ANY TIME WAS THE MOTHER MARRIED TO DATE OF MARRIAGE: PLACE OF MARRIAGE:

THIS NON-CUSTODIAL PARENT? O yEs [JNO

IF MARRIED ARE THEY DIVORCED? O yes [INo DATE OF DIVORCE: PLACE DIVORCE FILED:

WAS THE MOTHER MARRIED TO ARE THERE OTHER POSSIBLE

SOMEONE ELSE? (0 yes [No FATHERS? O yes [No

EXISTING CHILD SUPPORT COURT ORDER? Cl yes [JNO CITY AND STATE

INFORMATION ON THE CHILDREN FOR THIS ABSENT PARENT:

Did the mother have sexual relations with another man (not named above), during

Child’s Child’s Child’s date 30 days before or Social Security Middle of birth after when pregnancy Custody Number Child’s Last Name Child’s First Name Initial (MM/DD/YY) began for this child? Month

O1 YES [J NO

1 YES [j NO

01 YES [] NO

All cases for Temporary Assistance for Needy Families (TANF) must be referred for Child Support Enforcement. This information is correct to the best of my knowledge. I have read the “Important Child Support Information” section found on the eligibility application. I understand if I have intentionally withheld or misrepresented information, I could be disqualified from receiving public assistance.

I declare under penalty of perjury that the information I have provided on this document is true to the best of my knowledge and belief and that the statements contained herein are made for the purposes stated here, including but not limited to, obtaining assistance in establishing parentage and/or an order for child support along with the collection of child support.

Your Signature: Date Signed:

Transmittal Number: 13-0026-MM Approval Date: June 6, 2014 Effective Date: October 1, 2013 Nevada 9

Attachment 1

Electronic Benefits Transfer (EBT) Federal law states the intended period of use for SNAP benefits is 12 months from the date of issuance. DWSS is required to remove any unused SNAP benefits from an account 365 days after the benefit was issued and return them to the Federal government. Unused benefits are frozen 360 days after their issuance. If the client, or any adult member of the client’s household, has any outstanding SNAP debt, the frozen benefit will be applied towards the SNAP debt.

Unused TANF benefits are removed from a client’s EBT account 180 days after the benefit was issued.

Per Federal Law, TANF EBT benefits cannot be accessed from ATM machines or used to purchase items in the following

locations: casinos, gaming establishments, liquor stores or retail establishments which provide adult entertainment. Initials

Work Requirements If you are approved for TANF and/or SNAP, you may be required to cooperate with certain work requirements. Failure to comply with certain work requirements could disqualify you and/or other members of your household from participating in either program. For SNAP, if you or any other household member voluntarily quits a job or reduces work hours-without good cause, this may be considered failure to comply with work requirements. The SNAP disqualification period for failure to comply with work requirements is one month and until compliance for the first violation, three months and until compliance for the second violation, and six months and until compliance for the third violation. For TANF, failure to cooperate with work requirements agreed to in their Personal Responsibility Plan may result in the household losing their TANF benefits for three full months.

Important Child Support Information By signing this application and by receiving TANF benefits, you agree to assign your child support rights to the State of Nevada Division of Welfare and Supportive Services (DWSS). This is a condition of eligibility for your household to receive TANF benefits. If you are receiving TANF, any court ordered or stipulated child support paid directly to you is required by law to be surrendered immediately to DWSS or Child Support Enforcement (CSE). By signing this application, you are authorizing DWSS to transfer all or part of the support collected each month to pay back the TANF benefits your household received.

When applying for TANF, the law requires you to cooperate with CSE to establish paternity to get child support owed to you and/or any child(ren) for which you are applying. Good cause for not cooperating in pursuing child support or paternity may be allowed. If you do not cooperate with Child Support Enforcement and good cause is not established, your household will be ineligible for TANF.

If TANF is terminated and child support is collected, any portion due to you will be made as a direct deposit onto a Nevada Debit Card or into your bank account. A Nevada Debit Card will be issued to you unless you request payments by direct deposit into your bank account. Visit our website: dwss.nv.gov for more information.

You are responsible for repayment of child support amounts received in error, including child support payments from an IRS tax refund which are adjusted by the IRS. If you fail to enter into a repayment agreement with the CSE program, money collected on your behalf by the CSE program may be withheld for repayment and the outstanding balance may be reported to a collection agency.

DWSS may charge a $25.00 fee for child support services provided to clients who have never received public assistance.

Do you wish to pursue child support if your household is found ineligible for TANF? Initials LJ Yes [No

Reviews and Inyestigations

By signing this application, you are authorizing the Department of Health and Human Services to make 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 or will receive under programs administered by the DWSS, including childcare assistance. Information provided to the DWSS may be verified or investigated by federal, state and local officials including Quality Control staff. If you do not cooperate in the investigation, your benefits may be denied or terminated. If you make false or misleading statements, misrepresent, conceal or withhold facts necessary for the DWSS to make an accurate determination on your benefits or alter any document, your benefits may be denied, terminated or reduced. You are responsible for repayment of all monies, services and benefits (including childcare assistance) for which you were not entitled to. Additionally, you may be disqualified from receiving benefits in the future and criminally prosecuted or otherwise penalized according to state and federal law.

Individuals found guilty of an intentional program violation in TANF and/or SNAP are barred from program benefits for twelve (12) months for the first violation, twenty-four (24) months for a second violation and PERMANENTLY for the third violation. The unlawful use of SNAP is punishable by a fine up to $250,000, imprisonment for up to 20 years or both.

Initials Initials

Transmittal Number: 13-0026-MM Approval Date: June 6, 2014 Effective Date: October 1, 2013 Nevada 10

Attachment 1

Your Rights Anyone whose application for assistance has been denied, not acted on within a reasonable time frame, or whose benefits have been reduced or terminated may request a conference or hearing. You may request a conference or hearing by writing your local district office or the administration office. For SNAP, you may request a hearing by calling your local district office. You may also request a hearing by signing and returning the Notice of Decision you receive. You must request a hearing for TANF or SNAP within 90 days of the notice date. You will be notified of the hearing date, time and location in writing ten (10) days prior to the scheduled hearing. You may be represented at a conference/hearing by anyone whom you have given written authorization. This written authorization must be given to the DWSS office prior to the conference/hearing. You may request information on the various legal services that may be available in your community at no cost; please contact us for information. If you are dissatisfied with the hearing decision, you may appeal your case to your local District Court of the State of Nevada.

Important Information If you are applying for TANF and SNAP with this application and your TANF benefits are approved, any adjustment to your SNAP benefits will be made at the same time. With this application, you are waiving your right to 13 days advance notice of any change in your SNAP benefits resulting from TANF approval. If your TANF benefit is less than $10.00, you will receive no cash payment. .

The DWSS may mail information to you that may require you to respond by a certain date. If you are away from home, you are still responsible to respond by the required date. You may wish to make arrangements for your mail while you are away.

Your Responsibilities

If you are applying for TANF:

You must report changes in your mailing address immediately. Additional changes must be reported immediately after you apply and before you are approved benefits. Once your benefits are approved you must report the following changes and the change must be reported by the 5" of the following month. You must report changes such as your physical address, living expenses, subsidized housing value, marital status, employment status, any money you receive or income from any source, assets/resources, absent parent’s address, number of people in the home, the birth of a child, school attendance, absence of any household member even if it is temporary (if more than 30 days), and any other change which may affect your household benefits.

If you are applying for Supplemental Nutrition Assistance Program (SNAP):

You are required to report all changes in your household from the date you submit your application to the day of your interview. Once SNAP benefits are approved, you must report required changes within 10 days from the date the change happened based on your household’s specific reporting requirements. You will receive a notice informing you of your specific requirement.

If your household is designated as a Change Status Reporting Household you will be required to report changes such as your physical address, living expenses, subsidized housing value, marital status, employment status, any money you receive or income from any source, assets/resources, number of people in the home, birth of a child in your home, school attendance, absence of any household member even if it is temporary (if more than 30 days), and any other change which may affect your household benefits.

If your household is designated as a Simplified Reporting Household you must report if you move out of state or your household’s income exceeds 130% of the federal poverty level for your household size. If SNAP benefits are approved you will be notified of the income level for your household size.

Your caseworker may request additional proof of the change. You will be required to provide the proof by a certain date in order to continue your eligibility or to avoid an overpayment or underpayment of benefits.

The Supplemental Nutrition Assistance Program allows certain household expenses like rent, mortgage, property taxes, homeowner’s insurance, utility expenses, child/dependent care and child support paid by the household as a deduction to determine the amount of SNAP benefits your household is eligible for as long as the expense is reported and verified. Medical expenses over $35.00 are allowed if there is an elderly (age 60 or over) or disabled person applying for benefits. If you do not report or verify any of the expenses listed on the application, it will be considered that you do not want to receive a deduction for the unreported or unverified expense.

Initials Initials

Transmittal Number: 13-0026-MM Approval! Date: June 6, 2014 Effective Date: October 1, 2013 Nevada 1

Attachment 1

Release of Information 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.

Initials

I understand if I fail to initial pages 10-12 where indicated on this application, it does not release me or my household members from those requirements / obligations. If I am under age 18 and applying for TANF assistance I understand I must have an additional signature of an adult over age 18 to complete the application.

I understand the questions on this application and the penalty for hiding or giving false information. I agree to notify the Nevada State Division of Welfare and Supportive Services of any changes in my household circumstances that may affect my benefits. I understand failure to report changes may cause an overpayment that I would be responsible to pay back and could even be prosecuted by a court of law. I certify under penalty of perjury, my answers are correct and complete to the best of my knowledge and ability. I swear I have honestly reported the citizenship of myself and anyone I am applying for.

Signature or Mark of Applicant Date Signature or Mark of Spouse/ Date Second Parent of Child(ren)/Adult Representative

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

Your completed application may be submitted to your local Welfare office or mailed to PO Box 15400, Las Vegas, NV 89114.

IF YOU ARE NOT REGISTERED TO VOTE WHERE YOU LIVE NOW, WOULD YOU LIKE TO REGISTER TO VOTE HERE TODAY? (Please check one)

(J yes [JNO 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.

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 89710.

Transmittal Number: 13-0026-MM Approval Date: June 6, 2014 Effective Date: October 1, 2013 Nevada 12

Attachment 1

Non-Discrimination

“In accordance with Federal law and U.S. Department of Agriculture (USDA) and U.S. Department of Health and Human Services (HHS) policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, or disability. Under the Food Stamp Act and USDA policy, discrimination is prohibited also on the basis of religion or political beliefs.

“To file a complaint of discrimination, contact USDA or HHS. Write USDA, Director, Office of Civil Rights, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410 or call (800) 795-3272 (voice) or (202) 720-6382 ( TTY). Write HHS, Director, Office for Civil Rights, Room 506-F, 200 Independence Avenue, S.W., Washington, D.C. 20201 or call (202) 619-0403 (voice) or (202) 619-3257 (TTY). USDA and HHS are equal opportunity providers and employers.”

Your Rights

Anyone whose application for assistance has been denied, not acted on within a reasonable time frame, or whose benefits have been reduced or terminated, may request a conference or hearing. You may request a conference or hearing by writing your local district DWSS office or the administration office. For SNAP, you may request a hearing by calling your local district DWSS office. You may also request a hearing for assistance programs such as TANF or SNAP within 90 days of the notice date. You will be notified in writing 10 days prior to the hearing date, the time and location of the hearing. You may be represented at a conference/hearing by anyone you have given written authorization to which must be given to the DWSS office prior to the conference/hearing. You may request information on the various legal services which may be available in your community at-no cost, please contact us for information. If you are dissatisfied with the hearing decision, you may appeal your case to your local District Court of the State of Nevada.

Your Responsibilities

If you are applying for TANF:

You must report changes in your mailing address immediately. Additional changes must be reported immediately after you apply and before you are approved benefits. Once your benefits are approved you must report the following changes and the change must be reported by the 5" of the following month. You must report changes such as your physical address, living expenses, subsidized housing value, marital status, employment status, any money you receive or income from any source, assets/resources, absent parent’s address, number of people in the home, birth of a child in your home, school attendance, absence of any household member even if it is temporary (if more than 30 days), and any other change which may affect your household benefits.

If you are applying for Supplemental Nutrition Assistance Program (SNAP):

You are required to report all changes in your household from the date you submit your application to the day of your interview. Once SNAP benefits are approved, you must report required changes within 10 days from the date the change happened based on your household’s specific reporting requirements. You will receive a notice informing you of your specific requirement.

If your household is designated as a Change Status Reporting Household you will be required to report the same changes listed under the TANF reporting requirements listed above.

If your household is designated as a Simplified Reporting Household you must report if you move out of state or your household’s income exceeds 130% of the federal poverty level for your household size. Your household will be notified of this amount at approval. Your caseworker may request additional proof of the change. You will be required to provide the proof by a certain date in order to continue your eligibility or to avoid an overpayment or underpayment of benefits.

The Supplemental Nutrition Assistance Program allows certain household expenses like rent, mortgage, property taxes, homeowner’s insurance, utility expenses, child/dependent care and child support paid by the household as a deduction to determine the amount of SNAP benefits your household is eligible for as long as the expense is reported and verified. Medical expenses over $35.00 are allowed if there is an elderly or disabled person applying for benefits. If you do not report or verify any of the expenses listed on the application, it will be considered that you do not want to receive a deduction for the unreported or unverified expense.

Utilizing TANF funds, DWSS through the Nevada Public Health Foundation (NPHF), has developed a class to target pregnant and parenting teens receiving TANF cash assistance. Teen parents receiving TANF benefits and services are known as STARS (Supporting Teens Achieving Real-life Success) participants. This class has been expanded to include other pregnant and parenting teens receiving other forms of assistance such as SNAP and Child Welfare. This one-day class places emphasis on employment, success in the workplace, decision-making, money management and health, such as birth control and sexually transmitted diseases.

In addition, Community Action Teams, an entity of the Nevada Public Health Foundation, conduct community assessments of teen pregnancy and its prevention and identify potential methods for reducing teen pregnancy through abstinence-based programs. Youths, parents, business, churches, health care providers, law enforcement, schools and other organizations are encouraged to serve on the Community Action Teams. Men of all ages are also encouraged to serve as positive role models, reinforcing the postponement of sexual involvement message.

After you submit your application you may call our Voice Response Unit (VRU) system to find out if your case has been approved, denied, terminated or is still pending. The VRU system will also let you know when your benefits have been issued and the amount. For Southern Nevada, call (702) 486-1646; Northern Nevada, call (775) 684-7200; Rural Nevada, call (800) 992-0900, extension 47200. Your Personal Identification Number (PIN) for the VRU system is :

You may contact your caseworker at between the hours of to

Visit our website at http://dwss.ny.gov/ This is Your Copy, Keep This Page for Your Records

Transmittal Number: 13-0026-MM Approval Date: June 6, 2014 Effective Date: October 1, 2013 Nevada 13

Attachment 1

SECRETARY OF STATE ROSS MILLER Application No. STATE OF NEVADA HA VOTER REGISTRATION APPLICATION

BOX 3.- NAME Please write your name exactly as it appears on the BOX43.. ASSISTING IN THE COMPLETION OF THIS FORM If you are assisting Nevada driver's license, |.D. card, or Social Security card referenced in @ person to register ta vote, you must complete Box 13. FAILURE TO DO SO ISA Box 8. If you do not have any of these forms of identification, please see FELONY.

the instructions for Box &. DLINE:

By Mail—postmarked by Saturday, 31 days before an Election. In Person at DMV-—-by Saturday, 31 days before an Election, in Person At County Clerk’s or Registrar's Office—by Tuesday, 21 days

BOX 4.- HOME ADDRESS Your home address Is the street address assigned to the location at which you actually reside, If you reside at a location that has not been assigned a street address, a description of the

* EF

location at which you actually reside must be provided. A P.O. Box before an Election (for Municipal ions, in pi at City Clerk's). cannot be listed as a home address. For Special/Recall Elentions—contact your County Clerk or Registrar. BOX 8 - IDENTIFICATION REQUIREMENTS Federal and state law NOTICE You are urged to return your application to register to vote to the

require you to provide your NV driver's license or NV [OD number. ff youdo County Clerk/Registrar in person or by mail. If you choose to give your

nat have either, you must provide the last 4 digits of your social security licati r perso n to the in number (SSN). If you do not have any of these three forms of completed application to another person to ret County identification, please contact your County Clerk/Registrar after you have campleted and retumed this form:

ClerWRegistrar on your behalf, and the person fails to deliver the application to the County Clerk/Registrar, you will not be registered to vote. Please retain the duplicate copy or receipt from your application to register BOX 10 - REGISTRATION Mark your choice of a qualified party, to vote.

*"Nonpartisan® or “Other.” If you mark "Other," you may print the name of

an unlisted political party. If you register with a minor political party or as D.

a nonpartisan, you will raceive a nonpartisan ballot for the Primary Clerk or Registrar's Office. See Reverse. Election.

[_] CHECK THIS BOX TO RECEIVE A SAMPLE BALLOT IN LARGER TYPE

R?, Please contact your local County

oe Are you a citizen of the Uni! Will you be 18 years of age or over on or before Election Day? [_] Yes {_J No £7] New Registration Party Affiliation Change , t you checked “no" in response to either of these questions, do not complete this 1} {] Name Change Address Change form,

CORY . PATE NAS COG ESE TT

SHEET A SS i s Sé st as. Stare Zips Code |

Cate (MDT

Pras NV Divers License GF NV ID Card Number (i rEelther, ta ‘elephone NoCOpt:

Barty Regist "| ewear or affirm ~ 1am a U.S. citizen ~ | will be at least 18 years old by the date of

(Sh IESE Gly Gr

(2) Democratic Party the next election » | will have continuously resided in Nevacia at least 30 days in my courity and at least 10 days in my precinct before the next election + The preserit

(J Independent American Party address listed herein is my sole legal place of resiclence and | claim no other place

(7) Libertarian Party as my legal residence + | am not laboring under any felony conviction or other loss.

(CD Republican Party of civil rights that would make it unlawful for me to vote. \ deslare under penalty oF

CO other Party — write in Betow perjury that the foregoing is true and correct’

4 SIGNATURE OF APPLICANT (REQUIRED) # # DATE (REQUIRED) # (2 Nonpartisan (no party affiliation) dod VSuF Hate BNA TSSITHES DATETT WHEE YOU Were | POG (S VSS WANS USSSA, BUSS, ABE HE CUY, Stats E Zip COS SIF Giiar Residencey

Important! If you are assisting @ person to register to vote and you are not @ field registrar appointad by a County Clerk/Registrar of an employes of o voter registration agency, you MUST complete the following. Your signeture is required. Failure to do 30 [s a felony.

rai ‘nnenaiiy Aaaes: ce Cae

VALIDATING AGENCY USE ONLY. DO N

“ReRuCN STaMe HERE

Foe Fate + NAME OF PERSON RETAINING “THIS APPLICATION —

Acs tae a men, Rue Hcee rr, . Please call or visit ae TO FET ORRE

{Revised 6.2012) Transmittal Number: 13-0026-MM Approval Date: June 6, 2014 Effective Date: October 1, 2013

Nevada 14

Attachment 1

Medical Assistance Addendum

Complete this addendum if requesting to add medical coverage to your current SNAP/TANF application.

Name:

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.

OYes_ If yes, who? and answer questions 1 - 3 CINo _ If no, skip to question 3

1. Filing Status ([] Single Check only one box. [] Married filing jointly

CJMarried filing separately Name of spouse/partner: 2. Dependents | First Name Last Name Relationship Resides in Household ClYes [] No CiYes [] No OYes (J No CYes (] No 3. Are you being claimed as a dependent on someone else's tax return? DYes [] No

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

Please list all members requesting medical assistance:

Do any children, under the age of 19, have access to

public employee coverage? _[]Yes [] No If pregnant, how many babies are expected:

If under age 26, has anyone ever been in foster care? Dyes []No If yes, who? what state? Did they receive health care through a state Medicaid

9 Age when they left the program? program? Clyes 1 No

Does anyone need help with activities of daily living through personal assistance services or a medical facility? LlYes LINo_Ifyes, who?

Transmittal Number: 13-0026-MM Approval Date: June 6, 2014 Effective Date: October 1, 2013 Nevada 15

Attachment 1

Does anyone have medical bills for the past three months that you need help with? O Yes 1 No If yes, who? what months?

If you pay for certain things that can be deducte: ona federal income tax return, te ing us abou reduce your countable income. Note: You shouldn't include a cost that you already considered in your answer to net self-employment.

Ol Alimony $ How often?

C]_ Student loan interest $ How often?

(1 Other deductions $ How often? Type:

| Does anyone have health insurance, such as TRICARE, federal or state employee plans, Peace Corps., Veterans, Medicaid/Nevada Check-Up, Medicare, COBRA, Private, or other Retiree Health Plan? [] Yes O No

Does anyone have health insurance available through their employer? O Yes [] No

If yes, provide the following information:

I understand the following is an eligibility requirement to receive Medicaid benefits:

1) If anyone on this application receives Medicaid benefits, I 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.

How did you hear about these programs? Check ONLY one:

O_ Covering Kids & Families 1 _— School _ Tribal Resources Ol wIc Ol Clinic Ol Other 0 sFriend/Family Transmittal Number: 13-0026-MM Approval Date: June 6, 2014 Effective Date: October 1, 2013

Nevada 16

Attachment 1

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

Families 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.

Please choose a health plan:

Amerigroup: 1-800-600-4441 Health Plan of Nevada: 1-800-962-8074 For families living in the fee-for-service benefit area, services may be obtained from any Nevada Medicaid provider who will accept Nevada Check Up. 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

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 agree to allow my information to 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.

Transmittal Number: 13-0026-MM Approval Date: June 6, 2014 Effective Date: October 1, 2013 Nevada 17

Attachment 1

'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 Iswear I have honestly reported the citizenship status of myself and anyone I am applying for.

/__/

Signature or Mark of Applicant Date /__/

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 /_

Signature of Case Manager Date

Submit your application to the local Welfare Office | Did you remember to:

or, mail your application to:

Y Tell us about everyone in your family &

PO BOX 15400 household, even if they don't need insurance? Las Vegas, NV 89114

Y Attach verification of current monthly income?

vY Attach copy of insurance card (front & back)?

¥ Sign this application?

0 Telephone call to applicant C1 Copy of form mailed to applicant Date

Transmittal Number: 13-0026-MM Approval Date: June 6, 2014 Effective Date: October 1, 2013 Nevada 18

Attachment 2

USE OF THE ALTERNATIVE SINGLE STREAMLINED APPLICATION

O Paper Application Online Application

TRANSMITTAL NUMBER: STATE:

13-0026-MM Nevada

Through September 30, 2014, the state is using an interim alternative single streamlined application. After September 30, 2014, 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.

Transmittal Number: 13-0026-MM Approval Date: June 6, 2014 Effective Date: October 1, 2013 Nevada 1

Attachment 3

USE OF THE ALTERNATIVE SINGLE STREAMLINED APPLICATION

ElPaper Application Online Application

TRANSMITTAL NUMBER: STATE:

13-0026-MM Nevada

Through September 30, 2014, the state is using an interim alternative single streamlined application. After September 30, 2014, 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.

Transmittal Number: 13-0026-MM Approval Date: June 6, 2014 Effective Date: October 1, 2013 Nevada 1

cems Medicaid Eligibility

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

42 CFR 435, Subpart J and Subpart M

Eligibility Process

The state meets all the requirements of 42 CFR 435, Subpart J for processing applications, determining and verifying eligibility, and furnishing Medicaid.

Application Processing

Indicate which application the agency uses for individuals applying for coverage who may be eligible based on the applicable modified adjusted gross income standard.

Oo The single, streamlined application for all insurance affordability programs, developed by the Secretary in accordance with section 1413(b)(1)(A) of the Affordable Care Act

An alternative single, streamlined application developed by the state in accordance with section 1413(b)(1)(B) of the

Affordable Care Act and approved by the Secretary, which may be no more burdensome than the streamlined application developed by the Secretary.

An 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.

Indicate which application the agency uses for individuals applying for coverage who may be eligible on a basis other than the applicable modified adjusted gross income standard:

The single, streamlined application developed by the Secretary or one of the alternate forms developed by the state and

[7] approved by the Secretary, and supplemental forms to collect additional information needed to determine eligibility on such other basis, submitted to the Secretary.

An application designed specifically to determine eligibility on a basis other than the applicable MAGI standard which <~ minimizes the burden on applicants, submitted to the Secretary.

The agency's procedures permit an individual, or authorized person acting on behalf of the individual, to submit an application via the internet website described in 42 CFR 435.1200(f), by telephone, via mail, and in person.

The agency also accepts applications by other electronic means:

‘e . e HES nittat NO or 13-0026-MM Approval Date: June 6, 2014 Effective Date: October 1, 2013 Nevada 594-1

Page | of 2

Medicaid Eligibility

Indicate the other electronic means below:

Name of Method Description

Application may be submitted via fax

The agency has procedures to take applications, assist applicants and perform initial processing of applications for the eligibility groups listed below at locations other than those used for the receipt and processing of applications for the title IV-A program, including Federally-qualified health centers and disproportionate share hospitals.

Parents and Other Caretaker Relatives Pregnant Women

Infants and Children under Age 19

Redetermination Processing

Redeterminations of eligibility for individuals whose financial eligibility is based on the applicable modified adjusted gross income standard are performed as follows, consistent with 42 CFR 435.916:

{] Once every 12 months

rl 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 [M] information to complete the redetermination, it provides the individual with a pre-populated renewal form containing the information already available.

i Redeterminations of eligibility for individuals whose financial eligibility is not based on the applicable modified adjusted gross income standard are performed, consistent with 42 CFR 435.916 (check all that apply):

Once every 12 months

(1) Once every 6 months

[7] Other, more often than once every 12 months Coordination of Eligibility and Enrollment

The state meets all the requirements of 42 CFR 435, Subpart M relative to coordination of eligibility and enrollment between Medicaid, CHIP, Exchanges and other insurance affordability programs. The single state agency has entered into agreements with the Exchange and with other agencies administering insurance affordability programs.

