Table of Contents

State/Territory Name: Oklahoma State Plan Amendment (SPA) #: 13-09 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form 3) Superseding Pages Notice (delete if not applicable) 4) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES

Centers for Medicare & Medicaid Services Dallas Regional Office RA 1301 Young Street, Suite 833 CENTERS FOR MEDICARE & MEDICAID SERVICES

Dallas, Texas 75202 poet ecisaganipeataet at & CHILDREN’S HEALTH OPERATIONS

DIVISION OF MEDICAID & CHILDREN’S HEALTH - REGION VI

March 25, 2014

Dr. Garth Splinter

State Medicaid Director

2401 NW 23rd Street, Suite 1A Oklahoma City, Oklahoma 73107

Our Reference: SPA OK 13-09 Dear Dr. Splinter: We have reviewed the State’s proposed amendment to the Oklahoma State Plan submitted under Transmittal Number 13-09, dated September 19, 2013. This state plan amendment intends to establish a fee schedule for rehabilitative services that are part of the Programs of Assertive Community Treatment (PACT). Based on the information submitted, we have approved the amendment for incorporation into the official Oklahoma State Plan with an effective date change of July 1, 2013. A copy of the CMS- 179 and approved plan page are enclosed with this letter. If you have questions, please contact Tamara Sampson at (214) 767-6431.

Sincerely,

Bill Brooks Associate Regional Administrator

Ce: Tywanda Cox

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

FORM APPROVED OMB No. 0938-0193

TRANSMITTAL AND NOTICE OF APPROVAL OF

STATE PLAN MATERIAL FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES

1. TRANSMITTAL NUMBER

1 3-— 0 9 3. PROGRAM IDENTIFICATION: TTL SECURITY ACT (MEDICAID)

2. STATE

Oklahoma XIX OF THE SOCIAL

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

4. PROPOSED EFFECTIVE DATE

July 1, 2013

5. TYPE OF PLAN MATERIAL (Check One)

[1] NEW STATE PLAN (0 AMENDMENT TO BE CONSIDER’

ED AS A NEW PLAN [] AMENDMENT

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

6. FEDERAL STATUTE/REGULATION CITATION

42 CFR 440.130(d) and Section 1905(a)(13) of the Act 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT

See Attachment

‘7. FEDERAL BUDGET IMPACT

a. FFY 2013 288,496 b. FFY 2014 865,489

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 PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (/f Applicable)

See Attachment

10. SUBJECT OF AMENDMENT

Programs of Assertive Community Treatment (PACT) Reimbursement Methodology

11. GOVERNOR'S REVIEW (Check One) Oo GOVERNOR'S OFFICE REPORTED NO COMMENT [1] COMMENTS OF GOVERNOR'S OFFICE ENCLOSED [7] NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL

kl OTHER, AS SPECIFIED

The Governor does not review State Plan material.

12. SIGNATURE OF STATE AGENCY OFFICIAL

13. TYPED NAME Joel Nico Gomez 74. TITLE

Chief Executive Officer 15. DATE SUBMITTED

September 19, 2013

16. RETURN TO

Oklahoma Health Care Authority Attn: Garth Splinger

2401 N.W. 23rd. Suite 1A Oklahoma City, OK 73107

FOR REGIONAL OFFICE USE ONLY 17. DATE RECEIVED 18. DATE APPROVED 19-Sep-13 25-Mar-14 PLAN APPROVED - ONE COPY 79. EFFECTIVE DATE OF APPROVED MATERIAL 20. SIGNF 01-Jul-13 7. NAM 22. TITLE Associated Regional Administrator Bill Brooks Division of Medicaid and Children's Health c: Nico Gomez Cindy Roberts Tywanda Cox Garth Splinter FORM CMS-179 (07/92)

ATTACHMENT TO OK SPA # 13-09

8. Page Number of the Plan

9. Page Number of the Superseded

Section or Attachment

Plan Section or Attachment

Attachment 4.19-B, Page 29

Same Page, Revised 07-01-06, TN # 06-09

Attachment 4.19-B, Page 29a

Same Page, Revised 07-01-10, TN # 10-32

State: Oklahoma Date Received: September 19, 2013 Date Approved: March 25, 2014 Date Effective: July 1, 2013 Transmittal Number: OK 13-09 State: Oklahoma

Approved: 3/25/14 Effective: 7/1/13 Supersedes: None

State OKLAHOMA

Attachment 4.19-B

Page 29

METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES OTHER TYPES OF CARE

Rehabilitative Services

Outpatient Behavioral Health and Substance Use Disorder Treatment Services

Payment rates are established using state developed relative value weights for outpatient mental health and substance use disorder treatment services and a monetary conversion factor (CF), to determine the overall level of payment. Separate CFs are established for public and private programs. Children's services are paid using the same CF regardless of whether the provider is public or private. The formula for calculating the rate for each service is as follows: RVU x CF = Rate

Except as otherwise noted in the plan, state-developed fee schedule rates are the same for both governmental and private providers of outpatient behavioral health and substance use disorder treatment services. The Agency's fee schedule rate was set as of July 1, 2006 and is effective for services provided on or after that date. All rates are published on the Agency's website www.okhca.org.

Community Recovery Support

The Oklahoma Department of Mental Health and Substance Abuse Services (ODMHSAS) certifies and contracts with their Community Mental Health Centers to provide the service. The service is a 15 minute unit and the rate is $9.75 per unit.

Except as otherwise noted in the plan, state-developed fee schedule rates are the same for both governmental and private providers of community recovery support services. The Agency's fee schedule rate was set as of July 1, 2006 and is effective for services provided on or after that date. All rates are published on the Agency's website www.okhca.org.

Revised 07-01-2013

TN#__________

Approval Date __________

Effective Date __________ Supersedes TN#__________ State: Oklahoma Date Received: September 19, 2013 Date Approved: March 25, 2014 Date Effective: July 1, 2013 Transmittal Number: OK 13-09 13-09 3/25/14 7/1/13 06-09

State OKLAHOMA

Attachment 4.19-B

Page 29a

METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES OTHER TYPES OF CARE

Rehabilitative Services (Continued)

Programs of Assertive Community Treatment (PACT) Effective for services provided on or after July 1, 2008, reimbursement for rehabilitative services provided under the PACT multi-disciplinary clinical team delivery model will be made under a fee schedule applicable to each qualified practitioner. PACT teams must be certified by the Oklahoma Department of Mental Health and Substance Abuse Services. All rates are published on the Agency's website located at www.okhca.org. Uniform rate is paid to governmental and non-governmental providers.

Qualified Staff The PACT team shall have among its staff, persons with sufficient individual competence and professional qualifications and experience to provide the services described in Attachment 3.1-A, page 6a-1.3.

Services and Limitations Services include service coordination; crisis assessment and intervention; recovery and symptom management; individual counseling and psychotherapy; medication prescription, administration, monitoring and documentation; substance use disorder treatment; work-related services; activities of daily living services; social, interpersonal relationship and leisure-time activity services; support services or direct assistance to ensure that consumers obtain the basic necessities of daily life; and education support, and consultation to consumers' families and other major supports.

Reimbursement Assessments will be reimbursed per event. The fee schedule rates for qualified team members other than physicians and case managers will be reimbursed per 15 minute unit. The unit costs were derived from the 2006 average wage estimates for each team member as reported in the Bureau of Labor Statistics website for occupations for Oklahoma. The rate also includes employee benefits and indirect costs. Total costs were divided by the annual available productive time. In order to account for the fact that Medicaid enrollment for adults enrolled in PACT may not be continuous; the average caseload of 100 for a team of 10 assumed in the methodology was adjusted by a standardized enrollment continuity ratio for Oklahoma (75.6%) to account for lapses in coverage. The source document for the continuity ratio is from Table 1, “Improving Medicaid’s Continuity and Quality of Care”, by L. Ku.

Except as otherwise noted in the plan, state-developed fee schedule rates are the same for both governmental and private providers of PACT services. The agency's fee schedule rate was set as of July 1, 2013 and is effective for services provided on or after that date. All rates are published on the Agency's website www.okhca.org.

Revised 07-01-2013

TN#__________

Approval Date __________

Effective Date __________ Supersedes TN#__________ State: Oklahoma Date Received: September 19, 2013 Date Approved: March 25, 2014 Date Effective: July 1, 2013 Transmittal Number: OK 13-09 13-09 3/25/14 7/1/13 10-32

Table of Contents

State/Territory Name: Oklahoma State Plan Amendment (SPA) #: 13-10 Pharm This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form 3) Superseding Page Listing 4) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-14-26 Baltimore, Maryland 21244-1850 Disabled & Elderly Health Programs Group SEP 1 8 2013 Nico Gomez ChiefExecutive Officer Oklahoma Health Care Authority 2401 NW 23rct St., Suite 1A Oklahoma City, OK 73107 ATTN: Cindy Roberts Dear Mr. Gomez: CENHRS FOR MlDfC,\Rl & MWICAI[) SERVICES CENTER FOR MEDICAID & CHIP SERVICES We have reviewed Oklahoma State Plan Amendment (SPA) 13-10, Prescribed Drugs, received in the Dallas Regional Office on June 30, 2013. This amendment proposes to exclude from coverage benzodiazepines for all conditions and barbiturates for the treatment of epilepsy, cancer and chronic mental health disorders for full ben~fit dual eligible as Medicare Part D will provide this coverage. Based on the information provided, we are pleased to inform you that SPA 13-10 is approved with an effective date of April 1, 2013. A copy of the signed CMS-179 form, as well as the pages approved for incorporadon into the Oklahoma state plan will be forwarded by the Dallas Regional Office. If you have any questions regarding this SPA, please contact Wendy Tuttle at (410) 786-8690. cc: Bill Brooks, ARA, Dallas Regional Office Lynn Ward, Dallas Regional Office Sincerely,

Larry Reed Director Division of Pharmacy

OK Redacted SPAs Page 2

ATTACHMENT TO OK SPA # 13-09 Second Submission

8. Page Number of the Plan

9. Page Number of the Superseded

Section or Attachment

Plan Section or Attachment

Attachment 3.1.A.1, Page 1

Same Page, Revised 01-01-06, TN # 06-03

Attachment 3.1.A.1, Page 2

Same Page, Revised 01-01-06, TN # 06-03

Attachment 3.1.A.1 Page 1

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State Agency OKLAHOMA

MEDICAID PROGRAM: REQUIREMENTS RELATING TO PAYMENT FOR COVERED OUTPATIENT DRUGS FOR THE CATEGORICALLY NEEDY

Citation (s)

Provision (s)

1935(d)(1) 1. Effective January 1, 2006, the Medicaid agency will not cover any Part D drug for full-benefit dual eligible benefits under Part A or Part B.

1927(d)(2) and 1935(d)(2) 2. The Medicaid agency provides coverage for the following excluded or otherwise restricted drugs or classes of drugs, or their medical uses to all Medicaid-only recipients, and where noted, to full benefit dual eligible beneficiaries who have coverage under the Medicare Prescription Drug Benefit –Part D.

The following excluded drugs are covered:

 (a) agents when used for anorexia, weight loss, weight gain

 (b) agents when used to promote fertility

 (c) agents when used for cosmetic purposes or hair growth

 (d) agents when used for the symptomatic relief cough and colds

X (e) prescription vitamins and mineral products, except prenatal vitamins and fluoride

X (f) nonprescription drugs

(see specific information below)

Revised 04-01-13

TN No. _____________ Supersedes

Approval Date _________ Effective Date _____________ TN No. ________ State: Oklahoma Date Received: 6/30/13 Date Approved: 9/18/13 Transmittal Number: OK 13-10 13-10 06-03 9/18/13 4/1/13

Attachment 3.1.A.1 Page 2

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State Agency OKLAHOMA

MEDICAID PROGRAM: REQUIREMENTS RELATING TO PAYMENT FOR COVERED OUTPATIENT DRUGS FOR THE CATEGORICALLY NEEDY

Citation (s)

Provision (s)

1927(d)(2) and 1935(d)(2)  (g) covered outpatient drugs which the manufacturer seeks to require as a condition of sale that associated tests or monitoring services be purchased exclusively from the manufacturer or its designee

X (h) barbiturates (see specific coverage below)

X (i) benzodiazepines (all are covered for Medicaid-only beneficiaries. None are covered for full benefit dual eligible individuals.)

X (j) agents when used to promote smoking cessation (for non-Part D eligible individuals)

(f) Nonprescription drugs: The state maintains a complete listing of covered nonprescription (over-the-counter) drug categories on its public website found at http://www.okhca.org/rx

(h) Barbiturates: All items are covered for Medicaid-only beneficiaries. Barbiturates are covered for full benefit dual eligible members only when used to treat conditions other than seizures, cancer, or a chronic mental health condition.

(j) Agents when used to promote smoking cessation: All items, including nonprescription drugs, which are covered for Medicaid-only and full benefit dual eligible beneficiaries.

Revised 04-01-13

TN No. _____________ Supersedes

Approval Date _________ Effective Date _____________ TN No. _____________ State: Oklahoma Date Received: 6/30/13 Date Approved: 9/18/13 Transmittal Number: OK 13-10 13-10 06-03 9/18/13 4/1/13

Table of Contents State/Territory Name: Oklahoma State Plan Amendment (SPA) #: 13-15 CMCS/OSG: 12/2/13 This file contains the following documents in the order listed: 1) Approval Letter 2) Summary Form (with 179-like data) 3) Superseding Pages Notice (delete if not applicable) 4) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Dallas Regional Office 1301 Young Street, Suite 833 Dallas, Texas 75202 CENTfRS fOR MlOICAR( & MWICAID SERV!CfS CONSORTIUM FOR MEDICAID & CHILDREN'S HEALTH OPERATIONS DIVISION OF MEDICAID & CHILDREN'S HEALTH- REGION VI December 6, 2013 Dr. Garth Splinter State Medicaid Director 2401 NW 23rd Street, Suite 1A Oklahoma City, Oklahoma 73107 Our Reference: SPA OK 13-15 Dear Dr. Splinter: We have reviewed the State's proposed amendment to the Oklahoma State Plan submitted under Transmittal Number 13-15, dated September 27, 2013. This state plan amendment makes technical changes to reflect the current income limits for parents and caretaker relatives. Based on the information submitted, we have approved the amendment for incorporation into the official Oklahoma State Plan with an effective date change of July 1, 2013. A copy of the CMS- 179 and approved plan page are enclosed with this letter. If you have questions, please contact Tamara Sampson at (214) 767-6431. Sincerely, Bill Brooks Associate Regional Administrator Cc: Tywanda Cox /s/

DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES TO: REGIONAL ADMINISTRATOR CENTERS FOR MEDICARE & MEDICAID SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL (Check One) 1. TRANSMITTAL NUMBER 1 5 FORM APPROVED OMB No 0938-0193 2. STATE Oklahoma 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) 4. PROPOSED EFFECTIVE DATE July 1, 2013 D NEW STATE PLAN D AMENDMENT TO BE CONSIDERED AS A NEW PLAN ~AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate transmittalfor each amendment) 6. FEDERAL STATUTE/REGULATION CITATION 7. FEDERAL BUDGET IMPACT 42 CFR 435.223 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT See Attachment 10. SUBJECT OF AMENDMENT a. FFY b. FFY 2013 2014 Q 0 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable) See Attachment Make technical correction to Parent Caretaker eligibility standards 11. GOVERNOR'S REVIEW (Check One) 14. D GOVERNOR'S OFFICE REPORTED NO COMMENT D COMMENTS OF GOVERNOR'S OFFICE ENCLOSED D NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL Nico Gomez [ZJ OTHER, AS SPECIFIED The Governor does not review State Plan material. 16. RETURN TO Oklahoma Health Care Authority Attn: Cindy Roberts 2401 NW 23rd St., Suite 1A Oklahoma City, OK 73107 /s/ /s/

Attachment Oklahoma SPA 13-15 Box8. -&ttrplemeet 1~ to 4 ttaebFHeRt 2.8 A P1:1~e 1 Supplement 12 to Attachment 2.6-A Page 2 Box 9. ~Jevv Page 07 01 0~, T~J # Q~ 18- Wl#itfttwJA..~ per-- New Page 07-01-08, TN# 08-16 ~~ g:#{JJ'L P~ 'Y'+/ 's. (JljU) TN # 13-15 Approval Date: 12/6/13 Effective Date: 7/1/13

SUPPLEMENT 12 TO ATTACHMENT 2.6-A Page 2 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: OKLAHOMA ELIGIBILITY UNDER SECTION 1931 OF THE ACT (Continued) The agency applies higher resource standards than those in effect as of July 16, 1996, increased by no more than the percentage increases in the CPI-U since July 16, 1996, as follows: ___x_ The agency uses less restrictive income and/or resource methodologies than those in effect as of July 16, 1996, as follows: (1) Disregard the family's net countable resources exceeding the AFDC resource standard in effect on July 16, 1996. (2) Wages paid by the Census Bureau for temporary employment related to Census activities are excluded as countable earned income. (3) The income eligibility level is a block income disregard to 73% of the AFDC need standard as of 7/16/1996 (based on the need standard specified on Supplement 1 to Attachment 2.6-A page1). TN No. 13-15 Supersedes TN No. 08-16 State: Oklahoma Date Received: 30 September, 2013 Date Approved: 6 December, 2013 Date Effective: 1 July, 2013 Transmittal Number: 13-15 Revised 07-01-13 Approval Date 12 I 6 I 13 Effective Date 7 I 1 I 13

Table of Contents

State/Territory Name: Oklahoma State Plan Amendment (SPA) #: 13-16 This file contains the following documents in the order listed: 1) Approval Letter 2) Additional Companion letter 3) CMS 179 Form/Summary Form 4) Superseding Pages Notice 5) Approved SPA Pages 6) Additional Attachments that are part of the state plan (delete if not applicable)

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

Dallas Regional Office

1301 Young Street, Room 714

Dallas, Texas 75202

CMS

CENTERS FOR MEDICARE & MEDICAID SERVICES

DIVISION OF MEDICAID & CHILDREN’S HEALTH OPERATIONS

February 21, 2014

Dr. Garth Splinter

State Medicaid Director

2401 NW 23rd Street, Suite 1A Oklahoma City, Oklahoma 73107

Our Reference: SPA-OK-13-0016-MM2 Dear Dr. Splinter:

Enclosed is an approved copy of Oklahoma’s state plan amendment (SPA) OK-13-0016-MM2, which was submitted to the Centers for Medicare & Medicaid Services (CMS) on November 27, 2013. SPA OK-13-0016-MM2 incorporates the MAGI-based eligibility process requirements, including the single streamlined application, into Oklahoma’s Medicaid state plan in accordance with the Affordable Care Act. The effective date of this SPA is October 1, 2013.

The state is using an interim alternative single streamlined online application and by December 31, 2014 will implement a revised alternative single streamlined online application that addresses CMS concerns outlined in the companion letter issued with this SPA approval.

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

e $94, pages S94-1 and S94-2 e Attachment | — Statement of use with respect to the alternative single, streamlined online application

In addition, enclosed is a summary of state plan pages which are superseded by SPA 13-0016- MM2, which should also be incorporated into a separate section in the front of the state plan.

e Superseding Pages of State Plan Material, OK-13-0016-MM2

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 Tamara Sampson at (214) 767- 6431 or via e-mail at Tamara.Sampson@cms.hhs.gov.

Sincerely,

Bill Brooks Associate Regional Administrator Division of Medicaid & Children’s Health Operations

Enclosures

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

Dallas Regional Office

1301 Young Street, Room 714

Dallas, Texas 75202

CMS

(CENTERS FOR MEDICARE & MEDICAID SERVICES

DIVISION OF MEDICAID & CHILDREN’S HEALTH OPERATIONS

February 21, 2014

Dr. Garth Splinter

State Medicaid Director

2401 NW 23rd Street, Suite 1A Oklahoma City, Oklahoma 73107

Our Reference: SPA-OK-13-0016-MM2 Dear Dr. Splinter:

This letter is being sent as a companion to Centers for Medicare & Medicaid Services (CMS) approval of Oklahoma’s state plan amendment (SPA) transmittal OK-13-0016-MM2. CMS is granting approval for Form $94 — Eligibility Process OK-13-0016-MM2, which was submitted to CMS on November 27, 2013. Our review of this submission included a review of the online alternative single streamlined application developed by the state.