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

Transmittal Number: 13-0026-MM Approval Date: June 6, 2014 Effective Date: October 1, 2013 Nevada $94-2

Page 2 of 2

Table of Contents State/Territory Name: Nevada State Plan Amendment (SPA) #: 13-0029 This file contains the following documents in the order listed: 1) Approval Letter 2) Summary Form (with 179-like data) 3) Approved SPA Pages

l',, DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services San Francisco Regional Office 90 Seventh Street, Suite 5-300 (SW) San Francisco, CA 94103-6706 CENTERS FOR MEDICARE & MEDICAID SERVICES DIVISION OF MEDICAID & CHILDREN'S HEALTH OPERATIONS Michael J. Willden, Director Department of Health and Human Services 4126 Technology Way, Suite 100 Carson City, NV 89706 Dear Mr. Willden: JAN 8 4 2014 Enclosed for your records is an approved copy of Nevada's Alternative Benefit Plan (ABP) state plan amendment NV-13-0029. This ABP, which was submitted on November 7, 2013, meets all federal statutory and regulatory requirements for establishing an ABP. All requirements pertaining to ABPs must be met including, but not limited to: benefits, payment rates, reimbursement methodologies, cost-sharing state plan pages, and managed care service delivery systems (State Plan amendments and contracts). Future amendments to Nevada's approved Medicaid program (SPAs, waivers, contracts) may require corresponding amendments to the ABP if the change to the benefit in the approved State plan will be mirrored in the ABP. This ABP SPA is approved effective January 1 8 \ 2014. Attached are copies of the following pages to be incorporated into your State Plan: • Attachment 3.1-L: o ABP 1, page 1 o ABP 2a, page 1 o ABP 3, pages 1-2 o ABP4, page 1 o ABP 5, pages 1-36 o ABP 7, pages 1-2 o ABP 8, pages 1-2 o ABP 9, pages 1-2 o ABP 10, page 1 o ABP 11, page 1

Mr. Willden - Page 2 If you have any questions, please contact Brian Zolynas by phone at (415) 744-3601 or by email at Brian.Zolynas@crns.hhs.gov. Enclosure Sincerely, Is/ Gloria Nagle, Ph.D., MPA Associate Regional Administrator Division of Medicaid & Children's Health Operations cc: Laurie Squartsoff, Administrator, DHCFP Marta Stagliano, Chief, Compliance, DHCFP

NV.0477.ROO.OO- Jan 01,2014 Medicaid Alternative Benefit Plan: Summary Page (CMS 179) Statefferritory name: Nevada Transmittal Number: Page 1 ofl Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY =the last two digits ofthe submission year, and 0000 =a four digit number with leading zeros. The dashes must also be entered. NV-13-0029 Proposed EJ.~ctive Date ·-- 01/01/2014 (mm/dd/yyyy) Federal Budget Impact Federal Fiscal Year Amount First Year :2014 $117795520.00 ····················· ·-··"•'"' ···~-~--·-··-· ~~--~ ............. ......,. ______ ..,_ .. ....,. ............ ._ .. __ Second Year 2015 $285374375.00 Subject of Amendment Alternative Benefit Plan Governor's Office Review Governor's office reported no comment Comments of Governor's office received Describe: i"' i No reply received within 45 days of submittal @ Other, as specified Describe: The Governor's Office does not wish to review the State Plan Amendment. Signature of State Agency Official Submitted By: Page 1 of1 Robyn Heddy Last Revision Date: Jan 21,2014 Submit Date: Nov7,2013 ,.-: 01124/2014

DATE RECEIVED: DATE APPROVED: 11/07/2013 1/24/2014 PLAN APPROVED- ONE COPY ATTACHED EFFECTIVE DATE OF APPROVED MATERIAL: SIGNATURE OF REGIONAL OFFICIAL: 1/1/2014 Is/ TYPED NAME TITLE Gloria Nagle Associate Regional Administrator .

Alternative Benefit Plan Identify and define the population that will participate in the Alternative Benefit Plan. Alternative Benefit Plan Population Name: !Nevada Medicaid Newly Eligibles OMB Control Number: 0938-1148 OMB date: 10/31/2014 Identify eligibility groups that are included in the Alternative Benefit Plan's population, and which may contain individuals that meet any targeting criteria used to further define the population. < l"'"l::.'ul•u•y Groups Included in the Alternative Benefit Plan Population: Eligibility Group: IAdult Group Enrollment is available for all individuals in these eligibility group(s). Geographic Area Enrollment is mandatory or voluntary? II Mandatory The Alternative Benefit Plan population will include individuals from the entire state/territory. ....IY_e_s ___ __, Any other information the state/territory wishes to provide about the population (optional) .PRA Disclosure Statement 1n.''"v•. Uilll~<. to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete information collection is estimated to average 5 hours per response, including the time to review instructions, search existing data lr"'•"'"''"·"'" gather the data needed, and complete and review the information collection. If you have comments concerning the accw·acy of time estimate(s) or suggestions for improving this fonn, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN No: 13-0029 Nevada ABP 1 1 Approval Date: 1/24/14 Effective Date: 1/01114 V.20130724 Page I of I

Alternative Benefit Plan OMB Control Number: 0938-1148 OMB date: 10/31/2014 The state/territory has fully aligned its benefits in the Alternative Benefit Plan using Essential Health Benefits and subject to 19378 requirements with its Alternative Benefit Plan that is the state's approved Medicaid state plan that is not subject to 1937 y requirements. Therefore the state/territory is deemed to have met the requirements for voluntary choice of benefit package for es individuals exempt from mandatory participation in a section 1937 Alternative Benefit Plan. Explain how the state has fully aligned its benefits in the Alternative Benefit Plan using Essential Heilth Benefits and subject to 1937 requirements with its Alternative Benefit Plan that is the state's approved Medicaid state plan that is not subject to 193 7 requirements. state is using FEHB as the Base Benchmark and Secretary Approved Coverage as the 1937 Benchmark. Adding Habilitation- IMaintenanc:e Therapy as the EHB for both newly eligibles and existing Medicaid State Plan. The Medicaid State Plan will be modified the State Medicaid Plan and the Alternative Benefit Plan. PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 5 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this fonn, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN No: 13-0029 Nevada ABP2a 1 V.20130807 Approval Date: 1/24/14 Effective Date: 1/01114 Page 1 of I

Alternative Benefit Plan Select one of the following: OMB Control Number: 0938-1148 OMB date: 10/3112014 0 The state/territory is amending one existing benefit package for the population defined in Section l. ® The state/territory is creating a single new benefit package for the population defined in Section 1. Name of benefit package: Nevada Medicaid Newly Eligible Benefit Selection of the Section 1937 Coverage Option The state/territory selects as its Section 1937 Coverage option the following type of Benchmark Benefit Package or Benchmark- Equivalent Benefit Package under this Alternative Benefit Plan (check one): @Benchmark Benefit Package. 0 Benchmark-Equivalent Benefit Package. The state/territory will provide the following Benchmark Benefit Package (check one that applies): O The Standard Blue Cross/Blue Shield Preferred Provider Option offered through the Federal Employee Health Benefit Program (FEHBP). 0 State employee coverage that is offered and generally available to state employees (State Employee Coverage): O A commercial HMO with the largest insured commercial, non-Medicaid enrollment in the state/territory (Commercial HMO): ® Secretary-Approved Coverage. @ The state/territory offers benefits based on the approved state plan. O The state/territory offers an array of benefits from the section 1937 coverage option and/or base benchmark plan benefit packages, or the approved state plan, or from a combination of these benefit packages. ® The state/territory offers the benefits provided in the approved state plan. 0 Benefits include all those provided in the approved state plan plus additional benefits. 0 Benefits are the same as provided in the approved state plan but in a different amount, duration and/or scope. 0 The state/territory offers only a partial list of benefits provided in the approved state plan. 0 The state/territory offers a partial list of benefits provided in the approved state plan plus additional benefits. Please briefly identify the benefits, the source of benefits and any limitations: TN No: 13-0029 Nevada ABP3 1 Approval Date: 1/24/14 Effective Date: 1/01/14 Page 1 of2

Alternative Benefit Plan The state/territory must select a Base Benchmark Plan as the basis for providing Essential Health Benefits in its Benchmark or Benchmark-Equivalent Package. The Base Benchmark Plan is the same as the Section 1937 Coverage option. ~ Indicate which Benchmark Plan described at 45 CFR 156.IOO(a) the state/territory will use as its Base Benchmark Plan: 0 Largest plan by enrollment of the three largest small group insurance products in the state's small group market. 0 Any of the largest three state employee health benefit plans by enrollment. ® Any of the largest three national FEHBP plan options open to Federal employees in all geographies by enrollment. 0 Largest insured commercial non-Medicaid HMO. Plan name: I I L-----------------------------------------~ Other Infonnation Related to Selection of the Section 1937 Coverage Option and the Base Benchmark Plan (optional): 1. The state assures that all services in the base benchmark have been accounted for throughout the benefit chart found in ABP5. 2. The state assures the accuracy of all inf01mation in ABP5 depicting amount, duration and scope parameters of services authorized in the currently approved Medicaid state plan. PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of infonnation unless it displays a valid OM.B control number. The valid OM.B control number for this infonnation collection is 0938-1148. TI1e time required to complete this information collection is estimated to average 5 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the infonnation collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this fonn, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN No: 13-0029 Nevada ABP3 2 V.20130801 Approval Date: 1/24/14 Effective Date: 1/01/14 Page 2 of2

Alternative Benefit Plan OMB Control Number: 0938-1148 OMB date: 10/31/2014 IAttac.lnnent 4.18-A may be revised to include cost sharing for ABP services that are not otherwise described in the state plan. Any such sharing must comply with Section 1916 of the Social Security Act. The Alternative Benefit Plan for individuals with income over 100% FPL includes cost-sharing othe~ than that described in EJ Attachment 4.18-A. · Other Information Related to Cost Sharing Requirements (optional): PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 5 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN No: 13-0029 Nevada ABP4 1 V.20130807 Approval Date: 1/24/14 Effective Date: 1/01/14 Page I of I

Alternative Benefit Plan The state/territory proposes a "Benchmark-Equivalent'' benefit package.~ IBeJllefits Included in Alternative Benefit Plan Enter the specific name of the base benchmark plan selected: Federal Employees Health Benefit Plan BCBS Basic/Standard Option 2012 Benefit Plan O:MB Control Number: 0938-1148 O:MB date: 10/31/2014 Enter the specific name of the section 1937 coverage option selected, if other than Secretary-Approved. Otherwise, enter "Secretary-Approved." !"'"""""' Approv<d TN No: 13-0029 Nevada ABP5 1 Approval Date: 1/24/14 Effective Date: 1/01/14 Page 1 of36

I, Alternative Benefit Plan Iii Essential Health Benefit 1: Ambulatory patient services Collapse All D Benefit Provided: Source: !Physician Services llr-s-ta-te_P_l_an_l_90-5-(a_) __________ _, Authorization: Provider Qualifications: INoue I rl~_e_d_k_a-id __ S_ta_re_P_l_an ____________________ __, Amount Limit: Duration Limit: lnone j r-ln-/a-------------....:...------, Scope Limit: !within state licensing requirements Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: nla Benefit Provided: Source: ~~H_o_sp_i_ce_c_ar_e ____________________________ ~l ~ls_ta_re_P_I_a_n_l_9o_s_(_~--------------------~ Authorization: Provider Qualifications: ~~P-ri_o_r_A_u_th_o_ri_z_m_io_n ____________________ ~ll ~~-e_d_i_ca_id __ S_ta_te_P_I_an ____________________ ~ Amount Limit: Duration Limit: l~?_o_n_e ___________________________ -Jj jnone Scope Limit: Initial increment six months. Re-evaluate every 3 months. Other infom1ation regarding this benefit, including the specific nan1e of the source plan if it is not the base benchmark plan: nla Benefit Provided: Source: ~~H_o_m_e_H_e_a_h_h_c_a_re ________________________ ~j ~ls_ta_re __ P_la_n_I_9o_s_(_~ ___________________ ~ Authorization: Provider Qualifications: ~~P_ri_o_r_A_u_th_o_ri_z_at_io_n __________ ___JII~edicaid State Plan Amount Limit: Duration Limit: ~~N_on_e __________________ ~llnta Scope Limit: Skilled nursing, PT,OT,PT,ST,RT,dieticians, HH Aids. Must be intermittent services. TN No: 13-0029 Nevada ABP5 2 Approval Date: 1/24/14 Effective Date: 1/01/14 Pa_ge 2 of36

Alternative Benefit Plan Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: physician order & plan of care determine tx hours Benefit Provided: Source: IL.F_a_m_il_y_P_lru_m_in_g_s_e_rv_ic_e_s _________ --lllstate Plan 1905(a) Authorization: Provider Qualifications: ~~N_o_n_e ___________________________ ~ll L.~ __ ed_i_ca_i_d_S_ta_te_P_l_an ________________ ~ Amount Limit: Duration Limit: ~~N __ o_ne ________________________________ ~j ~~N_o_n_e ________________________________ ~ Scope Limit: jMust be FDA approved Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: nla Benefit Provided: Source: LjP_e_rs_o_n_al_C_a_r_e_s_erv __ ic_e_s ___________________ ~ll ~S_ta_t_e_P_lan __ I_9_o_s_(a_) ________________ ~ Authorization: Provider Qualifications: ~~P_n_·o_r_A_u_th_o_n_·z_m_io_n ____________________ ~l ~~M __ ed_i_cru_._d_S_ta_te __ PI_an _____________________ ~ Amow1t Limit: Duration Limit: ~~N_o_n_e ______________________ ~jjreassessment process Scope Limit: PCS include a rru1ge of human assistance provided to persons with disabilities and chronic conditions of all ages. Assistance with IADLs and ADLs. Other information regarding this benefit, including the specific name of the source plan ifit is not the base benchmark plan: The assessment is conducted by licensed physical and/or occupational therapist. Authorizations are dependent upon assessment process Blld will not exceed one year. Reassessments are required 30 days prior to expiration of authorization. Benefit Provided: Source: jL.P_n_·v_m_e_D_u_zy_N __ u_~_in_g ______________________ ~ll ~S_tm __ e_P_Ian __ l_90_5_(_~ ____________________ ~ Authorization: Provider Qualifications: L.A_u_th_o_r_iza_ti_o_n_r_eq~u_i_re_d __ in_e_x_c_es_s_o_f_l_im_i_ta_t_m_n ___ ~ ~~~-e_d_i_cru_'_d_S_ta_t_e_P_IBil __________________ ~ Amount Limit: Duration Limit: jsee Below TN No: 13-0029 ABP5 Approval Date: 1/24/14 evada 3 E ective Date: 1/0114 Pa_ge3 of36

Alternative Benefit Plan Scope Limit: The intent of private duty nursing is to assist the non-institutionalized recipient with complex direct skilled nursing care, to develop caregiver competencies through training and education, and to optimize recipient health status and outcomes. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Hourly service limitations are dependent upon diagnosis, caregiver availability, age and medicalltecessity. Hourly services may be exceeded with authorization. Benefit Provided: Source: j._o_u_tp_a_ti_en_t_H __ o_s_pi_.ta_l_s_e_rv_ic_e_s ________ --lllstate Plan I. 90S( a) Authorization: Provider Qualifications: J,_o_tl_le_r ______________ ___.IIMedicaid State Plan Amount Limit: Duration Limit: ~~N_on_e __________________ ~!Jwa Scope Limit: none Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Services require authorization dependent upon service being provided. Services provided include emergency room, radiology, laboratory, diagnostic, therapy, ambulatory surgery and observation. Benefit Provided: Source: ._c_I_in_ic_s_:(_I_9o_s_c_I_in_ic_s_u_n_d_e_rt_h_e_D_ir_e_ct_io_n_o_f_P_hy_s_) __ --l ._ls_ta_te_P_Ian __ l_90_5~(~~------------------~ Authorization: Provider Qualifications: ... JN_o_n_e ____ · -------------------'JIMedicaid State Plan Amount Limit: Duration Limit: l._n_o_n_e _____________________________________ ~l lnone Scope Limit: I within licensure requirements Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Services provided under the direction of a physician. TN No: 13-0029 Nevada ABP5 4 Approval Date: 1124114 Effective Date: 1/01/14 Pa.e:e4of36

..... Alternative Benefit Plan li] Essential Health Benefit 2: Emergency services Collapse All D Benefit Provided: Source: ~lc_Im __ ic_:_u_~_e_n_tc_~_e_c_Im_·_ic_s _______________ ~l ~ls_m_re __ P_IM_l_9o_s_(_~--------------------~ Authorization: Provider Qualifications: I ... N_o_n_e ________________ __,IIMedicaid State PIM Amount Limit: Duration Limit: ~-.IN_on_e _________ ___.lin/a Scope Limit: !within state licensing requirements. Other information reg~ding this benefit, mcluding the specific name of the source plan if it is not the base benchmark plan: Benefit Provided: Source: ... o_u_tp_a_ti_·e_n_t H_os_p_im_I:_E_m_e_r_g_ei_lc_y_R_o_o_m_c_·_ov_e_r_ag_e __ ....J ... ls_ta_t_e_P_la_n_l_9_o_s(_a_) __________ __, Authorization: Provider Qualifications: ... IN_o_n_e _______________ ....JI ... IM_e_d_i_cm_'_d_S_ta_te_P_I_M __________ __, Amount Limit Duration Limit: 1~-.N_on_e __________________ l~-.lw_a __________________ ~ Scope Limit: !within state licensing requirements. Other mformation reg~ding this benefit, mcluding the specific name of the source plan if it is not the base benchm~k plan: wa Benefit Provided: Source: l._r_rM_sp_o_rta_ti_on_:_E_m_e_r_ge_n_c_Y _________ .... IIstate Plan 1905(a) Authorization: Provider Qualifications: I ... N_o_n_e _______________ ....JIIMedicaid State Plan Amount Limit: Duration Lffilit: ~~n_o_ne ___________________________ __.l ~ln_o_ne _________________________ __, Scope Lffilit: none TN No: 13-0029 Nevada ABP5 5 Approval Date: 1124/14 Effective Date: 1/01/14 Page 5 of36

Alternative Benefit Plan Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: - ~--~----------------------------~ Emergent transports requiring "911" to acute facility and scheduled specialty care transports for hospital-to hospital transports of a critically ill or ill recipient by a ground or air ambulance vehicle needing medically necessary supplies and services at a level beyond scope ofEMT-intermediate or paramedic. TN No: 13-0029 Nevada ABP5 6 Approval Date: 1/24/14 Effective Date: 1/01/14 Page 6 of36

Alternative Benefit Plan li] Essential Health Benefit 3: Hospitalization Collapse All D Benefit Provided: Source: I~.....In_p_at_ie_n_t_ho_s_p_ita_l ___________ --.~llstate Plan 1905(a) Authorization: Provider Qualifications: ~~O_th_e_r ____________________________ ~l ~~~-e_d_ic_m_'d_S_ta_t_e_P_lan ____________________ ~ Amount Limit: Duration Limit: ~~N_o_n_e ________________________________ ~l !None Scope Limit: medlsurg tx; diagnostic testing; psychiatric/substance abuse/detox in a general acute care hospital;trauma;ICU; medical rehab. Other infonnation regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Admission, concurrent, and retrospective authorization requirements. ~edicare certified. Benefit Provided: Source: .... IIn_p_a_ti_en_t_H_o_s_pi_ta_J._· p_s_y_ch_ia:_t_ri_c _______________ __,llstate Plan 1905(a) Authorization: Provider Qualifications: ~...lc_o_n_cur_re_n_t_A_u_th_o_r_iz_a_ti_on ________ ___.ll~edicaid State Plan Amount Limit: Duration Limit: Dependent upon concurrent authorization Dependent upon authorization and recipient age. Scope Limit: Free-standing psychiatric hospital, or general med/surg hospital with a dedicated psychiatric unit. Services not covered for recipient ages 22-64 in a free-standing psychiatric hospital due to Institute for ~ental Disease(~) exclusion regulation. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: n/a Benefit Provided: Source: ._In_p_a_ti_en_t_H_o_s_pi_ta_I_:s_u_bs_t_an_c_e_A_b_u_se_(_d_&_ox_l_tx_) ______ ~ ~...ls_ta_te __ Pl_an __ 1_90_5~(-~ ____________________ ~ Authorization: Provider Qualifications: l._c_o_n_c_w_T_en_t_A_u_t_h_o_ri_za_t_io_n __________________ ~l ~~~ __ ed_i_c_ai_d_S_ta_t_e_P_la:n _____________________ ~:l Amount Limit: Duration Limit: ~..I D ....... et_o_x_s_da_;..ys_r_r_e_at_m_e_n_t_2_l_h_os..;;p_it_al_d_a..;.y_s __ --JIIunumited uretime admissions Scope Limit: Free-standing substance abuse tx hospitals or general hospitals with a specialized substance abuse tx unit 7 Page 7 of36

Alternative Benefit Plan w JC 1 tnc u es a secure, structure env1romnent, substance abuse professionals. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: All ages require results of urine drug screen or blood alcohol test at the time of the request for authorization. May exceed limits with authorization. Services not covered for recipient ages 22-64 in a free· standing psychiatric hospital due to Institute for Mental Disease (IMD) exclusion regulation. Benefit Provided: Source: I._I_np_a_ti_en_t_h_o_sp_it_a_I:_Tr_an_sp_Ian_ts ________ __.llstate Plan 1905(a) Authorization: Provider Qualifications: ILc_o_n_c_ur_r_en_t_A_u_tl_l_o_ri_za_t_io_n _________ .... IIMedicaid State Plan Amount Limit: Duration Limit: IL-n_o_n_e ___________________________ .... l Inane Scope Limit: Covered Adult transplants:bone marrow/stem cell, corneal, kidney, and Liver Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Admission, concurrent, and retrospective authorization requirements. Medicare certified. Benefit Provided: Source: ~I-np_a_ti_en_t_h_o_sp_ita_._I:_sk_i_ll_e& __ A_dm __ il_tD __ ay_s ________ __,ILs_~_te_._PI_an __ l_90_5_(a_) ______________ ~ Authorization: Provider Qualifications: [,_c_o_n_c_ur_r~en_t_A_u_th __ o_ri_za_t_io_n __________ ....~IIMedicaid State Plan Amount Limit: Duration Limit: I.._N_o_n_e _______________________ ....~l INane Scope Limit: Provides for ongoing hospital svs for those who don't require acute care but can't be discharged due to waiting for alternate placement. Not for convenience of caregiver. Must be due to medical intervention. Other infom1ation regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Admission, concurrent, and retrospective authorization requirements. Medicare certified. Benefit Provided: Source: LR_T_C_:_P_sy_c_h_ia_tr_i_c_R_e_si_d_en_t_iai_T_re_a_m_l_en_t_F_a_ci_li_zy ____ ~l LS_ta_te __ P_la_n_l_9_0_5(~a~) ____________________ ~ 1\uthorization: Provider Qualifications: l~..c_o_n_c_ur_r_en_t_A_u_t_h_o_ri_za_t_io_n _________ ...JIIMedicaid State Plan TN No: 13-0029 Nevada ABP5 8 Approval Date: 1/24/14 Effective Date: 1/01114 Page 8 of36

Alternative Benefit Plan Amount Limit: Duration Limit: LIN_o_n_e--------------------------------~1 INone Scope Limit: Psychiatric, medical-model facility accredited by Joint Commission, CARF, COA for recipients under age 21.providing active treatment, psychiatric services, psychological services therapeutic and behavioral modification, therapy, & nursing services. Other information regarding this benefit, including the specific name of the source plan jf,jt is not the base benchmark plan: ' Dependent upon concurrent authorization. Services not covered for recipient ages 22-64 in a free-standing psychiatric hospital due to Institute for Mental Disease (IMD) exclusion regulation. TN No: 13-0029 Nevada ABP5 9 Approval Date: 1/24/14 Effective Date: 1/01/14 Page 9 of36

Alternative Benefit Plan li] Essential Health Benefit 4: Maternity and newborn care Collapse All 0 Benefit Provided: Source: ~..IF_re_e_s_ta_n_d_in_g_B_i_rth_in_g_c_e_n_te_rs ________ ....JIIstate Plan l905(a) Authorization: Provider Qualifications: I._N_o_n_e ______________ __.jjMedicaid State Plan Amount Limit: Duration Limit: LIL_a_b_o_r,_d_e_liv_e_ry_,...;p;_o_s...;;tp_artum __ c_a_re ______ __.IILabor, delivery, postpartuin care· only Scope Limit: Natural childbirth procedures for labor, delivery, postpartum care and immediate newborn care. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Uncomplicated low-risk prenatal course is reasonably expected to result in a normal uncomplicated vaginal birth. Benefit Provided: Source: I~..P_h_y_si_ci_an_:_M_a_te_r_w_ty_S_e_N_I_·c_es __________ -....JI ... ls_ta_te ___ P_Ian __ l_9_05_(_~ ________________ ~ Authorization: Provider Qualifications: l~..o_th_e_r ______________________ -....JI ... IM_e_d_ic_ru_·d_sta_te_P_Ian ______________ ~ Amount Limit: Duration Limit: ._ln_o_n_e ________________________________ ~l Lln_o_n_e ________________________________ ~ Scope Limit: Obstetric/maternity/family planning procedures at time of delivery; newborn/neonatal/pediatric/postpartum Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: No authmization required for less than 48 hour nonnal vaginal delivery and/or 96 hour cesarean section delivery. C-section less than 39 weeks gestation and elective c-sections requires prior authorization. Benefit Provided: Source: ._II_np_a_ti_e_nt_h_o_s_p_ita_l_-m_at_em_ity _________ -.~llstate Plan 1905(a) Authorization: Provider Qualifications: ~..lc_o_n_c_ur_re_n_t_A __ uth __ o_ri_z_m_io_n __________________ ~ll L~_.ed_i_c_ru_d_S_ta_t_e_P_l_an ______________________ ~ Amount Limit: Duration Limit: ._ln_o_n_e ______________________ ~l jnone Scope Limit: Obstetric/maternity/family planning procedures at time of delivery; newborn/neonatal/pediatric TN No: 13-Q029 Nevada ABP5 10 Approval Date: 1/24/14 Effective Date: 1/01114 Pa_ge lO of 36

Alternative Benefit Plan Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Admission, concurrent, and retrospective authorization requirements. Medicare certified. No authorization required for less than 48 hour normal vaginal delivery and/or 96 hour cesarean section delivery. C-section less than 39 weeks gestation and elective c-sections requires prior authorization. Inpatient and physician maternity services. TN No: 13-0029 Nevada ABP5 11 Approval Date: 1/24/14 Effective Date: 1/01/14 Pa~e 11 of3(i

·'· Alternative Benefit Plan [!] Essential Health Benefit 5: Mental health and substance use disorder services including • behavioral health treatment Collapse All 0 Benefit Provided: Source: ~P-art_i_ai_H_o_s_pi_·m_li_m_t_io_n_~ __ HI_S_A_)_:P_HP __ (_l9_1_5_i) ______ ~ ~ls_ta_re_P_l_an __ l9_1_5_(i) ____________________ ~ Authorization: Provider Qualifications: I ... P_ri_o_r_A_u_th_o_ri_z_at_io_n __________ __.jiMedicaid State Plan Amount Limit: Duration Limit: Dependent upon authorization and intensity of need l._n_o_n_e ________________ _, Scope Limit: Medical model by a hospital, in an outpatient setting which encompasses a variety of psychiatric modalities to coordinate inrensive, comprehensive and multidisciplinary tx not generally provided in an outpatient setting. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Mental health rehab service based upon the assessed needs of the recipient based upon standardized assessments. The service has been standardized to a utilization system based upon a level of care placement system specific to children and adults. Benefit Provided: Source: ... m_re_n_s_iv_e_o_u_tp_a_tie_n_t_P_ro_g_rn_m __ ~_HJ __ sA_)_:I_o_P_(I_9_I_si_) __ _JI~s_m_re_P_l_an __ l9_1_5~(i) ____________________ ~ Authorization: Provider Qualifications: ... IP_r_io_r_A_u_t_ho_r_iz_a_tJ_·o_n ___________ ...JIIMedicaid State Plan Amount Limit: Duration Limit: Dependent upon authorization and intensity of need Scope Limit: I none Comprehensive interdisciplinary program of array of direct mental health/substance abuse & rehabilitative services which are expected to improve or maintain an individual's condition and functioning level for prevention of relapse or hospitalization. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Menml health rehab service based upon the assessed needs of the recipient based upon smndardized assessments. The service has been standardized to a utilization system based upon a level of care placement system specific to children and adults. Benefit Provided: Source: ~~~-HI--SA __ o_u_tp_a_ti_en_t_s_e_rv_i_ce_s_:R __ el_ta_b(_l_9_os_) ________ ~l ... ls_ta_t_e_P_la_n_l_9_os_(_~----------------------' Authorization: Provider Qualifications: Authorization required in excess of limitation I Medicaid State Plan Nevada 12 Effective Date: 1/01114 Pa~e 12 of36

Alternative Benefit Plan Amow1t Limit: Duration Limit: ~~N_o_n_e ______________________________ ~l ~~N_o_n_e------------------------------~ Scope Limit: Services recommended by physician/licensed practitioner of the healing arts, within their scope of practice wtder State law for the maximum reduction of a physical or mental disability and to restore the individual to the best functioning level. Other infom1ation regarding this benefit, including the specific name of the source plan if. it is not the base benchmark plan: • n/a TN No: 13·0029 Nevada ABP5 13 Approval Date: 1124/14 Effective Date: 1/01/14 Pa11;e 13 of36

Alternative Benefit Plan Iii Essential Health Benefit 6: Prescription drugs Benefit Provided: Coverage is at least the greater of one drug in each U.S. Pharmacopeia (USP) category and class or the same number of prescription drugs in each category and class as the base benchmark. Prescription Drug Limits (Check all that apply.): Authorization: Provider Qualifications: t&l Limit on days supply lves I Etate licensed I D Limit on number of prescriptions D Limit on brand drugs ' . t&l Other coverage limits t&l Preferred drug list Coverage that exceeds the minimum requirements or other: Follows all requirements under Section 1927 of the Social Security Act. Implementing the Nevada Medicaid State Plan pharmacy coverage 3.1 a. in its entirety. Nevada ABP prescription drug benefit plan is the san1e as under the approved Medicaid state plan for prescribed drugs. TN No: 13-0029 Nevada ABP5 14 Approval Date: 1/24/14 Effective Date: 1/01/14 Page 14 of36

Alternative Benefit Plan li] Essential Health Benefit 7: Rehabilitative and habilitative services and devices Collapse All D Benefit Provided: Source: LIP_h_ys_i_ca_l_Th __ er_a_py __ an_d_R_e_l_m_ed __ s_~_v_ic_es __________ ~l Lls_ta_re __ P_la_n_l_90_5~(~~--------------------~ Authorization: Provider Qualifications: LIP_ri_o_r_A_u_th_o_n_·za_t_w_n ____________________ ~l Ll~ __ ed_i_ca_i_d_S_ta_re_P_l_an ____________________ ~ Amount Limit: Durmion Limit: ~IN_on_e ___________________ ~I~IN_M ____________________ ~ Scope Limit: ~edically necessary therapy services for an illness or injury resulting in functional limitations which can respond or improve as a result of the prescribed therapy treatment plan in a reasonable, predictable period of time. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: n!a Benefit Provided: Source: ~aintenance Therapy:Physical Therapy & Related Svs I state Plan 1905(a) Authorization: Provider Qualifications: jLP_r_io_r_A_u_th_o_r_iz_m_io_n ____________________ ~l Ll~ __ ed_i_cru_._d_S_ta_re __ P_lan ______________________ ~ Amount Limit: Duration Limit: LIN_o_n_e ________________________________ ~ll LI_O_v_i_si_ts_e_v_e_cy __ th_r_ee_y_e_a_~------------------~ Scope Limit: Design or establish a maintenance plan, assure patient safety, train the patient, family membe~ and/or unskilled personnel and make infrequent but periodic reevaluations of the plan. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Service cannot be exceeded through prior authorization. The goals of a maintenance program are to maintain functional status at a level consistent with the patient's physical or mental limitations or to prevent decline in fw1ction. Benefit Provided: Source: LD_u_rn_b_l_e_~_e_d_ic_a_l_E_qu_i_p_m_e_nt __ :H_o_m __ e_H_e_al_th_c __ ar_e ____ ~ Lls_t_m_e_P_lan __ l_9_o_s_(a_) ______________________ ~ Authorization: Provider Qualifications: IL..P_n_·o_r_A_u_th_o_r_iza_t_io_n ____________ ...JIIMedicaid State Plan Amount Limit: Duration Limit: Authorization dependent upon the service loependent upon the service TN No: 13-0029 Nevada ABP5 15 Approval Date: 1/24/14 Effective Date: 1/01/14 Pa_ge 15 of 36

Alternative Benefit Plan Scope Limit: Items must have received approval by FDA and be consistent with approved use. Products for experimental or investigational purposes are non-covered. Consideration may be given to items classified by FDA as Humanitarian Device Exemptions (HDE). Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: n/a Benefit Provided: Source: ... IM_e_d_ic_a_l _su_P_P_li_es __ :H_o_m_e_H_e_a_lt_h_c_ar_e ______ ..JIIstate Plan 1905(a) Authorization: Provider Qualifications: ~A_u_t_h_on_·za __ t_io_n_r_e_qu_i_re_d ___ in_e_x_c_es_s_o_f_I_im_i_ta_t_io_n _____ ~IL.M_e_d_i_cm_._d_S_ta_t_~_P_Ian _______________________ ~ Amount Limit: Duration Limit: ._Q_u_an_ti_ty_l_im_it_a_ti_on_d_ep_e_n_d_e_nt_u_p_o_n_s_e_IVI_._ce ___ _. jufetime limit dependent on service Scope Limit: Items must have received approval by FDA and be consistent with approved use. Products for experimental or investigational purposes are non-covered. Consideration may be given to items classified by FDA as Humanitarian Device Exemptions (HDE). Other information regarding this benefit, including the specific name ofthe source plan if it is not the base benchmark plan: Benefit Provided: Source: ... o_rt_h_o_ti_cs_a_n_d_P_r_o_~_h_~_ic_s_:_P_ro_s_th_e_ti_c_D_e_v_ic_e_s ______ -..J ~ls_ta_t_e_P_Ia_n_I_.9_0_5~(a_) _________________________ ~ Authorization: Provider Qualifications: ... IP_ri_o_r_A_u_th_o_n_·z_at_io_n ____________ --JIIMedicaid State Plan Amount Limit: Duration Limit: ~A_u_tl_lo_I_·iz_a_ti_· o_n_d_e.:.p_en_d_e_n_t_u.:..p_on_ti_le_s_e_rv_i_ce ___ --1 I lifetime limit dependent on service Scope Limit: Items must have received approval by FDA and be consistent with approved use. Products for experimental or investigational purposes are non-covered. Consideration may be given to items classified by FDA as Humanitarian Device Exemptions (HDE). Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: n/a B~nefit Provided: Source: jocular- hardware : eyeglasses jjstate Plan 1905(a) TN No: 13-0029 ABP5 Approval Date: 1/24/14 Page 16 of36

•.. '· •' '· Alternative Benefit Plan Authorization: Provider Qualifications: ~A_u_ili_o_r_iz_a_ti_on __ re_q~u_ir_ed __ in_e_x_c_es_s_o_f_li_m_n_a_ti_on ___ ~ ~~~--ed_i_cru_._d_s_m_re_P_l_an ____________________ ~ Amount Limit: Duration Limit: ~~1_11_2_m_o_n_ili_s ________________________ ~l lwa Scope Limit: Change in refractive error must exceed plus or minus 0.5 diopter or 10 degrees in axis deviation in order to qualify within 12 mo limitation or EPSDT. . · Oilier information regarding this benefit, including ilie specific nan1e of the source plan if it is not the base benchmark plan: wa Benefit Provided: Source: ~O_c_cu_p_a_ti_or_la_l_T_h_er_a_PY_-_P_hy_s_ic_a_l_Th_e_ra_p_y_&_R_e_l_M_ed __ Sv_s~ ~ls_ta_re __ P_lan __ 1_9o_s_(_~--------------------~ Authorization: Provider Qualifications: '~P_ri_o_r_A_u_ili_o_n_· w __ io_n ___________________ __JII~edicaid State Plan Amount Limit: Duration Limit: I...._N_on_e __________ --'lln/a Scope Limit: ~edically necessary therapy services for an illness or injury resulting in functional limitations which can respond or improve as a result of the prescribed therapy treatment plan in a reasonable, predictable period oftime. Other information regarding iliis benefit, including ilie specific name of the source plan if it is not the base benchmark plan: wa Benefit Provided: Source: ~S_p_ee_c_h,_h_e_a_rin_g_a_n_d_l_ru_lg_u_~_e_-_P_h_ys_ic_a_l_T_he_r_ap_y_& __ R __ ~I~s_ta_re_P_l_an __ l_9o_s_(a_) ______________ ~----~ Authorization: Provider Qualifications: ._IP_ri_o_r_A_u_th_o_n_· za_t_io_n _____________ __JII~edica1d State Plan Amount Limit: Duration Limit: ~~n_o_n_e ______________________________ ~l In/a Scope Limit: ~edically necessary ilierapy services for an illness or injury resulting in functional limitations which can respond or improve as a result of the prescribed therapy treatment plan in a reasonable, predictable period of time. TN No: 13-0029 Nevada ABP5 17 Approval Date: 1/24114 Effective Date: 1/01/14 Page 17 of36

Alternative Benefit Plan Other infonnation regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: n/a Benefit Provided: Source: ~~A_d_ui_t_D_ay_H_e_ru_ili __ c_ar_e __________________ ~l ~ls_m_re_P_l_an_I_9_I_S(_n __________________ ~ Authorization: Provider Qualifications: ._IP_n_·o_r_A_u_ili_o_r_iza_t_io_n ____________ __,liMedicaid Smte Plan Amow1t Limit: Duration Limit: ._u_n_i_ve_r_sru_N_e_e_d_s_A_ss_e_s_sm __ en_t_&_Ph~y~s_ic_ian __ E_v_ru __ ~l ._n_o_n_e _______________________ ~ Scope Limit: Services include health and social services needed to ensure ilie optimal functioning of the participant. Services are generally furnished wiiliin four or more hours per day on a regularly scheduled basis. Recipient must be at least 18 years of age. Other infonnation regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: n/a Benefit Provided: Source: !Home Based Habilitation Services Stare Plan 1915{i) Authorization: Provider Qualifications: ILo_ili __ eJ_. ____________________________ ~I ._IM_e_d_ic_ru_·d __ sm_t_e_P_la_n _________________ ~ Amowtt Limit: Duration Limit: ILu_n_w_e_rn_a_·J_N_e_e~ __ A __ ss_e_ss_m_e_n_t_T_oo_I _______ ~I ... ln_o_n_e ___________________________ ~ Scope Limit: Pt. must have endurance for 3 hours of habilimtive services per day, 5 days per week. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Day tx program for individuals to assist in acquiring, retaining, and improving the self-help, socialization and adaptive skills necessary to reside successfully in home and community setting. Habilitaiton services are prescribed by a physician, and provided by ilie appropriate quruified staff. TN No: 13-0029 Nevada ABP5 18 Approval Date: 1/24/14 Effective Date: 1/01/14 Pa_ge 18 of36

Alternative Benefit Plan liJ Essential Health Benefit 8: Laboratory services Collapse All 0 Benefit Provided: Source: I .... L_a_b_or_a_to_ry_an_d_x_-_ra_y_s_e_rv_ic_e_s ________ .... llstate Plan l905(a) Authorization: Provider Qualifications: I,__P_ri_o_r_A_u_th_o_n_· za_n_· o_r_1 __________ -..:~jjMedicaid State Plan Amow1t Limit: Duration Limit: I ,__n_o_n_e ________________________________ ~l lnone Scope Limit: These services include, but not limited to microbiology, serology, immunohematology, cytology, histology, chemical,hematology, biophysical, toxicology or other methods of"in-vitro" exam of tissues, secretions, excretions or other human body parts. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Genotype and phenotype are covered and requires P A. Clinic and facility based services. Benefit Provided: Source: .... IL_a_bo_r_a_to_ry_an_d_X_-ra_y_s_em_·c_e_s:_d_ia_g_no_s_ti_c_s ____ __.II state Plan 1905(a) Authorization: Provider Qualifications: \,__N_o_n_e ______________ ---11\Medicaid State Plan Amount Limit: Duration Limit: ,__jn_o_n_e ______________________________ ~J lnone Scope Limit: jx-ray and diagnostic testing Other information regarding this benefit, including the specific name ofthe source plan if it is not the base benchmark plan: Medically necessary services for diagnosis and treatment of a specific illness, symptom, complaint or injury or to improve the function of a malformed body part. The investigational use for any radiological test is not covered. Clinic and facility based servic.es. TN No: 13-0029 Nevada ABP5 19 Approval Date: 1/24114. Effective Date: 1/01114 Page 19 of 36

Alternative Benefit Plan Iii Essential Health Benefit 9: Preventive and wellness services and chronic disease management Collapse All 0 The state/territory must provide, at a minimum, a broad range of preventive services including: "A" and "B" services recommended by the United States Preventive Services Task Force; Advisory Committee for Immunization Practices (ACIP) recommended vaccines; preventive care and screening for infants, children and adults recommended by HRSA's Bright Futures program/project; and additional preventive services for women recommended by the Institute of Medicine (I OM). Benefit Provided: Source: ~~P_r_ev_e_n_ti_ve __ s_erv __ ic_e_s ______________________ ~l Ljs_ta_re __ P_Ia_n_1_9_0_5(_a~)--------------------~ Authorization: Provider Qualifications: ~L~-o_n_e ______________________________ -JI LIM_e_d_ic_ru_·d __ S_ta_te_P_I_an ____________________ ~ Amount Limit: Duration Limit: ~loo_ne--------------------~~~~w_a ____________________ ~ Scope Limit: U.S. Preventive Services Task Force A&B recommendations, ACIP and Bright Future, and 10M Women's Health. Other information regarding this benefit, including the specific name of the source plan if it is not the base benclunark plan: Nevada State Plan Preventive services are exclusive to the USPSTF/ACIP/Bright Futures/10M EHB requirements. TN No: 13-0029 Nevada ABP5 20 Approval Date: 1/24/14 Effective Date: 1/01/14 Page 20 of36

Alternative Benefit Plan Iii Essential Health Benefit 10: Pediatric services including oral and vision care Collapse All 0 Benefit Provided: Source: Medicaid State Plan EPSDT Benefits !state Plan 1905(a) Authorization: Provider Qualifications: ~~N_o_n_e----------------------------~~~ LM_e_ru_·c_ru_·d_s_m_te __ P_Ian ____________________ ~ Amount Limit: Duration Limit: ILn_o_ne------------------------------~1 lnone Scope Limit: Medically necessary services for children under the age of21. Other information regarding this benefit, inclurung the specific name of the source plan if it is not the base benchmark plan: TN No: 13-0029 Nevada ABP5 21 Approval Date: 1/24/14 Effective Date: 1/01/14 Pa_ge 21 of 36

' Alternative Benefit Plan 0 Other Covered Benefits from Base Benchmark TN No: 13-0029 Nevada ABP5 22 Collapse All 0 Approval Date: 1/24/14 Effective Date: 1/01/14 Page 22 of36

Alternative Benefit Plan 181 Base Benchmark Benefits Not Covered due to Substitution or Duplication Collapse All D Base Benclunark Benefit that was Substituted: Source: IHeart, heart/lung transplant adults Base Benchmark Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Substituted for (hospital) Residential Treatment Center benefit for adolescents 19-20, up to 22 if in facility on birthday and Skilled Inpatient Administrative Days are mapped to EHB3. Base Benchmark Benefit that was Substituted: Source: pancreas, pancreas/liver transplant adults Base Benchmark Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Substituted for Residential Treatment Center benefit for adolescents 19-20, up to 22 if in facility on birthday and Skilled Administrative Days are mapped to EHB3. Base Benchmark Benefit that was Substituted: Source: Fertility, Accupuncture, Podiatry, Chiropractic Base Benchmark Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Substituted for personal care services and Private Duty Nursing Services are mapped to EHBl. Base Benchmark Benefit that was Substituted: Source: Physicians and other healthcare professionals Base Benchmark Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplication: covered under the Nevada Medicaid State Plan as EHB 1 (physician,family planning, clinic benefit). Base benchmark: covers services by physicians and other health care professionals determined to be medically necessary. Services include consultations, second surgical opinions, clinic visits, office visits, home visits, initial exam of newborn, and nutritional counseling. No service limitation. Base Benchmark Benefit that was Substituted: Source: ILab, X-ray and other diagnostic services Base Benchmark Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplication: covered under the Nevada Medicaid State Plan as EHB 8(lab and x-ray benefit). Services ordered by a physician. Billed by physician, independent laboratory, and/or outpatient hospital department. Base benchmark does not cover genetic screening, requires cancer diagnosis for BRCA testing. No service limitations. Base Benchmark Benefit that was Substituted: Source: !Preventive care, adult Base Benchmark Nevada 23 Effective Date: 1/01/14 Page 23 of36

Alternative Benefit Plan Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplication: Covered under the Nevada Medicaid State Plan as EHB9. Base benchmark: Services recommended under PP ACA. Services have quantity limitation, 1 per year. FDA approved immunizations. Group c<>unseling non-covered Base Benchmark Benefit that was Substituted: Source: !Preventive care, children Base Benchmark . Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplication: Covered tmder the Nevada Medicaid State Plan as EHB9 (preventive benefit). Nevada Medicaid does not limit STI. Base benchmark: Services recommended under the PPACA and AAP. Newborn visits and screens, lab test, hearing and visions screenings, FDA approved immunizations, screenings for STI, HPV, and HIV. STI limited to 1 per year. Base Benchmark Benefit that was Substituted: Source: !Maternity Care Base Benchmark Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplication: Covered under the Nevada Medicaid State Plan as EHB4 (free-standing birth centers, physician-maternity, inpatient-maternity benefit), and EHB5 (.BH/SA Outpatient Services benefit). Base benchmark: Prenatal care, tocolytic therapy, delivery postpartum care, surgery, anesthesia, and mental health tx for postpartum depression. No service limitations. Base Benchmark Benefit that was Substituted: Source: !Family plruming Base Benchmark Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplication: Covered under the Nevada Medicaid State Plan as EHB6(prescription benefit), EHB I (physician, fan1ily planning, clime, urgent care, outpatient hospital, emergency room benefit), EHB7(HH: medical supplies). Base benchmark: Contraceptive counseling, contraceptive supplies (oral, injectable, implants, transdennal, condoms), fitting, insertion, implantation, or removal of the contraception, voluntary sterilization. Non cover- reversal of voluntary sterilization. No service limitations. Base Benchmark Benefit that was Substituted: Source:- !Allergy care Base Benchmark Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplication: Covered under the Nevada Medicaid State Plan as EHB 1 (physician services, clinics benefits). Base benchmark: no service limitations. Base Benchmark Benefit that was Substituted: Source: lrreatment therapies Base Benchmark Nevada 24 Effective Date: 1/01/14 Pa~e 24 of36

Alternative Benefit Plan Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplication: Covered under the Nevada Medicaid State Plan as EHBl(physicians, clinics, outpatient hospital benefit) and EHB8(laboratory/x-ray benefit). Base benchmark: no service limitations. Base Benchmark Benefit that was Substituted: Source: lPT, ST,OT,Cognitive therapy Base Benchmark Explain the substitution or duplication, including indicating the substituted benefl't(s) or .the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplication: Covered under the Nevada Medicaid state Plan as EHB7(Physical therapy & related services; PT/ST/OT/Cognitive therapy benefit), EHB 1 (Outpatient Hospital benefit), EHBS(BHJSA Outpatient Services benefit). Nevada Medicaid State Plan provides a greater benefit for therapy services due to a lesser service limitation. Cognitive therapy covered under both medical and behavioral therapy. Base benchmark: covers licensed therapist or physician. Non-covers;Maintenance, recreation, education, exercise, and hippotherapy non-covered. Limited to 50 visits per calendar year for, combination ofPT, OT, ST. Base Benchmark Benefit that was Substituted: Source: !Hearing svs (testing,tx, supplies) Base Benchmark Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplication: Covered under the Nevada Medicaid State Plan as EHBl(physicians, clinics benefit),EHB7 (physical therapy & related services benefit, orthotics and prosthetics: prosthetic devices), EHB8 (laboratory, x-ray benefit). Nevada Medicaid State Plan provides a greater benefit for Hearing Aid services due to no annual expenditure limit. Base benchmark: Annual expe11diture amount on hearing aids. Base Benchmark Benefit that was Substituted: Source: !vision Services Base Benchmark Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplication: Covered under the Nevada Medicaid State Plan as EHB 1 (physician services and clinic benefit) EHB7 (ocular-hardware:eyeglass benefit). Nevada Medicaid State Plan provides for all medically necessary conditions. Service limitation exceeded through EPSDT. Base benchmark: covers exam related to amblyopia and strabismus for children under age 18. non-covered-routine eye exam and hardware. Base Benchmark Benefit that was Substituted: Source: !orthopedic and prosthetic devices Base Benchmark Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplication: Covered under the Nevada Medicaid State Plan as EHB7 (orthotics and prosthetic: prosthetic device benefit). Nevada Medicaid State Plan provides coverage of orthotics and prosthetics by licensed and Medicare certified/bonded providers. Base benchmark: lifetime limit on wigs as a result of cancer. Non- cover over-the-counter orthotics, shoes, arch supports, heel pads/supports. TN No: 13-0029 Nevada ABP5 25 Approval Date: 1/24/14 Effective Date: 1/01/14 Pa~e 25 of3li

\ Alternative Benefit Plan Base Benchmark Benefit that was Substituted: Source: !Durable medical equipment (DME) Base Benchmark Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplication: Covered under the Nevada Medicaid State Plan as EHB7(Durable medical equipment:home health care benefit). Nevada Medicaid State Plan provides a greater benefit for DME services due to coverage of bathroom equipment. Providers must be licensed, bonded and Medicare Certified.Base Benchmark: Annual expenditure amounts on SGD. Non-cover bathroom equipment. Base Benchmark Benefit that was Substituted: Source: !Medical supplies Base Benchmark Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplication: Covered under the Nevada Medicaid State Plan as EHB7(medical supplies: home health care benefit). Base Benchmark: no limitations. Base Benchmark Benefit that was Substituted: Source: .,Home health services Base Benchmark Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplication: Covered under the Nevada Medicaid State Plan as EHB l(home health care benefit). Nevada Medicaid State Plan provides a greater benefit for Home health services due to coverage ofPT,OT,ST,RT services under home health benefits and lesser service limitations. Base benchmark: service limitations up to 25 visits per calendar year, provider qualifications ofRNILPN, and skilled visit coverage only. Base Benchmark Benefit that was Substituted: Source: !Educational classes and programs Base Benchmark Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplication: Covered under the Nevada Medicaid State Plan as EHB 1 (physician and clinic benefit) and EHB9 (Preventive benefit) as physician services and other practitioners as preventive services, smoking and tobacco cessation, diabetic education, medical nutritional therapy. Base benchmark: non-cover educational classes not listed above. Base Benchmark Benefit that was Substituted: Source: jsurgical procedures Base Benchmark Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplication: Covered under the Nevada Medicaid State Plan as EHB3 (inpatient hospital, inpatient hospital: transplant benefit), EHBl (physician services, outpatient hospital services, 1905 clinics:under the direction of benefit) and EHB2 (outpatient hospital emergency room services and urgent care clinics benefit). Base benchmark: non covers reversal of voluntary sterilization, standby physician, routine tx of conditions of foot, cosmetic surgery and refractive surgery. p 26 Page 26 of36

Alternative Benefit Plan Base Benchmark Benefit that was Substituted: Source: !Reconstructive surgery Base Benchmark Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplication: Covered under the Nevada Medicaid State Plan as EHB3 (inpatient hospital, inpatient hospital: transplant benefit) , EHB 1 (physician services, outpatient hospital services, 1905 clinics:under the direction of benefit) and EHB2 (outpatient hospital emergency room services and urgent care clinics benefit). Base benchmark: non-covers cosmetic surgery, surgeries related to sex transfornfation, sexual dysfunction, and/or inadequacy. Unless in the case of post mastectomy due to cancer. ' Base Benchmark Benefit that was Substituted: Source: lora! and maxillofacial surgery Base Benchmark Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplication: Covered under the Nevada Medicaid State Plan as EHB3 (inpatient hospital), EHB 1 (physician services, outpatient hospital services, 1905 clinics:under the direction of benefit) and EHB2 (outpatient hospital emergency room services and urgent care clinics benefit). Covered in physician office, hospital, hospital outpatient, SNF, ASC center. Base benchmark: dental/orthodontic care only covered for accidental injuries. Base Benchmark Benefit that was Substituted: Source: !Anesthesia Base Benchmark Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplication: Covered under the Nevada Medicaid State Plan as EHB3 (inpatient hospital, inpatient hospital: transplant benefit), EHB 1 (physician services, outpatient hospital services, 1905 clinics:under the direction of benefit) and EHB2 (outpatient hospital emergency room services benefit). Base benchmark: Covered by qualified healthcare professionals in hospital (inpatient, outpatient), skilled nursing facility, ambulatory surgical center and office. No se1vice limitations. Base Benchmark Benefit that was Substituted: Source: !Inpatient hospital Base Benchmark Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplication: Covered under the Nevada Medicaid State Plan as EHB3(inpatient hospital, inpatient hospital: transplant, inpatient hospital: skilled/admin days benefit) and EHB4 (inpatient hospital:matemity and free- standing birthing center benefit) as Inpatient hospital services. Base benchmark services covers operating, recover, maternity and other treatment rooms. Prescribed drugs, Diagnostic studies, radiology, lab, pathology and supplies. : non· covered- nursing homes, extended care facilities, schools, residential treatment centers, private duty nurshtg. Base Benchmark Benefit that was Substituted: Outpatient hospital and ambulatory surgical center TN No: 13-0029 Nevada Source: Base Benchmark ABP5 27 Approval Date: 1/24/14 Effective Date: 1/01/14 Page 27 of36