Until December 31, 2014, the state is using an interim alternative single streamlined online application. This interim application needs to be revised to reflect the following three changes.

Necessary changes: Date by which changes will be completed:

The state will disable pre-ACA income April 30, 2014 determination rules and remove non-MAGI income types and childcare expenses from the online application.

The state will provide an opportunity for December 31, 2014 household members to indicate whether or not they are applying for coverage. Household members not seeking coverage for themselves will not be asked for citizenship and immigration status information. The request for a non-applicant’s Social Security Number will include notice that its provision is optional.

Necessary changes: Date by which changes will be completed:

The state will remove all Absent Parent December 31, 2014 questions from the application, beyond identifying whether any child has an absent parent, and a question about agreement to cooperate with the state to obtain medical support information post-eligibility.

Please submit the revised alternative single streamline online application to CMS for review no later than December 1, 2014 to ensure approval by December 31, 2014.

We continue to be available to provide technical assistance. If you have any additional questions or require any further assistance, please contact Tamara Sampson at (214) 767-6431 or via e- mail at Tamara.Sampson@cms.hhs.gov.

Sincerely,

Bill Brooks Associate Regional Administrator Division of Medicaid & Children’s Health Operations

MacPro Reporting System: Summary Page (CMS 179) Page | of 2

Control Panel

Medicaid State Plan Eligibility: Summary Page (CMS 179)

General Information

State/Territory name Oklahoma Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the

File Management

Tribal Input 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. Summary (CMS179) OK-13-0016

Proposed Effective Date

10/01/2013

Federal Statute/Regulation Citation

Federal Budget Impact

Federal Fiscal Year Amount First Year 2014 $ 1.00 Second Year 2015 $ 1,00 |

Subject of Amendment

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

MacPro Reporting System: Summary Page (CMS 179) Page 2 of 2

Signature of State Agency Official

Submitted By Tywanda Cox

Last Revision Date: Feb 19, 2014

Submit Date Nov 25, 2013 BACK

CONTINUE

Date Received: 11/27/2013 Date Approved: 02/21/2014 Signature of Regional Official:

PRINTED NAME and Title: Bill Brooks,

Associate Regional Administrator Division of Medicaid and Children's Health

___________________________________________________________________________ TN No: 13-0016 MM2 APPROVAL DATE: 02/21/2014 EFFECTIVE DATE: 10/1/2013 STATE: OKLAHOMA PAGE: Superseding Document Page 1 State: Oklahoma Date Received: 11/27/2013 Date Approved: 02/21/2014 Date Effective: 10/1/2013 Transmittal Number: 13-0016

Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 General Eligibility Requirements Eligibility Process S94 42 CFR 435, Subpart J and Subpart M Eligibility Process The state meets all the requirements of 42 CFR 435, Subpart J for processing applications, determining and verifying eligibility, and furnishing Medicaid. ✔ Application Processing Indicate which application the agency uses for individuals applying for coverage who may be eligible based on the applicable modified adjusted gross income standard. The single, streamlined application for all insurance affordability programs, developed by the Secretary in accordance with section 1413(b)(1)(A) of the Affordable Care Act An alternative single, streamlined application developed by the state in accordance with section 1413(b)(1)(B) of the Affordable Care Act and approved by the Secretary, which may be no more burdensome than the streamlined application developed by the Secretary. An attachment is submitted. An alternative application used to apply for multiple human service programs approved by the Secretary, provided that the agency makes readily available the single or alternative application used only for insurance affordability programs to individuals seeking assistance only through such programs. An attachment is submitted. Indicate which application the agency uses for individuals applying for coverage who may be eligible on a basis other than the applicable modified adjusted gross income standard: The single, streamlined application developed by the Secretary or one of the alternate forms developed by the state and approved by the Secretary, and supplemental forms to collect additional information needed to determine eligibility on such other basis, submitted to the Secretary. An attachment is submitted. An application designed specifically to determine eligibility on a basis other than the applicable MAGI standard which minimizes the burden on applicants, submitted to the Secretary. An attachment is submitted. The agency's procedures permit an individual, or authorized person acting on behalf of the individual, to submit an application via the internet website described in 42 CFR 435.1200(f), by telephone, via mail, and in person. The agency also accepts applications by other electronic means: Yes No State: Oklahoma Date Received: 11/27/2013 Date Approved: 02/21/2014 Date Effective: 10/1/2013 Transmittal Number: 13-0016

Medicaid Eligibility The agency has procedures to take applications, assist applicants and perform initial processing of applications for the eligibility groups listed below at locations other than those used for the receipt and processing of applications for the title IV-A program, including Federally-qualified health centers and disproportionate share hospitals. ✔ Parents and Other Caretaker Relatives Pregnant Women Infants and Children under Age 19 Redetermination Processing Redeterminations of eligibility for individuals whose financial eligibility is based on the applicable modified adjusted gross income standard are performed as follows, consistent with 42 CFR 435.916: ✔ Once every 12 months ■ Without requiring information from the individual if able to do so based on reliable information contained in the individual's account or other more current information available to the agency ■ If the agency cannot determine eligibility solely on the basis of the information available to it, or otherwise needs additional information to complete the redetermination, it provides the individual with a pre-populated renewal form containing the information already available. ■ Redeterminations of eligibility for individuals whose financial eligibility is not based on the applicable modified adjusted gross income standard are performed, consistent with 42 CFR 435.916 (check all that apply): ■ Once every 12 months Once every 6 months Other, more often than once every 12 months Coordination of Eligibility and Enrollment The state meets all the requirements of 42 CFR 435, Subpart M relative to coordination of eligibility and enrollment between Medicaid, CHIP, Exchanges and other insurance affordability programs. The single state agency has entered into agreements with the Exchange and with other agencies administering insurance affordability programs. ✔ PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. State: Oklahoma Date Received: 11/27/2013 Date Approved: 02/21/2014 Date Effective: 10/1/2013 Transmittal Number: 13-0016

State: Oklahoma Date Received: 11/27/2013 Date Approved: 02/21/2014 Date Effective: 10/1/2013 Transmittal Number: 13-0016 ___________________________________________________________________________ TN No: 13-0016-MM2 APPROVAL DATE: 02/21/2014 EFFECTIVE DATE: 10/1/2013 STATE: OKLAHOMA PAGE: Attachment Page 1

Table of Contents

State/Territory Name: Oklahoma State Plan Amendment (SPA) #: 13-17 MM1 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form 3) Summary Form 4) Approved SPA Pages

OK Redacted SPAs Page 2

OK Redacted SPAs Page 2

USE OF THE ALTERNATIVE SINGLE STREAMLINED APPLICATION ( )Paper Application ( X ) Online A pplication TRANSMITTAL NUMBER: 13-17 MM1 STATE: Oklahoma

The plan updates the eligibility standards for the State’s Medicaid mandatory and optional eligibility groups under the authority of the Social Security Act Section 1902(e)(14) and 42 Code of Federal Regulations (CFR) 435.603, and according to the new provisions of the Affordable Care Act (ACA).

OK13-17 Page 2

State: Oklahoma Date Received: 11/27/13 Date Approved: 1/16/14 Date Effective: 1/1/14 Transmittal Number: 13-17 ___________________________________________________________________________ TN No: 13-17

APPROVAL DATE: 1/16/14

EFFECTIVE DATE: 1/1/14 STATE: OKLAHOMA PAGE: Superseding Document Page 1

OK13-17 Page 3

State: Oklahoma Date Received: 11/27/13 Date Approved: 1/16/14 Date Effective: 1/1/14 Transmittal Number: 13-17 ___________________________________________________________________________ TN No: 13-17

APPROVAL DATE: 1/16/14

EFFECTIVE DATE: 1/1/14 STATE: OKLAHOMA PAGE: Superseding Document Page 2

OK13-17 Page 4

State: Oklahoma Date Received: 11/27/13 Date Approved: 1/16/14 Date Effective: 1/1/14 Transmittal Number: 13-17 ___________________________________________________________________________ TN No: 13-17

APPROVAL DATE: 1/16/14

EFFECTIVE DATE: 1/1/14 STATE: OKLAHOMA PAGE: S14 Page 1

OK13-17 Page 5

State: Oklahoma Date Received: 11/27/13 Date Approved: 1/16/14 Date Effective: 1/1/14 Transmittal Number: 13-17 ___________________________________________________________________________ TN No: 13-17

APPROVAL DATE: 1/16/14

EFFECTIVE DATE: 1/1/14 STATE: OKLAHOMA PAGE: S14 Page 2

OK13-17 Page 6

State: Oklahoma Date Received: 11/27/13 Date Approved: 1/16/14 Date Effective: 1/1/14 Transmittal Number: 13-17 ___________________________________________________________________________ TN No: 13-17

APPROVAL DATE: 1/16/14

EFFECTIVE DATE: 1/1/14 STATE: OKLAHOMA PAGE: S14 Page 3

OK13-17 Page 7

State: Oklahoma Date Received: 11/27/13 Date Approved: 1/16/14 Date Effective: 1/1/14 Transmittal Number: 13-17 ___________________________________________________________________________ TN No: 13-17

APPROVAL DATE: 1/16/14

EFFECTIVE DATE: 1/1/14 STATE: OKLAHOMA PAGE: S14 Page 4

OK13-17 Page 9

State: Oklahoma Date Received: 11/27/13 Date Approved: 1/16/14 Date Effective: 1/1/14 Transmittal Number: 13-17 ___________________________________________________________________________ TN No: 13-17

APPROVAL DATE: 1/16/14

EFFECTIVE DATE: 1/1/14 STATE: OKLAHOMA PAGE: S14 Page 5

OK13-17 Page 8

State: Oklahoma Date Received: 11/27/13 Date Approved: 1/16/14 Date Effective: 1/1/14 Transmittal Number: 13-17 ___________________________________________________________________________ TN No: 13-17

APPROVAL DATE: 1/16/14

EFFECTIVE DATE: 1/1/14 STATE: OKLAHOMA PAGE: S14 Page 6

OK13-17 Page 10

State: Oklahoma Date Received: 11/27/13 Date Approved: 1/16/14 Date Effective: 1/1/14 Transmittal Number: 13-17 ___________________________________________________________________________ TN No: 13-17

APPROVAL DATE: 1/16/14

EFFECTIVE DATE: 1/1/14 STATE: OKLAHOMA PAGE: S25 Page 1

OK13-17 Page 11

State: Oklahoma Date Received: 11/27/13 Date Approved: 1/16/14 Date Effective: 1/1/14 Transmittal Number: 13-17 ___________________________________________________________________________ TN No: 13-17

APPROVAL DATE: 1/16/14

EFFECTIVE DATE: 1/1/14 STATE: OKLAHOMA PAGE: S25 Page 2

OK13-17 Page 12

State: Oklahoma Date Received: 11/27/13 Date Approved: 1/16/14 Date Effective: 1/1/14 Transmittal Number: 13-17 ___________________________________________________________________________ TN No: 13-17

APPROVAL DATE: 1/16/14

EFFECTIVE DATE: 1/1/14 STATE: OKLAHOMA PAGE: S25 Page 3

OK13-17 Page 13

State: Oklahoma Date Received: 11/27/13 Date Approved: 1/16/14 Date Effective: 1/1/14 Transmittal Number: 13-17 ___________________________________________________________________________ TN No: 13-17

APPROVAL DATE: 1/16/14

EFFECTIVE DATE: 1/1/14 STATE: OKLAHOMA PAGE: S25 Page 4

OK13-17 Page 14

State: Oklahoma Date Received: 11/27/13 Date Approved: 1/16/14 Date Effective: 1/1/14 Transmittal Number: 13-17 ___________________________________________________________________________ TN No: 13-17

APPROVAL DATE: 1/16/14

EFFECTIVE DATE: 1/1/14 STATE: OKLAHOMA PAGE: S28 Page 1

OK13-17 Page 15

State: Oklahoma Date Received: 11/27/13 Date Approved: 1/16/14 Date Effective: 1/1/14 Transmittal Number: 13-17 ___________________________________________________________________________ TN No: 13-17

APPROVAL DATE: 1/16/14

EFFECTIVE DATE: 1/1/14 STATE: OKLAHOMA PAGE: S28 Page 2

OK13-17 Page 16

State: Oklahoma Date Received: 11/27/13 Date Approved: 1/16/14 Date Effective: 1/1/14 Transmittal Number: 13-17 ___________________________________________________________________________ TN No: 13-17

APPROVAL DATE: 1/16/14

EFFECTIVE DATE: 1/1/14 STATE: OKLAHOMA PAGE: S30 Page 1

OK13-17 Page 17

State: Oklahoma Date Received: 11/27/13 Date Approved: 1/16/14 Date Effective: 1/1/14 Transmittal Number: 13-17 ___________________________________________________________________________ TN No: 13-17

APPROVAL DATE: 1/16/14

EFFECTIVE DATE: 1/1/14 STATE: OKLAHOMA PAGE: S30 Page 2

OK13-17 Page 18

State: Oklahoma Date Received: 11/27/13 Date Approved: 1/16/14 Date Effective: 1/1/14 Transmittal Number: 13-17 ___________________________________________________________________________ TN No: 13-17

APPROVAL DATE: 1/16/14

EFFECTIVE DATE: 1/1/14 STATE: OKLAHOMA PAGE: S30 Page 3

OK13-17 Page 19

State: Oklahoma Date Received: 11/27/13 Date Approved: 1/16/14 Date Effective: 1/1/14 Transmittal Number: 13-17 ___________________________________________________________________________ TN No: 13-17

APPROVAL DATE: 1/16/14

EFFECTIVE DATE: 1/1/14 STATE: OKLAHOMA PAGE: S30 Page 4

OK13-17 Page 20

State: Oklahoma Date Received: 11/27/13 Date Approved: 1/16/14 Date Effective: 1/1/14 Transmittal Number: 13-17 ___________________________________________________________________________ TN No: 13-17

APPROVAL DATE: 1/16/14

EFFECTIVE DATE: 1/1/14 STATE: OKLAHOMA PAGE: S30 Page 5

OK13-17 Page 21

State: Oklahoma Date Received: 11/27/13 Date Approved: 1/16/14 Date Effective: 1/1/14 Transmittal Number: 13-17 ___________________________________________________________________________ TN No: 13-17

APPROVAL DATE: 1/16/14

EFFECTIVE DATE: 1/1/14 STATE: OKLAHOMA PAGE: S32 Page 1

OK13-17 Page 22

State: Oklahoma Date Received: 11/27/13 Date Approved: 1/16/14 Date Effective: 1/1/14 Transmittal Number: 13-17 ___________________________________________________________________________ TN No: 13-17

APPROVAL DATE: 1/16/14

EFFECTIVE DATE: 1/1/14 STATE: OKLAHOMA PAGE: S33 Page 1

OK13-17 Page 23

State: Oklahoma Date Received: 11/27/13 Date Approved: 1/16/14 Date Effective: 1/1/14 Transmittal Number: 13-17 ___________________________________________________________________________ TN No: 13-17

APPROVAL DATE: 1/16/14

EFFECTIVE DATE: 1/1/14 STATE: OKLAHOMA PAGE: S50 Page 1

OK13-17 Page 24

State: Oklahoma Date Received: 11/27/13 Date Approved: 1/16/14 Date Effective: 1/1/14 Transmittal Number: 13-17 ___________________________________________________________________________ TN No: 13-17

APPROVAL DATE: 1/16/14

EFFECTIVE DATE: 1/1/14 STATE: OKLAHOMA PAGE: S51 Page 1

OK13-17 Page 25

State: Oklahoma Date Received: 11/27/13 Date Approved: 1/16/14 Date Effective: 1/1/14 Transmittal Number: 13-17 ___________________________________________________________________________ TN No: 13-17

APPROVAL DATE: 1/16/14

EFFECTIVE DATE: 1/1/14 STATE: OKLAHOMA PAGE: S52 Page 1

OK13-17 Page 26

State: Oklahoma Date Received: 11/27/13 Date Approved: 1/16/14 Date Effective: 1/1/14 Transmittal Number: 13-17 ___________________________________________________________________________ TN No: 13-17

APPROVAL DATE: 1/16/14

EFFECTIVE DATE: 1/1/14 STATE: OKLAHOMA PAGE: S52 Page 2

OK13-17 Page 27

State: Oklahoma Date Received: 11/27/13 Date Approved: 1/16/14 Date Effective: 1/1/14 Transmittal Number: 13-17 ___________________________________________________________________________ TN No: 13-17

APPROVAL DATE: 1/16/14

EFFECTIVE DATE: 1/1/14 STATE: OKLAHOMA PAGE: S52 Page 3

OK13-17 Page 28

State: Oklahoma Date Received: 11/27/13 Date Approved: 1/16/14 Date Effective: 1/1/14 Transmittal Number: 13-17 ___________________________________________________________________________ TN No: 13-17

APPROVAL DATE: 1/16/14

EFFECTIVE DATE: 1/1/14 STATE: OKLAHOMA PAGE: S52 Page 4

OK13-17 Page 29

State: Oklahoma Date Received: 11/27/13 Date Approved: 1/16/14 Date Effective: 1/1/14 Transmittal Number: 13-17 ___________________________________________________________________________ TN No: 13-17

APPROVAL DATE: 1/16/14

EFFECTIVE DATE: 1/1/14 STATE: OKLAHOMA PAGE: S52 Page 5

OK13-17 Page 30

State: Oklahoma Date Received: 11/27/13 Date Approved: 1/16/14 Date Effective: 1/1/14 Transmittal Number: 13-17 ___________________________________________________________________________ TN No: 13-17

APPROVAL DATE: 1/16/14

EFFECTIVE DATE: 1/1/14 STATE: OKLAHOMA PAGE: S52 Page 6

OK13-17 Page 31

State: Oklahoma Date Received: 11/27/13 Date Approved: 1/16/14 Date Effective: 1/1/14 Transmittal Number: 13-17 ___________________________________________________________________________ TN No: 13-17

APPROVAL DATE: 1/16/14

EFFECTIVE DATE: 1/1/14 STATE: OKLAHOMA PAGE: S52 Page 7

OK13-17 Page 32

State: Oklahoma Date Received: 11/27/13 Date Approved: 1/16/14 Date Effective: 1/1/14 Transmittal Number: 13-17 ___________________________________________________________________________ TN No: 13-17

APPROVAL DATE: 1/16/14

EFFECTIVE DATE: 1/1/14 STATE: OKLAHOMA PAGE: S52 Page 8

OK13-17 Page 33

State: Oklahoma Date Received: 11/27/13 Date Approved: 1/16/14 Date Effective: 1/1/14 Transmittal Number: 13-17 ___________________________________________________________________________ TN No: 13-17

APPROVAL DATE: 1/16/14

EFFECTIVE DATE: 1/1/14 STATE: OKLAHOMA PAGE: S52 Page 9

OK13-17 Page 34

State: Oklahoma Date Received: 11/27/13 Date Approved: 1/16/14 Date Effective: 1/1/14 Transmittal Number: 13-17 ___________________________________________________________________________ TN No: 13-17

APPROVAL DATE: 1/16/14

EFFECTIVE DATE: 1/1/14 STATE: OKLAHOMA PAGE: S53 Page 1

OK13-17 Page 35

State: Oklahoma Date Received: 11/27/13 Date Approved: 1/16/14 Date Effective: 1/1/14 Transmittal Number: 13-17 ___________________________________________________________________________ TN No: 13-17

APPROVAL DATE: 1/16/14

EFFECTIVE DATE: 1/1/14 STATE: OKLAHOMA PAGE: S53 Page 2

OK13-17 Page 36

State: Oklahoma Date Received: 11/27/13 Date Approved: 1/16/14 Date Effective: 1/1/14 Transmittal Number: 13-17 ___________________________________________________________________________ TN No: 13-17

APPROVAL DATE: 1/16/14

EFFECTIVE DATE: 1/1/14 STATE: OKLAHOMA PAGE: S53 Page 3

OK13-17 Page 37

State: Oklahoma Date Received: 11/27/13 Date Approved: 1/16/14 Date Effective: 1/1/14 Transmittal Number: 13-17 ___________________________________________________________________________ TN No: 13-17

APPROVAL DATE: 1/16/14

EFFECTIVE DATE: 1/1/14 STATE: OKLAHOMA PAGE: S54 Page 1

OK13-17 Page 38

State: Oklahoma Date Received: 11/27/13 Date Approved: 1/16/14 Date Effective: 1/1/14 Transmittal Number: 13-17 ___________________________________________________________________________ TN No: 13-17

APPROVAL DATE: 1/16/14

EFFECTIVE DATE: 1/1/14 STATE: OKLAHOMA PAGE: S55 Page 1

OK13-17 Page 39

State: Oklahoma Date Received: 11/27/13 Date Approved: 1/16/14 Date Effective: 1/1/14 Transmittal Number: 13-17 ___________________________________________________________________________ TN No: 13-17

APPROVAL DATE: 1/16/14

EFFECTIVE DATE: 1/1/14 STATE: OKLAHOMA PAGE: S55 Page 2

OK13-17 Page 40

State: Oklahoma Date Received: 11/27/13 Date Approved: 1/16/14 Date Effective: 1/1/14 Transmittal Number: 13-17 ___________________________________________________________________________ TN No: 13-17

APPROVAL DATE: 1/16/14

EFFECTIVE DATE: 1/1/14 STATE: OKLAHOMA PAGE: S57 Page 1

OK13-17 Page 41

State: Oklahoma Date Received: 11/27/13 Date Approved: 1/16/14 Date Effective: 1/1/14 Transmittal Number: 13-17 ___________________________________________________________________________ TN No: 13-17

APPROVAL DATE: 1/16/14

EFFECTIVE DATE: 1/1/14 STATE: OKLAHOMA PAGE: S57 Page 2

OK13-17 Page 42

State: Oklahoma Date Received: 11/27/13 Date Approved: 1/16/14 Date Effective: 1/1/14 Transmittal Number: 13-17 ___________________________________________________________________________ TN No: 13-17

APPROVAL DATE: 1/16/14

EFFECTIVE DATE: 1/1/14 STATE: OKLAHOMA PAGE: S57 Page 3

OK13-17 Page 43

State: Oklahoma Date Received: 11/27/13 Date Approved: 1/16/14 Date Effective: 1/1/14 Transmittal Number: 13-17 ___________________________________________________________________________ TN No: 13-17

APPROVAL DATE: 1/16/14

EFFECTIVE DATE: 1/1/14 STATE: OKLAHOMA PAGE: S59 Page 1

OK13-17 Page 44

State: Oklahoma Date Received: 11/27/13 Date Approved: 1/16/14 Date Effective: 1/1/14 Transmittal Number: 13-17 ___________________________________________________________________________ TN No: 13-17

APPROVAL DATE: 1/16/14

EFFECTIVE DATE: 1/1/14 STATE: OKLAHOMA PAGE: S59 Page 2

Table of Contents

State/Territory Name: Oklahoma State Plan Amendment (SPA) #: 13-18 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form 3) Superseded Page list 4) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Cc RA & Dallas Regional Office

CENTERS FOR MEDICARE & MEDICAID SERVICES

1301 Young Street, Suite 833 CONSORTIUM FOR MEDICAID Dallas, Texas 75202 & CHILDREN’S HEALTH OPERATIONS

DIVISION OF MEDICAID & CHILDREN’S HEALTH - REGION VI

February 21, 2014

Dr. Garth Splinter

State Medicaid Director

2401 NW 23rd Street, Suite 1A Oklahoma City, Oklahoma 73107

Our Reference: SPA-OK-13-18-MM3 Dear Dr. Splinter:

We have reviewed the proposed amendment to your Medicaid State Plan submitted under Transmittal Number (TN) 13-18. With the approval of TN 13-18, CMS has reviewed and approved eligibility standards for the State’s Medicaid mandatory and optional eligibility groups under the authority of the Social Security Act Section 1902(e)(14) and 42 Code of Federal Regulations (CFR) 435.603, and according to the new provisions of the Affordable Care Act (ACA).

Transmittal Number 13-18 is approved with an effective date of January 1, 2014, as requested. A signed and dated copy of the Transmittal No. 13-18 summary is enclosed, along with the

approved plan pages and their attachments.

If you have any questions, please contact Tamara Sampson at (214) 767-6431.

Sincerely,

Bill Brooks Associate Regional Administrator Division of Medicaid and Children’s Health

Enclosures

MacPro Reporting System: Summary Page (CMS 179) Page | of 2

Control Panel

General Information

File Management

Tribal Input

Summary (CMS179)

Medicaid State Plan Eligibility: Summary Page (CMS 179)

State/Territory name Oklahoma

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. OK-13-0018

Proposed Effective Date

01/01/2014

Federal Statute/Regulation Citation

Federal Budget Impact

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

Subject of Amendment

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

MacPro Reporting System: Summary Page (CMS 179)

Page 2 of 2

Signature of State Agency Official

Submitted By Tywanda Cox

Last Revision Date: Feb 19, 2014 Submit Date Dec 17, 2013 BACK

CONTINUE

Date Received: Date Approved:

PRINTED NAME and Title:

11/27/2013 02/21/2014 Signature of Regional Official:

Bill Brooks, Associate Regional Administrator Division of Medicaid and Children's Health

State: Oklahoma Date Received: 11/27/2013 Date Approved: 02/21/2014 Date Effective: 1/1/2014 Transmittal Number: 13-0018 ___________________________________________________________________________ TN No: 13-0018 MM3 APPROVAL DATE: 02/21/2014 EFFECTIVE DATE: 1/1/2014 STATE: OKLAHOMA PAGE: Superseding Document Page 1

State: Oklahoma Date Received: 11/27/2013 Date Approved: 02/21/2014 Date Effective: 1/1/2014 Transmittal Number: 13-0018 ___________________________________________________________________________ TN No: 13-0018-MM3 APPROVAL DATE: 02/21/2014 EFFECTIVE DATE: 1/1/2014 STATE: OKLAHOMA PAGE: S10 Page 1

State: Oklahoma Date Received: 11/27/2013 Date Approved: 02/21/2014 Date Effective: 1/1/2014 Transmittal Number: 13-0018 ___________________________________________________________________________ TN No: 13-0018-MM3 APPROVAL DATE: 02/21/2014 EFFECTIVE DATE: 1/1/2014 STATE: OKLAHOMA PAGE: S10 Page 2

Table of Contents

State/Territory Name: Oklahoma State Plan Amendment (SPA) #: 13-20 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form 3) Superseding Page List 4) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Cc RA & Dallas Regional Office

CENTERS FOR MEDICARE & MEDICAID SERVICES

1301 Young Street, Suite 833 CONSORTIUM FOR MEDICAID Dallas, Texas 75202 & CHILDREN’S HEALTH OPERATIONS

DIVISION OF MEDICAID & CHILDREN’S HEALTH - REGION VI

February 24, 2014

Dr. Garth Splinter

State Medicaid Director

2401 NW 23rd Street, Suite 1A Oklahoma City, Oklahoma 73107

Our Reference: SPA-OK-13-20-MM5 Dear Dr. Splinter:

We have reviewed the proposed amendment to your Medicaid State Plan submitted under Transmittal Number (TN) 13-20. With the approval of TN 13-20, CMS has reviewed and approved eligibility standards for the State’s Medicaid mandatory and optional eligibility groups under the authority of the Social Security Act Section 1902(e)(14) and 42 Code of Federal Regulations (CFR) 435.603, and according to the new provisions of the Affordable Care Act (ACA).

Transmittal Number 13-20 is approved with an effective date of January 1, 2014, as requested. A signed and dated copy of the Transmittal No. 13-20 summary is enclosed, along with the

approved plan pages and their attachments.

If you have any questions, please contact Tamara Sampson at (214) 767-6431.

Sincerely,

Bill Brooks Associate Regional Administrator Division of Medicaid and Children’s Health

Enclosures

MacPro Reporting System: Summary Page (CMS 179) Page | of 2

Control Panel

Medicaid State Plan Eligibility: Summary Page (CMS 179)

General Information

State/Territory name Oklahoma Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the

File Management

Tribal Input 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. Summary (CMS179) OK-13-0020

Proposed Effective Date

01/01/2014

Federal Statute/Regulation Citation

Federal Budget Impact

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

Subject of Amendment

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

SPAs Page 3

State: Oklahoma Date Received: 11/27/2013 Date Approved: 02/24/2014 Date Effective: 1/1/2014 Transmittal Number: 13-0020 ___________________________________________________________________________ TN No: 13-0020 MM5 APPROVAL DATE: 02/24/2014 EFFECTIVE DATE: 1/1/2014 STATE: OKLAHOMA PAGE: Superseding Document Page 1

State: Oklahoma Date Received: 11/27/2013 Date Approved: 02/24/2014 Date Effective: 1/1/2014 Transmittal Number: 13-0020 ___________________________________________________________________________ TN No: 13-0020-MM5 APPROVAL DATE: 02/24/2014 EFFECTIVE DATE: 1/1/2014 STATE: OKLAHOMA PAGE: S88 Page 1

State: Oklahoma Date Received: 11/27/2013 Date Approved: 02/24/2014 Date Effective: 1/1/2014 Transmittal Number: 13-0020 ___________________________________________________________________________ TN No: 13-0020-MM5 APPROVAL DATE: 02/24/2014 EFFECTIVE DATE: 1/1/2014 STATE: OKLAHOMA PAGE: S88 Page 2

State: Oklahoma Date Received: 11/27/2013 Date Approved: 02/24/2014 Date Effective: 1/1/2014 Transmittal Number: 13-0020

State: Oklahoma Date Received: 11/27/2013 Date Approved: 02/24/2014 Date Effective: 1/1/2014 Transmittal Number: 13-0020

Table of Contents

State/Territory Name: Oklahoma State Plan Amendment (SPA) #: 14-07 MM7 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Dallas Regional Office 1301 Young Street, Room 714 Dallas, Texas 75202

DIVISION OF MEDICAID & CHILDREN’S HEALTH OPERATIONS

January 29, 2015

Dr. Garth Splinter State Medicaid Director 2401 NW 23rd Street, Suite 1A Oklahoma City, Oklahoma 73107

Our Reference: SPA OK-14-0007-MM7

Dear Dr. Splinter:

We have reviewed the State’s proposed amendment to the Oklahoma State Plan submitted under Transmittal Number 14-0007, dated March 31, 2014. This state plan amendment establishes the procedures for Hospital Presumptive Eligibility.

In its SPA, the State has proposed high threshold performance standards. (At least 95% of individuals determined eligible for HPE submit the full Medicaid application within the required time frame of 15 days after the HPE application is completed; and at least 95% of individuals determined eligible for HPE who submit a full Medicaid application are found by the OHCA to be eligible for Medicaid.) CMS has discussed these performance standards with the state on several occasions and we understand that the state feels strongly about the performance standards and does not want to consider a phase in or hold harmless period for implementation. While the state does have the flexibility to select and set its own performance metrics, CMS is responsible for ensuring that states can provide a program for those hospitals that want to serve as qualified entities. To this point, CMS will periodically ask for updates from the state regarding the number of hospitals enrolled in the program, and may request to revisit these performance standards if the state reports that no hospitals are able to meet the threshold and are disenrolled from the program.

Based on the information submitted, we have approved the amendment for incorporation into the official Oklahoma State Plan with an effective date change of January 1, 2014. A copy of the CMS-179 and approved plan page are enclosed with this letter.

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 Tamara Sampson at (214) 767- 6431 or via e-mail at Tamara.Sampson@cms.hhs.gov.

Sincerely,

Bill Brooks Associate Regional Administrator Division of Medicaid & Children’s Health Operations

Enclosures

OK.0891.R00.00 - Jan 01, 2014 file:///I|/DMCH/State%20Plan/Oklahoma/2014/14-07%20MM7%20(891)/OK%2014-0007%20-%20CMS%20179.htm[01/29/2015 11:52:54 AM] Medicaid State Plan Eligibility: Summary Page (CMS 179) State/Territory name: Oklahoma 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. Proposed Effective Date (mm/dd/yyyy) Federal Statute/Regulation Citation Federal Budget Impact Federal Fiscal Year Amount First Year $ Second Year $ Subject of Amendment 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: Signature of State Agency Official Submitted By: Tywanda Cox Last Revision Date: Jan 23, 2015 Submit Date: Mar 31, 2014 OK-14-0007 01/01/2014 42 CFR 435.1110 2014 5607000.00 2015 7476000.00 Hospital Presumptive Eligibility Governor's Office does not review State Plan Amendments. Date Received: 31 March, 2014 Date Approved: 29 January, 2015 Date Effective: 1 January, 2014 Signature of the Approving Official: Printed Name and Title: Bill Brooks, Associate Regional Administrator Division of Medicaid & Children's Health

Page 1 of 3 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Presumptive Eligibility by Hospitals S21 42 CFR 435.1110 One or more qualified hospitals are determining presumptive eligibility under 42 CFR 435.1110, and the state is providing Medicaid coverage for individuals determined presumptively eligible under this provision. Yes No The state attests that presumptive eligibility by hospitals is administered in accordance with the following provisions: ✔ A qualified hospital is a hospital that: ■ Participates as a provider under the Medicaid state plan or a Medicaid 1115 Demonstration, notifies the Medicaid agency of its election to make presumptive eligibility determinations and agrees to make presumptive eligibility determinations consistent with state policies and procedures. ■ Has not been disqualified by the Medicaid agency for failure to make presumptive eligibility determinations in accordance with applicable state policies and procedures or for failure to meet any standards that may have been established by the Medicaid agency. ■ Assists individuals in completing and submitting the full application and understanding any documentation requirements. Yes No The eligibility groups or populations for which hospitals determine eligibility presumptively are: ■ Pregnant Women ■ Infants and Children under Age 19 ■ Parents and Other Caretaker Relatives ■ Adult Group, if covered by the state ■ Individuals above 133% FPL under Age 65, if covered by the state ■ Individuals Eligible for Family Planning Services, if covered by the state ■ Former Foster Care Children ■ Certain Individuals Needing Treatment for Breast or Cervical Cancer, if covered by the state ■ Other Family/Adult groups: Eligibility groups for individuals age 65 and over Eligibility groups for individuals who are blind Eligibility groups for individuals with disabilities Other Medicaid state plan eligibility groups Demonstration populations covered under section 1115 The state establishes standards for qualified hospitals making presumptive eligibility determinations. State: Oklahoma Date Received: 31 March, 2014 Date Approved: 29 January, 2015 Date Effective: 1 January, 2014 Transmittal Number: OK 14-0007 TN: OK 14-0007 Date Approved: 1-29-15 Date Effective: 1-1-14

Page 2 of 3 Medicaid Eligibility Yes No Select one or both: The state has standards that relate to the proportion of individuals determined presumptively eligible who submit a regular application, as described at 42 CFR 435.907, before the end of the presumptive eligibility period. Description of standards: At least 95% of individuals determined eligible for HPE submit the full Medicaid application within the required time frame of 15 days after the HPE application is completed. The state has standards that relate to the proportion of individuals who are determined eligible for Medicaid based on the submission of an application before the end of the presumptive eligibility period. Description of standards: At least 95% of individuals determined eligible for HPE who submit a full Medicaid application are found by the OHCA to be eligible for Medicaid. The presumptive period begins on the date the determination is made. ■ The end date of the presumptive period is the earlier of: ■ The date the eligibility determination for regular Medicaid is made, if an application for Medicaid is filed by the last day of the month following the month in which the determination of presumptive eligibility is made; or The last day of the month following the month in which the determination of presumptive eligibility is made, if no application for Medicaid is filed by that date. Periods of presumptive eligibility are limited as follows: ■ No more than one period within a calendar year. No more than one period within two calendar years. No more than one period within a twelve-month period, starting with the effective date of the initial presumptive eligibility period. Other reasonable limitation: The state requires that a written application be signed by the applicant, parent or representative, as appropriate. Yes No The state uses a single application form for Medicaid and presumptive eligibility, approved by CMS. The state uses a separate application form for presumptive eligibility, approved by CMS. A copy of the application form is included. An attachment is submitted. State: Oklahoma Date Received: 31 March, 2014 Date Approved: 29 January, 2015 Date Effective: 1 January, 2014 Transmittal Number: OK 14-0007 TN: OK 14-0007 Date Approved: 1-29-15 Date Effective: 1-1-14

Page 3 of 3 Medicaid Eligibility The presumptive eligibility determination is based on the following factors: ■ The individual’s categorical or non-financial eligibility for the group for which the individual’s presumptive eligibility is being determined (e.g., based on age, pregnancy status, status as a parent/caretaker relative, disability, or other requirements specified in the Medicaid state plan or a Medicaid 1115 demonstration for that group) ■ Household income must not exceed the applicable income standard for the group for which the individual's presumptive eligibility is being determined, if an income standard is applicable for this group. ■ State residency Citizenship, status as a national, or satisfactory immigration status The state assures that it has communicated the requirements for qualified hospitals, and has provided adequate training to the hospitals. A copy of the training materials has been included. ✔ An attachment is submitted. PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. State: Oklahoma Date Received: 31 March, 2014 Date Approved: 29 January, 2015 Date Effective: 1 January, 2014 Transmittal Number: OK 14-0007 TN: OK 14-0007 Date Approved: 1-29-15 Date Effective: 1-1-14

Hospital Presumptive Eligibility OHCA Training for Qualified Hospitals State: Oklahoma Date Received: 31 March, 2014 Date Approved: 29 January, 2015 Date Effective: 1 January, 2014 Transmittal Number: OK 14-0007 TN: OK 14-0007 Date Approved: 1-29-15 Date Effective: 1-1-14

AGENDA • HPE as part of the Continuum of Coverage • HPE Overview • How Hospitals Can Participate in HPE • Who is Eligible to Enroll in Medicaid through HPE? • What are the Benefits? • How the HPE Process Works • Contact Information State: Oklahoma Date Received: 31 March, 2014 Date Approved: 29 January, 2015 Date Effective: 1 January, 2014 Transmittal Number: OK 14-0007 TN: OK 14-0007 Date Approved: 1-29-15 Date Effective: 1-1-14

HPE as Part of the Continuum of Coverage State: Oklahoma Date Received: 31 March, 2014 Date Approved: 29 January, 2015 Date Effective: 1 January, 2014 Transmittal Number: OK 14-0007 TN: OK 14-0007 Date Approved: 1-29-15 Date Effective: 1-1-14

ACA COVERAGE CHANGES The Affordable Care Act (ACA) was signed into law in March 2010; it makes major changes to how people secure health coverage in the U.S. Coverage changes include: • Medicaid and CHIP expansion and improvements • Health insurance marketplaces for individuals and small businesses • Private insurance market reforms State: Oklahoma Date Received: 31 March, 2014 Date Approved: 29 January, 2015 Date Effective: 1 January, 2014 Transmittal Number: OK 14-0007 TN: OK 14-0007 Date Approved: 1-29-15 Date Effective: 1-1-14

THE NEW VISION FOR MEDICAID AND CHIP • Single, Streamlined Application – Individuals can apply for Marketplace coverage and all insurance affordability programs (Medicaid, CHIP, premium tax credits) on one application • Simplified Eligibility and Enrollment Rules – Modified Adjusted Gross Income (MAGI) is the new income methodology based on IRS- defined concepts of income and household to determine Medicaid and CHIP eligibility for children, pregnant women, parents and caretaker relatives, and adults 19-64 • Modernized Eligibility Systems – Increases use of automated rules engines to enable real-time eligibility determinations; individuals can apply for coverage online State: Oklahoma Date Received: 31 March, 2014 Date Approved: 29 January, 2015 Date Effective: 1 January, 2014 Transmittal Number: OK 14-0007 TN: OK 14-0007 Date Approved: 1-29-15 Date Effective: 1-1-14

THE NEW VISION FOR MEDICAID AND CHIP • Children’s Coverage Improvements – All children up to age 19 with family incomes up to 133% FPL are now Medicaid-eligible • Hospital Presumptive Eligibility – Hospitals can now determine individuals to be presumptively eligible for Medicaid State: Oklahoma Date Received: 31 March, 2014 Date Approved: 29 January, 2015 Date Effective: 1 January, 2014 Transmittal Number: OK 14-0007 TN: OK 14-0007 Date Approved: 1-29-15 Date Effective: 1-1-14

Hospital Presumptive Eligibility (HPE) Overview State: Oklahoma Date Received: 31 March, 2014 Date Approved: 29 January, 2015 Date Effective: 1 January, 2014 Transmittal Number: OK 14-0007 TN: OK 14-0007 Date Approved: 1-29-15 Date Effective: 1-1-14