Alternative Benefit Plan Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplication: Covered under the Nevada Medicaid State Plan as EHB 1 (Outpatient hospital services benefit) ambulatory services and EHB4 (free-standing birthing center benefit) maternity/newborn care. Base benchmark services covers operating, recovery, and other treatment rooms, free-standing birthing centers, pre-surgical testing performed within one day of surgery. Observation, radiology, diagnostics, supplies, therapies, treatment therapies, and free-standing ASC services. No service limitations. Base Benchmark Benefit that was Substituted: Source: !Hospice care Base Benchmark Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplication: Covered under the Nevada Medicaid State Plan as EHB l(hospice benefit) ambulatory and EHB3 (Inpatient hospital benefit) hospitalization. Base benchmark covers home and facility services. Service limited to 7 consecutive days for home and 30 consecutive days in facility. Episodes may be reauthorized. Non-covered- homemaker, home health aide. Base Benchmark Benefit that was Substituted: Source: !Ambulance-Emergency Base Benchmark Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplication: Covered under the Nevada Medicaid State Plan as EHB2 (transportation:emergency benefit) emergency services. Base benchmark covers emergency transport/ambulance with covered hospital inpatient care related to medical emergency and/or covered hospice care. Non-covered: non-emergency transport. Base Benchmark Benefit that was Substituted: Source: Accidental injury (ER) Medical emergency Base Benchmark Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Esse11tial Health Benefits: Duplication: Covered under the Nevada Medicaid State Plan as EHB2 (outpatient hospital: emergency room benefit) emergency services. Base benchmark covers inpatient and physician benefits under emergency services. No limitations. Base Benclunark Benefit that was Substituted: Source; IMH/SA professional services Base Benchmark Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplication: Covered under the Nevada Medicaid State Plan as EHB 1 (physician services benefit) EHB5 (MHISA: partial hospitalization; Intensive outpatient program; outpatient services benefit). Nevada Medicaid State Plan provides a greater benefit for MH/SA rehab services including, day treatment (medical model), BST, PSR and peer support. Base benchmark covers professional services for individual, group therapy, office visits, home visits, pharmacotherapy, and psychological testing. Covered in outpatient hospital dept. and inpatient visit. Must be licensed professional. Non-covered: non-licensed professionals, marital, family, educational or other counseling/training services, testing and tx for learning disabilities and TN No: 13-0029 ABP5 Approval Date: 1/24114 Page 28 of36

Alternative Benefit Plan Base Benchmark Benefit that was Substituted: Source: MHJSA inpatient hospital or other covered facility Base Benchmark Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits; Duplication: Covered under the Nevada Medicaid State Plan as EHB3(MH/SA lnpatienfhospital:substance abuse, Inpatient hospital: psychiatric, Inpatient hospital: Skilled/ Admin Days, RTC!Psychiatric Residential Treatment Facilities benefit). Services for individuals age 22-64 are non-covered by Nevada Medicaid in an IMD. Base benchmark covers MHJSA inpatient services. Non-covered: non-licensed professionals, marital, family, educational or other counseling/training services, testing and tx for learning disabilities and mental retardation, applied behavior analysis (ABA) or ABA therapy, services performed or billed by residential treatment centers, schools, halfway houses, residential camps, and light boxes. Base Benchmark Benefit that was Substituted: Source: MHJSA outpatient hospital or covered facility Base Benchmark Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplication: Covered under the Nevada Medicaid State Plan as EHBS (MH/SA: partial hospitalization; Intensive outpatient program; outpatient services benefit). Services for individuals age 22-64 are non- covered by Nevada Medicaid in an IMD. Base benchmark covers outpatient hospital, partial hospitalization, facility-based intensive outpatient treatment, diagnostic testing, and psychological testing. Non-covered: non-licensed professionals, marital, family, educational or other counseling/training services, testing and tx for learning disabilities and mental retardation, applied behavior analysis (ABA) or ABA therapy, services performed or billed by residential treatment centers, schools, halfway houses, residential camps, and light boxes. Base Benchmark Benefit that was Substituted: Source: !Prescription drug benefits Base Benchmark Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplication: Covered under the Nevada Medicaid State Plan as EHB6 (prescription drug benefit) Pharmacy services. Nevada Medicaid is required to comply with all regulatory requirements of Section 1927 of the Social Security Act. Base benchmark covers a four-tier system·to categorize their payment levels for drugs; Tier 1: generic drugs, Tier 2: Preferred brand-name drugs, Tier 3: non-preferred brand-name drugs, and Tier 4: specialty drugs. Base Benchmark Benefit that was Substituted: Source: !Dental benefits Base Benchmark Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplication: Covered under the Nevada Medicaid State Plan as EHB10 (EPSDT benefit} Pediatric Oral Services. Nevada Medicaid covers under EPSDT and Dental services. Base benchmark: covers eval, xray, Nevada 29 Effective Date: 1/01/14 Pa~e 29 of36

Alternative Benefit Plan !preventive, palliative and extractiOns. Service limttations- preventive (l/yr), xray(l/3yr) Base Benchmark Benefit that was Substituted: Source: lrransplant benefits Base Benchmark Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplication: Covered under the Nevada Medicaid State Plan as EHB2 (hospitalization benefit) and EHB 1 (ambulatory benefit) . Base benchmark covers bone marrow, stem cell, liver, comea transplants. Reference Substitution section for additional transplants. TN No: 13-0029 Nevada ABP5 30 Approval Date: 1124/14 Effective Date: 1/01/14 Page 30 of36

Alternative Benefit Plan t8J Other Base Benchmark Benefits Not Covered Base Benchmark Benefit not Included in the Alternative Benefit Plan: I Adult Dental Source: Base Benchmark Explain why the state/territory chose not to include this benefit: Adult dental benefit from the base benchmark plan (FEHBP) will not be covered in the ABP. TN No: 13-0029 Nevada ABP5 31 Collapse All 0 Approval Date: 1/24/14 Effective Date: 1/01114 Page 31 of36

Alternative Benefit Plan 181 Other 1937 Covered Benefits that are not Essential Health Benefits Collapse All D Other 1937 Benefit Provided: Source: I I Section 193 7 Coverage Option Benchmark Benefit ._!_ar_g_e_te_d_C_as_e_M_an_a_g_em_en_t _________ _,_ Package Authorization: Provider Qualifications: ~A_u_th_o_n_·za_t_io_n_re_q~u_rr_ed __ in_e_x_c_es_s_o_f_li_m_n_&_i_on __ _, ._IM_e_d_ic_ru_'d_S_m_te_P_I_an __________ ~ Amount Limit: Duration Limit: ~~3_0_h_o_u_rs_p_e_r_m_o_n_th ______________ ~l ~ln_la _____________________ ~ Scope Limit: 7 covered target groups. Seriously Mentally Ill, Severe Emotional Disturbance, Axis I (non SED non SMl), Juvenile Protective Services, Child Welfare, Developmentally Delayed ages 0-3, Mental Retardation and Related Conditions. Other: n/a Other 1937 Benefit Provided: Source: lnst. Facility for Individuals wllntellectuals wiD Section 1937 Coverage Option Benchmark Benefit Package Authorization: Provider Qualifications: I._P_n_·o_r_A_u_th_o_n_'z_at_io_n __________ ___JIIMedicaid State Plan Amount Limit: Duration Limit: ._IB_as_e_d_u_p_o_n_a_u_th_o_n_·za_t_io_n_de_t_enn_i_na_t_io_n ______ ---JI lnone Scope Limit: Must be certified and comply with all Federal Cond of Participation in 8 areas, including mngt, client protections, facility staffing, active tx services, client behavior & facility practices, healthcare services, physical enviro, & dietetic svcs. Other: Institutional Facility for Individuals with Intellectual with Disabilities Formally ICF/MR Other 1937 Benefit Provided: Source: I Section 1937 Coverage Option Benchmark Benefit Transportation (11on-emergency) Package Authorization: Provider Qualifications: ._lo_th_e_r ______________ ---'jiMedicaid State Plan Amount Limit: Duration Limit: !Dependent upon service llnone TN No: 13-0029 Nevada ABP5 32 Approval Date: 1/24/14 Effective Date: 1/01/14 Page 32 of36

Alternative Benefit Plan Scope Limit: NET includes; charter air flight, commercial air, rotary wing, fixed wing, ground ambulance, bus (local and out-of-town), paratransit (private and public), private vehicle, and taxi. Other: Non-Emergency Transportation (NET) services are provided to all Medicaid recipients through the contracted NET broker and must be authorized by the broker. Other 1937 Benefit Provided: Source: I Section 193 7 Coverage Option Benchmark Benefit Dental Package Authorization: Provider Qualifications: ~~P-ri_o_r_A_u_tll_o_ri_z_&_io_n ____________________ ~l biM_e_d_i_cru_·d __ S_ta_te_P_l_a_n __________________ ~ Amount Limit: Duration Limit: ~~s_ee_b_e_w_w ____________________________ ~j !none Scope Limit: Individuals under the age of21 Medicaid-eligible for EPSDT benefits receive comprehensive dental care such as periodic and routine dental services needed for restoration of teeth, prevention, and maintenance of dental health. Other: Individuals over age 21,Dental services for Medicaid-eligible adults who qualifY for full benefits receive emergency extractions, palliative care, and may also be eligible to receive prosthetic care (dentures/partials) under certain guidelines and limitations. Other 1937 Benefit Provided: Source: I Section 1937 Coverage Option Benchmark Benefit Nursing Facility Package Authorization: Provider Qualifications: ~...lo_th_e_r ______________ ~IIMedicaid State Plan Amount Limit: Duration Limit: t...lb_as_e_d_u~p_o_n_le_v_e_l_o_f_cru_·_e_sc_r_ee_n_s ___________ --JJin/a Scope Limit: Level of Care assessment to determine appropriateness ofNF placement. Options include; NF standard, NF ventilator dependent, Pediatric specialty l/11, and Behaviorally Complex. P ASRR IIII screens completed for behavioral health rule out procedures. Other: Provide health related care and services on a 24-hour basis to individuals,due to medical disorders, injw-ies, developmental disabilities, and/or related cognitive and behavioral impairments, exhibit the need for medical,nursing, rehab, psychosocial, management. Qther 1937 Benefit Provided: joptometrist TN No: 13-0029 Source: Section 1937 Coverage Option Benchmark Benefit Package ABP5 Approval Date: 1/24/14 Page 33 of36

Alternative Benefit Plan Authorization: Provider Qualifications: LA_u_fu __ or_iz_a_ti_·o_n_r_e~qu_i_re_d __ in_e_x_c_e_ss_o_f_l_hn_i_ta_t_io_n ____ ~ Ll~ __ ew_·_ca_i_d_S_m_re __ P_lan ______________________ ~ Amount Limit: Duration Limit: II exam per 12 months Scope Limit: Other: Ophfualmologist no limit for medical condition, no P A under physician visit. Ocular exam for medical exam by optometrist do not require PA, ICD9 required. (glaucoma, diabetes, follow up from cataract surgery, EPSDT referral) Other 1937 Benefit Provided: Source: I Section 1937 Coverage Option Benchmark Benefit Peer Support Services: Rehab (1905) Package Aufuorization: Provider Qualifications: LA_u_t_ho_r_iz_a_t_J·o_n_r_e~qu_i_re_d __ t·n_e_x_c_es_s_o_f_l_im_i_tan __ ·o_n ____ ~ ~~~ __ ew_·_c_ai_d_S_m_t_e_P_I __ an ____________________ ~ Amount Limit: Duration Lhnit: LIN_o_n_e--------------------------------~1 ~~N_o_n_e--------------------------------~ Scope Limit: Rehab intetventions to restore recipient to highest level of functioning through peer supporters. Other: ~ental healfu rehab service based upon an the assessed needs of the recipient based upon standardized assessments. The service has been standardized to a utilization system based upon a level of care placement system specific to children and adults. Other 193 7 Benefit Provided: Source: Basic Skills/Psychosocial Rehab: Rehab ( 1905) Section 1937 Coverage Option Benchmark Benefit Package Authorization: Provider Qualifications: LA_u_fu_o_r_iza __ ti_o_n_r_eq~u_i_re_d_i_n_e_x_c_es_s_o_f_li_m_i_ta_ti_o_n ____ ~ Ll~ __ ed_i_c_ru_d_S_ta_t_e_P_lru __ t ____________________ ~ Amount Limit: Duration Limit: Lln_o_n_e--------------------------------~1 lnone Scope Limit: BST services help recipients acquire (learn) constructive cognitive and behavioral skills through positive reinforcement, modeling, operant condition and other techniques. PSR target psychological functioning within a variety of social settings. ~er: ~ental health rehab service based upon an fue assessed needs offue recipient based upon standardized assessments. The service has been standardized to a utilization system based upon a level of care placement Nevada 34 Effective Date: 1/01/14 Page 34 of36

Alternative Benefit Plan !system specific to chddren and adults. Other 1937 Benefit Provided: Source: I Section 1937 Coverage Option Benchmark Benefit Respiratory Therapy Package Authorization: Provider Qualifications: !Prior Authorization !!Medicaid State Plan ~------------------------------~ Amount Limit: Duration Limit: ~~N_o_n_e------------------------------~1 INane Scope Limit: Medically necessary therapy services for an illness or injury resulting in functional limitations which can respond or improve as a result of the prescribed therapy treatment plan in a reasonable, predictable period of time. Other: nla Other 1937 Benefit Provided: Source: I Section 193 7 Coverage Option Benchmark Benefit Tobacco-cessation for Pregnant Women Package Authorization: Provider Qualifications: l~....o_th_e_r __________________________ ___j! !Medicaid State Plan Amount Limit: Duration Limit: ~~no_ne __ ~-----------------~~~~nl-a _____________________ ~ Scope Limit: Services provided according to the USPSTF. Other: TN No: 13-0029 Nevada ABP5 35 Approval Date: 1/24/14 Effective Date: 1/01/14 Page 35 of36

Alternative Benefit Plan D Additional Covered Benefits (This category of benefits is not applicable to the adult group under section 1902(a)(10)(A)(i)(VIII) of the Act.) PRA Disclosure Statement Collapse All 0 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 nuntber for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 5 hours per response, including the time to revi!;)W instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN No: 13-0029 Nevada ABP5 36 Approval Date: 1/24/14 Effective Date: 1/01/14 V.20l308l4 Pa_ge 36 of 36

Alternative Benefit Plan the target population includes persons under 21, please complete the following assurances regarding EPSDT. Otherwise, skip to the Prescription Drug Coverage Assurances below. alternative benefit plan includes beneficiaries under 21 years of age. 0 The state/territory assures that the notice to an individual includes a description of the method for ensuring access to EPSDT services (42 CFR 440.345). 0 The state/territory assures EPSDT services will be provided to individuals under 21 years of age who are covered under the state/ territory plan under section 1902(a)(10)(A) of the Act. Indicate whether EPSDT services will be provided only through an Alternative Benefit Plan or whether the state/territory will provide additional benefits to ensure EPSDT services: @ Through an Alternative Benefit Plan. 0 Through an Alternative Benefit Plan with additional benefits to ensure EPSDT services as defined in 1905(r). Other Inforn1ation regarding how ESPDT benefits will be provided to participants under 21 years of age (optional): The benefit plan is identical to the State Medicaid Plan which includes EPSDT. Prescription Drug Coverage Assurances 0 The state/territory assures that it meets the minimum requirements for prescription drug coverage in section 193 7 of the Act and implementing regulations at 42 CFR 440.34 7. Coverage is at least the greater of one drug in each United States Pharmacopeia (USP) category and class or the same number of prescription drugs in each category and class as the base benchmark. 0 The state/territory assures that procedures are in place to allow a beneficiary to request and gain access to clinically appropriate prescription drugs when not covered. 0 The state/territory assures that when it pays for outpatient prescription drugs covered under an Alternative Benefit Plan, it meets the requirements of section 1927 of the Act and inlplementing regulations at 42 CFR 440.345, except for those requirements that are directly contrary to amount, duration and scope of coverage permitted under section 193 7 of the Act. 0 The state/territory assures that when conducting prior authorization of prescription drugs under an Alternative Benefit Plan, it complies with prior authorization program requirements in section 1927(d)(S) of the Act. Other Benefit Assurances 0 The state/territory assures that substituted benefits are actuarially equivalent to the benefits they replaced from the base benchmark plan, and that the state/territory has actuarial certification for substituted benefits available for CMS inspection if requested by CMS. 0 The state/territory assures that individuals will have access to services in Rural Health Clinics (RHC) and Federally Qualified Health Centers (FQHC) as defined in subparagraphs (B) and (C) of section 1905(a)(2) of the Social Security Act. 0 The state/territory assures that payment for RHC and FQHC services is made in accordance with the requirements of section 1902(bb) of the Social Security Act. TN No: 13-0029 Nevada ABP7 1 Approval Date: 1/24/14 Effective Date: 1/01/14 Page 1 of2

Alternative Benefit Plan IZI The state/territory assures that it will comply with the requirement of section 1937(b)(5) of the Act by providing, effective January 1, 2014, to all Alternative Benefit Plan participants at least Essential Health Benefits as described in section 1302(b) of the Patient Protection and Affordable Care Act. 1Z1 The state/territory assures that it will comply with the mental health and substance use disorder parity requirements of section l937(b)(6) of the Act by ensuring that the financial requirements and treatment limitations applicable to mental health.or substance use disorder benefits comply with the requirements of section 2705(a) of the Public Health Service Act in the same manner as such requirements apply to a group health plan. IZI The state/teiTitory assures that it will comply with section 1937(b)(7) of the Act by ensuring thai benefits provided to Alternative Benefit Plan participants include, for any individual described in section 1905(a)(4)(C), medical assistance for family planning services and supplies in accordance with such section. IZI The state/territory assures transportation (emergency and non-emergency) for individuals enrolled in an Alternative Benefit Plan in accordance with 42 CFR 431.53. 1Z1 The state/territory assures, in accordance with 45 CPR 156.115(a)(4) and 45 CFR 147.130, that it will provide as Essential Health Benefits a broad range of preventive services including: "A" and "B" services recommended by the United States Preventive Services Task Force; Advisory Committee for Immunization Practices (ACIP) recommended vaccines; preventive care and screening for infants, children and adults recommended by HRSA's Bright Futures program/project; and additional preventive services for women recommended by the Institute of Medicine (IOM). PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 5 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN No: 13-0029 Nevada ABP7 2 V.20130807 Approval Date: 1/24/14 Effective Date: 1/01/14 Page 2 of2

Alternative Benefit Plan OMB Control Number: 0938-1148 OMB date: 10/3112014 II"T<wu'" detail on the type of delivery system(s) the state/territory will use for the Alternative Benefit Plan's benchmark benefit package or fbeJnch,mark:-,equivalent benefit package, including any variation by the participants' geographic area. of service delivery system(s) the state/territory will use for this Alternative Benefit Plan(s). one or more service delivery systems: 181 Managed care. 181 Managed Care Organizations (MCO). D Prepaid Inpatient Health Plans (PIHP). D Prepaid Ambulatory Health Plans (P AHP). D Primary Care Case Management (PCCM). I8J Fee-for-service. D Other service delivery system. 0 The state/territory certifies that it will comply with all applicable Medicaid laws and regulations, including but not limited to sections 1903(m), 1905(t), and 1932 of the Act and 42 CFR Part 438, in providing managed care services through this Alternative Benefit Plan. This includes the requirement for CMS approval of contracts and rates pursuant to 42 CFR 438.6. IMima;ged Care Implementation Please describe the implementation plan for the Alternative Benefit Plan under managed care including member, stakeholder, and provider outreach efforts. Both of the State's managed care organizations (MCO) are modifying their systems edits to allow for the payment of claims based on the ABP. Both plans are using a combination of USPS mail, email; web announcements and FAX blasts to confirm for providers that they will provide these benefits. Recipients and stakeholders are being notified by those same methods as well as personal contact at meetings and health fairs. MCO implementation will follow the san1e time lines as fee for service. Managed Care Organization The managed care delivery system is the same as an already approved managed care program. The managed care program is operating under (select one): 0Section 1915(a) voluntary managed care program. 0 Section 1915(b) managed care waiver. @Section 1932(a) mandatory managed care state plan an1endment. o'section 1115 demonstration. 0 Section 193 7 Alternative {Benchmark) Benefit Plan state plan amendment. Nevada Effective Date: 1/01/14 Page 1 of2

Alternative Benefit Plan Identify the date the managed care program was approved by CMS: 16/12/12 (with effectiviiJ Describe pro~am below: The DHCFP's managed care program currently offers a risk-based capitated rate program operated through contracts with Managed Care Organizations (Vendors). DHCFP contracts with Vendors to provide covered medically necessary services for eligible recipients at an established risk-based capitation rate. Enrollment in a managed care organization is mandatory for FMC/TANF/CHAP recipients as well as the new Medicaid Adult Group (effective January 1, 2014), when there is more than one managed care option from which to choose in a particular geographic service area. Managed care enrollment is mandatory for all CHIP recipients when ~n option is available in their service area. . Recipients who are SED/SMI, Indian Health may opt out of managed Care. Additional Information: MCO (Optional) Provide any additional details regarding this service delivery system (optional): I I Fee-For-Service Options Indicate whether the state/territory offers traditional fee-for-service and/or services managed under an administrative services organization: ®Traditional state-managed fee-for-service 0 Services managed under an administrative services organization (ASO) arrangement Please describe this fee-for-service delivery system, including any bundled payment arrangements, pay for performance, fee-for- service care management models/non-risk, contractual incentives as well as the population served via this delivery system. l Additional Information: Fee-For-Service (Optional) Provide any additional details regarding this service delivery system (optional): l:he FFS delivery area is in the rural region of the state for the Newly Eligibles, TANF/CHAP, and MABD.ls MABD in the urban areas of Washoe County and Clark County. The services covered for the FFS will be identical to the Medicaid State Plan. PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of infom1ation unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 5 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN No: 13-0029 Nevada ABP8 2 Approval Date: 1/24114 Effective Date: 1/01/14 V.20130718 Page 2 of2

Alternative Benefit Plan OMB Control Number: 0938-1148 OMB date: 10/31/2014 The state/territory provides the Alternative Benefit Plan through the payment of employer sponsored insurance for participants with such coverage, with additional benefits and services provided through a Benchmark or Benchmark-Equivalent Benefit Package. Provide a description of employer sponsored insurance, including the population covered, the amount of premium assistance by population, employer sponsored insurance activities including required contribution, cost-effectiveness test requirements, and benefit information: · ' Nevada Medicaid may pay insurance premiums through Employer-Based Group Health Plans for individuals and families when it is cost effective for the agency. In determining cost-effectiveness, the fiscal agent uses a formula as set forth in the State Plan or considers whether the individual has catastrophic illness or condition (e.g., AIDS or AIDS-related conditions, Down Syndrome, cerebral palsy, cystic fibrosis, fetal alcohol syndrome, etc.) DHCFP's Health Insurance Premium Payment (HIPP) program, as of ll/22/2013, covered 92 fee-for-service recipients. The monthly HIPP premiums that are paid by the State totaled $40,883, the average monthly claims cost avoided by the State due to HIPP coverage was $198,506. This means that the HIPP program saved the State $157,623 ($198,506- $40,883) in November 2013. This means that the annual savings of the HIPP program is estimated to be $1,891,476 ($157,623 * 12). The HIPP program is eligible to any fee-for-service recipient that has access to an employer sponsored group health plan that provides physician and major medical coverage. The cost-effectiveness test is as follows: 1) The recipient and their family are eligible if the Medicaid recipient has a catastrophic illness; 2) If the recipient does not have a catastrophic condition then the recipient and their family are eligible if the previous six month average ofMedicaid paid claims is more than twice the monthly HIPP coverage premium. The HIPP payments are generally made directly to the employer or the health insurer; however, the payments could be made to the recipient as a last resort. DHCFP or its agent validates that the HIPP coverage is in effect every thirty to sixty days. The state/territory otherwise provides for payment of premiums. Provide a description including the population covered, the amount of premium assistance by population, required contributions, cost-effectiveness test requirements, and benefits information . .. ,~, ... , ... Medicaid may pay insurance premiums through Employer-Based Group Health Plans for individuals and families when it is effective for the agency. In determining cost-effectiveness, the fiscal agent uses a formula as set forth in the State Plan or lco,nst.CI.etrs whether the individual has catastrophic illness or condition (e.g., AIDS or AIDS-related conditions, Down Syndrome, lce;:•·e;:ora• palsy, cystic fibrosis, fetal alcohol syndrome, etc.) s Health Insurance Premium Payment (HIPP) program, as of 11122/2013, covered 92 fee-for-service recipients. The monthly HI.PP premiums that are paid by the State totaled $40,883, the average monthly claims cost avoided by the State due to coverage was $198,506. This means that the HIPP program saved the State $157,623 ($198,506- $40,883) in November This means that the annual savings of the HIPP program is estimated to be $1,891,476 ($157,623 * 12). HIPP program is eligible to any fee-for-service recipient that has access to an employer sponsored group health plan that lnr•:-.v•,ne~ physician and major medical coverage. The cost-effectiveness test is as follows: 1) The recipient and their family are if the Medicaid recipient has a catastrophic illness; 2) If the recipient does not have a catastrophic condition then the lrec:ipientand their family are eligible if the previous six month average ofMedicaid paid claims is more than twice the monthly ,coverage premium. TheHIPP TN No: 13-0029 Nevada are to the ABP9 1 could be made to the Approval Date: 1/24/14 Effective Date: 1/01/14 Page 1 of2

Alternative Benefit Plan rectptent as a last resort. UHCI'P or 1ts agent Valldates that the HIPP coverage IS tn ettect every thirty to SIXty days. Other Information Regarding Employer Sponsored Insurance or Payment of Premiums: The state assures that ESI coverage is established in sections 3.2 and 4.22(h) of the state's approved Medicaid state plan. The beneficiary will receive a benefit package that includes a wrap of benefits aroWld the employer sponsored insurance plan that equals the benefit package to which the beneficiary is entitled. For a Medicaid beneficiary who receives coverage in a health plan in the individual market through the state's approved Medicaid state plan that provides premium assistance under section 1905(a) and regulations codified at 42 CFR §435.1015, the state assures that the Medicaid beneficiary will receive a benefit package that includes a wrap of benefits around the individual market health plan that equals the benefit package to which the beneficiary is entitled. The beneficiary will not be responsible for payment of premiums or other cost sharing that exceeds nominal levels a~ established at 42 CFR part 447 subpart A. i. The additional benefits, on top of the ESI, to which the beneficiary is entitled include those called out in ABP 7 (FQHCiRHC services, family planning services, etc.) PRA Disclosure Statement I According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 5 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this fonn, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN No: 13-0029 Nevada ABP9 2 Approval Date: 1/24/14 Effective Date: 1/01/14 Page 2 of2

Alternative Benefit Plan · OMB Control Number: 0938-1148 OMB date: 10/31/2014 1Z1 The state/territory assures that Alternative Benefit Plan coverage is provided in accordance with Federal upper payment limit requirements and other economy and efficiency principles that would otherwise be applicable to the services or delivery system through which the coverage and benefits are obtained. Economy and efficiency will be achieved using the same approach as used for Medicaid state plan services. 1Z1 The state/territory will continue to comply with all other provisions ofthe Social Security Act in the administration of the state/ territory plan under this title. 1Z1 The state/territory assures that Alternative Benefit Plan benefits designs shall conform to the non-discrimination requirements at 42 CFR 430.2 and 42 CFR 440.347(e). 1Z1 The state/territory assures that all providers of Alternative Benefit Plan benefits shall meet the provider qualification requirements of the Base Benchmark Plan and/or the Medicaid state plan. PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 5 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estin1ate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN No: 13-0029 Nevada ABP10 1 V.20130807 Approval Date: 1/24/14 Effective Date: 1/01114 Page 1 of I

Alternative Benefit Plan OMB Control Number: 0938-1148 OMB date: 10/31/2014 The state/territory provides assurance that, for each benefit provided under an Alternative Benefit Plan that is not provided through managed care, it will use the payment methodology in its approved state plan or hereby submits state plan amendment Attachment 4.19a, 4.19b or 4.19d, as appropriate, describing the payment methodology for the benefit. . 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 intbrmation collection is estimated to average 5 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland21244-1850. TN No: 13-0029 Nevada ABP 11 1 V.20130807 Approval Date: 1/24/14 Effective Date: 1/01/14 Page 1 of 1

Table of Contents State/Territory Name: Nevada State Plan Amendment (SPA) #: 13-031 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS-179 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services San Francisco Regional Office 90 Seventh Street, Suite 5-300 (SW) San Francisco, CA 94103-6706 DIVISION OF MEDICAID & CHILDREN'S HEALTH OPERATIONS FEB 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: Enclosed is an approved copy of Nevada State Plan Amendment (SPA) 13-031. This SPA was submitted to my office on December 13,2013 requesting to amend Attachment 3.1-F to reflect updated processes and eligibility groups for the managed care program and to incorporate the updated version of the Attachment 3.1-F template. The approval is effective October 1, 2013. Attached are copies ofthe following pages to be incorporated into your State Plan: • Attachment 3.1-F, Pages 1-26 If you have any questions, please contact Brian Zolynas by phone at (415) 744-3601 or by email at Brian.Zolynas@.cms.hhs.gov . Enclosure Sincerely, /s/ Gloria Nagle, Ph.D., MPA Associate Regional Administrator Division of Medicaid & Children's Health Operations cc: Laurie Squartsoff, Administrator, DHCFP Marta Stagliano, Chief, Compliance, DHCFP

DEPARTMENT OF HEALTH AND HUMAN SERVICES HE;:~;~;;;;: :~;-~~~~~~E ~~-~-P-P-R-OV-A-~--~F-r ·l.·T-R;,j\isMiiTA'L-NUMBER: FO.R..\-1 APPROVED OMH NO. 0938-0191 STATE PLAN MATE.RIAL , 13·031 2. STATE NEVADA ~·3:-P-ROGitl-\-~ilfJEN-pri=F=-Ic::-:A-T--IO-:N:-::-, .-. 'f=I='T=-L-=E-X_I_X .. OF ~fli.E FOR: HEALTH CARE FJNANCING ADMINISTRATION SOCIAL SECURITY ACT (MEDICAID) .... ,,, __ ,.......,."""~~""'-m ""'""'h''''''''''"'"--'-'~' •• -TO: REGIONAL ADMINISTRATOR ........ ._ _____ ._ ........................ ==-----~---- 4. PROPOSED EFFECTIVE DATE October t, 2013 HEALTH CARE FINANCING ADMINISTRATION DEPARTMENT Of HEALTH. AND HUMAN SERVICES --·--·--··· ____ ,_ 5. TYPE OF PLAN MATERIAL One): 0 NEW STATE PLAN AMENDM~~!!~.~-~ CONSIDERED AS NEW PLAN ~AMENDMENT . - -·- COMPL~:rE J.?_Lp~-~~-~-J:HRin 0 IF T! HS}S AN AMEN [)M~.!':f.I_(Sepqrate 1'r0f~vmittal[or each amendmet!!)__ __ . . a. FFY ~m 2014 $0 Section l903(m)(2)(H) and 42 CFR 438.50(g) b. FFY JWH 2 015 $0 FEDERAl, STATUTE/REGULATION CITATION: ~-FEDERAL HUDGET IMPACT: 8. PAGE. NLfMBEli OF THE PLAN SECTION OR A T'l'ACHMENT: 9. PACJE NUMBER~OF THE-SliPERSEDED PLAN SECTION OR ATTACHMENT ({(Applicable): ' Attachment 3.1·Ji", pgs. 1 fi I ~ Attachment 3 . .1-F, pgs. 1 - 21 ----------c --,_........--................ _2_6 --.. ·- _ ............ J;::~ ~-;.~~ .. ~~.;.:.: l ~ ~ j (TN 0 7- 011) 10. SUBJECT OF AMENDMENT: and Nevada is amending the State Plan to reflect updated processes and eligibility groups as they relate to the DHCFP's Managed Car-e Programs. -------,--~ ~=-----: ........ - ....... _____ _ 11. GOVERNOR'S REVIEW (Check One): 0 GOVERNOR'S OFFICE REPORTED NO COMMENT 0 COMMENTS OF GOVERNOR'S OFFICE ENCLOSED 0 NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL -----· ____ , ___ ._ ......... _________ _ [X] OTHER, AS SPECIFIED: The Governor's Office does not wish to review the State Plan Amendment !6. RETURN TO: 12. SIClNAfl ii5_.:l:I/itbf.di'wlfl: Jvdlf.."f!.cy OFFICIAL: .. /J: . / ...... "~' ----·------! S Ch P • - 1-3.-TYPED NAME~- .. -------r. Marta tagliano, ief of. rogram .~.ntcgrity DHCFP/Medicaid Michael J. Willd~!J ................ -------------···--.. ·-----1 1100 East Winiam Street, Suite 101 14. TITLE: Carson City, NV 89701 Director, Department o~ !!.~!!tb 3f!...4_Humau ~r~~---- .~ ........ ~~-- 15. DATE SUBMITfED: DEC 1 3 ZU!J ____________ ,,,_ .. , ...... ·------------ FOR REGIONAL OFFICE USE ONLY -1-7-. D_A_T_E_R_E-=c=EI"""'v=E=D-~-e-ce_mb_e_r_1_3_,_2_0.:;__1.;;;...3~;:...;;..;;;;..;;;...; ................ ]18. DATE APPRO_V_E-·D_: __ f_E_B_Z_1_2_0_14 _____ _ PLAN APPROVED ·ONE COPY ATTACHED 19. EFFECTIVE DATE ofi-A·-_ -PP_R_o_v_E_··o-.-MA-. ·iERIAL: -·-·-- 20~siGNA1·uR£oF REoi'()_N_A-:-L-o:-F __ F_Ic=I-A_L_: -----.. - october 1, 2013 ~/ -2-1-. T_YP_E_D....,.N_AM_E=-:-----·--·...... ---+22:.iTiiE·~· ----------------- Gloria Nagle, Ph.D., MPA Associate Re ional Administrator ~---~----=~~~~~~~~~~~~~~~~ 23. REMARKS: Pen and ink changes to Boxes 7, 8, 9, and 11. FOR!v1 HCFA-179 (07-92)

CMS-PM-XX-X Date: State: Nevada ATTACHMENT 3.1-F Page 1 OMB No.:0938-0933 Citation Condition or Requirement 1932(a)(1)(A) 1932(a)(1)(B)(i) 1932(a)(1 )(B)(ii) 42 CFR 438.50(b )(1) TN No. 13-031 Supersedes TN No. 09-11 A. Section 1932(a)(1)(A) of the Social Security Act. The State of Nevada enrolls Medicaid beneficiaries on a mandatory basis into managed care entities (managed care organization (MCOs) and/or Primary Care Case Managers (PCCMs)) in the absence of section 1115 or section 1915(b) waiver authority. This authority is granted under section 1932(a)(1)(A) of the Social Security Act (the Act). Under this authority, a state can amend its Medicaid state plan to require certain categories of Medicaid beneficiaries to enroll in managed care entities without being out of compliance with provisions of section 1902 of the Act on statewideness (42 CFR 431.50), freedom of choice (42 CFR 431.51) or comparability (42 CFR 440.230). This authority may not be used to mandate enrollment in Prepaid Inpatient Health Plans (PIHPs ), Prepaid Ambulatory Health Plans (PAHPs), nor can it be used to mandate the enrollment of Medicaid beneficiaries who are Medicare eligible, who are Native American Indians (unless they would be enrolled in certain plans-see D.2.ii. below), or who meet certain categories of"special needs" beneficiaries (see D.2.iii.- vii.) The State also enrolls eligible Medicaid beneficiaries on a mandatory basis into a Primary Care Case Management (PCCM) program under the authority of a Section 1115 Research and Demonstration Waiver, titled the Nevada Comprehensive Care Waiver (NCCW). B. General Description of the Program and Public Process. For B.1 and B.2, place a check mark on any or all that apply. 1. The State will contract with an i. MCO ii.PCCM (including capitated PCCMs that qualify as PAHPs). ~iii. Both The State of Nevada Division of Health Care Financing and Policy (DHCFP- aka Nevada Medicaid) oversees the administration of all Medicaid Managed Care Organizations (MCOs) and Medicaid PCCM program(s) in the state. Nevada Medicaid operates a fee-for- service and a managed care reimbursement and service delivery system with which to provide covered medically necessary services to its Medicaid eligible population. Contracted Managed Care Organizations (MCOs) are currently the primary managed care Approval Date fEB 2 1 2014 Effective Date: October 1, 2013

CMS-PM-XX-X Date: State: Nevada ATTACHMENT 3.1-F Page 2 OMB No.:0938-0933 Citation Condition or Requirement 42 CFR 438.50(b )(2) 42 CFR 438.50(b)(3) TN No. 13-031 Supersedes TN No. 09-11 entities providing Medicaid managed care in Nevada; at this time, Nevada Medicaid does not contract with PIHPs or P AHPs. Enrollment in an MCO is mandatory for Family Medical Category (FMC) (TANF (Section 1931), CHAP (poverty level pregnant women, infants, and children)] and the Adult Group (Childless Adults, ages 19-64 years, effective January 1, 2014) beneficiaries when there is more than one MCO option from which to choose in a geographic service area and optional in areas where only one plan exists. The eligibility and aid code determination functions for the Medicaid applicant and eligible population is the responsibility of the Division of Welfare and Supportive Services (DWSS). Enrollment in a PCCM under the NCCW is mandatory for Family Medical Category [FMC (TANF& CHAP)], MAABD, Parents & Caretakers, Pregnant Women, Infants and Children Under age 19, Former Foster care Children, Transitional Medical and Post Medical fee-for-service beneficiaries who meet program eligibility criteria and are not part of a PCCM excluded group, including those enrolled in an MCO. Those who qualify for the program will receive the benefit of a care manager who will facilitate improved health outcomes for the beneficiary. Medicaid eligibility and aid code determinations for Medicaid applicants are the responsibility of the Division of Welfare and Supportive Services (DWSS). Once enrolled in Medicaid Fee-For Service (FFS), the PCCM will determine who qualifies for the PCCM program based on the eligibility criteria. 2. The payment method to the contracting MCO entity will be: 1. fee for service; _K_ii. capitation; This applies to MCOs and PCCM. 111. a case management fee; _K_iv. a bonus/incentive payment; This applies to PCCM. _lL_v. a supplemental payment; This applies to MCOs, or _lL_vi. other. (Please provide a description below). Capitation: MCO contracts are comprehensive risk contracts and are paid a risk-based capitated rate for each eligible, enrolled Medicaid Approval Date fEB 2 1 2014 Effective Date: October 1, 2013

CMS-PM-XX-X Date: State: Nevada ATTACHMENT3.1-F Page 3 OMB No.:0938-0933 Citation Condition or Requirement 1905(t) 3. 42 CFR 440.168 42 CFR 438.6(c)(5)(iii)(iv) beneficiary on a per-member, per-month (PMPM) basis. These capitated rates are certified to be actuarially sound. Stop Loss: Stop Loss occurs when costs of care exceed a threshold during a specified time period. Stop Loss is a re-insurance program where risk is shared between the DHCFP and the MCO for outlier episodic claims. For inpatient claims above a defined threshold, the State pays 75%, and the MCO Vendor has a co-pay of the remaining 25%. Very Low Birth Weight Newborns (VLBW): Payments for high-risk very low birth weight newborns are revenue neutral.VLBW payments are paid out of the zero-to-one year age band of capitation based on the risk-adjusted expectation ofVLBW birth occurrences, per number of member-months' exposure. MCO plans submit clinical proof of VLBW ( <1500 grams) occurrences and are paid according to date and time of delivery. Should eligible VLBW births exceed actuarial limits, MCO plans are fully at-risk for the remainder of the plan year. PCCM: PCCM contracts are paid at a PMPM basis for each eligible, enrolled Medicaid beneficiary. In addition, incentive payments could be made when the PCCM achieves specific cost savings goals and/or quality improvement measures. For states that pay a PCCM on a fee-for-service basis, incentive payments are permitted as an enhancement to the PCCM's case management fee, if certain conditions are met. If applicable to this state plan, place a check mark to affirm the state has met all of the following conditions (which are identical to the risk incentive rules for managed care contracts published in 42 CFR 438.6( c )(5)(iv) ). 1. Incentive payments to the PCCM will not exceed 5% of the total FFS payments for those services provided or authorized by the PCCM for the period covered. n. Incentives will be based upon specific activities and targets. TN No. 13-031 Supersedes Approval Date fEB 2 1 2014 Effective Date: October 1, 2013 TN No. 09-11

CMS-PM-XX-X Date: State: Nevada ATTACHMENT 3.1-F Page 4 OMB No.:0938-0933 Citation Condition or Requirement 42 CFR 438.50(b)(4) 1932(a)(l)(A) TN No. 13-031 Supersedes TN No. 09-11 m. Incentives will be based upon a fixed period of time. IV. Incentives will not be renewed automatically. v. Incentives will be made available to both public and private PCCMs. v1. Incentives will not be conditioned on intergovernmental transfer agreements. _lL vii. Not applicable to this 1932 state plan amendment. 4. Describe the public process utilized for both the design of the program and its initial implementation. In addition, describe what methods the state will use to ensure ongoing public involvement once the state plan program has been implemented. (Example: public meeting, advisory groups.) Pursuant to 42 CFR 438.50(b)(4), the State shall provide public notice to promote public involvement in the design and initial implementation of the program as well as during contract procurement. The public notice shall be a notice of publication published in a newspaper in Southern Nevada and in a newspaper in Northern Nevada. The Medical Care Advisory Committee (MCAC) advises the DHCFP regarding provisions of services for the health and medical care of Medicaid beneficiaries. Under the PCCM, an outreach plan is required and designed to educate stakeholders on its activities within the State. 5. The state plan MCO program will_/will not _lL implement mandatory enrollment into managed care on a statewide basis. If not statewide, mandatory X I voluntary __ enrollment will be implemented in the following county/area(s): i. county/counties (mandatory) Urban Clark and Washoe counties For Native Americans, the Severe Emotional Disturbance (SED) group, the Serious Mental Illness (SMI) group and children who qualify as Children with Special Health Care Needs (CSHCN) in Urban Clark and Washoe counties, enrollment is voluntary and beneficiaries may "opt out" of the MCOs. Approval Date fEB 2 1 2014 Effective Date: October 1, 2013

CMS-PM-XX-X Date: State: Nevada ATTACHMENT 3.1-F Page 5 OMB No.:0938-0933 Citation Condition or Requirement 1932(a)(1)(A)(i)(I) 1903(m) 42 CFR 438.50(c)(1) 1932(a)(1 )(A)(i)(I) 1905 (t) 42 CFR 438.50(c)(2) 1902(a)(23)(A) 1932(a)(1)(A) 42 CFR 438.50(c)(3) 1932(a)(1)(A 42 CFR 431.51 1905(a)( 4)(C) 1932(a)(1)(A) 42 CFR 438 42 CFR 438.50(c)(4) 1903(m) TN No. 13-031 Supersedes TN No. 03-04 ii. county/counties (voluntary) ________ _ m. area/areas (mandatory) _________ _ iv. area/areas (voluntary) _________ _ Mandatory enrollment occurs in the areas of Clark County and Washoe County for the MCOs for eligible beneficiaries. Mandatory enrollment in the PCCM is statewide for eligible beneficiaries. C. State Assurances and Compliance with the Statute and Regulations. If applicable to the state plan, place a check mark to affirm that compliance with the following statutes and regulations will be met. 1. X The state assures that all of the applicable requirements of section 1903(m) of the Act, for MCOs and MCO contracts will be met. 2. _]L_The state assures that all the applicable requirements of section 1905 (t) of the Act for PCCMs and PCCM contracts will be met. Under the authority of the NCCW, the PCCM allows registered nurses to serve as primary care case managers for the PCCM program. 3. X The state assures that all the applicable requirements of section 1932 (including subpart (a)(1)(A)) of the Act, for the state's option to limit freedom of choice by requiring recipients to receive their benefits through managed care entities will be met. 4. _ll_The state assures that all the applicable requirements of 42 CFR 431.51 regarding freedom of choice for family planning services and supplies as defined in section 1905 (a)(4)(C) will be met. 5. X The state assures that all applicable managed care r~quirements of 42 CFR Part 438 for MCOs and PCCMs will be met. Approval Date fEB 2 1 2014 Effective Date: October l, 2013

CMS-PM-XX-X Date: State: Nevada ATTACHMENT 3.1-F Page 6 OMB No.:0938-0933 Citation Condition or Requirement 1932(a)(1)(A) 42 CFR 438.6(c) 42 CFR 438.50(c)(6) 1932(a)(1)(A) 42 CFR 447.362 42 CFR 438.50(c)(6) 45 CFR 74.40 1932(a)(1)(A)(i) TN No. 13-031 Supersedes TN No. 09-11 Under the authority of the NCCW, the following requirements of the State Plan are waived for the PCCM program: 1) Amount, duration and scope of services; 2) Comparability; and 3) Freedom of choice. 6. X The state assures that all applicable requirements of CFR 438.6(c) for payments under any risk contracts will be met. 7. _K.._The state assures that all applicable requirements of 42 CFR 447.362 for payments under any non-risk contracts will be met. 8. _2L_The state assures that all applicable requirements of 45 CFR 92.36 for procurement of contracts will be met. D. Eligible groups 1. List all eligible groups that will be enrolled on a mandatory basis. The State of Nevada Managed Care Program requires the mandatory enrollment of beneficiaries found eligible for Medicaid program coverage under the following Medicaid eligibility categories when there are two or more MCOs in the geographic service area or when the beneficiaries meet the PCCM eligibility criteria under the NCCW: Groups (a)- (m) (below) are eligible for MCO enrollment under 1932(a): a. Family Medical Category (FMC)/Temporary Assistance for Needy Families (TANF); b. Family Medical Category (FMC)/Two parent TANF; c. Family Medical Category (FMC)/T ANF-Related Medical Only; d. Family Medical Category (FMC)/T ANF-Post Medical (pursuant to Section 1925 of the Social Security Act (the Act); e. Family Medical Category (FMC)/TANF-Transitional Medical (under Section 1925 of the Act); Approval Date fEB 2 1 2014 Effective Date: October 1, 2013

CMS-PM-XX-X Date: State: Nevada ATTACHMENT 3.1-F Page 7 OMB No.:0938-0933 Citation Condition or Requirement TN No. 13-031 Supersedes TN No. 03-04 f. Family Medical Category (FMC)/T ANF Related(Sneede vs. Kizer); g. Family Medical Category (FMC)/Child Health Assurance Program (CHAP); h. Aged Out Foster Care (young adults who have "aged out" of foster care); 1. Parents and Other Caretaker Relatives (Section 435.110); j. Pregnant Women (Section 435.116); k. Infants and Children Under Age 19 (Section 435.118); 1. Former Foster Care Children (Section 435.10); and m. Adult Group (Childless Adults, ages 19- 64 years) (Section 435.119). In accordance with the 1115 Nevada Comprehensive Care Waiver (NCCW), the following groups (n) - (y) are PCCM eligibile and enrollment is mandatory. n. Low Income Families with Children (SSA 1902 (a)(lO)(A)(i)(I), SSA 1931, Eligibility rule CFR 435.110); o. Pregnant Women and Children (CFR 435.116 and 435.118, SSA 1902); p. Transitional Related Medicaid-Transitional Medical Assistance (TMA) (SSA 1902 (a)(10)(A)(i)(I), SSA 408(a)(11)(A), SSA 1925, SSA 1931 (c)(2); q. Extended Post Medical (SSA 1902(a)(10)(A)(i)(I), SSA 408(a)(11)(B), SSA 1931(c)(1); r. Adoption Support Medical (IV -E) (SSA 1902(a)(10)(A)(i)(I), 473(b)(3), IV-E Adoption Support Program, Public Law 96- 272; s. Supplemental Security Income (SSI) Recipients And Deemed SSI Recipients (SSA 1902(a)(10)(A)(i)(II)SSI recipients, SSA 1902(a)(10)(A)(i)(II)(aa) disabled children who lost SSI when the definition of disability for children changed in 1996, SSA 1902(a)(10)(A)(i)(II)(cc) individuals who are under 21 years of age eligible for Medicaid in the month that applied for SSI, SSA 1619(a), SSA 1905(q)/1902(a)(10)(A)(i)(II) (bb), SSA 1619(b); t. Pickle Amendment (Section 503 of Public Law 94-566, 42 U.S.C., 1396a); u. Aged & Blind lndividuals-SSI Supplement-Independent Living (IL) (42 CFR 435.130, Section 402-Public Law 98- 21); v. Disabled Adult Children Approval Date 2 1 2014 Effective Date: October 1, 2013

CMS-PM-XX-X Date: State: Nevada ATTACHMENT 3.1-F Page 8 OMB No.:0938-0933 Citation Condition or Requirement 1932(a)(2)(B) 42 CFR 438.50(d)(1) 1932(a)(2)(C) 42 CFR 438.50(d)(2) TN No. 13-031 Supersedes TN No. 09-11 w. Early Widows and Widowers (ages 60-64) (SSA 1634 (d), 42 CFR 435.138); x. Disabled Widows and Widowers (1634(b), 435.137); and y. Foster Care Medical-Aged Out (AO) (SSA 1902(a)(10)(A)(ii) (XVII). Per the NCCW, the following groups have optional enrollment in a PCCM: a. Ticket to Work and Work Incentives Improvement Act (TWWIIA) (SSA 1902 (a)(10)(A)(ii)(XV), Ticket to Work and Work Incentives Improvement Act 1999 (TWWIIA); b. Adoption Support Medical (NON IV -E) (SSA 1902(a)(10)9A)(ii)(VIII), 42 U.S.C. 671); and c. Aged & Blind Individuals-SSI Supplement-Adult Group Care Facility (AGCF) ( 42 CFR 453.232). 2. Mandatory exempt groups identified in 1932(a)(1)(A)(i) and 42 CFR 438.50. Use a check mark to affirm if there is voluntary enrollment in any of the following mandatory exempt groups. i. __ Recipients who are also eligible for Medicare. If enrollment is voluntary, describe the circumstances of enrollment. (Example: Recipients who become Medicare eligible during mid-enrollment, remain eligible for managed care and are not disenrolled into fee-for-service.) n. _.X Indians who are members of Federally recognized Tribes except when the MCO or PCCM is operated by the Indian Health Service or an Indian Health program operating under a contract, grant or cooperative agreement with the Indian Health Service pursuant to the Indian Self Determination Act; or an Urban Indian program operating under a contract or grant with the Indian Health Service pursuant to title V of the Indian Health Care Improvement Act. Native Americans may opt out of managed care programs. Approval Date fEB Z l 2014 Effective Date: October l, 2013

CMS-PM-XX-X Date: State: Nevada ATTACHMENT 3.1-F Page 9 OMB No.:0938-0933 Citation Condition or Requirement 1932(a)(2)(A)(i) 42 CFR 438.50(d)(3)(i) 1932( a )(2)(A)(iii) 42 CFR 438.50(d)(3)(ii) 1932(a)(2)(A)(v) 42 CFR 438.50(3)(iii) 1932(a)(2)(A)(iv) 42 CFR 438.50(3)(iv) 1932( a )(2)(A)(ii) 42 CFR 438.50(3)(v) Children defined as Severely Emotionally Disturbed (SED) or as Children with Special Health Care Needs (CSHCN) and adults defined as Seriously Mentally Ill (SMI) have voluntary enrollment in managed care. iii. _Children under the age of 19 years, who are eligible for Supplemental Security Income (SSI) under title XVI. 1v. __ Children under the age of 19 years who are eligible under 1902(e)(3) of the Act. v. __ Children under the age of 19 years who are in foster care or other out-of-the-home placement. vi. __ Children under the age of 19 years who are receiving foster care or adoption assistance under title IV-E. Adopted children with special needs under the age of 19 years receiving non-IV -E state adoption assistance who do not meet the eligibility criteria for federal participation in the IV-E adoption support program can voluntarily enroll in the PCCM (1902 (a)(lO)(A)(ii)(VIII). vii. _x_ Children under the age of 19 years who are receiving services through a family-centered, community based, coordinated care system that receives grant funds under section 501(a)(1)(D) of title V, and is defined by the state in terms of either program participation or special health care needs. This rule applies to the MCO programs, not the PCCM program(s). This group may opt out of the MCOs. E. Identification of Mandatory Exempt Groups 1932(a)(2) 42 CFR 438.50(d) TN No. 13-031 Supersedes TN No. 09-11 1. Describe how the state defines children who receive services that are funded under section 501(a)(1)(D) of title V. (Examples: children receiving services at a specific clinic or enrolled in a particular program.) Children receiving services through a family-centered, community- based, coordinated care system receiving grant funds under section Approval Date fEB 2 1 2014 Effective Date: October l, 2013