WHAT IS HOSPITAL PRESUMPTIVE ELIGIBILITY (HPE)? • HPE is a mandate of the Affordable Care Act • As of Jan. 1, 2014, hospitals can immediately determine Medicaid eligibility for certain individuals who are likely to be eligible • Eligibility under PE is temporary but allows immediate access to coverage for eligible individuals State: Oklahoma Date Received: 31 March, 2014 Date Approved: 29 January, 2015 Date Effective: 1 January, 2014 Transmittal Number: OK 14-0007 TN: OK 14-0007 Date Approved: 1-29-15 Date Effective: 1-1-14

HOW HPE WORKS TO GET PEOPLE CONNECTED TO COVERAGE AND CARE • HPE improves individuals’ access to SoonerCare and necessary services by providing another channel to apply for coverage • It ensures the hospital will be reimbursed for services provided, just as if the individual was enrolled in standard SoonerCare • HPE should be considered a bridge to being connected with long term coverage options State: Oklahoma Date Received: 31 March, 2014 Date Approved: 29 January, 2015 Date Effective: 1 January, 2014 Transmittal Number: OK 14-0007 TN: OK 14-0007 Date Approved: 1-29-15 Date Effective: 1-1-14

How Hospitals Can Participate in HPE State: Oklahoma Date Received: 31 March, 2014 Date Approved: 29 January, 2015 Date Effective: 1 January, 2014 Transmittal Number: OK 14-0007 TN: OK 14-0007 Date Approved: 1-29-15 Date Effective: 1-1-14

HOW HOSPITALS CAN PARTICIPATE IN HPE • Hospital participation in HPE is optional • To make HPE determinations, a hospital must: -Participate in the SoonerCare program -Notify OHCA of its election to make HPE determinations by submitting a Statement of Interest and Attestation page to OHCA Provider Enrollment -Agree to make HPE determinations consistent with policies and procedures of the OHCA by completing a Memorandum of Understanding and returning it to OHCA Provider Enrollment -Hospital staff must attend HPE trainings and pass HPE certification State: Oklahoma Date Received: 31 March, 2014 Date Approved: 29 January, 2015 Date Effective: 1 January, 2014 Transmittal Number: OK 14-0007 TN: OK 14-0007 Date Approved: 1-29-15 Date Effective: 1-1-14

STATEMENT OF INTEREST State: Oklahoma Date Received: 31 March, 2014 Date Approved: 29 January, 2015 Date Effective: 1 January, 2014 Transmittal Number: OK 14-0007 TN: OK 14-0007 Date Approved: 1-29-15 Date Effective: 1-1-14

ATTESTATION FORM State: Oklahoma Date Received: 31 March, 2014 Date Approved: 29 January, 2015 Date Effective: 1 January, 2014 Transmittal Number: OK 14-0007 TN: OK 14-0007 Date Approved: 1-29-15 Date Effective: 1-1-14

HOSPITAL STAFF ELIGIBLE TO MAKE HPE DETERMINATIONS Once a hospital is a qualified entity: • A qualified hospital must assign a PE Hospital Administrator to be in charge of the program and coordinate PE activities with the OHCA. • Any hospital employee who is properly trained and certified can make HPE determinations as an Authorized Hospital Employee (AHE). • This includes employees in hospital-owned physician practices or clinics, including those in off-site locations as long as they are contracted as a “hospital” • Participating hospitals may not delegate HPE determinations to non- hospital staff • Third party vendors or contractors may not make PE determinations State: Oklahoma Date Received: 31 March, 2014 Date Approved: 29 January, 2015 Date Effective: 1 January, 2014 Transmittal Number: OK 14-0007 TN: OK 14-0007 Date Approved: 1-29-15 Date Effective: 1-1-14

STAFF TRAINING AND CERTIFICATION • All AHEs chosen by the hospital to make HPE determinations will be required to have HPE training -AHEs and PE Program Administrators will be required to attest that they have participated in training and have passed certification • On-site training will be provided by OHCA Provider Service personnel • Training materials will be made available on the OHCA public website at www.okhca.org • Additional or follow-up training will be available as needed by OHCA Provider Service personnel State: Oklahoma Date Received: 31 March, 2014 Date Approved: 29 January, 2015 Date Effective: 1 January, 2014 Transmittal Number: OK 14-0007 TN: OK 14-0007 Date Approved: 1-29-15 Date Effective: 1-1-14

HPE AUDITS & PERFORMANCE STANDARDS • All HPE applications are subject to audit by the OHCA, and they will be performed on a routine basis to determine accuracy rate. • In addition, the OHCA will be reviewing HPE hospitals to make sure they comply with other HPE regulations and conditions, including the Memorandum of Understanding. • The OHCA has the authority to take corrective action against hospitals, including termination from the HPE program, if the hospital does not follow the OHCA policies or does not meet established standards. • The OHCA reserves the right to change these performance guidelines in order to improve the overall integrity and performance of the HPE program. State: Oklahoma Date Received: 31 March, 2014 Date Approved: 29 January, 2015 Date Effective: 1 January, 2014 Transmittal Number: OK 14-0007 TN: OK 14-0007 Date Approved: 1-29-15 Date Effective: 1-1-14

HPE PERFORMANCE STANDARDS • For this provider, at least 95 percent of individuals determined eligible for HPE submit the full SoonerCare application within the required time frame of 15 days after the HPE application is completed. • For this provider, at least 95 percent of individuals determined eligible for HPE who submit a full SoonerCare application are found by the OHCA to be eligible for SoonerCare. • For this provider, at least 95 percent of HPE claims paid under HPE(measured in total dollar amount and the number of claims paid) are for individuals found eligible for SoonerCare. State: Oklahoma Date Received: 31 March, 2014 Date Approved: 29 January, 2015 Date Effective: 1 January, 2014 Transmittal Number: OK 14-0007 TN: OK 14-0007 Date Approved: 1-29-15 Date Effective: 1-1-14

HPE PERFORMANCE STANDARDS •For this provider, at least 95 percent of claims paid under HPE (measured in total dollar amount and the number of claims paid) are for individuals found eligible for SoonerCare beyond any initial data exchange income verification check. •For this provider, at least 99 percent of HPE applications include an Eligibility Verification Check with the HPE application using the OHCA’s Secure Provider Portal. State: Oklahoma Date Received: 31 March, 2014 Date Approved: 29 January, 2015 Date Effective: 1 January, 2014 Transmittal Number: OK 14-0007 TN: OK 14-0007 Date Approved: 1-29-15 Date Effective: 1-1-14

Who is Eligible to Enroll in SoonerCare through HPE? What are the Benefits? State: Oklahoma Date Received: 31 March, 2014 Date Approved: 29 January, 2015 Date Effective: 1 January, 2014 Transmittal Number: OK 14-0007 TN: OK 14-0007 Date Approved: 1-29-15 Date Effective: 1-1-14

POPULATIONS ELIGIBLE FOR HPE DETERMINATIONS • Individuals who do not currently receive SoonerCare benefits and have not had a PE period within the last 365 days. • Individuals applying for PE must be Oklahoma residents and be US citizens or Qualified Aliens who have lived in the US legally for five years with proper documentation. • Individuals who fall into one of the following income-based groups: – Parent and caretaker relative group – Children – Former Foster Care – Pregnant Women (Coverage will be limited to antepartum only) – Breast and Cervical Cancer – Family Planning (SoonerPlan) State: Oklahoma Date Received: 31 March, 2014 Date Approved: 29 January, 2015 Date Effective: 1 January, 2014 Transmittal Number: OK 14-0007 TN: OK 14-0007 Date Approved: 1-29-15 Date Effective: 1-1-14

HPE INCOME ELIGIBILITY CHART • Please see the PE Worksheet for the income standard for each population covered under HPE • AHEs will determine if the member applying for HPE benefits is eligible based on the information provided on the HPE application. This will include information about the member’s household composition and income. State: Oklahoma Date Received: 31 March, 2014 Date Approved: 29 January, 2015 Date Effective: 1 January, 2014 Transmittal Number: OK 14-0007 TN: OK 14-0007 Date Approved: 1-29-15 Date Effective: 1-1-14

DURATION OF ELIGIBILITY UNDER HPE • HPE period begins with, and includes, the day on which the hospital makes the HPE determination • HPE period ends with the earlier of: -the day on which the OHCA makes the eligibility determination after a full SoonerCare application is submitted; or -the last day of the month following the month in which the hospital makes the HPE determination, if the individual does not file a full SoonerCare application by that time State: Oklahoma Date Received: 31 March, 2014 Date Approved: 29 January, 2015 Date Effective: 1 January, 2014 Transmittal Number: OK 14-0007 TN: OK 14-0007 Date Approved: 1-29-15 Date Effective: 1-1-14

DETERMINING HPE ELIGIBILITY • HPE eligibility will be determined using the new Modified Adjusted Growth Income (MAGI) methodology that was created under the ACA. • In order to assist hospitals in understanding how to apply MAGI methodology, OHCA has provided the CMS training: PE MAGI Household and Income Training Manual. • OHCA will be providing additional training on the MAGI rules, separate from this general HPE training and guidance, to help hospitals prepare for HPE. State: Oklahoma Date Received: 31 March, 2014 Date Approved: 29 January, 2015 Date Effective: 1 January, 2014 Transmittal Number: OK 14-0007 TN: OK 14-0007 Date Approved: 1-29-15 Date Effective: 1-1-14

COVERED SERVICES UNDER PE • Benefits are the same as those provided under the SoonerCare group for which the individual is determined presumptively eligible • Exceptions -Pregnant women - benefits limited to ambulatory prenatal care (birthing expenses are not covered) -Family planning group - benefits limited to family planning services and supplies State: Oklahoma Date Received: 31 March, 2014 Date Approved: 29 January, 2015 Date Effective: 1 January, 2014 Transmittal Number: OK 14-0007 TN: OK 14-0007 Date Approved: 1-29-15 Date Effective: 1-1-14

How The HPE Process Works State: Oklahoma Date Received: 31 March, 2014 Date Approved: 29 January, 2015 Date Effective: 1 January, 2014 Transmittal Number: OK 14-0007 TN: OK 14-0007 Date Approved: 1-29-15 Date Effective: 1-1-14

THE HPE DETERMINATION PROCESS At the individual’s initial visit, HPE worker should take the following steps: 1. Providers must verify that the applicant is not currently eligible for SoonerCare through the SoonerCare Provider Portal Eligibility Verification System (EVS). 2. Assist individual with completing HPE application if not already enrolled in SoonerCare. Assist individual in completing required questions. 3. Determine if individual meets HPE criteria (See MAGI training slides for more info). State: Oklahoma Date Received: 31 March, 2014 Date Approved: 29 January, 2015 Date Effective: 1 January, 2014 Transmittal Number: OK 14-0007 TN: OK 14-0007 Date Approved: 1-29-15 Date Effective: 1-1-14

THE HPE DETERMINATION PROCESS 4. Print/provide eligibility notice to the member. 5. Summarize benefits and answer any questions. 6. Email the individual’s application and benefits eligibility to OHCA. 7. Encourage application for full SoonerCare. Hospital staff should follow up with the individual within 15 days of the start of the PE as required by their Memorandum of Understanding . State: Oklahoma Date Received: 31 March, 2014 Date Approved: 29 January, 2015 Date Effective: 1 January, 2014 Transmittal Number: OK 14-0007 TN: OK 14-0007 Date Approved: 1-29-15 Date Effective: 1-1-14

THE ELIGIBILITY VERIFICATION SYSTEM • The EVS will allow providers to review current member SoonerCare eligibility to ensure HPE applicants are not currently enrolled in SoonerCare. • The EVS can be accessed through the Provider Portal. • The EVS is already used by most SoonerCare providers to ensure member eligibility and accurate claims billing. State: Oklahoma Date Received: 31 March, 2014 Date Approved: 29 January, 2015 Date Effective: 1 January, 2014 Transmittal Number: OK 14-0007 TN: OK 14-0007 Date Approved: 1-29-15 Date Effective: 1-1-14

HOSPITAL PE APPLICATION • A paper application is the only acceptable form of application for HPE • Completed applications should be submitted to OHCA, via email, within five days of the application date for processing. • The hospital will be responsible for following back up with the member to apply with a full SoonerCare application and for providing the correct/new SoonerCare ID for eligible participants. State: Oklahoma Date Received: 31 March, 2014 Date Approved: 29 January, 2015 Date Effective: 1 January, 2014 Transmittal Number: OK 14-0007 TN: OK 14-0007 Date Approved: 1-29-15 Date Effective: 1-1-14

HOSPITAL PE APPLICATION State: Oklahoma Date Received: 31 March, 2014 Date Approved: 29 January, 2015 Date Effective: 1 January, 2014 Transmittal Number: OK 14-0007 TN: OK 14-0007 Date Approved: 1-29-15 Date Effective: 1-1-14

HOSPITAL PE APPLICATION State: Oklahoma Date Received: 31 March, 2014 Date Approved: 29 January, 2015 Date Effective: 1 January, 2014 Transmittal Number: OK 14-0007 TN: OK 14-0007 Date Approved: 1-29-15 Date Effective: 1-1-14

HOSPITAL PE APPLICATION State: Oklahoma Date Received: 31 March, 2014 Date Approved: 29 January, 2015 Date Effective: 1 January, 2014 Transmittal Number: OK 14-0007 TN: OK 14-0007 Date Approved: 1-29-15 Date Effective: 1-1-14

HOSPITAL PE APPLICATION State: Oklahoma Date Received: 31 March, 2014 Date Approved: 29 January, 2015 Date Effective: 1 January, 2014 Transmittal Number: OK 14-0007 TN: OK 14-0007 Date Approved: 1-29-15 Date Effective: 1-1-14

VERIFICATION OF ELIGIBILITY CRITERIA FOR HPE • Individual cannot be required to provide proof/documentation of any PE eligibility criteria – (e.g., can’t require medical verification of pregnancy) • Hospital/state must accept self-attestation of income, citizenship status, and proof of residency State: Oklahoma Date Received: 31 March, 2014 Date Approved: 29 January, 2015 Date Effective: 1 January, 2014 Transmittal Number: OK 14-0007 TN: OK 14-0007 Date Approved: 1-29-15 Date Effective: 1-1-14

APPLICATION PROCESS • AHEs will use the MAGI methodology to determine HPE eligibility based upon applicant information • AHEs will provide written notice to the member of the determination results • Hospital personnel will provide the determination, via email, to OHCA for processing • HPE Program Administrators are to oversee AHE determinations to ensure that the PE determinations and procedures are done in accordance with OHCA rules and regulations. State: Oklahoma Date Received: 31 March, 2014 Date Approved: 29 January, 2015 Date Effective: 1 January, 2014 Transmittal Number: OK 14-0007 TN: OK 14-0007 Date Approved: 1-29-15 Date Effective: 1-1-14

HOW TO INPUT/SUBMIT DATA • HPE staff will email completed and approved applications to OHCA HPE@okhca.org for processing by OHCA • If AHEs or HPE Program Administrators have any questions about the PE program, they can contact the OHCA for clarification and answers. State: Oklahoma Date Received: 31 March, 2014 Date Approved: 29 January, 2015 Date Effective: 1 January, 2014 Transmittal Number: OK 14-0007 TN: OK 14-0007 Date Approved: 1-29-15 Date Effective: 1-1-14

APPROVAL AND DENIAL NOTICES • Hospitals must provide individuals with a written notice after the HPE determination is made, which includes: -Whether the HPE was approved or denied; -If approved, beginning and ending dates of the HPE period that will be extended if the individuals files a SoonerCare application and eligibility is not determined by that time; -If denied, the reason for the denial and the option to submit a regular SoonerCare application. State: Oklahoma Date Received: 31 March, 2014 Date Approved: 29 January, 2015 Date Effective: 1 January, 2014 Transmittal Number: OK 14-0007 TN: OK 14-0007 Date Approved: 1-29-15 Date Effective: 1-1-14

APPROVAL AND DENIAL NOTICES • Hospital must notify OHCA of PE approvals (and date range for the HPE period) within five days by emailing approved applications to OHCA for processing • Hospitals will need to keep records of all PE applications for at least seven years State: Oklahoma Date Received: 31 March, 2014 Date Approved: 29 January, 2015 Date Effective: 1 January, 2014 Transmittal Number: OK 14-0007 TN: OK 14-0007 Date Approved: 1-29-15 Date Effective: 1-1-14

CONNECTING TO FULL SOONERCARE COVERAGE OUTSIDE THE HOSPITAL • Individuals can apply for full SoonerCare coverage: -Online at www.mySoonerCare.org -By mailing the paper application -In-person, at your local county OKDHS office • Individuals can find help completing the single streamlined application by calling the SoonerCare Helpline at 800-987-7767 State: Oklahoma Date Received: 31 March, 2014 Date Approved: 29 January, 2015 Date Effective: 1 January, 2014 Transmittal Number: OK 14-0007 TN: OK 14-0007 Date Approved: 1-29-15 Date Effective: 1-1-14

HOSPITAL PRESUMPTIVE ELIGIBILITY CONTACT AND ADDITIONAL RESOURCES • For questions or more information on OHCA’s Hospital Presumptive Eligibility policies, please contact: Provider Services at 800-522-0114 or 405-522-6205 option 1 • Policy and information can also be found on our public website at www.okhca.org State: Oklahoma Date Received: 31 March, 2014 Date Approved: 29 January, 2015 Date Effective: 1 January, 2014 Transmittal Number: OK 14-0007 TN: OK 14-0007 Date Approved: 1-29-15 Date Effective: 1-1-14

PE Application Hospital Information:

Screening:

EVS screen checked?  Yes  No (Note: A printout of the EVS screen must be attached to the PE application.)

Existing or former member found in EVS?  Yes  No If Yes, SoonerCare ID: __________________.

Is the member currently eligible for SoonerCare?  Yes  No If yes, which program: ____________________

Has the member had an approved PE within the past 365 days?  Yes  No

Member’s PE Program:  Pregnancy  Parent or Caretaker Relative  Child under 19

 Family Planning  Former Foster child age 18‐26 Member Demographics:

Legal Name: _____________________________________________________________________________________ (Ex: Joseph, not Joe) First name Middle Name Last Name

Maiden Name Suffix

Date of Birth: _______________ Gender:  Female  Male SSN: ___________________________

Pregnant: Yes  No If pregnant, due date: ________________ Number of babies expected:_________________

Race & Ethnicity: Check all that apply.  American Indian or Alaskan Native Asian Black or African American Native Hawaiian or other Pacific Islander  White Or  Member declined to answer

Hispanic or Latino origin:  Yes  No  Member declined to answer

Is this person a US citizen or here legally for at least five years as a qualified alien with documentation? Yes  No

If this person is here as a qualified alien, please provide the Date of Entry: ____________________

If this person is here as a qualified alien, please provide the Alien Identification Number: ______________________

Member State Residency

Does the member live in Oklahoma? Yes  No

Authorized Hospital Employee Name:

Provider ID number:

Provider’s telephone:

State: Oklahoma Date Received: 31 March, 2014 Date Approved: 29 January, 2015 Date Effective: 1 January, 2014 Transmittal Number: OK 14-0007 TN: OK 14-0007 Date Approved: 1-29-15 Date Effective: 1-1-14

PE Application

Member Contact information

Home address: ______________________________________ ___________________________________________

Street

City

State Zip

Mailing address: __________________________________________________________________________________

Street

City

State Zip

Telephone number: (____)_____‐_______ Email: _________________________________________________

Member Household Information: (This information comes from the PE Worksheet)

Number of people in the member’s household, including the member: _________

Total countable household income per month (from HPE worksheet): $___________

Other Insurance Information:

Does the member have major medical coverage or any other health insurance coverage? Yes  No

If yes, have the member provide a copy of their insurance card if available.

Provider Acknowledgement:

You are advising the OHCA of your determination that the individual applying for benefits is presumptively eligible for Medicaid based on information provided by the individual. You are responsible for assisting the individual in completing a full application for SoonerCare within the next 15 days. You acknowledge that the presumptive eligibility benefits will begin on the day the presumptive eligibility determination was made and are not retroactive. Presumptive benefits also negate any pending Notification of Date of Service (NODOS) request for backdate of coverage.