CMS-PM-XX-X Date: State: Nevada ATTACHMENT 3.1-F PagelO OMB No.:0938-0933 Citation Condition or Requirement 1932(a)(2) 42 CFR 438.50(d) 1932(a)(2) 42 CFR 438.50( d) 1932(a)(2) 42 CFR 438.50 (d) TN No. 13-031 Supersedes TN No. 09-11 501(a) (1) (D) of Title V are defined by the state in terms of either program participation and/or parental or legal guardian identification. 2. Place a check mark to affirm if the state's definition of title V children is determined by: _lL_i. program participation, __ ii. special health care needs, or iii.Both The State's definition of these children is based on program participation and/or parental or legal guardian identification. 3. Place a check mark to affirm if the scope of these title V services is received through a family-centered, community-based, coordinated care system. _ _x_i. yes ii. no 4. Describe how the state identifies the following groups of children who are exempt from mandatory enrollment: (Examples: eligibility database, self- identification) 1. Children under 19 years of age who are eligible for SSI under title XVI; All of these children are identified by aid code in the eligibility system. System edits prevent enrollment of these Medicaid eligibles into managed care. ii. Children under 19 years of age who are eligible under section 1902 (e)(3) of the Act; All of these children are identified by aid code in the eligibility system. System edits prevent enrollment of these Medicaid eligibles into managed care. This group may be under a waiver plan which excludes them from mandatory enrollment. iii. Children under 19 years of age who are in foster care or other out-of-home placement; Approval Date fEB 2 1 2014 Effective Date: October 1, 2013

CMS-PM-XX-X Date: State: Nevada ATTACHMENT 3.1-F Page 11 OMB No.:0938-0933 Citation Condition or Requirement 1932(a)(2) 42 CFR 438.50(d) TN No. 13-031 Supersedes TN No. 09-11 All of these children are identified by aid code in the eligibility system. System edits prevent enrollment of these Medicaid eligibles into managed care. Children, aged 18 years to under 19 years old, with qualifying health conditions who are identified as being eligible for the Foster Care Medical-Aged Out (AO) group have optional enrollment in the PCCM program. iv. Children under 19 years of age who are receiving foster care or adoption assistance. All of these children are identified by aid code in the eligibility system. System edits prevent enrollment of these Medicaid eligibles into MCOs. Children with qualifying health conditions, who are identified as being eligible for the Adoption Support Medical (IV-E) group, have mandatory enrollment in the PCCM program. 5. Describe the state's process for allowing children to request an exemption from mandatory enrollment based on the special needs criteria as defined in the state plan if they are not initially identified as exempt. (Example: self-identification) Nevada has a database and self-identification mechanism for children with special health care needs. If a child is identified as a Child with Special Health Care Needs (CSHCN) following enrollment in an MCO, the parent or legal guardian is notified of their right to keep the child enrolled with the MCO or to request the child's disenrollment. If the parent or legal guardian decides to keep the child enrolled, the MCO is required to provide all services available under the Managed Care Contract. In addition, if the Individualized Family Service Plan (IFSP) or Individual Education Plan (IEP) has identified services which are not covered under Medicaid through the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) benefit, or covered under the Managed Care Contract, the MCO is responsible for providing case management services on behalf of the child and family in order to ensure referral and linkage to other community resources in obtaining these identified services. If the parent or legal guardian elects to disenroll the child from the MCO, the child will be disenrolled from the Approval Date fEB 2 1 2014 Effective Date: October 1, 2013

CMS-PM-XX-X Date: State: Nevada ATTACHMENT 3.1-F Page 12 OMB No.:0938-0933 Citation Condition or Requirement 1932(a)(2) 42 CFR 438.50(d) MCO pursuant to 42 CFR 438.56(e)(l) after which covered medically necessary services will be reimbursed through Medicaid FFS. 6. Describe how the state identifies the following groups who are exempt from mandatory enrollment into managed care: (Examples: usage of aid co4es in the eligibility system, self- identification) 1. Recipients who are also eligible for Medicare. Dual Medicare-Medicaid eligibles are identified by aid code. System edits prevent enrollment of these Medicaid eligibles into Managed Care. n. Indians who are members of Federally recognized Tribes except when the MCO or PCCM is operated by the Indian Health Service or an Indian Health program operating under a contract, grant or cooperative agreement with the Indian Health Service pursuant to the Indian Self Determination Act; or an Urban Indian program operating under a contract or grant with the Indian Health Service pursuant to title V of the Indian Health Care Improvement Act. American Indian identifying information, if provided by the beneficiary, is available from the eligibility system. Identification of American Indians can also occur directly from the beneficiary, parent, or guardian. 42 CFR 438.50 F. List other eligible groups (not previously mentioned) who will be exempt from mandatory enrollment. Beneficiaries with comprehensive group or individual health insurance coverage, including Medicare, insurance provided to military dependents, and any insurance purchased from another organization or agency which cannot be billed by an MCO are exempt from mandatory enrollment. The NCCW exempts a number of groups from enrollment in the PCCM. 42 CFR 438.50 G. List all other eligible groups who will be permitted to enroll on a voluntary basis TN No. 13-031 Supersedes TN No. 09-11 The following Medicaid beneficiaries are exempt from mandatory enrollment, but they are allowed to voluntarily enroll in an MCO, if they so Approval Date fEB Z l 2014 Effective Date: October 1, 2013

CMS-PM-XX-X Date: State: Nevada ATTACHMENT 3.1-F Page 13 OMB No.:0938-0933 Citation Condition or Requirement 1932(a)(4) 42 CFR 438.50 1932(a)(4) 42 CFR 438.50 TN No. 13-031 Supersedes TN No. 09-11 choose: 1. Family Medical Category (FMC) [TANF and CHAP] adults diagnosed as Seriously Mentally Ill (SMI); 2. Family Medical Category (FMC) [TANF and CHAP] Children diagnosed as Seriously Emotionally Disturbed (SED); 3. Family Medical Category (FMC) [T ANF and CHAP] Children diagnosed as Child(ren) with Special Health Care Needs (CSHCN); and 4. Adult Group (Childless Adults, ages 19-64 years who also qualify as Seriously Mentally Ill (SMI), effective January 1, 2014). H. Enrollment process. 1. Definitions An existing provider-recipient relationship is one in which the provider was the main source of Medicaid services for the recipient during the previous year. This may be established through state records of previous managed care enrollment or fee-for-service experience or through contact with the recipient. 1. A provider is considered to have "traditionally served" Medicaid recipients if it has experience in serving the Medicaid population. 2. State process for enrollment by default. Describe how the state's default enrollment process will preserve: i. the existing provider-recipient relationship (as defined 1n H.1.i). New members will be allowed the opportunity to select an MCO with their Primary Care Provider (PCP) in network. Returning Medicaid beneficiaries will be assigned to their former MCO and PCP. The MCO will then ensure that the prior provider- beneficiary relationship is preserved if the provider is still in that MCO's network. The State will provide new Medicaid beneficiaries with the websites and phone numbers of the State's contracted Medicaid MCOs. New Medicaid beneficiaries will be asked to complete Approval Date fEB 2 l 2 ~ 14 Effective Date: October l, 2013

CMS-PM-XX-X Date: State: Nevada ATIACHMENT 3.1-F Page 14 OMB No.:0938-0933 Citation Condition or Requirement 1932(a)(4) 42 CFR 438.50 TN No. 13-031 Supersedes TN No. 09-11 their selection of an MCO at the time of Medicaid application. If none is chosen, the State will complete a default enrollment process, and they will be automatically assigned to an MCO based upon an algorithm developed by the State to distribute enrollees among the MCOs. 11. the relationship with providers that have traditionally served Medicaid recipients (as defined in H.2.ii). Prior to auto-assigning a beneficiary to an MCO, the State will review the beneficiary's past enrollment records to determine whether the beneficiary has a prior MCO relationship. If such a relationship is confirmed, and the beneficiary has been ineligible for Medicaid managed care, the beneficiary will be auto- assigned to that MCO. The MCO will then ensure that the prior provider-beneficiary relationship is preserved if the provider is still in that MCO's network. 111. the equitable distribution of Medicaid recipients among qualified MCOs and PCCMs available to enroll them, (excluding those that are subject to intermediate sanction described in 42 CFR 438.702(a)(4)); and disenrollment for cause in accordance with 42 CFR 438.56 ( d)(2). (Example: No auto-assignments will be made if MCO meets a certain percentage of capacity.) When assigning a beneficiary to a previous MCO is not possible, the State will distribute beneficiaries equitably among qualified MCOs based upon an algorithm developed by the DHCFP. The State may also adjust the auto-assignment algorithm in consideration of the MCO's clinical performance measure results or other measurements. Under the NCCW, there is only one PCCM available to Medicaid beneficiaries. Beneficiaries enrolled in the PCCM will be given the choice of at least two care managers in the PCCM. 3. As part of the state's discussion on the default enrollment process, include the following information: 1. The state of Nevada will _A_/will not __ use a lock-in for MCO enrollment. Approval Date fEB 2 1 2014 Effective Date: October 1, 2013

CMS-PM-XX-X Date: State: Nevada ATTACHMENT 3.1-F Page 15 OMB No.:0938-0933 Citation Condition or Requirement TN No. 13-031 Supersedes TN No. 09-11 For the MCOs, the total lock-in period is 12 months inclusive of the initial 90 days up front to disenroll without cause. The beneficiaries will be notified of their option to change MCOs at least 60 days prior to the end of the lock-in period. Beneficiaries will be allowed to change MCOs during the annual open enrollment period. PCCM beneficiaries are locked-in without an open enrollment period based upon the Freedom of Choice option waived under the authority of the NCCW. PCCM beneficiaries are allowed to change care managers at any time. n. The time frame for recipients to choose a health plan before being auto-assigned will be at the time of Medicaid application. MCO beneficiaries are asked to complete their selection of an MCO at the time of Medicaid application before being auto- assigned, unless they have a previous history with an MCO. Returning beneficiaries without family currently enrolled in an MCO will be assigned to their most recent MCO with an opportunity to choose a new MCO at the next Open Enrollment, at least once every 12 months. Returning beneficiaries with family currently enrolled in an MCO will automatically be enrolled in their family's MCO. PCCM beneficiaries are automatically enrolled in the PCCM in the next administrative month once they meet program eligibility criteria for enrollment. iii. Describe the state's process for notifying Medicaid recipients of their auto-assignment. (Example: state generated correspondence.) Potential enrollees are notified of their choice options and asked to complete their selection of an MCO at the time of Medicaid application. They are notified of their right to disenroll with cause at any time through the written enrollment packet provided by the MCO and by a letter generated by the MMIS. They are also informed of the State's default enrollment process or auto assignment process. The State prior approves the written enrollment packet which the contracted MCOs use to provide this notification to potential enrollees, including the websites and phone numbers of the MCOs. Approval Date FEB 2 1 2014 Effective Date: October l, 2013

CMS-PM-XX-X Date: State: Nevada ATIACHMENT3.1-F Page 16 OMB No.:0938-0933 Citation Condition or Requirement TN No. 13-031 Supersedes TN No. 09-11 For PCCM, the State will provide notice of enrollment to the beneficiary in advance of any initial contact by the PCCM. 1v. Describe the state's process for notifying the Medicaid recipients who are auto-assigned of their right to disenroll without cause during the first 90 days of their enrollment. (Examples: state generated correspondence, HMO enrollment packets etc.) All MCO enrollees who are entitled to disenroll without cause will receive a letter detailing that they have 90 days to change MCOs, even if they were automatically assigned to an MCO. Beneficiaries may disenroll without cause within the first 90 days of enrollment in the MCO and at least once every 12 months. Beneficiaries may disenroll with cause at any time.The request to disenroll from the MCO is made in writing to the MCO and occurs upon MCO approval. Details on how to submit a disenrollment request is explained to enrollees in the enrollment packet they are provided at the time they are determined eligible for MCO enrollment. PCCM enrollees may disenroll with cause at any time. They will be provided disenrollment rights and procedures in writing from the PCCM. v. Describe the default assignment algorithm used for auto- assignment. (Examples: ratio of plans in a geographic service area to potential enrollees, usage of quality indicators.) Returning MCO enrollees will be assigned to their most recent MCO, regardless if they lost Medicaid eligibility or were in Medicaid FFS during this time, unless a family member has an open case. If the enrollee's return to MCO eligibility occurs during an open enrollment period, then the beneficiary will be allowed to choose their MCO at the time of MCO re-eligibility. If the beneficiary does not select an MCO, they will be auto assigned to an MCO. Following auto-assignment, they will have 90 days to change their MCO plan. Returning beneficiaries who join an open case where another family member is currently enrolled in an MCO, will be assigned to the same MCO as the rest of the family and will not individually have a 90 day right to change period, nor will their addition to the family qualify any other members of the family Approval Date fEB 3 1 2014 Effective Date: October l, 2013

CMS-PM-XX-X Date: State: Nevada ATTACHMENT 3.1-F Page 17 OMB No.:0938-0933 Citation Condition or Requirement TN No. 13-031 Supersedes TN No. 09-11 for a right to change outside of the regular open enrollment period. Returning beneficiaries without a family member currently part of an open case will be auto assigned to their most recent MCO. New additions to an open case, whether newborn or additional family members who join the household after the MCO has been established, are also assigned to the same MCO as the rest of the family and do not have 90 days to change MCOs; these new case members, as well as the rest of the family, remain locked-in until the next open enrollment period. The new addition will be assigned to the family's MCO whether or not they are an adult or child, and regardless of the time they have been absent from the case. They will not be given an option to change MCOs until the next open enrollment period. Enrollment in the MCO will begin at the beginning of the rext administratively possible month. Returning beneficiaries, and those being added to an open case, will be notified of this assignment by mail and informed that they can disenroll at the next open enrollment period. For a true first time beneficiary, that is one who has never been enrolled in an MCO, they will be given information on all MCOs and will be asked to complete their selection of an MCO at the time of Medicaid application. Their choice will go into effect the first day of the next administratively possible month. Absent a choice by the beneficiary, they will be assigned to an MCO using the auto assignment algorithm shown below. The beneficiary will be allowed 90 days to change plans and will then be locked in until the next open enrollment period, never to exceed 12 months. Regardless of which enrollment or auto assignment process is used, the head of household will be notified of all choices that need to be made, the timeframe for making these choices, and the consequence of not making a choice. To reduce large disparities and adverse risk between MCOs, the State uses a default assignment algorithm for auto-assignment of first time beneficiaries. The algorithm will give weighted preference to any new MCO, as well as MCOs with significantly lower enrollments. This is based on a formula developed by the Approval Date fEB 2 1 2014 Effective Date: October 1, 2013

CMS-PM-XX-X Date: State: Nevada ATTACHMENT 3.1-F Page 18 OMB No.:0938-0933 Citation Condition or Requirement Number of Plans in Geographic Service Area 2 plans 3 plans 4 plans State. The State may also adjust the auto-assignment algorithm in consideration of the MCO's clinical performance measure results or other measurements. The algorithm is as follows: *Auto Assignment Algorithm Percentage of Percentage of Percentage of Percentage of Beneficiaries Beneficiaries Beneficiaries Beneficiaries Assigned to Assigned to Assigned to Assigned to 4th Largest Plan 2nd Largest 3rd Largest Largest Plan Plan Plan 34% 66% 17% 33% 50% 10% 10% 30% 50% * The function of the algorithm is to ultimately achieve no more than a 10% differential in enrollment between all MCO contractors. Once the differential is achieved, use of this algorithm will be discontinued and head of households will be auto assigned on rotating basis. v1. Describe how the state will monitor any changes in the rate of default assignment. (Example: usage of the Medical Management Information System (MMIS), monthly reports generated by the enrollment broker) The State will monitor the auto-assignment rates on a monthly basis through a generated MMIS system report. 1932(a)(4) I. State assurances on the enrollment process 42 CFR 438.50 TN No. 13-031 Supersedes TN No. 09-11 Place a check mark to affirm the state has met all of the applicable requirements of choice, enrollment, and re-enrollment. 1. _ll_The state assures it has an enrollment system that allows recipients who are already enrolled to be given priority to continue that enrollment if the MCO or PCCM does not have capacity to accept all who are seeking enrollment under the program. 2. _lL The state assures that, per the choice requirements in 42 CFR 438.52, Medicaid recipients enrolled in either an MCO or PCCM model Approval Date fEB 2 1 2014 Effective Date: October 1, 2013

CMS-PM-XX-X Date: State: Nevada ATTACHMENT 3.1-F Page 19 OMB No.:0938-0933 Citation Condition or Requirement will have a choice of at least two entities unless the area is considered rural as defined in 42 CFR 438.52(b)(3). Under the authority of the NCCW, freedom of choice for the PCCM(s) is restricted to a choice of at least two care managers in the PCCM. 3. __ The state plan program applies the rural exception to choice requirements of 42 CFR 438.52(a) for MCOs and PCCMs. This exception to choice applies to the PCCM(s). Under the NCCW authority, beneficiaries are allowed to choose from at least two care managers. This does not apply to the MCOs, which are only located in urban areas. _This provision is not applicable to this 1932 State Plan Amendment. 4. _The state limits enrollment into a single Health Insuring Organization (RIO), if and only if the RIO is one of the entities described in section 1932(a)(3)(C) of the Act; and the recipient has a choice of at least two primary care providers within the entity. (California only.) _lL This provision 1s not applicable to this 1932 State Plan Amendment. 5. X The state applies the automatic reenrollment provision in accordance with 42 CFR 438.56(g) if the recipient is disenrolled solely because he or she loses Medicaid eligibility for a period of 2 months or less. _This provision is not applicable to this 1932 State Plan Amendment. 1932(a)(4) J. Disenrollment 42 CFR 438.50 TN No. 13-031 Supersedes TN No. 09-11 1. The state will _K_/will not_ use lock-in for managed care. Nevada uses lock-in for the MCOs. MCO beneficiaries will never be locked in for more than 12 months. There will be one open enrollment period at least annually. Nevada uses lock-in for the PCCM with no open enrollment periods since there is only one PCCM; however, they will have the option to Approval Date fEB 2 1 2014 Effective Date: October 1, 2013

CMS-PM-XX-X Date: State: Nevada ATTACHMENT 3.1-F Page20 OMB No.:0938-0933 Citation Condition or Requirement TN No. 13-031 Supersedes TN No. 09-11 choose between a minimum of two care managers at least once every 12 months. 2. The lock-in will apply for _.1L months (up to 12 months). There is an open enrollment period at least annually. PCCM enrollment is locked-in for all beneficiaries with no open enrollment periods since there is only one PCCM; however, they will have the option to choose between a minimum of two care managers at least once every 12 months. 3. Place a check mark to affirm state compliance. _x_The state assures that beneficiary requests for disenrollment (with and without cause) will be permitted in accordance with 42 CFR 438.56(c). Subject to the limitations outlined in Section H.3.(v) of this State Plan, an enrolled beneficiary may request disenrollment from the MCO with or without cause during the first 90 days of enrollment. Enrollment is mandatory in the PCCM program and there is only one PCCM from which to choose. There are no time restrictions for disenrollment with cause for the MCOs or the PCCM. Circumstances for disenrollment with cause are: • The MCO beneficiary moves out of the MCO service area. • The plan does not, because of moral or religious objections, cover the service the beneficiary seeks. • The beneficiary needs related services (for example a cesarean section and a tubal ligation) to be performed at the same time; not all related services are available within the network; and the beneficiary's primary care provider or another provider determines that receiving the services separately would subject the beneficiary to unnecessary risk. • The PCCM beneficiary moves into the MCO service area. • Other reasons, including but not limited to, poor quality of care, lack of access to services covered under the contract, or lack of Approval Date_+f.._E .... B~2-.Al-'Z~D-'-l4_ Effective Date: October 1, 2013

CMS-PM-XX-X Date: State: Nevada ATTACHMENT 3.1-F Page21 OMB No.:0938-0933 Citation Condition or Requirement 1932(a)(5) 42 CFR 438.50 42 CFR 438.10 1932(a)(5)(D) 1905(t) TN No. 13-031 Supersedes TN No. 09-11 access to providers experienced in dealing with the beneficiary's health care needs. 4. Describe any additional circumstances of"cause" for disenrollment (if any). For cause disenrollments can be determined by the DHCFP on a case by case basis where one MCO is better able to provide for unusual needs of a specific family member, while at the same time the other MCO is better able to provide for unusual needs of a different family member. K. Information requirements for beneficiaries Place a check mark to affirm state compliance. __K_ The state assures that its state plan program is in compliance with 42 CFR 438.10(i) for information requirements specific to MCOs and PCCM programs operated under section 1932(a)(l) A)(i) state plan amendments. (Place a check mark to affirm state compliance.) L. List all services that are excluded for each model (MCO & PCCM) 1. All services provided at Indian Health Service Facilities and Tribal Clinics: Native Americans may access and receive covered medically necessary services at Indian Health Service (IHS) facilities and Tribal Clinics. If a Native American voluntarily enrolls with an MCO and seeks covered services from IHS, the MCO should request and receive medical records regarding those covered services/treatments provided by IHS. If treatment is recommended by IHS and the enrollee seeks the recommended treatment through the MCO, the MCO must either provide the service or must document why the service is not medically necessary. The documentation may be reviewed by the DHCFP or other reviewers. The MCO is required to coordinate all services with IHS. If a Native American beneficiary elects to disenroll from the MCO, the disenrollment will commence no later than the first day of the next administrative month and the services will then be reimbursed by FFS. Enrollment in the PCCM program is voluntary for Native American Medicaid FFS beneficiaries who meet the PCCM-qualifying health conditions. Approval Date FEB z 1 zO 14 Effective Date: October 1, 2013

CMS-PM-XX-X Date: State: Nevada ATTACHMENT 3.1-F Page22 OMB No.:0938-0933 Citation Condition or Requirement TN No. 13-031 Supersedes TN No. NEW 2. Non-emergency transportation The DHCFP or its designee will authorize and arrange for all medically necessary non-emergency transportation. The MCO must verify medical appointments upon request by the DHCFP or its designee. 3. All Nursing Facility stays over forty-five (45) days The MCO is required to cover the first 45 days of a nursing facility admission, pursuant to the Medicaid Services Manual (MSM). The MCO is also required to collect any patient liability (pursuant to 42 CFR 435.725) for each month a capitated payment is received, pursuant to the MSM. The MCO shall notify the DHCFP by the fortieth (40th) day of any nursing facility stay admission expected to exceed forty-five (45) days. The enrollee will be disenrolled from the MCO and the stay will be covered by FFS commencing on the 46th day of the facility stay. The DHCFP will retroactively adjust the capitation payment to cover only that portion of the month that the beneficiary is enrolled. 4. Swing bed stays in acute hospitals over forty-five (45) days The MCO is required to cover the first forty-five (45) days of a swing bed admission pursuant to the MSM. The MCO is also required to collect any patient liability for each month a capitated payment is received, pursuant to the MSM. The MCO shall notify the DHCFP by the fortieth (40th) day of any swing bed stay expected to exceed forty- five ( 45) days. The enrollee will be disenrolled from the MCO and the stay will be covered by FFS commencing on the forty-sixth (46th) day of the facility stay. The DHCFP will retroactively adjust the capitation payment to cover only that portion of the month that the beneficiary is enrolled. 5. School Based Child Health Services (SBCHS) The DHCFP has an agreement with several school districts to provide selected medically necessary covered services through School Based Child Health Services (SBCHS) to eligible Title XIX Medicaid beneficiaries. Eligible Medicaid enrollees, who are three (3) years of age and older, can be referred to a school based child health service for an evaluation by their private physician, school physician, special education teacher, school nurse, school counselor, parent or guardian, or social worker. If Approval Date fEB 2 1 2014 Effective Date: October 1, 2013

CMS-PM-XX-X Date: State: Nevada ATTACHMENT 3.1-F Page23 OMB No.:0938-0933 Citation Condition or Requirement TN No. 13-031 Supersedes TN No. NEW the child is found eligible for these services, then an Individual Education Plan (IEP) is developed for the child. The IEP specifies services needed for the child to meet educational goals. A copy of the IEP will be sent to the child's PCP within the managed health care plan, and maintained in the enrollee's medical record. The school districts provide, through school district employees or contract personnel, the majority of specified medically necessary covered services. Medicaid reimburses the school districts for these services in accordance with the school district contract. The Vendors will provide covered medically necessary services beyond those available through the school districts, or document why the services are not medically necessary. The documentation may be reviewed by the DHCFP or its designees. Title XIX Medicaid eligible children are not limited to receiving health services through the school districts. Services may be obtained through the Vendor rather than the school district, if requested by the parent/legal guardian. The Vendor case manager shall coordinate with the school district in obtaining any services which are not covered by the plan or the school district. 6. Intermediate Care Facility for the Mentally Retarded (ICF/MR) Residents of ICF/MR facilities are not eligible for enrollment with the MCO.If a beneficiary is admitted to an ICF/MR after MCO enrollment, the beneficiary will be disenrolled from the MCO and the admission, bed day rate, and ancillary services will be reimbursed through FFS. The DHCFP will retroactively adjust the capitation payment to cover only that portion of the month that the beneficiary is enrolled. 7. Residential Treatment Center (RTC) Medicaid enrollees will be disenrolled from the MCO in the month following the RTC admission. The RTC admission, bed day rate, and ancillary services will be reimbursed through FFS thereafter for Title XIX Medicaid Beneficiaries. 8. Hospice Medicaid beneficiaries who are receiving hospice services are not eligible for enrollment with the MCO. If a Medicaid beneficiary is made eligible for hospice services after MCO enrollment, the beneficiary will be disenrolled from the MCO and the hospice services will be h FFS. DHCFP will retroactive! ad·ust the Effective Date: October l, 2013

CMS-PM-XX-X Date: State: Nevada ATTACHMENT 3.1-F Page24 OMB No.:0938-0933 Citation Condition or Requirement TN No. 13-031 Supersedes TN No. NEW capitation payment to cover only that portion of the month that the beneficiary is enrolled. 9. Institutions for Mental Diseases (IMDs) for Title XIX eligible beneficiaries ages twenty two (22) through sixty five (65) years of age Federal regulations stipulate that FFP is not allowable for IMD services for patients who are between the ages of22 through 64 years of age. The federal regulation allows for coverage of beneficiaries who are receiving inpatient psychiatric services, including IMD, to beneficiaries immediately prior to reaching age 21 years to continue services until (1) the service is no longer needed or (2) the date the beneficiary reaches the age of 22 years. A patient on conditional release or convalescent leave from an IMD is not considered to be a patient in an IMD per the federal regulation. Beneficiaries admitted to an IMD after MCO enrollment may be disenrolled. The DHCFP will retroactively adjust the capitation payment to cover only that portion of the month that the beneficiary is enrolled. 10. Adult Day Health Care (ADHC) Recipients who are receiving ADHC (Provider Type 39) services are not eligible for enrollment with the MCO. If a recipient is made eligible for ADHC after MCO enrollment, the recipient will be disenrolled and the ADHC will be reimbursed through FFS. The DHCFP will retroactively adjust the capitation payment to cover only that portion of the month that the beneficiary is enrolled. 11. Home and Community Based Waiver (HCBW) Services Beneficiaries who are receiving HCBW Services are not eligible for enrollment with the MCO. If a beneficiary is made eligible for HCBW Services after MCO enrollment, the beneficiary will be disenrolled and the HCBW Services will be reimbursed through FFS. The DHCFP will retroactively adjust the capitation payment to cover only that portion of the month that the beneficiary is enrolled. Approval Date fEB Z 1 2014 Effective Date: October 1, 2013

CMS-PM-XX-X Date: State: Nevada ATTACHMENT 3.1-F Page25 OMB No.:0938-0933 Citation Condition or Requirement 12. Pre-Admission Screening and Resident Review (PASRR) and Level of Care (LOC) Assessments A PASRR and LOC are reimbursed by FFS. Conducting a PASRR and LOC will not prompt MCO disenrollment. However, if the beneficiary is admitted into a nursing facility as the result of a PASRR and LOC, the MCO is responsible for the first 45 days of admission for the beneficiary (see 3., above). 13. Seriously Emotionally Disturbed/Severely Mentally Ill SED/SMI, with limitations The MCO must ensure enrollees who are referred for evaluation for SED/SMI or who have been determined SED/SMI by the health plan are obtaining the medically necessary evaluations and that enrollees are transitioned, as necessary, to another provider in order to obtain their mental health services if such services are not available within the network. The MCO is required to notify the DHCFP if a Title XIX Medicaid beneficiary elects to disenroll with the MCO following the determination ofSEO/SMI and forward the enrollee's medical records to the provider from whom the enrollee will receive the covered mental health services. However, in the event the Medicaid enrollee, who has received such a determination, chooses to remain enrolled with the MCO, the M<;::O will be responsible for providing all patient care. 1932 (a)(1)(A)(ii) M. Selective contracting under a 1932 state plan option TN No. 13-031 Supersedes TN No. NEW To respond to items #1 and #2, place a check mark. The third item requires a brief narrative. The state will __ /will not _A_ intentionally limit the number of entities it contracts under a 1932 state plan option. 1. __ The state assures that if it limits the number of contracting entities, this limitation will not substantially impair beneficiary access to services. 2. Describe the criteria the state uses to limit the number of entities it contracts under a 1932 state plan option. (Example: a limited number of providers and/or enrollees.) 3. _The selective contracting provision in not applicable to this state plan. Approval Date fEB 2 1 2014 Effective Date: October 1, 2013

CMS-PM-XX-X Date: State: Nevada Citation Condition or Requirement ATTACHMENT 3.1-F Page26 OMB No.:0938-0933 According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0933. The time required to complete this information collection is estimated to average 10 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Baltimore, Maryland 21244-1850. CMS-10120 (exp. 01/31!2008) TN No. 13-031 Supersedes TN No. NEW Approval Date _ __._f...._F .... B_,2~11:----"'-'-20L...L1_._4 Effective Date: October 1, 2013

Table of Contents

State/Territory Name: Nevada State Plan Amendment (SPA) #: 13-0035-MM This file contains the following documents in the order listed:

1) Approval Letter 2) Summary Form (with 179-like data) 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES as “

Centers for Medicare & Medicaid Services f an _ “a

San Francisco Regional Office 90 Seventh Street, Suite 5-300 (6W) CENTERS FOR MEDICARE & MEDICAID SERVICES

San Francisco, CA 94103-6706

DIVISION OF MEDICAID & CHILDREN’S HEALTH OPERATIONS

Michael J. Willden, Director DEC 19 2013 Department of Health and Human Services

4126 Technology Way, Suite 100

Carson City, NV 89706

Dear Mr. Willden:

Enclosed is an approved copy of Nevada State Plan Amendment (SPA) 13-0035-MM, which was submitted to CMS on December 17, 2013. SPA 13-0035-MM incorporates the New Adults Below 133% eligibility group into Nevada’s Medicaid State Plan in accordance with the Affordable Care Act. The effective date of the SPA is January 1, 2014.

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

e $32, Pages S32-1 and $32-2

If you have any questions, please contact Brian Zolynas by phone at (415) 744-3601 or by email at Brian.Zolynas@cms.bhs.gov . :

Sincerely,

/s/ Gloria Nagle, Ph.D., MPA Associate Regional Administrator Division of Medicaid & Children’s Health Operations Enclosure

ce: Laurie Squartsoff, Administrator, DHCFP Marta Stagliano, Chief, Compliance, DHCFP

Medicaid State Plan Eligibility: Summary Page (CMS 179)

State/Territory name: Nevada

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.

13-0035

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

Federal Statute/Regulation Citation 1902(a)(10)(A)(i)(VIID, 42CFR 435.119

Federal Budget Impact

Federal Fiscal Year Amount First Year 2014 $ 160557401.00 Second Year 2015 $ 278790327.00 Subject of Amendment

State plan amendment submitted for $32 seperate from mandatory group SPA's

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

Comments of Governor's office received Describe:

No reply received within 45 days of submittal

Other, as specified Describe: The Governor's Office does not wish to review the State Plan Amendment.

Signature of State Agency Official Submitted By: Robyn Heddy Last Revision Date: Dec 17, 2013 Submit Date: Dec 17, 2013

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

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

The state covers the Adult Group as described at 42 CFR 435.119. @ Yes (© No [i] Adult Group - Non-pregnant individuals age 19 through 64, not otherwise mandatorily eligible, with income at or below 133% FPL.

The state attests that it operates this eligibility group in accordance with the following provisions: [lf Individuals qualifying under this eligibility group must meet the following criteria: [| Have attained age 19 but not age 65. [Mf Are not pregnant. [lM Are not entitled to or enrolled for Part A or B Medicare benefits.

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

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

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

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

[Mf There is no resource test for this eligibility group.

Parents or other caretaker relatives living with a child under the age specified below are not covered unless the child is [ll receiving benefits under Medicaid, CHIP or through the Exchange, or otherwise enrolled in minimum essential coverage, as defined in 42 CFR 435.4.

@ Under age 19, or C A higher age of children, if any, covered under 42 CFR 435.222 on March 23, 2010: [li] Presumptive Eligibility

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

C Yes @ No

PRA Disclosure Statement

Transmittal Number: NV-13-0035-MM Approval Date: DEC 1 9 2013 Effective Date: January 1, 2014 Nevada $32-1

Page | of 2

cms Medicaid Eligibility

UR HO RE AAR UREN EVN

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

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

Transmittal Number: NV-13-0035-MM Approval Date: DEC 1 9 2013 ettective Date: January 1, 2014 Nevada $32-2

Page 2 of 2

Table of Contents State/Territory Name: Nevada State Plan Amendment (SPA) #: 14-0001 MM7 This file contains the following documents in the order listed: 1) Approval Letter 2) Companion Letter 3) CMS 179 Form/Summary Form (with 179-like data) 4) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services San Francisco Regional Office 90 Seventh Street, Suite 5-300 (5W) San Francisco, CA 94103-6706

DIVISION OF MEDICAID & CHILDREN’S HEALTH OPERATIONS

September 10, 2015 Richard Whitley, Director Department of Health and Human Services 4126 Technology Way, Suite 100 Carson City, NV 89706

Dear Mr. Whitley:

Enclosed is an approved copy of Nevada State Plan Amendment (SPA) 14-0001. This SPA was submitted to my office on March 31, 2014 to allow qualified hospitals to determine individuals presumptively eligible (PE) for Medicaid based on preliminary information.

The effective date of this SPA is January 1, 2014. Enclosed are the following approved state plan pages to be incorporated within your approved state plan:  S21, Pages 1-3  Hospital PE Application  Hospital PE Training Materials

Please note that there is also a companion letter included in this approval package. This companion letter addresses the need for Nevada to establish a system to process a PE period on the date the hospital PE determination is made and to be able to automatically end a PE period on the date of a full Medicaid determination, if a full Medicaid application is filed. Otherwise, the PE period must end on last day of the month following the month in which the determination of presumptive eligibility was made.

If you have any questions, please have your staff contact Peter Banks at (415) 744-3782 or at Peter.Banks@cms.hhs.gov.

Sincerely,

/s/

Henrietta Sam-Louie

Acting Associate Regional Administrator

Division of Medicaid & Children’s Health Operations

cc: Marta Jensen, Administrator, DHCFP

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services San Francisco Regional Office 90 Seventh Street, Suite 5-300 (5W) San Francisco, CA 94103-6706

DIVISION OF MEDICAID & CHILDREN’S HEALTH OPERATIONS

September 10, 2015 Richard Whitley, Director Department of Health and Human Services 4126 Technology Way, Suite 100 Carson City, NV 89706

Dear Mr. Whitley:

This letter is being sent as a companion to our approval of Nevada State Plan Amendment (SPA) NV- 14-0001, which proposes to implement presumptive eligibility (PE) conducted by hospitals in the Medicaid State Plan in accordance with the Affordable Care Act. This amendment was submitted on March 31, 2014, with an effective date of January 1, 2014.

Section 1902(a) of the Social Security Act (the Act) requires that states have a State Plan for medical assistance that meets certain Federal requirements that set out a framework for the State program. Implementing regulations at 42 Code of Federal Regulations (CFR) 430.10 require that the State Plan be a comprehensive written statement describing the nature and scope of the State’s Medicaid Program and that it contain all information necessary for the Centers for Medicare & Medicaid Services (CMS) to determine whether the plan can be approved to serve as the basis for Federal financial participation (FFP) in the state program. While the SPA is approvable, CMS’ analysis determined that additional changes related to the state’s implementation of the hospital presumptive eligibility provision are needed. 42 CFR 435.1101 specifies that a period of PE “ends with the earlier of – (1) In the case of a child on whose behalf a Medicaid application has been filed, the day on which a decision is made on that application; or (2) In the case of a child on whose behalf a Medicaid application has not been filed, the last day of the month following the month in which the determination of presumptive eligibility was made.” This requirement for period of presumptive eligibility applies to children under 42 CFR 435.1102, to other populations according to 42 CFR 435.1103, and to individuals determined presumptively eligible by hospitals according to 42 CFR 435.1110. Pursuant to these regulations, Nevada (“the state”) must start a PE period when the hospital PE determination is made. The start date should not be made retroactive to the beginning of the month or another date. Further, the state must end a PE period when a full Medicaid determination is made, if a full Medicaid application is filed. Otherwise, the PE period must end on last day of the month following the month in which the determination of presumptive eligibility was made. . Individuals found eligible for Medicaid are transitioned to coverage pursuant to the state’s policies regarding enrollment and retroactive coverage. For individuals denied Medicaid eligibility, the PE period

must end on the date of the full Medicaid determination and cannot extend to the end of the month or further. Nevada is not able to start a PE period on the date that the hospital PE determination is made. Further, Nevada is not able to automatically end a PE period on the date of a full Medicaid determination. To correct this issue, the state is manually monitoring enrollees in the state’s hospital PE program. The state will claim Federal Financial Participation (FFP) only for claims submitted during a PE period as defined in 42 CFR 435.1101. For claims that occur outside of the PE period as defined in 42 CFR 435.1101, the state will not claim FFP. The state described this approach on August 12, 2015 and said it would conduct an analysis of claims and apply this approach starting in January 2015, i.e., the first date that hospitals started performing the hospital PE determinations. The state intends to perform this manual monitoring and FFP adjustment step until the logic can be embedded into the state’s Medicaid Management Information System. Within 30 days of this letter, please reply to CMS to confirm receipt and agreement to the description in this letter, including effective dates. If you have any questions about this letter or need any additional information, please contact Peter Banks of my staff at either 415-744-3782 or by email at Peter.Banks@cms.hhs.gov.

Sincerely,

/s/

Henrietta Sam-Louie

Acting Associate Regional Administrator

Division of Medicaid & Children’s Health Operations

cc: Marta Jensen, Administrator, DHCFP

logged in as PBANKS(CMS RO Staff) read only mode application rev c01 Medicaid State Plan Eligibility NV.0880.R00.00 - Jan 01, 2014 Home Logout Finder Save Validate Print Help Control Panel General Information File Management Tribal Input Summary (CMS179) State/Territory name: Nevada Medicaid State Plan Eligibility: Summary Page (CMS 179) Transmittal Number: Please enter the Transmittal Number (TN) in the format ST- YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. NV-14-0001 Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation 42 CFR 435.1110 Federal Budget Impact Federal Fiscal Year Amount First Year 2014 $ 0.00 Second Year 2015 $ 0.00 Subject of Amendment Character Count:73 out of 2000   New state plan amendment section S21 Presumptive eligibility by hospitals Governor's Office Review Governor's office reported no comment Comments of Governor's office received Page 1 of 2 MacPro Reporting System: Summary Page (CMS 179)

Submitted By: Robyn Heddy Last Revision Date: Aug 28, 2015 Submit Date: Mar 31, 2014 Describe:   No reply received within 45 days of submittal Other, as specified Describe:   Signature of State Agency Official FAQs | Form Support | Contact | Medicaid.gov | CMS.gov Page 2 of 2 MacPro Reporting System: Summary Page (CMS 179)

9/10/2015

9/10/2015

9/10/2015

Application for Presumptive Eligibility for Medicaid Use this form to find out quickly if you qualify for presumptive eligibility for Medicaid. Presumptive eligibility offers you and your family immediate access to health care while you apply for regular Medicaid or other health coverage. To find out if you qualify for regular Medicaid or other health coverage, you must complete and submit an Application for Health Insurance to the Division of Welfare and Supportive Services. While you wait to learn if you qualify for regular Medicaid or other health coverage, you can get your health services through the presumptive eligibility program. You can apply for medical assistance online at www.dwss.nv.gov You can complete a paper application and submit by mailing the application to: Division of Welfare and Supportive Services PO Box 15400 Las Vegas, NV 89114 Who can qualify for presumptive eligibility for Medicaid? You can qualify for presumptive eligibility for Medicaid if you meet all of these rules: • Your income is below the federal poverty level for a family of your size • You are a U.S. citizen, U.S. national, or eligible immigrant • You do not already have Medicaid • You have not had presumptive eligibility for Medicaid in Nevada in the past 24 months • You are in one of the groups that qualifies for presumptive eligibility for Medicaid: o Children under age 19 o Parents and caretaker relatives o Pregnant women o Other adults age 19-64 o Aged Out of Foster Care Need help with your application? You can get personalized assistance completing your application from community partners or local division staff. Find a location nearest your home: Visit www.dwss.nv.gov and choose contact us, or call 1-800-992-0900 (voice) or 1-800-326-6888(TTY) Form xxxx TN NO: 14-0001 Approval Date: Effective Date: 1/1/14 9/10/2015

1 Tell us about yourself We ask for this information so that we can contact you about this application. Name (first, middle last) Home address (leave blank if you don't have one) City State ZIP Code Mailing address (if different from home address) You must have a mailing address Phone number (if you have one) Email address (if you have one) 2 Tell us about your family List yourself and the members of your immediate family who live with you. Include your spouse and your children, under age 19, if they live with you. Name (first, middle, last) Relationship to you Gender Date of Birth (XX/XX/XXXX) Applying for presumptive eligibility for Medicaid? (Yes or No) Already had Medicaid? (Yes or No) Social Security Number (optional) U.S. Citizen, U.S. National, or eligible immigrant? (Yes or No) Resident of Nevada? (Yes or No) Answer for family members who are applying. If a person is not applying, these questions are optional, but providing the information can speed up the application process. (Same as above) Self 3 Other questions Answer these questions for yourself and your family members listed in Section 2. Your answers will make it easier to find out if you and any family members qualify. Is anyone applying for presumptive eligibility pregnant?  Yes  No If yes, who? Expected due date? How many babies does she expect? Is anyone who is applying for presumptive eligibility for Medicaid receiving Medicare?  Yes  No If yes, who? Has anyone applying for presumptive eligibility for Medicaid, if under the age of 26, ever been in foster care in the state of Nevada?

 Yes  No If yes, who?

Age when they left the program: Form xxxx TN NO: 14-0001 Approval Date: Effective Date: 1/1/14 9/10/2015

4 Tell us about your family’s income Write the total income before taxes are taken out for all family members listed in Section 2. Job income For example, wages, salaries, and self-employment income. Amount $ _________________ How often? (check one)  W e e kly  Biwe e kly  Mo n th ly  Ye a rly Amount $ _________________ How often? (check one)  W e e kly  Biwe e kly  Mo n th ly  Ye a rly Other income For example, unemployment checks, alimony, or disability payments from the Social Security Administration (SSDI). Do not include Supplemental Security Income (SSI payments) or any child support you receive. Amount $ _________________ How often? (check one)  Weekly  Biwe e

Amount $ _________________ How often? (check one)  W e e kly  Biwe e kly  Mo n th ly  Ye a rly 5 Health Plan Selection Families 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 6 Sign this form here 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. I swear I have honestly reported the citizenship status of myself and anyone I am applying for. Your signature: Date: Form xxxx TN NO: 14-0001 Approval Date: Effective Date: 1/1/14 9/10/2015

7 If you qualify for presumptive eligibility for Medicaid, what happens next? • You will get a letter from the hospital saying you were approved. • You can start using your presumptive eligibility for Medicaid coverage right away for services such as doctor visits, hospital care, and prescription drugs. You can go to any health care provider who accepts Medicaid, starting the day you are approved. o To start using your presumptive eligibility for Medicaid, the hospital will give you a letter saying you are approved. Use the letter to get services until you get a card in the mail. The card should arrive within 7 - 10 days. If you lose the letter, you can call customer service at 1-800-992-0900. o If the letter says you qualify for presumptive eligibility for Medicaid because you are pregnant, you can get care at outpatient clinics or other places in the community. Presumptive eligibility for Medicaid will not cover the cost if you are admitted to a hospital. • If you do not fill out and send the Application for Health Insurance to see if you qualify for regular Medicaid or other health coverage, your presumptive eligibility for Medicaid coverage will end on the last day of the month after the month you are approved. o For example, if you qualified for presumptive eligibility for Medicaid in January, it will end on the last day of February. • To see if you qualify for regular Medicaid or other health coverage: You can apply for medical assistance online at www.dwss.nv.gov You can complete a paper application and submit by mailing the application to: Division of Welfare and Supportive Services PO Box 15400 Las Vegas, NV 89114 The hospital will give you an application. 8 If you do not qualify for presumptive eligibility for Medicaid, what happens next? You will get a letter from the hospital saying you were not approved. You cannot appeal the hospital's decision. BUT, you can still apply for regular Medicaid or other health coverage by completing the Application for Health Insurance online at dwss.nv.gov or by telephone or on paper. Form xxxx TN NO: 14-0001 Approval Date: Effective Date: 1/1/14 9/10/2015

Division of Welfare and Supportive Services Hospital Presumptive Eligibility Training Working for the Welfare of ALL Nevadans 1 TN NO: 14-0001 Approval Date: Effective Date: 1/1/14 9/10/2015

Training Objectives - HPE Overview - Eligible Populations - Eligibility Period and Benefits - Hospital Qualifications - Becoming an HPE Provider - The HPE Application - Program Integrity Working for the Welfare of ALL Nevadans 2 TN NO: 14-0001 Approval Date: Effective Date: 1/1/14 9/10/2015

HPE Overview • HPE is a process under the Affordable Care Act to connect eligible people to Medicaid • Participating in HPE is optional for hospitals • Hospitals must follow federal and state requirements and performance standards • States have discretion how to operate HPE to ensure appropriate PE determinations are made Working for the Welfare of ALL Nevadans 3 TN NO: 14-0001 Approval Date: Effective Date: 1/1/14 9/10/2015

Eligible Populations • Pregnant women (up to 165% FPL) • Infants and children 1-5 (up to 165% FPL) • Children 6-19 (up to 138% FPL) • Parents and caretaker relatives (up to 138% FPL) • Non-disabled adults, 19-64 w/o Medicare (up to 138% FPL) • Aged out of Foster Care (not based on income) Working for the Welfare of ALL Nevadans 4 TN NO: 14-0001 Approval Date: Effective Date: 1/1/14 9/10/2015

Eligibility Criteria • Not currently enrolled in Medicaid • Attest to household size and income • Attest to citizenship/ qualified immigrant status, state residency requirements • Cannot have been enrolled via HPE within the last twenty four months Working for the Welfare of ALL Nevadans 5 TN NO: 14-0001 Approval Date: Effective Date: 1/1/14 9/10/2015

Eligibility Period • Begins the day HPE determination made • If customer completes a full Medicaid application, HPE ends the day the DWSS full Medicaid determination is made • If no Full Medicaid application filed, HPE ends the last day of the month following HPE determination • HPE is only allowed once every 24 months (and only once per pregnancy) Working for the Welfare of ALL Nevadans 6 TN NO: 14-0001 Approval Date: Effective Date: 1/1/14 9/10/2015

HPE Benefits • Benefits are the same as those provided under Medicaid • Federal regulations limit HPE benefits for pregnant women to ambulatory pre-natal care only (no inpatient, non-prenatal care) Working for the Welfare of ALL Nevadans 7 TN NO: 14-0001 Approval Date: Effective Date: 1/1/14 9/10/2015

Hospital Qualifications • Is an active Nevada Medicaid provider • Has an active HPE contract addendum in place • Has at least one trained/certified HPE staff member • Agrees to be listed on DHCFP website as authorized site for application assistance Working for the Welfare of ALL Nevadans 8 TN NO: 14-0001 Approval Date: Effective Date: 1/1/14 9/10/2015

Hospital Qualifications Con’t • Operates within the State of Nevada • Agrees to make HPE determinations consistent with the departments policies and procedures • Has not been disqualified by the agency to conduct HPE determinations • Assists ensures 90% of applicants made eligible via HPE complete full DWSS Medicaid application before end of HPE eligibility period • Ensures 94% of Presumptive Eligibility determinations are correctly determined based on State HPE policies and must be entered into the HPE portal correctly from information gathered. Working for the Welfare of ALL Nevadans 9 TN NO: 14-0001 Approval Date: Effective Date: 1/1/14 9/10/2015

Becoming an HPE Provider • Register with DHCFP provider enrollment unit • Complete a Hospital Presumptive Eligibility Contract addendum • Hospital staff complete initial and ongoing training Working for the Welfare of ALL Nevadans 10 TN NO: 14-0001 Approval Date: Effective Date: 1/1/14 9/10/2015

The HPE Application • Requires HPE application to be completed by applicant or responsible household member. • HPE staff enter eligibility results into Access Nevada Presumptive Eligibility system. • Hospital must provide written notice of eligibility determination to the applicant. • The HPE application cannot be approved if applicant is over income or does not meet citizenship/residency requirements. Working for the Welfare of ALL Nevadans 11 TN NO: 14-0001 Approval Date: Effective Date: 1/1/14 9/10/2015

Submitting HPE Applications • Step 1: Identify potential PE candidate and check EVS system to determine if individual has current eligibility • Step 2: Applicant to complete streamlined PE application • Step 3: Interview applicant for attestations and complete eligibility determination • Step 4: Enter presumptive eligibility determination into Access Nevada Presumptive eligibility system (Note: this is formal notification to the State) • Step 5: Provide an HPE Notice of Decision on hospital letterhead • Step 6: Encourage client to complete full Medicaid application. If possible schedule process with available resources or provide instructions on possible methods of submission. (Note: Handouts available in class) Working for the Welfare of ALL Nevadans 12 TN NO: 14-0001 Approval Date: Effective Date: 1/1/14 9/10/2015

The HPE Notice of Decision • Hospital provides HPE Notice of Decision explaining whether applicant is eligible • Notice must explain: o If denied, reason for denial and that no appeal right are available. o If approved, identify the • HPE time period, including exact date applicant was determined eligible • Date the full application must be submitted to continue coverage • Appointment time to complete full Medicaid application (if applicable) Working for the Welfare of ALL Nevadans 13 TN NO: 14-0001 Approval Date: Effective Date: 1/1/14 9/10/2015

Reimbursement • All claims for HPE services will be submitted to DHCFP and reimbursed on a fee-for- service basis • No payments are made for completing HPE determinations • No payments are made for completing full Medicaid applications • Can not charge applicants to apply for HPE or assist with full Medicaid applications Working for the Welfare of ALL Nevadans 14 TN NO: 14-0001 Approval Date: Effective Date: 1/1/14 9/10/2015

Program Integrity • HPE is a powerful tool- hospital staff have authority to determine eligibility for Medicaid • DWSS and DHCFP have a fiduciary duty to ensure taxpayer funds are appropriately spent • State reimbursement rates remain at regular Medicaid rates during the presumptive eligibility period regardless of HPE determination, creating potential losses to general funds if eligibility determinations are incorrect. Working for the Welfare of ALL Nevadans 15 TN NO: 14-0001 Approval Date: Effective Date: 1/1/14 9/10/2015

Program Integrity Reporting Con’t • The DWSS Performance Review and Evaluation Unit(PRE) will monitor and identify trends in order to conduct additional investigations and take necessary corrective action 16 Working for the Welfare of ALL Nevadans TN NO: 14-0001 Approval Date: Effective Date: 1/1/14 9/10/2015

Program Integrity Reporting • DWSS will generate monthly reports with the following information: • Number of HPE applications by: o Specific hospital facility o Percentage of HPE individuals who completed a full Medicaid application before the end of the PE period. o Percentage of PE decisions determined accurately based on DWSS factors of eligibility. 17 TN NO: 14-0001 Approval Date: Effective Date: 1/1/14 9/10/2015

Program Integrity Con’t • PRE will perform regular on-site audits of HPE qualified hospitals • PRE will inspect records, policies and procedures, documentation and compliance with HPE requirements • If PRE audit results in open Medicaid investigation for fraud, waste, or abuse, the department may implement disciplinary action 18 TN NO: 14-0001 Approval Date: Effective Date: 1/1/14 9/10/2015