Signatures:

Member: ________________________________________

Date: ___________________

Authorized Hospital Employee: ____________________________________ Date: ___________________

HPE Program Administrator: ____________________________________ Date: ___________________

State: Oklahoma Date Received: 31 March, 2014 Date Approved: 29 January, 2015 Date Effective: 1 January, 2014 Transmittal Number: OK 14-0007 TN: OK 14-0007 Date Approved: 1-29-15 Date Effective: 1-1-14

PE Application Household Income and Size: List Other Household Members (Use Additional Pages if more space is needed)

Other Household Members

Relationship to Applicant

Total household size (including member):

_______________________

List Countable Income: (Use Additional Pages if more space is needed)

Household Member

Type/Source of Income

Amount

Frequency Monthly Total

Total household income per month:

$ _______________________

Member’s eligibility group:  Pregnancy  Child under 19  Parent or Caretaker Relative  Family Planning  Former Foster child age 18‐26

Compare member’s income with the maximum monthly income allowed based on household size:

MAXIMUM INCOME ($) Household Size Eligibility Group 1 2 3 4 5 6 7 8 9 10 Child under 19 2,043 2,753 3,463 4,175 4,885 5,594 6,306 7,016 7,726 8,438 Family Planning or Pregnancy 1,294 1,744 2,193 2,644 3,094 3,543 3,994 4,444 4,893 5,344 Parent or Caretaker Relative 467 603 759 934 1,093 1,252 1,411 1,570 1,692 1,286 Former Foster child N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A

Attestation: Based on the category of eligibility, household size, and income, I attest that (patient name)

____________________________  does  does NOT meet the criteria for presumptive eligibility.

Authorized signature: _______________________________________ Date of determination: _____________ PE Worksheet

State: Oklahoma Date Received: 31 March, 2014 Date Approved: 29 January, 2015 Date Effective: 1 January, 2014 Transmittal Number: OK 14-0007 TN: OK 14-0007 Date Approved: 1-29-15 Date Effective: 1-1-14

PE Application

Household Income and Size:

List Other Additional Household Members

Other Household Members Relationship to Applicant

Total household size (including member):

_______________________

List Countable Income:

Household Member

Type/Source of Income

Amount

Frequency Monthly Total

Total household income per month:

$ _______________________

Additional Pages State: Oklahoma Date Received: 31 March, 2014 Date Approved: 29 January, 2015 Date Effective: 1 January, 2014 Transmittal Number: OK 14-0007 TN: OK 14-0007 Date Approved: 1-29-15 Date Effective: 1-1-14

Table of Contents State/Territory Name: Oklahoma State Plan Amendment (SPA) #: 14-0014 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form 3) Approved Page

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 1301 Young Street Dallas, Texas 75202

Regional Operations Group

October 4, 2019

Our Reference: SPA OK 14-0014

Melody Anthony Chief Executive Officer 4345 N. Lincoln Blvd. Oklahoma City, Oklahoma 73105

Dear Ms. Anthony:

Enclosed is a copy of approved Oklahoma State Plan Amendment (SPA) No. 14-0014, with an effective date of July 1, 2014. This amendment was submitted to make changes to the state’s Medicaid Premiums and Cost Sharing requirements.

This letter affirms that OK 14-0014 is approved effective July 1, 2014 as requested by the State.

We are including the amended State Plan pages, the new Medicaid Model Data Lab (MMDL) pages, and the CMS-179 which lists those new and amended pages.

If you have any questions regarding this matter you may contact Stacey Shuman at 214-767-6479, or by email at stacey.shuman@cms.hhs.gov.

Sincerely,

Bill Brooks

Director

Centers for Medicaid & CHIP Services

Regional Operations Group

Cc: Billy Bob Farrell, ROG Dallas

Terri Fraser, CMS Baltimore

Sandra Puebla, OHCA

Medicaid Premiums and Cost Sharing: 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. Proposed Effective Date (mm/dd/yyyy) Federal Statute/Regulation Citation Federal Budget Impact Subject of Amendment Cost sharing increases 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: Governor's office does not review State Plan Amendments Signature of State Agency Official State/Territory name: Oklahoma OK-14-0014 07/01/2014 42 CFR 447.50 through 447.60 Federal Fiscal Year Amount First Year 2014 $ -1300731.00 Second Year 2015 $ -5202926.00   Submitted By: Sandra Puebla Last Revision Date: Sep 24, 2019 Submit Date: Sep 30, 2014 Date Received: September 30, 2014 Date Approved: October 4, 2019 Signature of Regional Official: Printed Name and Title: Bill Brooks, Director, Regional Operations Group

Medicaid Premiums and Cost Sharing: General Information, Public Notice and Comment General Information: Submission Title: short (under 100 characters) label used to identify this submission in the web application PDFs superseded by this SPA (Include Transmittal Number): Section 4, Page 54; TN# 03-12 Section 4, Page 55; TN# 03-12 Section 4, Page 56; TN# 93-06 Section 4, Page 56a; TN# 93-06 Section 4, Page 56b; TN# 92-01 Section 4, Page 56c; TN# 03-07 Section 4, Page 56d; TN# 95-01 Section 4, Page 56e; TN# 93-06 Section 4, Page 56f; TN# 93-06 Attachment 4.18-A, Page 1; TN# 10-05 Attachment 4.18-A, Page 1.1; TN# 10-05 Attachment 4.18-A, Page 2; TN# 10-05 Attachment 4.18-A, Page 3; TN# 10-05 Attachment 4.18-B, Page 1; TN# 10-05 Attachment 4.18-B, Page 2; TN# Not available Attachment 4.18-C, Page 2; TN# 03-07 Attachment 4.18-C, Page 3; TN# 03-07 Attachment 4.18-D, Page 1; TN# 92-01 Attachment 4.18-D, Page 2; TN# 92-01 Attachment 4.18-E, Page 1; TN# 92-01 Attachment 4.18-E, Page 2; TN# 92-01 Description: State Plan Amendment to revise cost sharing requirements for Oklahoma Medicaid members. State/Territory name: Oklahoma Transmittal Number: OK-14-0014 OK MPC 14-0014     State: Oklahoma Date Received: 30 September, 2014 Date Approved: 4 October, 2014 Effective Date: 1 July, 2014 Transmittal Number: 14-0014

Page 1 of 2 Medicaid Premiums and Cost Sharing State Name: Oklahoma OMB Control Number: 0938‐1148 Transmittal Number: OK - 14 - 0014 Cost Sharing Requirements G1 1916 1916A 42 CFR 447.50 through 447.57 (excluding 447.55) The state charges cost sharing (deductibles, co-insurance or co-payments) to individuals covered under Medicaid. Yes The state assures that it administers cost sharing in accordance with sections 1916 and 1916A of the Social Security Act and 42 CFR 447.50 through 447.57. ✔ General Provisions The cost sharing amounts established by the state for services are always less than the amount the agency pays for the service. ✔ No provider may deny services to an eligible individual on account of the individual's inability to pay cost sharing, except as elected by the state in accordance with 42 CFR 447.52(e)(1). ■ The process used by the state to inform providers whether cost sharing for a specific item or service may be imposed on a beneficiary and whether the provider may require the beneficiary to pay the cost sharing charge, as a condition for receiving the item or service, is (check all that apply): ■ The state includes an indicator in the Medicaid Management Information System (MMIS) The state includes an indicator in the Eligibility and Enrollment System The state includes an indicator in the Eligibility Verification System The state includes an indicator on the Medicaid card, which the beneficiary presents to the provider Other process Contracts with managed care organizations (MCOs) provide that any cost-sharing charges the MCO imposes on Medicaid enrollees are in accordance with the cost sharing specified in the state plan and the requirements set forth in 42 CFR 447.50 through 447.57. ■ Cost Sharing for Non-Emergency Services Provided in a Hospital Emergency Department The state imposes cost sharing for non-emergency services provided in a hospital emergency department. No Cost Sharing for Drugs The state charges cost sharing for drugs. Yes The state has established differential cost sharing for preferred and non-preferred drugs. No All drugs will be considered preferred drugs. ■ TN: OK 14-0014 Date Approved: 10/04/2019 Date Effective: 07/01/2014 Supersedes: NEW PAGE State: Oklahoma Date Received: 30 September, 2014 Date Approved: 4 October, 2019 Date Effective: 1 July, 2014 Transmittal Number: 14-0014

Page 2 of 2 Medicaid Premiums and Cost Sharing Beneficiary and Public Notice Requirements Consistent with 42 CFR 447.57, the state makes available a public schedule describing current cost sharing requirements in a manner that ensures that affected applicants, beneficiaries and providers are likely to have access to the notice. Prior to submitting a SPA which establishes or substantially modifies existing cost sharing amounts or policies, the state provides the public with advance notice of the SPA, specifying the amount of cost sharing and who is subject to the charges, and provides reasonable opportunity for stakeholder comment. Documentation demonstrating that the notice requirements have been met are submitted with the SPA. The state also provides opportunity for additional public notice if cost sharing is substantially modified during the SPA approval process. ✔ Other Relevant Information When changes to cost sharing are made and to meet the notice requirements to alert providers of changes in cost sharing policy, the State will initiate a notice process that is consistent with the process described in 42 CFR 447.205, which is used to inform providers and the public of any payment rate changes. This process will inform providers of any changes in Statewide method or standards for setting payment rates. To engage stakeholders, State Plan amendments and/or changes in policy are presented at regularly scheduled, bi-monthly Tribal Consultations and the proposed SPA page, noting the changes in red-line, are posted for a 30-day public review period on the Agency's website. Significant changes in rates and methodology are considered by the State Plan Rate Committee as well as the OHCA Board of Directors. In accordance with 42 CFR 447.57, member letter OHCA 2014-03 regarding the changes in co-pays was sent to all SoonerCare members and the current cost sharing public schedule is available on the Agency's public website at http://okhca.org/benefitcomparison. PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938‐1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4‐26‐05, Baltimore, Maryland 21244‐1850. V.20160722 TN: OK 14-0014 Date Approved: 10/04/2019 Date Effective: 07/01/2014 Supersedes: NEW PAGE State: Oklahoma Date Received: 30 September, 2014 Date Approved: 4 October, 2019 Date Effective: 1 July, 2014 Transmittal Number: 14-0014

Page 1 of 3 Medicaid Premiums and Cost Sharing State Name: Oklahoma OMB Control Number: 0938‐1148 Transmittal Number: OK - 14 - 0014 Cost Sharing Amounts - Categorically Needy Individuals G2a 1916 1916A 42 CFR 447.52 through 54 The state charges cost sharing to all categorically needy (Mandatory Coverage and Options for Coverage) individuals. Yes Services or Items with the Same Cost Sharing Amount for All Incomes Add Service or Item Amount Dollars or Percentage Unit Explanation Remove Add Inpatient Hospital Services 10.00 $ Day Up to $75.00 maximum Remove Add Outpatient Hospital Services 4.00 $ Visit Remove Add Organized Outpatient Clinic Services 4.00 $ Visit Remove Add Ambulatory Surgery Services 4.00 $ Visit Remove Add Physician Services 4.00 $ Visit Remove Add Physician Assistant/ Anesthesiologist Assistant 4.00 $ Visit Remove Add Advanced Practice Nurse Services 4.00 $ Visit Remove Add Optometrist Services 4.00 $ Visit Remove Add Durable Medical Equipment Services 4.00 $ Item Blood glucose testing supplies & insulin syringes have $0 copay (effective 9.1.15). Remove Add Home Health Agency Services 4.00 $ Visit Remove Add Rural Health Clinic (RHC) Services 4.00 $ Visit Remove Add Federally Qualified Health Center (FQHC) Services 4.00 $ Visit Remove Add Medicare Part B Crossover Claims 1.00 $ Visit Remove Add Behavioral health and substance abuse services - inpatient 10.00 $ Day Up to $75.00 maximum Remove Add Behavioral health and substance abuse services - outpatient 3.00 $ Visit Remove TN: OK 14-0014 Date Approved: 10/04/2019 Date Effective: 07/01/2014 Supersedes: NEW PAGE State: Oklahoma Date Received: 30 September, 2014 Date Approved: 4 October, 2019 Date Effective: 1 July, 2014 Transmittal Number: 14-0014

Page 2 of 3 Medicaid Premiums and Cost Sharing Add Service or Item Amount Dollars or Percentage Unit Explanation Remove Add Laboratory and X-ray Services 4.00 $ Visit Remove Add Prescription Drugs 4.00 $ Prescription Limited to the drug benefit under the state plan. Tobacco cessation products have $0 copay (effective 09/01/15). Prenatal vitamins have $0 copay. Birth control has a $0 copay. Naloxone have $0 copay (effective 11/01/17). Remove Add Preferred generic drugs for HCBS waiver members 0.00 $ Prescription HCBS waiver members incur tiered copays for prescription drugs through an additional benefit that is supplied through the 1915(c) HCBS waivers. Remove Add Prescription Drugs drug valued between $0 - $10.00 for HCBS waiver members 0.65 $ Prescription HCBS waiver members incur tiered copays for prescription drugs through an additional benefit that is supplied through the 1915(c) HCBS waivers. Remove Add Prescription Drugs drug valued between $10.01 - $25.00 for HCBS waiver members 1.20 $ Prescription HCBS waiver members incur tiered copays for prescription drugs through an additional benefit that is supplied through the 1915(c) HCBS waivers. Remove Add Prescription Drugs drug valued between $25.01 - $50.00 for HCBS waiver members 2.40 $ Prescription HCBS waiver members incur tiered copays for prescription drugs through an additional benefit that is supplied through the 1915(c) HCBS waivers. Remove Add Prescription Drugs drug valued at $50.01 or more for HCBS waiver members 3.50 $ Prescription HCBS waiver members incur tiered copays for prescription drugs through an additional benefit that is supplied through the 1915(c) HCBS waivers. Remove Services or Items with Cost Sharing Amounts that Vary by Income Service or Item: Remove Service or Item Indicate the income ranges by which the cost sharing amount for this service or item varies. Add Incomes Greater than Incomes Less than or Equal to Amount Dollars or Percentage Unit Explanation Remove Add Remove Add Service or Item Cost Sharing for Non-preferred Drugs Charged to Otherwise Exempt Individuals If the state charges cost sharing for non-preferred drugs (entered above), answer the following question: The state charges cost sharing for non-preferred drugs to otherwise exempt individuals. TN: OK 14-0014 Date Approved: 10/04/2019 Date Effective: 07/01/2014 Supersedes: NEW PAGE State: Oklahoma Date Received: 30 September, 2014 Date Approved: 4 October, 2019 Date Effective: 1 July, 2014 Transmittal Number: 14-0014

Page 3 of 3 Medicaid Premiums and Cost Sharing Cost Sharing for Non-emergency Services Provided in the Hospital Emergency Department Charged to Otherwise Exempt Individuals If the state charges cost sharing for non-emergency services provided in the hospital emergency department (entered above), answer the following question: The state charges cost sharing for non-emergency services provided in the hospital emergency department to otherwise exempt individuals. PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938‐1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4‐26‐05, Baltimore, Maryland 21244‐1850. V.20181119 TN: OK 14-0014 Date Approved: 10/04/2019 Date Effective: 07/01/2014 Supersedes: NEW PAGE State: Oklahoma Date Received: 30 September, 2014 Date Approved: 4 October, 2019 Date Effective: 1 July, 2014 Transmittal Number: 14-0014

Page 1 of 1 Medicaid Premiums and Cost Sharing State Name: Oklahoma OMB Control Number: 0938‐1148 Transmittal Number: OK - 14 - 0014 Cost Sharing Amounts - Medically Needy Individuals G2b 1916 1916A 42 CFR 447.52 through 54 The state charges cost sharing to all medically needy individuals. 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. V.20181119 TN: OK 14-0014 Date Approved: 10/04/2019 Date Effective: 07/01/2014 Supersedes: NEW PAGE State: Oklahoma Date Received: 30 September, 2014 Date Approved: 4 October, 2019 Date Effective: 1 July, 2014 Transmittal Number: 14-0014

Page 1 of 1 Medicaid Premiums and Cost Sharing State Name: Oklahoma OMB Control Number: 0938‐1148 Transmittal Number: OK - 14 - 0014 Cost Sharing Amounts - Targeting G2c 1916 1916A 42 CFR 447.52 through 54 The state targets cost sharing to a specific group or groups of individuals. 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. V.20181119 TN: OK 14-0014 Date Approved: 10/04/2019 Date Effective: 07/01/2014 Supersedes: NEW PAGE State: Oklahoma Date Received: 30 September, 2014 Date Approved: 4 October, 2019 Date Effective: 1 July, 2014 Transmittal Number: 14-0014

Page 1 of 6 Medicaid Premiums and Cost Sharing State Name: Oklahoma OMB Control Number: 0938‐1148 Transmittal Number: OK - 14 - 0014 Cost Sharing Limitations G3 42 CFR 447.56 1916 1916A The state administers cost sharing in accordance with the limitations described at 42 CFR 447.56, and 1916(a)(2) and (j) and 1916A(b) of the Social Security Act, as follows: ✔ Exemptions Groups of Individuals - Mandatory Exemptions The state may not impose cost sharing upon the following groups of individuals: Individuals ages 1 and older, and under age 18 eligible under the Infants and Children under Age 18 eligibility group (42 CFR 435.118). ■ Infants under age 1 eligible under the Infants and Children under Age 18 eligibility group (42 CFR 435.118), whose income does not exceed the higher of: ■ 133% FPL; and ■ If applicable, the percent FPL described in section 1902(l)(2)(A)(iv) of the Act, up to 185 percent. ■ Disabled or blind individuals under age 18 eligible for the following eligibility groups: ■ SSI Beneficiaries (42 CFR 435.120). ■ Blind and Disabled Individuals in 209(b) States (42 CFR 435.121). ■ Individuals Receiving Mandatory State Supplements (42 CFR 435.130). ■ Children for whom child welfare services are made available under Part B of title IV of the Act on the basis of being a child in foster care and individuals receiving benefits under Part E of that title, without regard to age. ■ Disabled children eligible for Medicaid under the Family Opportunity Act (1902(a)(10)(A)(ii)(XIX) and 1902(cc) of the Act). ■ Pregnant women, during pregnancy and through the postpartum period which begins on the last day of pregnancy and extends through the end of the month in which the 60-day period following termination of pregnancy ends, except for cost sharing for services specified in the state plan as not pregnancy-related. ■ Any individual whose medical assistance for services furnished in an institution is reduced by amounts reflecting available income other than required for personal needs. ■ An individual receiving hospice care, as defined in section 1905(o) of the Act. ■ Indians who are currently receiving or have ever received an item or service furnished by an Indian health care provider or through referral under contract health services. ■ Individuals who are receiving Medicaid because of the state's election to extend coverage to the Certain Individuals Needing Treatment for Breast or Cervical Cancer eligibility group (42 CFR 435.213). ■ TN: OK 14-0014 Date Approved: 10/04/2019 Date Effective: 07/01/2014 Supersedes: NEW PAGE State: Oklahoma Date Received: 30 September, 2014 Date Approved: 4 October, 2019 Date Effective: 1 July, 2014 Transmittal Number: 14-0014

Page 2 of 6 Medicaid Premiums and Cost Sharing Groups of Individuals - Optional Exemptions The state may elect to exempt the following groups of individuals from cost sharing: The state elects to exempt individuals under age 19, 20 or 21, or any reasonable category of individuals 18 years of age or over. Yes Indicate below the age of the exemption: Under age 19 Under age 20 Under age 21 Other reasonable category The state elects to exempt individuals whose medical assistance for services furnished in a home and community-based setting is reduced by amounts reflecting available income other than required for personal needs. No Services - Mandatory Exemptions The state may not impose cost sharing for the following services: Emergency services as defined at section 1932(b)(2) of the Act and 42 CFR 438.114(a). ■ Family planning services and supplies described in section 1905(a)(4)(C) of the Act, including contraceptives and pharmaceuticals for which the state claims or could claim federal match at the enhanced rate under section 1903(a)(5) of the Act for family planning services and supplies. ■ Preventive services, at a minimum the services specified at 42 CFR 457.520, provided to children under 18 years of age regardless of family income, which reflect the well-baby and well child care and immunizations in the Bright Futures guidelines issued by the American Academy of Pediatrics. ■ Pregnancy-related services, including those defined at 42 CFR 440.210(a)(2) and 440.250(p), and counseling and drugs for cessation of tobacco use. All services provided to pregnant women will be considered pregnancy-related, except those services specificially identified in the state plan as not being related to pregnancy. ■ Provider-preventable services as defined in 42 CFR 447.26(b). ■ Enforceability of Exemptions The procedures for implementing and enforcing the exemptions from cost sharing contained in 42 CFR 447.56 are (check all that apply): To identify that American Indians/Alaskan Natives (AI/AN) are currently receiving or have ever received an item or service furnished by an Indian health care provider or through referral under contract health services in accordance with 42 CFR 447.56(a)(1)(x), the state uses the following procedures: ■ The state accepts self-attestation The state runs periodic claims reviews The state obtains an Active or Previous User Letter or other Indian Health Services (IHS) document The Eligibility and Enrollment and MMIS systems flag exempt recipients TN: OK 14-0014 Date Approved: 10/04/2019 Date Effective: 07/01/2014 Supersedes: NEW PAGE State: Oklahoma Date Received: 30 September, 2014 Date Approved: 4 October, 2019 Date Effective: 1 July, 2014 Transmittal Number: 14-0014

Page 3 of 6 Medicaid Premiums and Cost Sharing Other procedure Additional description of procedures used is provided below (optional): The State undertakes the following processes to ensure individuals who meet cost sharing exemptions as per 42 CFR 447.56(a)(1)(x) are not assessed cost sharing: • An automatic, periodic claims review which examines members' claims to verify if they have incurred a paid claim from an Indian Health facility or contracted health services provider. When applicable, the information is loaded into MMIS to ensure no cost sharing is applied.

• The Agency's accepts self-attestation in accordance with 42 CFR 447.56(a)(1)(x) in the following way: - From September 1, 2019 to June 30, 2020, the State will accept verbal self-attestation (i.e., via telephone) for individuals who meet the requirements for cost sharing exemptions as per the federal regulation noted above during the interim period while the State makes necessary changes to the online application for self-attestation cost sharing exemptions. Individuals will need to verbally respond “yes” when asked if they are AI/AN and must also respond “yes” when asked if they are eligible to receive, is currently receiving, or has ever received an item or service furnished by an Indian health care provider or through referral under contract health services. In order to be exempt from cost sharing, there must be an affirmative answer to both questions from the individual(s). The State accepts verbal self-attestation at face value based on the aforementioned process and will not conduct or require any other verification. The verbal self- attestation mirrors the self-attestation process that the online application will apply beginning July 1, 2020. - Beginning July 1, 2020, the online SoonerCare application will ask the applicant(s) whether they are AI/AN; if the applicant(s) responds "yes", a follow-up question will require an answer as to whether the applicant(s) is eligible to receive, is currently receiving, or has ever received an item or service furnished by an Indian health care provider or through referral under contract health services. If the applicant(s) responds "yes" to the second question, the applicant(s) will be exempt from all cost sharing. In order to be exempt from cost sharing, there must be an affirmative answer to both questions from the applicant(s). The State accepts self-attestation at face value based on the aforementioned process and will not conduct or require any other verification.

To identify all other individuals exempt from cost sharing, the state uses the following procedures (check all that apply): ■ The MMIS system flags recipients who are exempt The Eligibility and Enrollment System flags recipients who are exempt The Medicaid card indicates if beneficiary is exempt The Eligibility Verification System notifies providers when a beneficiary is exempt Other procedure Additional description of procedures used is provided below (optional): MMIS is programmed not to deduct copayments from claims for Medicaid recipients and services that are exempt from cost sharing as identified in 42 CFR 447.56(a). Payments to Providers The state reduces the payment it makes to a provider by the amount of a beneficiary's cost sharing obligation, regardless of whether the provider has collected the payment or waived the cost sharing, except as provided under 42 CFR 447.56(c). ✔ TN: OK 14-0014 Date Approved: 10/04/2019 Date Effective: 07/01/2014 Supersedes: NEW PAGE State: Oklahoma Date Received: 30 September, 2014 Date Approved: 4 October, 2019 Date Effective: 1 July, 2014 Transmittal Number: 14-0014

Page 4 of 6 Medicaid Premiums and Cost Sharing Payments to Managed Care Organizations The state contracts with one or more managed care organizations to deliver services under Medicaid. No Aggregate Limits Medicaid premiums and cost sharing incurred by all individuals in the Medicaid household do not exceed an aggregate limit of 5 percent of the family's income applied on a quarterly or monthly basis. ✔ The percentage of family income used for the aggregate limit is: ■ 5% 4% 3% 2% 1% Other: % The state calculates family income for the purpose of the aggregate limit on the following basis: ■ Quarterly Monthly The state has a process to track each family's incurred premiums and cost sharing through a mechanism that does not rely on beneficiary documentation. Yes Describe the mechanism by which the state tracks each family's incurred premiums and cost sharing (check all that apply): ■ As claims are submitted for dates of services within the family's current monthly or quarterly cap period, the state applies the incurred cost sharing for that service to the family's aggregate limit. Once the family reaches the aggregate limit, based on incurred cost sharing and any applicable premiums, the state notifies the family and providers that the family has reached their aggregate limit for the current monthly or quarterly cap period, and are no longer subject to premiums or cost sharing. Managed care organization(s) track each family's incurred cost sharing, as follows: Other process: The agency considers all cost sharing to be paid by the beneficiary in the calculation of whether a beneficiary has incurred out-of-pocket expenses up to the family's aggregate limit. The State's MMIS calculates family income for the purpose of the aggregate limit on a monthly basis. To accommodate households in different delivery systems (i.e., ABD and TANF combined families; MCO and PCCM or different forms of managed care combined families; managed care and fee-for-service combined families), cost sharing is tracked for each beneficiary and a report is provided to Agency staff to analyze and ensure the beneficiary out-of-pocket expenses do not exceed the family's aggregate limit. TN: OK 14-0014 Date Approved: 10/04/2019 Date Effective: 07/01/2014 Supersedes: NEW PAGE State: Oklahoma Date Received: 30 September, 2014 Date Approved: 4 October, 2019 Date Effective: 1 July, 2014 Transmittal Number: 14-0014

Page 5 of 6 Medicaid Premiums and Cost Sharing Describe how the state informs beneficiaries and providers of the beneficiaries' aggregate family limit and notifies beneficiaries and providers when a beneficiary has incurred premiums and cost sharing up to the aggregate family limit and individual family members are no longer subject to premiums or cost sharing for the remainder of the family's current monthly or quarterly cap period: ■ The Agency informs beneficiaries of their aggregate household cost sharing cap amount upon eligibility determination via a member letter or a secure e-message. A separate notification will be issued to beneficiaries when they have incurred premiums and cost sharing up to the aggregate family limit and are no longer subject to premiums or cost- sharing on a monthly basis. Beneficiaries of households in different delivery systems (i.e., ABD and TANF combined families; MCO and PCCM or different forms of managed care combined families; managed care and fee-for-service combined families) are informed via a member letter or a secure e-message of their aggregate household cost sharing cap amount as well as when they have incurred premiums and cost sharing up to the aggregate family limit and are no longer subject to premiums or cost sharing during any monthly cap period.

Providers have access to a secure electronic portal which allows them to determine if a member is subject to a copay. When individual family members are no longer subject to cost sharing for the remainder of the family's monthly cap period, the secure electronic portal will reflect that the member should not be charged a copay prompting the provider to notify the member. A zero dollar copay is indicated for those members/services not subject to cost sharing. The state has a documented appeals process for families that believe they have incurred premiums or cost sharing over the aggregate limit for the current monthly or quarterly cap period. Yes Describe the appeals process used: Members can appeal the calculation of the aggregate cap; members are also notified of appeal rights at the initial eligibility determination and upon redetermination of the member's eligibility. Members may contact the SoonerCare Helpline at 1-800-987-7767. A representative will review the Member Cost Sharing information in the MMIS to be able to determine the amount of cost sharing that has been processed in the current review period and verify if the member has made over payments in cost sharing. Member Services and Provider Services Representatives educate providers to refund members who have overpaid cost sharing. Members have the right to appeal the decision through the official OHCA member appeals process as per Oklahoma Administrative Code (OAC): 317:2-1-2. Describe the process used to reimburse beneficiaries and/or providers if the family is identified as paying over the aggregate limit for the month/quarter: ■ The MMIS system tracks cost sharing expenditures incurred across household members and re-sets at the beginning of each month. Systematic tracking of cost sharing occurs in real time as claims are adjudicated in MMIS. Providers have access through a secure electronic portal to information that the member should not be charged a copay. Further, if the member is identified as paying over the aggregate limit for the month, the provider will issue reimbursement to the member. If the State is responsible for reimbursement to the provider, the State will re-process the claim with provider and notify provider to reimburse the member. Describe the process for beneficiaries to request a reassessment of their family aggregate limit if they have a change in circumstances or if they are being terminated for failure to pay a premium: ■ Members can request a reassessment of their 5% aggregate cap when they update information regarding their change in circumstances at any time using Oklahoma's online application or they can call the SoonerCare Helpline to have a representative update their information. The state imposes additional aggregate limits, consistent with 42 CFR 447.56(f)(5). No TN: OK 14-0014 Date Approved: 10/04/2019 Date Effective: 07/01/2014 Supersedes: NEW PAGE State: Oklahoma Date Received: 30 September, 2014 Date Approved: 4 October, 2019 Date Effective: 1 July, 2014 Transmittal Number: 14-0014

Page 6 of 6 Medicaid Premiums and Cost Sharing PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938‐1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4‐26‐05, Baltimore, Maryland 21244‐1850. V.20160722 TN: OK 14-0014 Date Approved: 10/04/2019 Date Effective: 07/01/2014 Supersedes: NEW PAGE State: Oklahoma Date Received: 30 September, 2014 Date Approved: 4 October, 2019 Date Effective: 1 July, 2014 Transmittal Number: 14-0014

54 State/Territory: OKLAHOMA 4.18 Recipient Cost Sharing and Similar Charges THIS PAGE LEFT INTENTIONALLY BLANK Revised 07-01-14 TN # ___________ Approval Date ________ Effective Date ___________ Supersedes TN # ____________ OK 14-0014 10/04/2019 07/01/2014 03-0012 State: Oklahoma Date Received: 30 September, 2014 Date Approved: 4 October, 2019 Effective Date: 1 July, 2014 Transmittal Number: 14-0014

55 State/Territory: OKLAHOMA 4.18(b)(2) (continued) THIS PAGE LEFT INTENTIONALLY BLANK Revised 07-01-14 TN # ___________ Approval Date Effective Date ____________ Supersedes TN # ____________ OK 14-0014 10/04/2019 07/01/2014 03-0012 State: Oklahoma Date Received: 30 September, 2014 Date Approved: 4 October, 2019 Effective Date: 1 July, 2014 Transmittal Number: 14-0014

56 Revision: HCFA-PM-91-4 (BPD) OMB No.: 0938- AUGUST 1991 State/Territory: OKLAHOMA 4.18(b) (continued) THIS PAGE LEFT INTENTIONALLY BLANK Revised 07-01-14 TN# ___________ Approval Date Effective Date ____________ Supersedes TN# ____________ OK 14-0014 10/04/2019 07/01/2014 93-0006 State: Oklahoma Date Received: 30 September, 2014 Date Approved: 4 October, 2019 Effective Date: 1 July, 2014 Transmittal Number: 14-0014

56a Revision: HCFA-PM-91-4 (BPD) OMB No.: 0938- AUGUST 1991 State/Territory: OKLAHOMA 4.18(b)(3) (continued) THIS PAGE LEFT INTENTIONALLY BLANK Revised 07-01-14 TN# ___________ Approval Date Effective Date ____________ Supersedes TN# ____________ OK 14-0014 10/04/2019 07/01/2014 93-0006 State: Oklahoma Date Received: 30 September, 2014 Date Approved: 4 October, 2019 Effective Date: 1 July, 2014 Transmittal Number: 14-0014

56b Revision: HCFA-PM-91-4 (BPD) OMB No.: 0938- AUGUST 1991 State/Territory: OKLAHOMA 4.18(b)(4) THIS PAGE LEFT INTENTIONALLY BLANK Revised 07-01-14 TN# ___________ Approval Date Effective Date ____________ Supersedes TN# ____________ OK 14-0014 10/04/2019 07/01/2014 92-0001 State: Oklahoma Date Received: 30 September, 2014 Date Approved: 4 October, 2019 Effective Date: 1 July, 2014 Transmittal Number: 14-0014

56c Revision: HCFA-PM-91-4 (BPD) OMB No.: 0938- AUGUST 1991 State: OKLAHOMA 4.18(c) THIS PAGE LEFT INTENTIONALLY BLANK Revised 07-01-14 TN# ___________ Approval Date Effective Date ____________ Supersedes TN# ____________ OK 14-0014 10/04/2019 07/01/2014 03-0007 State: Oklahoma Date Received: 30 September, 2014 Date Approved: 4 October, 2019 Effective Date: 1 July, 2014 Transmittal Number: 14-0014

56d Revision: HCFA-PM-91-4 (BPD) OMB No.: 0938- AUGUST 1991 State: OKLAHOMA 4.18(c)(2) (continued) THIS PAGE LEFT INTENTIONALLY BLANK Revised 07-01-14 TN# ___________ Approval Date Effective Date ____________ Supersedes TN# ____________ OK 14-0014 10/04/2019 07/01/2014 95-0001 State: Oklahoma Date Received: 30 September, 2014 Date Approved: 4 October, 2019 Effective Date: 1 July, 2014 Transmittal Number: 14-0014

56e Revision: HCFA-PM-91-4 (BPD) OMB No.: 0938- AUGUST 1991 State/Territory: OKLAHOMA 4.18(c)(3) THIS PAGE LEFT INTENTIONALLY BLANK Revised 07-01-14 TN# ___________ Approval Date Effective Date ____________ Supersedes TN# ____________ OK 14-0014 10/04/2019 07/01/2014 93-0006 State: Oklahoma Date Received: 30 September, 2014 Date Approved: 4 October, 2019 Effective Date: 1 July, 2014 Transmittal Number: 14-0014

56f Revision: HCFA Region VI OMB No.: 0938- SEPTEMBER 1992 State/Territory: OKLAHOMA 4.18(c)(3) (continued) THIS PAGE LEFT INTENTIONALLY BLANK Revised 07-01-14 TN# ___________ Approval Date Effective Date ____________ Supersedes TN# ___________ OK 14-0014 10/04/2019 07/01/2014 93-0006 State: Oklahoma Date Received: 30 September, 2014 Date Approved: 4 October, 2019 Effective Date: 1 July, 2014 Transmittal Number: 14-0014

Revision: HCFA-PM-85-14 (BERC) ATTACHMENT 4.18-A SEPTEMBER 1985 Page 1 OMB N): 0938-0193 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: Oklahoma THIS PAGE LEFT INTENTIONALLY BLANK Revised 07-01-14 TN # _________ Approval Date ______________ Effective Date ______________ Supersedes TN # _________ OK 14-0014 10/04/2019 07/01/2014 10-0005 State: Oklahoma Date Received: 30 September, 2014 Date Approved: 4 October, 2019 Effective Date: 1 July, 2014 Transmittal Number: 14-0014

Revision: HCFA-PM-85-14 (BERC) ATTACHMENT 4.18-A SEPTEMBER 1985 Page 1.1 OMB N): 0938-0193 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: Oklahoma THIS PAGE LEFT INTENTIONALLY BLANK Revised 07-01-14 TN # _________ Approval Date ____________ Effective Date ____________ Supersedes TN # _________ OK 14-0014 10/04/2019 07/01/2014 10-0005 State: Oklahoma Date Received: 30 September, 2014 Date Approved: 4 October, 2019 Effective Date: 1 July, 2014 Transmittal Number: 14-0014

Revision: HCFA-PM-85-14 (BERC) ATTACHMENT 4.18-A SEPTEMBER 1985 Page 2 OMB N): 0938-0193 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: Oklahoma THIS PAGE LEFT INTENTIONALLY BLANK Revised 07-01-14 TN # _________ Approval Date ____________ Effective Date _____________ Supersedes TN # _________ OK 14-0014 10/04/2019 07/01/2014 10-0005 State: Oklahoma Date Received: 30 September, 2014 Date Approved: 4 October, 2019 Effective Date: 1 July, 2014 Transmittal Number: 14-0014

Revision: HCFA-PM-85-14 (BERC) ATTACHMENT 4.18-A SEPTEMBER 1985 Page 3 OMB N): 0938-0193 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: Oklahoma THIS PAGE LEFT INTENTIONALLY BLANK Revised 07-01-14 TN # _________ Approval Date ____________ Effective Date _____________ Supersedes TN # _________ OK 14-0014 10/04/2019 07/01/2014 10-0005 State: Oklahoma Date Received: 30 September, 2014 Date Approved: 4 October, 2019 Effective Date: 1 July, 2014 Transmittal Number: 14-0014

MSA-PI-74-6 ATTACHMENT 4.18-B FEBRUARY 26, 1974 Page 1 State: Oklahoma STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT THIS PAGE LEFT INTENTIONALLY BLANK Revised 07-01-14 TN # _________ Approval Date ____________ Effective Date _____________ Supersedes TN # _________ OK 14-0014 10/04/2019 07/01/2014 10-0005 State: Oklahoma Date Received: 30 September, 2014 Date Approved: 4 October, 2019 Effective Date: 1 July, 2014 Transmittal Number: 14-0014

MSA-PI-74-6 ATTACHMENT 4.18-B February 28, 1974 Page 2 State: Oklahoma STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT THIS PAGE LEFT INTENTIONALLY BLANK Revised 07-01-14 TN # _________ Approval Date ____________ Effective Date _____________ Supersedes TN # _________ OK 14-0014 10/04/2019 07/01/2014 74-0093 State: Oklahoma Date Received: 30 September, 2014 Date Approved: 4 October, 2019 Effective Date: 1 July, 2014 Transmittal Number: 14-0014

Revision: HCFA-PM-85-14 (BERC) ATTACHMENT 4.18-C SEPTEMBER 1985 Page 2 State: Oklahoma THIS PAGE LEFT INTENTIONALLY BLANK Revised 07-01-14 TN # _________ Approval Date ____________ Effective Date _____________ Supersedes TN # _________ OK 14-0014 10/04/2019 07/01/2014 03-0007 State: Oklahoma Date Received: 30 September, 2014 Date Approved: 4 October, 2019 Effective Date: 1 July, 2014 Transmittal Number: 14-0014

Revision: HCFA-PM-85-14 (BERC) ATTACHMENT 4.18-C SEPTEMBER 1985 Page 3 State: Oklahoma STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT THIS PAGE LEFT INTENTIONALLY BLANK Revised 07-01-14 TN # _________ Approval Date ____________ Effective Date _____________ Supersedes TN # _________ OK 14-0014 10/04/2019 07/01/2014 03-0007 State: Oklahoma Date Received: 30 September, 2014 Date Approved: 4 October, 2019 Effective Date: 1 July, 2014 Transmittal Number: 14-0014

Revision: HCFA-PM-91-4 (BPD) ATTACHMENT 4.18-D AUGUST 1991 Page 1 OMB No.: 0938- STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State/Territory: Oklahoma THIS PAGE LEFT INTENTIONALLY BLANK Revised 07-01-14 TN # _________ Approval Date ____________ Effective Date _____________ Supersedes TN # _________ OK 14-0014 10/04/2019 07/01/2014 92-0001 State: Oklahoma Date Received: 30 September, 2014 Date Approved: 4 October, 2019 Effective Date: 1 July, 2014 Transmittal Number: 14-0014

Revision: HCFA-PM-91-4 (BPD) ATTACHMENT 4.18-D AUGUST 1991 Page 2 OMB No.: 0938- STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State/Territory: Oklahoma THIS PAGE LEFT INTENTIONALLY BLANK Revised 07-01-14 TN # _________ Approval Date ____________ Effective Date _____________ Supersedes TN # _________ OK 14-0014 10/04/2019 07/01/2014 92-0001 State: Oklahoma Date Received: 30 September, 2014 Date Approved: 4 October, 2019 Effective Date: 1 July, 2014 Transmittal Number: 14-0014

Revision: HCFA-PM-91-4 (BPD) ATTACHMENT 4.18-E AUGUST 1991 Page 1 OMB No.: 0938- STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State/Territory: Oklahoma THIS PAGE LEFT INTENTIONALLY BLANK Revised 07-01-14 TN # _________ Approval Date ____________ Effective Date _____________ Supersedes TN # _________ OK 14-0014 10/04/2019 07/01/2014 92-0001 State: Oklahoma Date Received: 30 September, 2014 Date Approved: 4 October, 2019 Effective Date: 1 July, 2014 Transmittal Number: 14-0014