Hospital Disqualification • Federal regulations allow states to disqualify hospitals from participating in HPE for failure to meet standards: o 90% of all individuals made presumptively eligible must submit a regular application before the end of their HPE period o 94% of all Presumptive Eligibility decisions must be correctly determined based on State HPE policies and must be entered into the portal correctly from information gathered. 19 TN NO: 14-0001 Approval Date: Effective Date: 1/1/14 9/10/2015

Hospital Disqualification Con’t • Qualified hospitals not meeting the above-stated standards will be placed on a corrective action plan (CAP) and will be given one calendar quarter from the date of the CAP to come into compliance • Hospital will be disqualified if after completion of the CAP and additional training, the State determines the hospital is not capable of making HPE determinations in compliance with standards 20 Working for the Welfare of ALL Nevadans TN NO: 14-0001 Approval Date: Effective Date: 1/1/14 9/10/2015

Questions? Working for the Welfare of ALL Nevadans 21 TN NO: 14-0001 Approval Date: Effective Date: 1/1/14 9/10/2015

©DWSS Confidential. All rights reserved. Questions about this material? Send an e-mail query to Training. We will respond within 48 hours as well as post your question and answer to the FAQ section which can be found at the end of this e-learning module. Presumptive Eligibility Non-Financial Factors TN NO: 14-0001 Approval Date: Effective Date: 1/1/14 9/10/2015

©DWSS Confidential. All rights reserved. Non-Financial Factors Factors to Presumptive Eligibility Financial Factors Non - Financial Factors TN NO: 14-0001 Approval Date: Effective Date: 1/1/14 9/10/2015

©DWSS Confidential. All rights reserved. Non-Financial Factors Name of Individual Age Residency Relationship Household Composition Citizenship Social Security Number* Identification Pregnancy *Providing a Social Security Number or Tax ID number is not required for a PE determination. TN NO: 14-0001 Approval Date: Effective Date: 1/1/14 9/10/2015

©DWSS Confidential. All rights reserved. 4 Name Individuals names are recorded in the DWSS system according to Social Security Records When completing name searches in IEVS always search according to what the client states their name is on their *Social Security Card TN NO: 14-0001 Approval Date: Effective Date: 1/1/14 9/10/2015

©DWSS Confidential. All rights reserved. Household Size AM limit 100% FPL 122% FPL 138% FPL 164% 205% 400% 1 $229 $958 $1,169 $1,322 $1,571 $1,964 $3,832 2 $296 $1,293 $1,577 $1,784 $2,121 $2,651 $5,172 3 $363 $1,628 $1,986 $2,247 $2,670 $3,337 $6,512 4 $430 $1,963 $2,395 $2,709 $3,219 $4,024 $7,852 5 $496 $2,298 $2,804 $3,171 $3,769 $4,711 $9,192 6 $563 $2,633 $3,212 $3,634 $4,318 $5,398 $10,532 7 $630 $2,968 $3,621 $4,096 $4,868 $6,084 $11,872 8 $697 $3,303 $4,030 $4,558 $5,417 $6,771 $13,212 Each Add $67 $335 $412 $462 $549 $687 $1,340 Aid Code Description Income Limit AM Parents & Adult Caretakers 0 - AM Limit AM1 Expanded Parent & Adult Caretakers AM Limit - 138% CH Children & Pregnant Women Child 6-18 Less than 122% Child 0-5 Less than 164% Pregnant Women Less than 164% CH1 Expanded Children's Group for Children Under 19 123% - 138% CA Non Parents (19-64) Less than 138% Income Levels TN NO: 14-0001 Approval Date: Effective Date: 1/1/14 9/10/2015

©DWSS Confidential. All rights reserved. 6 Income level and Age AO - Foster Care This eligible category does not have a financial limit, however they must meet the definition of an individual who has “Aged out of Foster Care” Medical Manual B-220 A. under 26 years of age; and B. were in foster care in Nevada, under the responsibility of the state at the time they turned 18 years of age; and C. were enrolled in Medicaid while in foster care; https://dwss.nv.gov/pdf/Manuals/Medical/b200.pdf TN NO: 14-0001 Approval Date: Effective Date: 1/1/14 9/10/2015

©DWSS Confidential. All rights reserved. 7 Age AM – Parents & Caretakers 19 and over Evaluate income at the AM level Expanded AM1 – Parents & Caretakers 19-64 Evaluate income at the 138% FPL TN NO: 14-0001 Approval Date: Effective Date: 1/1/14 9/10/2015

©DWSS Confidential. All rights reserved. 8 Age CH – Children 0 – 5 & Pregnant Women Evaluate income at or under 165% FPL CH – Children 6 – 18 Evaluate income at or under 122% FPL CH1 – Children 6 – 18 Evaluate income between123 -138% FPL TN NO: 14-0001 Approval Date: Effective Date: 1/1/14 9/10/2015

©DWSS Confidential. All rights reserved. 9 Age Accept the client’s statement for age. TN NO: 14-0001 Approval Date: Effective Date: 1/1/14 9/10/2015

©DWSS Confidential. All rights reserved. 10 Citizenship Upon completion of the application the Head of Household attests to the citizenship of all members Individuals requesting medical assistance must be •US Citizens, or •Have legal immigration status TN NO: 14-0001 Approval Date: Effective Date: 1/1/14 9/10/2015

©DWSS Confidential. All rights reserved. 11 Citizenship Client statement is accepted for both proof of US Citizenship and Lawful Presence. TN NO: 14-0001 Approval Date: Effective Date: 1/1/14 9/10/2015

©DWSS Confidential. All rights reserved. 12 Non-Citizens Qualified Non-Citizen An individual who was born outside of the United States and is currently residing lawfully in the US and have maintained that status for 5 years or more.* Not Qualified Non-Citizen An individual who was born outside of the United States and is currently residing lawfully in the US and have maintained that status for less than 5 years.* Undocumented Non-Citizen An individual who was born outside of the United States and is currently not residing under any lawful status. *or has a another specialized qualifying status. TN NO: 14-0001 Approval Date: Effective Date: 1/1/14 9/10/2015

©DWSS Confidential. All rights reserved. 13 Qualified Non-Citizens Qualified Non-Citizens Individuals who are residing lawfully in the US and have maintained lawful status for 5 years or more Battered non-citizen who are residing lawfully in the US and has maintained lawful status for 5 years or more Refugee, Asylee, Withholding Deportation, Cuban/Haitian Entrant, Amerasian immigrant Veteran, active duty or un- remarried surviving spouse or child of a veteran Obtains citizenship TN NO: 14-0001 Approval Date: Effective Date: 1/1/14 9/10/2015

©DWSS Confidential. All rights reserved. 14 Other Qualified Non-Citizens Qualified Non-Citizens A victim of trafficking and their spouses and children The individual was receiving Title XVI SSI benefits on or before 8/22/96 Native American born in Canada possessing at least 50% blood of an American Indian race or a member of an Indian Tribe listed in E&P Manual C-700 TN NO: 14-0001 Approval Date: Effective Date: 1/1/14 9/10/2015

©DWSS Confidential. All rights reserved. 15 Non-Citizens Include all non-citizens in the count when determining the assistance unit size TN NO: 14-0001 Approval Date: Effective Date: 1/1/14 9/10/2015

©DWSS Confidential. All rights reserved. 16 Residency Clients must be living in Nevada with the intention of making Nevada their home permanently OR must be living in Nevada with a job commitment or seeking employment. Clients are not required to have a fixed place of residence to meet this requirement. Client statement is accepted for Nevada Residency TN NO: 14-0001 Approval Date: Effective Date: 1/1/14 9/10/2015

©DWSS Confidential. All rights reserved. 17 Residency Non-citizens who are currently admitted to the United States lawfully but only for a temporary or specified time do not meet residency requirements and will not be eligible for any assistance including Emergency Medical. •Foreign Government Representative •Visitors for business or pleasure including exchange visitors •Aliens in travel status while traveling through the US •Crewmembers on shore leave •Foreign students; etc. TN NO: 14-0001 Approval Date: Effective Date: 1/1/14 9/10/2015

©DWSS Confidential. All rights reserved. 18 Social Security Number Each individual (including children) seeking Medicaid, will be asked for their Social Security Number and/or tax ID number. *Providing a Social Security Number or Tax ID number is not required for a PE determination. TN NO: 14-0001 Approval Date: Effective Date: 1/1/14 9/10/2015

©DWSS Confidential. All rights reserved. 19 Household Determination Individuals living in the same home must declare their relationship to one another. Adults who are living with minor children of a specified degree and are the child’s parent/primary caretaker will be certified under the Family Medical programs. TN NO: 14-0001 Approval Date: Effective Date: 1/1/14 9/10/2015

©DWSS Confidential. All rights reserved. 20 Household Determination When establishing a household include all individuals who live at the same residence who are associated to one another by blood or by marriage. TN NO: 14-0001 Approval Date: Effective Date: 1/1/14 9/10/2015

©DWSS Confidential. All rights reserved. 21 Household Determination Accept client attestation (statement) of household composition. Adults living with minor children who are not the primary caretaker or parent will be evaluated for CH (if pregnant) or CA TN NO: 14-0001 Approval Date: Effective Date: 1/1/14 9/10/2015

©DWSS Confidential. All rights reserved. 22 Caretaker Relatives Natural/adoptive/step parents and children are always included together in the same household. Exclude any other relatives if living in the home. If the natural/adoptive/step parent is not in the home, then include the relative caregiver in the household with the child/children they are the caring for TN NO: 14-0001 Approval Date: Effective Date: 1/1/14 9/10/2015

©DWSS Confidential. All rights reserved. 23 Pregnancy Women Accept client attestation (statement) for pregnancy as well as number of unborn(s) Due date must be entered with the PE determination, accept client statement for the due date. TN NO: 14-0001 Approval Date: Effective Date: 1/1/14 9/10/2015

©DWSS Confidential. All rights reserved. Questions TN NO: 14-0001 Approval Date: Effective Date: 1/1/14 9/10/2015

Table of Contents State/Territory Name: Nevada State Plan Amendment (SPA) #: 14-0002 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services San Francisco Regional Office 90 Seventh Street, Suite 5-300 (5W) San Francisco, CA 94103-6706

DIVISION OF MEDICAID & CHILDREN’S HEALTH OPERATIONS

August 18, 2014 Romaine Gilliland, Director Department of Health and Human Services 4126 Technology Way, Suite 100 Carson City, NV 89706

Dear Mr. Gilliland:

Enclosed is an approved copy of Nevada State Plan Amendment (SPA) 14-0002. This SPA was submitted to my office on June 6, 2014 requesting to amend Attachments 3.1-F and 3.1-L to eliminate the option for individuals within Nevada’s Newly Eligible population who have been determined to be seriously mentally ill to disenroll from Medicaid managed care plans.

The approval is effective June 1, 2014. Attached are copies of the following pages to be incorporated into your State Plan:

• Attachment 3.1-F, Pages 4, 9, 13, and 25 • Attachment 3.1-L: o ABP 1, Page 1 o ABP 2a, Page 1 o ABP 3, Pages 1-2 o ABP 4, Page 1 o ABP 5, Pages 1-36 o ABP 7, Pages 1-2 o ABP 8, Pages 1-2 o ABP 9, Pages 1-2 o ABP 10, Page 1 o ABP 11, Page 1

Mr. Gilliland – Page 2

If you have any questions, please contact Brian Zolynas by phone at (415) 744-3601 or by email at Brian.Zolynas@cms.hhs.gov .

Sincerely,

/s/

Hye Sun Lee, MPH

Associate Regional Administrator

Division of Medicaid & Children’s Health Operations

Enclosure

cc: Laurie Squartsoff, Administrator, DHCFP

State/Territory name: Nevada Submitted By: Robyn Heddy Last Revision Date: Aug 7, 2014 Submit Date: Jun 6, 2014 Medicaid Alternative Benefit Plan: Summary Page (CMS 179) Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. NV-14-0002 Proposed Effective Date 06/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation Sections 1905(t); 1932(a)(1)(A); 1932(a)(2)(C); 1932(a)(5)(D); and 42 CFR 438.50; 42 CFR 438.50. (d)(2) Federal Budget Impact Federal Fiscal Year Amount First Year 2014 $ Second Year 2015 $ Subject of Amendment Make managed care enrollment mandatory, in Washoe and Clark counties, for the newly eligible childless adults and expanded parent and caretaker populations, who have been determined to be Seriously Mentally Ill (SMI). Governor's Office Review Governor's office reported no comment Comments of Governor's office received Describe: No reply received within 45 days of submittal Other, as specified Describe: The Governor's Office does not wish to review the State Plan Amendment. Signature of State Agency Official

CMS-PM-XX-X Date:

State: _ Nevada

ATTACHMENT 3.1-F Page 4 OMB No.:0938-0933

Citation

Condition or Requirement

42. CFR 438,.50(b)(4)

1932(a)(1)(A)

4.

iii. Incentives will be based upon a fixed period of time.

iv. Incentives will not be renewed automatically. vy. Incentives will be made available to both public and private PCCMs.

vi. Incentives will not be conditioned’ on intergovernmental transfer agreements.

_X_ vii. Not applicable to this 1932 state plan amendment.

Describe the public process utilized for both the design of the program and its initial implementation. In addition, describe what methods the state will use to ensure ongoing public involvement once the state plan program has been implemented. (Example: public meeting, advisory groups.)

Pursuant to 42 CFR 438.50(b)(4), the State shall provide public notice to promote public involvement in the design and initial implementation of the program as well as during contract procurement. The public notice shall be a notice of publication published in a newspaper in Southern Nevada and in a newspaper in Northern Nevada. The Medical Care Advisory Committee (MCAC) advises the DHCFP regarding provisions of services for the health and medical care of Medicaid beneficiaries. Under the PCCM, an outreach plan is required and designed to educate stakeholders on its activities within the State.

The state plan MCO program will__/will not _X_ implement mandatory enrollment into managed care on a statewide basis. If not statewide, mandatory _ X _/ voluntary enrollment will be implemented in the following county/area(s):

i. county/counties (mandatory) Urban Clark and Washoe counties

For Native Americans, children defined as the Severely Emotionally Disturbed (SED), adults defined as Seriously Mentally Ill (SMI) and children who qualify as Children with Special Health Care Needs (CSHCN) in Urban Clark and Washoe counties, enrollment is voluntary and beneficiaries may “opt out” of the MCOs.

Nevada Medicaid Newly Eligibles, defined as childless adults ages 19-64, and the expanded parent and caretakers ages 19-64, who are made eligible as part of the Patient Protection and Affordable Care Act (PPACA) expansion population and who are receiving the Alternative Benefit Plan, cannot opt out of managed care, where available, based on a determination of Serious Mental Illness (SMI).

TN No. 14-002 Supersedes TN No. 13-031

Approval Date: ALG 4 8 2044 Effective Date: June 1, 2014

CMS-PM-XX-X Date:

State: _ Nevada

ATTACHMENT 3.1-F Page 9 OMB No.:0938-0933

Citation

Condition or Requirement

1932(a)(2)(A)() 42 CFR 438.50(d)(3)(i)

1932(a)(2)(A)(iii) 42 CFR 438.50(d)(3)(ii)

1932(a)(2)(A)(v) 42 CFR 438.50(3)(iii)

1932(a)(2)(A)(iv) 42 CFR 438.50(3)(iv)

1932(a)(2)(A)(ii) 42 CFR 438.50(3)(v)

E.

1932(a)(2) 42 CFR 438.50(d)

iii.

iv.

Vv.

vi.

vii.

Children defined as Severely Emotionally Disturbed (SED) or as Children with Special Health Care Needs (CSHCN) and adults defined as Seriously Mentally Il] (SMI) have voluntary enrollment in managed care.

Nevada Medicaid Newly Eligibles, defined as childless adults ages 19-64, and the expanded parent and caretakers ages 19- 64, who are made eligible as part of the PPACA expansion population and who are receiving the Alternative Benefit Plan, cannot opt out of managed care, where available, based on a determination of Serious Mental Illness (SMI).

Children under the age of 19 years, who are eligible for Supplemental Security Income (SSI) under title XVI.

____ Children under the age of 19 years who are eligible

under 1902(e)(3) of the Act.

Children under the age of 19 years who are in foster care or other out-of-the-home placement.

Children under the age of 19 years who are receiving foster care or adoption assistance under title IV-E.

Adopted children with special needs under the age of 19 years receiving non-IV-E state adoption assistance who do not meet the eligibility criteria for federal participation in the [V-E adoption support program can voluntarily enroll in the PCCM (1902 (a)(10)(A)Cii) (VIED.

_X_ Children under the age of 19 years who are receiving

services through a family-centered, community based, coordinated care system that receives grant funds under section 501(a)(1)(D) of title V, and is defined by the state in terms of either program participation or special health care needs.

This rule applies to the MCO programs, not the PCCM program(s). This group may opt out of the MCOs.

Identification of Mandatory Exempt Groups

1.

Describe how the state defines children who receive services that are funded under section 501(a)(1)(D) of title V. (Examples: children receiving services at a specific clinic or enrolled in a particular

program.)

TN No. 14-002 Supersedes TN No. 13-031

Approval Date: AMG 1 8 2014

Effective Date: June 1, 2014

CMS-PM-XX-X Date:

State: _ Nevada

ATTACHMENT 3.1-F Page 13 OMB No.:0938-0933

Citation

Condition or Requirement

H.

1932(a)(4) 42 CFR 438.50

1932(a)(4) 42 CFR 438.50

choose:

1.

Family Medical Category (FMC) [TANF and CHAP] adults diagnosed as Seriously Mentally Ill (SMI) - Nevada Medicaid Newly Eligibles, defined as childless adults ages 19-64, and the expanded parent and caretakers ages 19-64, who are made eligible as part of the PPACA expansion population and who are receiving the Alternative Benefit Plan, cannot opt out of managed care, where available, based on a determination of Serious Mental Illness (SMI);

Family Medical Category (FMC) [TANF and CHAP] Children diagnosed as Seriously Emotionally Disturbed (SED); and

Family Medical Category (FMC) [TANF and CHAP] Children diagnosed as Child(ren) with Special Health Care Needs (CSHCN).

Enrollment process.

1,

Definitions

An existing provider-recipient relationship is one in which the provider was the main source of Medicaid services for the recipient during the previous year. This may be established through state records of previous managed care enrollment or fee-for-service experience or through contact with the recipient.

i. A provider is considered to have "traditionally served" Medicaid recipients if it has experience in serving the Medicaid population.

State process for enrollment by default. Describe how the state’s default enrollment process will preserve: i. _ the existing provider-recipient relationship (as defined in H.1.i).

New members will be allowed the opportunity to select an MCO with their Primary Care Provider (PCP) in network. Returning Medicaid beneficiaries will be assigned to their former MCO and PCP. The MCO will then ensure that the prior provider-beneficiary relationship is preserved if the provider is still in that MCO’s network.

The State will provide new Medicaid beneficiaries with the websites and phone numbers of the State’s contracted Medicaid MCOs. New Medicaid beneficiaries will be asked to complete

TN No. 14-002 Supersedes TN No. 13-031

Approval Date: AUG T 82014 Effective Date: June 1, 2014

CMS-PM-XX-X Date:

State: _ Nevada

ATTACHMENT 3.1-F Page 25 OMB No.:0938-0933

Citation

Condition or Requirement

12.

13.

Pre-Admission Screening and Resident Review (PASRR) and Level of Care (LOC) Assessments

A PASRR and LOC are reimbursed by FFS. Conducting a PASRR and LOC will not prompt MCO disenrollment. However, if the beneficiary is admitted into a nursing facility as the result of a PASRR and LOC, the MCO is responsible for the first 45 days of admission for the beneficiary (see 3., above).

Seriously Emotionally Disturbed/Severely Mentally Ill SED/SMI, with limitations

The MCO must ensure enrollees who are referred for evaluation for SED/SMI or who have been determined SED/SMI by the health plan are obtaining the medically necessary evaluations and that enrollees are transitioned, as necessary, to another provider in order to obtain their mental health services if such services are not available within the network. The MCO is required to notify the DHCFP if a Title XIX Medicaid beneficiary elects to disenroll with the MCO following the determination of SED/SMI and forward the enrollee’s medical records to the provider from whom the enrollee will receive the covered mental health services. However, in the event the Medicaid enrollee, who has received such a determination, chooses to remain enrolled with the MCO, the MCO will be responsible for providing all patient care.

Nevada Medicaid Newly Eligibles, defined as childless adults ages 19-64, and the expanded parent and caretakers ages 19-64, who are made eligible as part of the PPACA expansion population and who are receiving the Alternative Benefit Plan, cannot opt out of managed care, where available, based on a determination of Serious Mental Illness (SMI).

1932 (a)(1)(A)(ii) M. — Selective contracting under a 1932 state plan option

To respond to items #1 and #2, place a check mark. The third item requires a brief narrative.

The state will /will not _X_ intentionally limit the number of entities it contracts under a 1932 state plan option.

1,

3.

___ The state assures that if it limits the number of contracting entities, this limitation will not substantially impair beneficiary access to services.

Describe the criteria the state uses to limit the number of entities it contracts under a 1932 state plan option. (Example: a limited number of providers

and/or enrollees.)

___ The selective contracting provision in not applicable to this state plan.

TN No. 14-002 Supersedes TN No. 13-031

Approval Date: ANG j 82 014 Effective Date: June 1, 2014

Nevada TN No: 14-0002 Supersedes TN No: 13-0029 ABP 1 1 Approval Date: August 18, 2014 Effective Date: June 1, 2014

Nevada TN No: 14-0002 Supersedes TN No: 13-0029 ABP 2a 1 Approval Date: August 18, 2014 Effective Date: June 1, 2014

Nevada TN No: 14-0002 Supersedes TN No: 13-0029 ABP 3 1 Approval Date: August 18, 2014 Effective Date: June 1, 2014

Nevada TN No: 14-0002 Supersedes TN No: 13-0029 ABP 3 2 Approval Date: August 18, 2014 Effective Date: June 1, 2014

Nevada TN No: 14-0002 Supersedes TN No: 13-0029 ABP 4 1 Approval Date: August 18, 2014 Effective Date: June 1, 2014

Nevada TN No: 14-0002 Supersedes TN No: 13-0029 ABP 5 1 Approval Date: August 18, 2014 Effective Date: June 1, 2014

Nevada TN No: 14-0002 Supersedes TN No: 13-0029 ABP 5 2 Approval Date: August 18, 2014 Effective Date: June 1, 2014

Nevada TN No: 14-0002 Supersedes TN No: 13-0029 ABP 5 3 Approval Date: August 18, 2014 Effective Date: June 1, 2014

Nevada TN No: 14-0002 Supersedes TN No: 13-0029 ABP 5 4 Approval Date: August 18, 2014 Effective Date: June 1, 2014

Nevada TN No: 14-0002 Supersedes TN No: 13-0029 ABP 5 5 Approval Date: August 18, 2014 Effective Date: June 1, 2014

Nevada TN No: 14-0002 Supersedes TN No: 13-0029 ABP 5 6 Approval Date: August 18, 2014 Effective Date: June 1, 2014

Nevada TN No: 14-0002 Supersedes TN No: 13-0029 ABP 5 7 Approval Date: August 18, 2014 Effective Date: June 1, 2014

Nevada TN No: 14-0002 Supersedes TN No: 13-0029 ABP 5 8 Approval Date: August 18, 2014 Effective Date: June 1, 2014

Nevada TN No: 14-0002 Supersedes TN No: 13-0029 ABP 5 9 Approval Date: August 18, 2014 Effective Date: June 1, 2014

Nevada TN No: 14-0002 Supersedes TN No: 13-0029 ABP 5 10 Approval Date: August 18, 2014 Effective Date: June 1, 2014

Nevada TN No: 14-0002 Supersedes TN No: 13-0029 ABP 5 11 Approval Date: August 18, 2014 Effective Date: June 1, 2014

Nevada TN No: 14-0002 Supersedes TN No: 13-0029 ABP 5 12 Approval Date: August 18, 2014 Effective Date: June 1, 2014

Nevada TN No: 14-0002 Supersedes TN No: 13-0029 ABP 5 13 Approval Date: August 18, 2014 Effective Date: June 1, 2014

Nevada TN No: 14-0002 Supersedes TN No: 13-0029 ABP 5 14 Approval Date: August 18, 2014 Effective Date: June 1, 2014

Nevada TN No: 14-0002 Supersedes TN No: 13-0029 ABP 5 15 Approval Date: August 18, 2014 Effective Date: June 1, 2014

Nevada TN No: 14-0002 Supersedes TN No: 13-0029 ABP 5 16 Approval Date: August 18, 2014 Effective Date: June 1, 2014

Nevada TN No: 14-0002 Supersedes TN No: 13-0029 ABP 5 17 Approval Date: August 18, 2014 Effective Date: June 1, 2014

Nevada TN No: 14-0002 Supersedes TN No: 13-0029 ABP 5 18 Approval Date: August 18, 2014 Effective Date: June 1, 2014

Nevada TN No: 14-0002 Supersedes TN No: 13-0029 ABP 5 19 Approval Date: August 18, 2014 Effective Date: June 1, 2014

Nevada TN No: 14-0002 Supersedes TN No: 13-0029 ABP 5 20 Approval Date: August 18, 2014 Effective Date: June 1, 2014

Nevada TN No: 14-0002 Supersedes TN No: 13-0029 ABP 5 21 Approval Date: August 18, 2014 Effective Date: June 1, 2014

Nevada TN No: 14-0002 Supersedes TN No: 13-0029 ABP 5 22 Approval Date: August 18, 2014 Effective Date: June 1, 2014

Nevada TN No: 14-0002 Supersedes TN No: 13-0029 ABP 5 23 Approval Date: August 18, 2014 Effective Date: June 1, 2014

Nevada TN No: 14-0002 Supersedes TN No: 13-0029 ABP 5 24 Approval Date: August 18, 2014 Effective Date: June 1, 2014

Nevada TN No: 14-0002 Supersedes TN No: 13-0029 ABP 5 25 Approval Date: August 18, 2014 Effective Date: June 1, 2014

Nevada TN No: 14-0002 Supersedes TN No: 13-0029 ABP 5 26 Approval Date: August 18, 2014 Effective Date: June 1, 2014

Nevada TN No: 14-0002 Supersedes TN No: 13-0029 ABP 5 27 Approval Date: August 18, 2014 Effective Date: June 1, 2014

Nevada TN No: 14-0002 Supersedes TN No: 13-0029 ABP 5 28 Approval Date: August 18, 2014 Effective Date: June 1, 2014

Nevada TN No: 14-0002 Supersedes TN No: 13-0029 ABP 5 29 Approval Date: August 18, 2014 Effective Date: June 1, 2014

Nevada TN No: 14-0002 Supersedes TN No: 13-0029 ABP 5 30 Approval Date: August 18, 2014 Effective Date: June 1, 2014