Revision: HCFA-PM-91-4 (BPD) ATTACHMENT 4.18-E AUGUST 1991 Page 2 OMB No.: 0938- STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State/Territory: Oklahoma THIS PAGE LEFT INTENTIONALLY BLANK Revised 07-01-14 TN # _________ Approval Date ____________ Effective Date _____________ Supersedes TN # _________ OK 14-0014 10/04/2019 07/01/2014 92-0001 State: Oklahoma Date Received: 30 September, 2014 Date Approved: 4 October, 2019 Effective Date: 1 July, 2014 Transmittal Number: 14-0014

Table of Contents

State/Territory Name: Oklahoma State Plan Amendment (SPA) #: 15-0008 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form 3) Approved SPA Page

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Dallas Regional Office 1301 Young Street, Suite 833 Dallas, Texas 75202 DIVISION OF MEDICAID & CHILDREN’S HEALTH - REGION VI

December 22, 2015 Dr. Garth Splinter State Medicaid Director Oklahoma Health Care Authority 4345 North Lincoln Blvd. Oklahoma City, OK, 73105 Our Reference: SPA OK 15-008 Dear Dr. Splinter: We have reviewed the State's proposed amendment to the Oklahoma State Plan submitted under Transmittal Number 15-08, dated September 26, 2015. This state plan amendment corrects the Relative Value Unit (RVU) practice expense for physician services provided in a facility setting. Based on the information submitted, we have approved the amendment for incorporation into the official Oklahoma State Plan with an effective date change of July 1, 2015. A copy of the CMS- 179 and approved plan page are enclosed with this letter. If you have questions, please contact Suzette Seng at (214) 767-6478. Bill Brooks Associate Regional Administrator Cc: Tywanda Cox

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB No. 0938-0193 1. TRANSMITTAL NUMBER 2. STATE 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID TO: REGIONAL ADMINISTRATOR 4. PROPOSED EFFECTIVE DATE CENTERS FOR MEDICARE & MEDICAID SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL (Check One) NEW STATE PLAN AMENDMENT TO BE CONSIDERED AS A NEW PLAN x AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate transmittal for each amendment) 6. FEDERAL STATUTE/REGULATION CITATION 7. FEDERAL BUDGET IMPACT $ $ 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable) 10. SUBJECT OF AMENDMENT 11. GOVERNOR'S REVIEW (Check One) GOVERNOR'S OFFICE REPORTED NO COMMENT X OTHER, AS SPECIFIED COMMENTS OF GOVERNOR'S OFFICE ENCLOSED The Governor does not review State NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL Plan material. 12. SIGNATURE OF STATE AGENCY OFFICIAL 16. RETURN TO 13. TYPED NAME 14. TITLE 15. DATE SUBMITTED FOR REGIONAL OFFICE USE ONLY 17. DATE RECEIVED 18. DATE APPROVED PLAN APPROVED - ONE COPY ATTACHED 19. EFFECTIVE DATE OF APPROVED MATERIAL 20. SIGNATU L 21. TYPED NAME 22. TITLE 23. REMARKS c: Nico Gomez Garth Splinter Tywanda Cox FORM CMS-179 (07/92) (1,148,906) (4,498,991) a. FFY 2015 b. FFY 2016 Attachment 4.19-B, Page 3 Chief Executive Officer OHCA will apply the correct RVU practice expense similar to Medicare for physician services performed in a facility setting instead of always using the non-facility rate Oklahoma Health Care Authority Attn: Tywanda Cox 4345 N. Lincoln Blvd Oklahoma City, OK 73105 July 1, 2015 Oklahoma 1 5 0 8 TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL Same Page, Revised 07-01-14, TN #14-0020 FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES 42 CFR 440.50 Joel Nico Gomez 22 December 2015 1 July 2015 Bill Brooks Asscociate Regional Administrator Division of Medicaid & Children's Health 26 September 2015

State: OKLAHOMA Attachment 4.19-B Page 3 METHODS AND STANDARDS FOR ESTABLISHING RATES OTHER TYPES OF CARE 1. Payment for physicians’ services (includes medical and remedial care and services) Payment for physician’s services, radiology services and services rendered by other practitioners under the scope of their practice under State law, are covered under the Agency fee schedule. The payment amount for each service paid under the fee schedule is the product of a uniform relative value unit (RVU) for each service and a conversion factor (CF). The CF converts the relative values into payment amounts. The general formula for calculating the fee schedule can be expressed as: RVU x CF = Rate ESPDT screenings and eye exams by optometrists have been incorporated into the fee schedule The fee schedule is uniformly applied to public and private providers unless otherwise described in the plan. The fee schedules for the above listed services are maintained in the Agency database and posted to the Agency’s website (www.okhca.org). Effective February 1, 2010, payment will not be made to physicians or other practitioners for three national coverage demonstrations which relate to serious, preventable errors in medical care. These errors include surgery performed on wrong body part, surgery performed on wrong patient, and wrong surgery performed on patient. Effective for services provided on or after 04-01-10, the rates in effect on 03-31-10 will be decreased by 3.25%. Effective for services provided on or after 07-01-14, the rates in effect on 06-30-14 will be decreased by 7.75%. Effective 07-01-15, payment for physician services is based on place of service and utilizes both facility and non-facility Medicare physician fee schedule total RVUs to determine reimbursement. Revised 07-01-15 TN#______________ Approval Date_______________ Effective Date________________ Supersedes TN #_______________ 15-008 7/01/15 12/22/15 14-0020 0 State: Oklahoma Date Received: September 26, 2015 Date Approved: December 22, 2015 Date Effective: July 1, 2015 Transmittal Number: 15-0008

Table of Contents

State/Territory Name: Oklahoma State Plan Amendment (SPA) #: 16-0015 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form 3) Approved Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Dallas Regional Office 1301 Young Street, Suite 833 Dallas, Texas 75202 DIVISION OF MEDICAID & CHILDREN’S HEALTH - REGION VI April 21, 2016 Our Reference: SPA OK 16-15 Becky Pasternik-Ikard State Medicaid Director 2401 NW 23rd Street, Suite 1A Oklahoma City, Oklahoma 73107 Dear Ms. Pasternik-Ikard: We have reviewed the State’s proposed amendment to the Oklahoma State Plan submitted under Transmittal Number 16-15, dated February 10, 2016. This state plan amendment clarifies the Hospital Presumptive Eligibility performance standard metrics. Based on the information submitted, we have approved the amendment for incorporation into the official Oklahoma State Plan with an effective date change of January 1, 2016. A copy of the CMS-179 and approved plan page are enclosed with this letter. If you have any questions, please contact Suzette Seng of my staff at (214) 767-6478 or by email at suzette.seng@cms.hhs.gov. Sincerely, Bill Brooks Associate Regional Administrator Cc: Melinda Thomason Sandra Puebla Tywanda Cox 1

State/Territory name: Oklahoma Submitted By: Tywanda Cox Last Revision Date: Mar 8, 2016 Submit Date: Mar 8, 2016 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. 16-15 Proposed Effective Date 01/01/2016 (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 Update to Hospital Presumptive Eligibility Slides 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: Governor's Office does not review State Plan Amendments. Signature of State Agency Official Page 1 of 2 Official Submission Date: February 10, 2016 (Was officially submitted to SPA/Waiver Mailbox on 2/10/16)

Page 2 of 2 February 10, 2016 January 1, 2016 April 21, 2016 Bill Brooks Associate Regional Adminstrator Division of Medicaid and Children's Health CMS 179

HPE PERFORMANCE STANDARDS • Provider (hospital facility) has at least 95 percent of individuals determined eligible for HPE submit the full SoonerCare application within the required time frame of 15 days after the HPE application is completed. • Provider has at least 95 percent of individuals determined eligible for HPE who submit a full SoonerCare application are found by the OHCA to be eligible for SoonerCare. S12- Page 20 of 47 TN: 16-15 Date Approved: 04/21/16 Date Effective: 01/01/16 Superseded By: TN 14-07 MM7 State: Oklahoma Date Received: February 10, 2016 Date Approved: April 21, 2016 Date Effective: January 1, 2016

HPE PERFORMANCE STANDARDS • Provider has at least 99 percent of HPE applications include an Eligibility Verification Check with the HPE application using the OHCA’s Secure Provider Portal. S12- Page 21 of 47 TN: 16-15 Date Approved: 04/21/16 Date Effective: 01/01/16 Superseded By: TN 14-07 MM7 State: Oklahoma Date Received: February 10, 2016 Date Approved: April 21, 2016 Date Effective: January 1, 2016

Table of Contents State/Territory Name: Oklahoma State Plan Amendment (SPA) #: 18-006 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form 3) Approved Page

1

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Dallas Regional Office 1301 Young Street, Suite 833 Dallas, Texas 75202

DIVISION OF MEDICAID & CHILDREN’S HEALTH - REGION VI

July 12, 2018

Our Reference: SPA OK 18-06

Becky Pasternik-Ikard Chief Executive Officer 4345 N. Lincoln Blvd. Oklahoma City, Oklahoma 73105

Dear Ms. Pasternik-Ikard:

Enclosed is a copy of approved Oklahoma State Plan Amendment (SPA) No. 18-06, with an effective date of September 1, 2018. This amendment was submitted update the state’s Early and Periodic Screening, Diagnostic and Treatment (EPSDT) periodicity schedule.

This letter affirms that OK 18-06 is approved effective September 1, 2018 as requested by the State.

We are enclosing the CMS-179 and the following amended plan pages.

o Attachment 3.1-A, 1a-6

If you have any questions regarding this matter you may contact Stacey Shuman at 214-767- 6479, or by email at stacey.shuman@cms.hhs.gov.

Sincerely,

Bill Brooks

Associate Regional Administrator

CC: Billy Bob Farrell, DMCH Dallas

Stacey Shuman, DMCH Dallas

Rachel Dressel, CMS Baltimore

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB No. 0938-0193 1. TRANSMITTAL NUMBER 2. STATE 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) TO: REGIONAL ADMINISTRATOR 4. PROPOSED EFFECTIVE DATE CENTERS FOR MEDICARE & MEDICAID SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL (Check One) NEW STATE PLAN AMENDMENT TO BE CONSIDERED AS A NEW PLAN x AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate transmittal for each amendment) 6. FEDERAL STATUTE/REGULATION CITATION 7. FEDERAL BUDGET IMPACT $ $ 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable) 10. SUBJECT OF AMENDMENT 11. GOVERNOR'S REVIEW (Check One) GOVERNOR'S OFFICE REPORTED NO COMMENT X OTHER, AS SPECIFIED COMMENTS OF GOVERNOR'S OFFICE ENCLOSED The Governor does not review State NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL Plan material. 12. SIGNATURE OF STATE AGENCY OFFICIAL 16. RETURN TO 13. TYPED NAME 14. TITLE 15. DATE SUBMITTED FOR REGIONAL OFFICE USE ONLY 17. DATE RECEIVED 18. DATE APPROVED PLAN APPROVED - ONE COPY ATTACHED 19. EFFECTIVE DATE OF APPROVED MATERIAL 20. S 21. TYPED NAME 22. TITLE 23. REMARKS c: Becky Pasternik-Ikard Tywanda Cox FORM CMS-179 (07/92) May 30, 2018 $130,007 $1,661,573 a. FFY 2018 b. FFY 2019 May 30, 2018 Attachment 3.1-A, Page 1a-6 Chief Executive Officer Update the EPSDT periodicty schedule within the State Plan Oklahoma Health Care Authority Attn: Tywanda Cox 4345 N. Lincoln Blvd. Oklahoma City, OK 73105 September 1, 2018 Oklahoma 1 8 0 6 Bill Brooks July 12, 2018 Associate Regional Administrator (ARA), Division of Medicaid and Children's Health TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL Attachment 3.1-A, Page 1a-6; TN # 06-15 FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES September 1, 2018 42 CFR 440.40(b); 42 CFR 441.58 Becky Pasternik-Ikard

State: OKLAHOMA Attachment 3.1-A Page 1a-6 AMOUNT, DURATION AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED CATEGORICALLY NEEDY 4b. Early and Periodic Screening, Diagnosis and Treatment of Conditions Found A. Screening Services 1. Initial Screen. Periodic, comprehensive child health assessments are provided by a licensed medical or osteopathic physician, physician assistant, or advanced practice nurse practitioner to each eligible individual under the age of 21. An initial EPSDT screening may be requested by an eligible individual at any time and must be provided without regard to whether the individual's age coincides with the established periodicity schedule. At a minimum these assessments must include the following components: (a) Comprehensive Health and/or Developmental history; (b) Comprehensive unclothed physical exam; (c) Appropriate Immunizations; (d) Health Education; (e) Appropriate Laboratory Tests; (f) Lead Toxicity Screening; (g) Vision Services; and (h) Dental Services. 2. Periodicity Schedule(s). The preventive pediatric health care periodicity schedule recommended by the American Academy of Pediatrics (AAP) has been adopted for use by the State for eligible individuals from age birth through 20 (this will eliminate the prenatal and 21 year old visit shown on the AAP Periodicity Schedule). Immunizations are to be checked and provided as needed according to the Advisory Committee on Immunization Practices (ACIP) schedule. Vision and Hearing screens are subject to their own periodicity schedule. However, age appropriate vision and hearing screens must be performed. Dental screens begin at the first sign of tooth eruption by the primary care provider and with each subsequent visit to determine if the child needs a referral to a dental provider. Dental services, including the initial direct referral to a dentist, must occur according to the periodicity of examination, preventive dental services, anticipatory guidance, and oral treatment for infants, children, and adolescents recommended by the American Academy of Pediatric Dentistry (AAPD). 3. Optional Screens. Periodic screening must be provided in accordance with the recommended AAP periodicity schedule following the initial screening. lnterperiodic screenings must be provided when medically necessary to determine the existence of suspected physical or mental illnesses or conditions. A partial screening may be paid if the provider cannot provide all of the minimum components of the screening. Revised 09-01-18 TN#_______________ Approval Date_____________ Effective Date______________ Supersedes TN#_______________ 18-06 07/12/18 09/01/2018 06-15 State: Oklahoma Date Received: 30 May, 2018 Date Approved: 12 July, 2018 Effective Date: 1 September, 2018 Transmittal Number: 18-06

Table of Contents State/Territory Name: Oklahoma State Plan Amendment (SPA) #: 19-0001 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form 3) Approved Page

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 1301 Young Street Dallas, Texas 75202

Regional Operations Group

May 7, 2019

Our Reference: SPA OK 19-0001

Becky Pasternik-Ikard Chief Executive Officer 4345 N. Lincoln Blvd. Oklahoma City, Oklahoma 73105

Dear Ms. Pasternik-Ikard:

Enclosed is a copy of approved Oklahoma State Plan Amendment (SPA) No. 19-0001, with an effective date of January 1, 2019. This amendment was submitted to revise the state plan to comply with federal regulations and reflect that children under twenty-one (21) years of age, who are residing in an inpatient psychiatric facility must be provided all medically necessary services, regardless of whether such services are noted in the plan of care.

This letter affirms that OK 19-0001 is approved effective January 1, 2019 as requested by the State.

We are including the CMS-179 and the following amended plan page:

o Attachment 3.1-A, Page 7a-2

If you have any questions regarding this matter you may contact Stacey Shuman at 214-767-6479, or by email at stacey.shuman@cms.hhs.gov.

Sincerely,

Bill Brooks

Director

Centers for Medicaid & CHIP Services

Regional Operations Group

Cc: Billy Bob Farrell, Branch Manager

Jan Covello, CMS Baltimore

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB No. 0938-0193 TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES 1. TRANSMITTAL NUMBER 2. STATE 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) 4. PROPOSED EFFECTIVE DATE TO: REGIONAL ADMINISTRATOR CENTERS FOR MEDICARE & MEDICAID SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL (Check One) NEW STATE PLAN AMENDMENT TO BE CONSIDERED AS NEW PLAN AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate transmittal for each amendment) 6. FEDERAL STATUTE/REGULATION CITATION 7. FEDERAL BUDGET IMPACT a. FFY__________________ $ __________________ b. FFY__________________ $ __________________ 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable) 10. SUBJECT OF AMENDMENT 11. GOVERNOR’S REVIEW (Check One) GOVERNOR’S OFFICE REPORTED NO COMMENT OTHER, AS SPECIFIED COMMENTS OF GOVERNOR’S OFFICE ENCLOSED NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL 12. SIGNATURE OF STATE AGENCY OFFICIAL 13. TYPED NAME 14. TITLE 15. DATE SUBMITTED 16. RETURN TO FOR REGIONAL OFFICE USE ONLY 17. DATE RECEIVED 18. DATE APPROVED PLAN APPROVED - ONE COPY ATTACHED 19. TE OF APPROVED MATERIAL 20. SIGNATURE OF REGIONAL OFFICIAL 21. TYPED NAME 22. TITLE 23. REMARKS EFFECTIVE DA FORM CMS-179 (07/92) Instructions on Back 1 9 0 0 01 Oklahoma January 1, 2019 42 CFR 440.160; Section 12005 of the Cures Act; 1905(a)(16) of the Act 2019 0 2020 0 Attachment 3.1-A, Page 7a-2 Attachment 3.1-A, Page 7a-2; TN # 18-02 EPSDT services provided to children in inpatient psychiatric facilities Becky Pasternik-Ikard Chief Executive Officer March 22, 2019 Oklahoma Health Care Authority Attn: Nicole Nantois 4345 N. Lincoln Blvd. Oklahoma City, OK 73105 March 22, 2019 May 7, 2019 January 1, 2019 Bill Brooks Director, Centers for Medicaid and CHIP Services Regional Operations Group, South

State OKLAHOMA Attachment 3.1-A Page 7a-2 AMOUNT, DURATION AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED CATEGORICALLY NEEDY 16. Inpatient Psychiatric Services for individuals under Age 21 (42 CFR 440.160) (A) Eligible Providers (42 CFR 441.151; 42 CFR 440.160) Inpatient psychiatric services for individuals under age 21 (or age 22 if the individual was receiving services prior to reaching age 22) are provided under the direction of a physician pursuant to an individual's plan of care and are limited to those who are receiving such services in an institution which is: • A psychiatric hospital that undergoes a State survey to determine whether the hospital meets the requirements for participation in Medicare as a psychiatric hospital as specified in 42 CFR 482.60, or is accredited by a national organization whose psychiatric hospital accrediting program has been approved by CMS; or • A hospital with an inpatient psychiatric program that undergoes a State survey to determine whether the hospital meets the requirements for participation in Medicare as a hospital, as specified in 42 CFR part 482, or is accredited by a national accrediting organization whose hospital accrediting program has been approved by CMS; or • A psychiatric facility that is not a hospital (defined as a Psychiatric Residential Treatment Facility (PRTF) in 42 CFR 483.352) that is accredited by the Joint Commission on Accreditation of Healthcare Organizations (TJC), the Council on Accreditation for Families and Children, the Commission on Accreditation of Rehabilitation Facilities (CARF), or by any other accrediting organization, with comparable standards, that is recognized by the State. Early and Periodic, Screening, Diagnostic, and Treatment (EPSDT) services that are determined medically necessary in order to correct or ameliorate health conditions are provided to individuals under age 21 in inpatient psychiatric hospitals and facilities regardless of whether such services are identified in the individual’s plan of care. The State assures that it meets all requirements in 42 CFR 440.160, 42 CFR 441 Subpart D, and 42 CFR 483 Subpart G. (B) Services Provided under Arrangement The State assures that psychiatric facilities: • arrange for and oversee the provision of all services; • maintain all medical records of care furnished to the individual; and • ensure that all services are furnished under the direction of a physician. Revised 01/01/19 TN#___________ Approval Date___________ Effective Date ___________ Supersedes TN#____________ 19-0001 05/07/2019 01/01/2019 18-0002 State: Oklahoma Date Received: 22 March, 2019 Date Approved: 7 May, 2019 Effective Date: 1 January, 2019 Transmittal Number: 19-0001

Table of Contents State/Territory Name: Oklahoma State Plan Amendment (SPA) #: 19-0038 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form 3) Approved Page

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 1301 Young Street Dallas, Texas 75202

Regional Operations Group

November 4, 2019

Our Reference: SPA OK 19-0038

Melody Anthony State Medicaid Director 4345 N. Lincoln Blvd. Oklahoma City, Oklahoma 73105

Dear Ms. Anthony:

Enclosed is a copy of approved Oklahoma State Plan Amendment (SPA) No. 19-0038, with an effective date of November 1, 2019. This amendment was submitted to increase the behavioral health standard targeted case management units.

This letter affirms that OK 19-0038 is approved effective November 1, 2019 as requested by the State.

We are including the CMS-179 and the following amended plan page:

• Supplement 1 to Attachment 3.1-A, Page 1g

If you have any questions regarding this matter you may contact Stacey Shuman at 214-767-6479, or by email at stacey.shuman@cms.hhs.gov.

Sincerely,

Bill Brooks

Director

Centers for Medicaid & CHIP Services

Regional Operations Group

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB No. 0938-0193 TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES 1. TRANSMITTAL NUMBER 2. STATE 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) 4. PROPOSED EFFECTIVE DATE TO: REGIONAL ADMINISTRATOR CENTERS FOR MEDICARE & MEDICAID SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL (Check One) NEW STATE PLAN AMENDMENT TO BE CONSIDERED AS NEW PLAN AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate transmittal for each amendment) 6. FEDERAL STATUTE/REGULATION CITATION 7. FEDERAL BUDGET IMPACT a. FFY__________________ $ __________________ b. FFY__________________ $ __________________ 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable) 10. SUBJECT OF AMENDMENT 11. GOVERNOR’S REVIEW (Check One) GOVERNOR’S OFFICE REPORTED NO COMMENT OTHER, AS SPECIFIED COMMENTS OF GOVERNOR’S OFFICE ENCLOSED NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL 12. SIGNATURE OF STATE AGENCY OFFICIAL 13. TYPED NAME 14. TITLE 15. DATE SUBMITTED 16. RETURN TO FOR REGIONAL OFFICE USE ONLY 17. DATE RECEIVED 18. DATE APPROVED PLAN APPROVED - ONE COPY ATTACHED 19. TE OF APPROVED MATERIAL 20. SIGNATURE OF REGIONAL OFFICIAL 21. TYPED NAME 22. TITLE 23. REMARKS EFFECTIVE DA FORM CMS-179 (07/92) Instructions on Back 13. TYPED NAME 12. SIGNATU T RE OF STA T T A 1 9 0 0 38 Oklahoma November 1, 2019 42 CFR 440.169 2020 5,184,688 2021 5,733,984 SUPPLEMENT 1 TO ATT. 3.1-A, Page 1g SUPPLEMENT 1 TO ATT. 3.1-A, Page 1g; TN # 17-013 Increase of behavioral health standard targeted case management units Melody Anthony State Medicaid Director 10/09/2019 Oklahoma Health Care Authority Attn: Maria Maule 4345 N. Lincoln Blvd. Oklahoma City, OK 73105 10/09/2019 11/04/2019 11/01/2019 Bill Brooks Director, Centers for Medicaid & CHIP Services Regional Operations Group

State: OKLAHOMA SUPPLEMENT 1 TO ATTACHMENT 3.1-A Page 1g STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT CASE MANAGEMENT SERVICES (continued) Target Group: Chronically and/or severely mentally ill age 18 years and older or children who are at imminent risk of out-of home placement due to psychiatric or substance abuse reasons. Access to Services (42 CFR 441.18(a)(2), 42 CFR 441.18(a)(3), 42 CFR 441.18(a)(6)): The State assures the following: • Case management (including targeted case management) services will not be used to restrict an individual's access to other services under the plan. • Individuals will not be compelled to receive case management services, condition receipt of case management (or targeted case management) services on the receipt of other Medicaid services, or condition receipt of other Medicaid services on receipt of case management (or targeted case management) services; and • Providers of case management services do not exercise the agency's authority to authorize or deny the provision of other services under the plan. Payment (42 CFR 441.18(a)(4)): • Payment for case management or targeted case management services under the plan does not duplicate payments made to public agencies or private entities under other program authorities for this same purpose. Limitations: • Case management does not include the following: o Activities not consistent with the definition of case management services under Section 6052 of the Deficit Reduction Act (DRA); the direct delivery of an underlying medical, educational, social, or other service to which an eligible individual has been referred. (2001 SMD) o Activities integral to the administration of foster care programs. (2001 SMD); and o Activities for which third parties are liable to pay. (2001 SMD) • The State assures that individuals meeting provider qualifications under the plan to provide case management as well as other direct medical, educational, social or other services for which an eligible individual has been referred will not provide both case management and direct services to the same individual. • Effective for services provided on or after 11-01-19, standard case management will be limited to 12 units per member per month. Additional units may be authorized for members that meet established medical necessity criteria. Revised 11-01-19 TN # _____________ Approval Date _____________ Effective Date ______________ Supersedes TN #_____________ 19-0038 11/04/2019 11/01/2019 17-0013 State: Oklahoma Date Received: 09 October, 2019 Date Approved: 04 November, 2019 Effective Date: 1 November, 2019 Transmittal Number: 19-0038

Table Table of Contents State/Territory Name: New Hampshire State Plan Amendment (SPA) #: 20-0019 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 Center for Medicaid & CHIP Services 233 North Michigan Ave., Suite 600 Chicago, Illinois 60601 Financial Management Group Lori Shibinette, Commissioner Department of Health and Human Services State of New Hampshire 129 Pleasant Street Concord, NH 03301 RE: TN 20-0019 Dear Commissioner Shibinette: We have reviewed the proposed New Hampshire (NH) State Plan Amendment (SPA) to Attachment 4.19-B, which was submitted to the Centers for Medicare & Medicaid Services (CMS) on March 23, 2020. This plan amendment updates the allowance for a 3.1% increase in extended services to pregnant women and personal care reimbursement rates. Based upon the information provided by the State, we have approved the amendment with an effective date of January 1, 2020. We are enclosing the approved CMS-179 and a copy of the new state plan pages. Please note that our approval relates only to the requested change in payment methodology and CMS may still have questions on the funding structure in determining its consistent with section 1902(a)(2) and 1903(a) of the Act as implemented by 42 CFR § 433.54. Therefore, our approval relates only to the requested change in payment methodology and that the resultant rates and related expenditures are consistent with section 1902(a)(30)(A) of the Act. Approval of the subject SPA does not relieve the State of its responsibility to comply with federal laws and regulations, and to ensure that claims for federal funding are consistent with all applicable requirements. If you have any additional questions or need further assistance, please contact James Moreth at 206-615-2043 or James.Moreth@cms.hhs.gov. Sincerely, Todd McMillion Director Division of Reimbursement Review Enclosures cc: Henry Lipman, State Medicaid Director Diane Peterson, Medicaid Business and Policy April 21, 2020

DEPARTMENT OF HEALTH ANDHUMAN SERVICES CENTERS FOR MEDICARE & MEOICAIO SERVICES

FORMAPPROVED OMB No, 0938-0103

T. TRANSMITTAL NUMBER 2. STATE TRANSMITTAL AND NOTICE OF APPROVAL OF 20-9019 NH

STATE PLAN MATERIAL FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES

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

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

4. PROPOSED EFFECTIVE DATE January 1, 2020

5. TYPE OF PLAN MATERIAL (Check One) | CONEW STATE PLAN

(CIAMENDMENT TO BE CONSIDERED AS NEW PLAN

{AMENDMENT

COMPLETE BLOCKS 6 THRU 10 IF THIS 1S AN AMENDMENT (Separate transmittal for each amendment)

6. FEDERAL STATUTE/REGULATION CITATION 42 CFR 440.167, 42 CFR 435.170, 42 CFR Part 447

7. FEDERAL BUDGET IMPACT FFY 2020: $3,601 (pers care} unknown (PW)

6. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT

Attachment 4.19-B, Page 5

Ei il 4 cai ni PW 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (if Applicable)

Attachment 4,19-B, Page 5, TN 15-003

10. SUBJECT OF AMENDMENT

Extended Services to Pregnant Women and Personal Care Services - NH 2020 Budget Increase

77. GOVERNOR'S REVIEW (Check One) + « CIGOVERNOR’S OFFICE REPORTED NO COMMENT

(COICOMMENTS OF GOVERNOR'S OFFICE ENCLOSED ™ [DONO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL

BJOTHER, AS SPECIFIED: comments, if any, will follow

Ann H. Landry

16, RETURN TO

Dawn Landry

Division of Medicaid Servicas/Brown Building Department of Heaith and Human Services 129 Pleasant Street

74. TITLE Associate Commissioner

Concord, NH 03301

45. DATE SUBMITTED 5. OATES 0312312020 FOR REGIONAL OFFICE USE ONLY 77. DATE RECEIVED 18. DATE APPROVED 03/23/2020 04/21/2020

PLAN APPROVED - ONE COPY ATTACHED

79. EFFECTIVE DATE OF APPROVED MATERIAL 01/01/2020

i. -_ OF REGIONAL OFFICIAL

21. TYPED NAME Todd McMillion

22, TITLE

Director, Division of Reimbursement Review

23. REMARKS

FORM CMS-179(07/92)

Title XIX – NH Attachment 4.19-B Page 5 PAYMENT RATES FOR ALL TYPES OF CARE OTHER THAN INPATIENT HOSPITAL, SKILLED NURSING, OR INTERMEDIATE NURSING CARE SERVICES 20. Extended Services to Pregnant Women –Payment for extended services to pregnant women provided by agencies under contract with the Division of Public Health, e.g., "Home Visiting NH and Child/Family Health Care Support" and "Extended Services to Pregnant Women," is made in accordance with a fee schedule established by the department For agencies under contract, rates were set as of January 1, 2020, and are effective for services provided on or after that date. For all other providers, payment is made pursuant to the methodologies described in Attachment 4.19-B for the specific covered service or practitioner. No provider shall bill or charge the department more than the provider’s usual and customary charge. All fee schedules are accessible at www nhmmis nh.gov under the "documents and forms" tab, and are applicable to all public and private providers. 21. a) Rural Health Clinics (RHC’s)-Non Hospital Based – Payment for non-hospital based RHC’s is made according to the same methodology used for Federally Qualified Health Centers (FQHC) and FQHC Look-A-Likes (LAL’s) as described on page 5a through 5f.** b) Rural Health Clinics (RHC’s) – Hospital Based – Payment for hospital based RHC’s is made according to the methodology described on page 5g.** 22. Personal Care Services – Payment for personal care services is made in accordance with a fee schedule established by the department. Rates were set as of January 1, 2020, and are effective for services provided on or after that date. No provider shall bill or charge the department more than the provider’s usual and customary charge. All fee schedules are accessible at www.nhmmis.nh.gov under the “documents and forms” tab, and are applicable to all public and private providers. 23. Federally Qualified Health Centers (FQHC’s) and FQHC Look-A-Likes (LAL’s) – Payment for FQHC’s and FQHC LAL’s is made according to the methodology described on page 5a. ** _______________________________________________________________________ **Addendum to 21a and 23 above, RHC’s and FQHC/FQHC-LAL’s: ____X____ The payment methodology for RHC’s/FQHC’s/FQHC-LAL’s will conform to section 702 of the Benefits Improvement and Protection Act (BIPA) of 2000. ______ The payment methodology for RHC’s/FQHC’s/FQHC-LAL’s will conform to the BIPA 2000 requirements for a prospective payment system (PPS). ___X__ The payment methodology for RHC’s/FQHC’s/FQHC-LAL’s will conform to the BIPA 2000 requirements for an alternative payment methodology. The payment amount determined under this methodology: (1) is agreed to by the state and the center or clinic; and (2) results in payment to the center or clinic of an amount which is at least equal to the PPS payment rate. (Addendum continued on next page) TN No: 20-0019 Supersedes Approval Date ________ Effective Date: 01/01/2020 TN No: 15-003 04/21/20

Table of Contents State/Territory Name: Oklahoma State Plan Amendment (SPA) #: 21-0002 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS Form 179 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 601 East 12th Street, Suite 355 Kansas City, Missouri 64106-2898 Medicaid & CHIP Operations Group December 4, 2020 Melody Anthony State Medicaid Director Oklahoma Health Care Authority 4345 North Lincoln Boulevard Oklahoma City, OK 73105 Dear Ms. Anthony: On September 8, 2020, the Centers for Medicare & Medicaid Services (CMS) received Oklahoma State Plan (SPA) No. 21-0002. This SPA was submitted to add an Alternative Benefit Plan (ABP) , which will be implemented July 1, 2021. We are pleased to inform you that SPA 21-0002 was approved on December 2020, with an effective date of July 1, 2021, as requested by the state. Enclosed is a copy of the CMS 179 summary form, as well as the approved pages for incorporation into the Oklahoma State Plan. All requirements pertaining to ABPs must be met including, but not limited to: benefits, payment rates, reimbursement methodologies, cost-sharing state plan pages, and (if applicable) managed d Medicaid program (SPAs, waivers, contracts) may require corresponding amendments to the ABP if the changes to the benefit to the approved state plan will be mirrored in the ABP. If you have any questions regarding this matter you may contact Deborah Read (816) 426-5925 or by e-mail at Deborah.read@cms.hhs.gov. X Enclosures cc: Sandra Puebla, Oklahoma Health Care Authority Jan Covello, DBC Megan Buck, Program Branch Manager James G. Scott, Director Division of Program Operations Sincerely,

Medicaid Alternative Benefit Plan: Summary Page (CMS 179)

State/Territory name: Oklahoma 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.

21-0002

Proposed Effective Date 07/01/2021 (mm/dd/yyyy)

Federal Statute/Regulation Citation Section 1937 of the Social Security Act; 42 CFR Part 440, Subpart C

Federal Budget Impact Federal Fiscal Year Amount

First Year 2021 $ 0.00

Second Year 2022 $ 0.00

Subject of Amendment

Establish Oklahoma’s alternative benefit package (ABP) for individuals in the adult group ages 19-64 with incomes at or below 133% of the federal poverty level (FPL) (as per section 1902(a)(10)(A)(i)(VIL]) of the Social Security Act and 42

a v

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 review State Plan amendments.

Signature of State Agency Official Submitted By: Sandra Puebla Last Revision Date: Sep 8, 2020

Submit Date: Sep 8, 2020

Transmittal Number: OK 21-000 Supersedes: NEW Approval Date: Effective Date:

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DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-26-12 Baltimore, Maryland 21244-1850 Financial Management Group Melody Anthony State Medicaid Director Oklahoma Health Care Authority 4345 N. Lincoln Blvd. Oklahoma City, OK 73105 Re: Oklahoma Title XIX FMAP State Plan Amendment, Transmittal #21-0003 Dear Ms. Anthony: We have reviewed the proposed Federal Medical Assistance Payment (FMAP) State Plan Amendment (SPA), OK 21-0003, which was submitted to the Centers for Medicare & Medicaid Services on September 8, 2020. This SPA describes the methodology used by the state for determining the appropriate FMAP rates, including the increased FMAP rates, available under the provisions of the Affordable Care Act applicable for the medical assistance expenditures under the Medicaid program associated with enrollees in the new adult group adopted by the state and described in 42 CFR 435.119. Based on the information provided, the Medicaid SPA 21-0003 is approved with an effective date of July 1, 2021. We are enclosing the approved Form CMS-179 and the Medicaid state plan pages. If you have any additional questions or need further assistance, please contact Deborah Read at (816) 426-5925 or by email at Deborah.Read@cms.hhs.gov. Sincerely, Jennifer Clark, Acting Director Division of Financial Policy Enclosures cc: Traylor Rains, Oklahoma Health Care Authority Sandra Puebla, Oklahoma Health Care Authority Jennifer L. Clark -S Digitally signed by Jennifer L. Clark -S Date: 2020.12.04 15:54:02 -05'00'

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB No. 0938-0193 TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES 1. TRANSMITTAL NUMBER 2. STATE 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) 4. PROPOSED EFFECTIVE DATE TO: REGIONAL ADMINISTRATOR CENTERS FOR MEDICARE & MEDICAID SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL (Check One) NEW STATE PLAN AMENDMENT TO BE CONSIDERED AS NEW PLAN AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate transmittal for each amendment) 6. FEDERAL STATUTE/REGULATION CITATION 7. FEDERAL BUDGET IMPACT a. FFY__________________ $ __________________ b. FFY__________________ $ __________________ 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable) 10. SUBJECT OF AMENDMENT 11. GOVERNOR’S REVIEW (Check One) GOVERNOR’S OFFICE REPORTED NO COMMENT OTHER, AS SPECIFIED COMMENTS OF GOVERNOR’S OFFICE ENCLOSED NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL 12. SIGNATURE OF STATE AGENCY OFFICIAL 13. TYPED NAME 14. TITLE 15. DATE SUBMITTED 16. RETURN TO FOR REGIONAL OFFICE USE ONLY 17. DATE RECEIVED 18. DATE APPROVED PLAN APPROVED - ONE COPY ATTACHED 19. TE OF APPROVED MATERIAL 20. SIGNATURE OF REGIONAL OFFICIAL 21. TYPED NAME 22. TITLE 23. REMARKS EFFECTIVE DA FORM CMS-179 (07/92) Instructions on Back 12. S . S . SIGNA N TURE RE RE R OF STA T TE TE TE AGENCY A 13. TYPED NAME 2 1 0 0 03 Oklahoma July 1, 2021 1905(y)(1) of the Act 2021 0 2022 0 Supplement 18 to Attachment 2.6-A, Page 1 Supplement 18 to Attachment 2.6-A, Page 2 Supplement 18 to Attachment 2.6-A, Page 3 Supplement 18 to Attachment 2.6-A, Page 4 Supplement 18 to Attachment 2.6-A, Page 5 Supplement 18 to Attachment 2.6-A, Page 6 Establish methodology to claim the appropriate FMAP rate for individuals enrolled in the new adult group Melody Anthony State Medicaid Director 09/08/2020 Oklahoma Health Care Authority Attn: Traylor Rains 4345 N. Lincoln Blvd. Oklahoma City, OK 73105 

  -HQQLIHU&ODUN $FWLQJ'LUHFWRU'LYLVLRQRI)LQDQFLDO3ROLF\  Jennifer L. Clark -S Digitally signed by Jennifer L. Clark -S Date: 2020.12.04 15:54:40 -05'00'

Supplement 18 to Attachment 2.6A Page 1 1 TN – Approval Date – Effective Date – State Plan Under Title XIX of the Social Security Act State: METHODOLOGY FOR IDENTIFICATION OF APPLICABLE FMAP RATES The State will determine the appropriate FMAP rate for expenditures for individuals enrolled in the adult group described in 42 CFR 435.119 and receiving benefits in accordance with 42 CFR Part 440 Subpart C. The adult group FMAP methodology consists of two parts: an individual-based determination related to enrolled individuals, and as applicable, appropriate population-based adjustments. Part 1 – Adult Group Individual Income-Based Determinations For individuals eligible in the adult group, the state will make an individual income-based determination for purposes of the adult group FMAP methodology by comparing individual income to the relevant converted income eligibility standards in effect on December 1, 2009, and included in the MAGI Conversion Plan (Part 2) approved by CMS on . In general, and subject to any adjustments described in this SPA, under the adult group FMAP methodology, the expenditures of individuals with incomes below the relevant converted income standards for the applicable subgroup are considered as those for which the newly eligible FMAP is not available. The relevant MAGI-converted standards for each population group in the new adult group are described in Table 1. Oklahoma 05/14/2020 21-0003 12/4/2020 07/01/2021

Supplement 18 to Attachment 2.6A Page 2 2 TN – Approval Date – Effective Date – Table 1: Adult Group Eligibility Standards and FMAP Methodology Features Covered Populations Within New Adult Group Applicable Population Adjustment Population Group Relevant Population Group Income Standard For each population group, indicate the lower of: x The reference in the MAGI Conversion Plan (Part 2) to the relevant income standard and the appropriate cross-reference, or x 133% FPL. If a population group was not covered as of 12/1/09, enter “Not covered”. Resource Proxy Enrollment Cap Special Circumstances Other Adjustments Enter “Y” (Yes), “N” (No), or “NA” in the appropriate column to indicate if the population adjustment will apply to each population group. Provide additional information in corresponding attachments. A B C D E F Parents/Caretaker Relatives Disabled Persons, non- institutionalized Disabled Persons, institutionalized Children Age 19 or 20 Childless Adults Attachment A, Column C, Line 1 of Part 2 of the CMS approved MAGI conversion Plan, including any subsequent CMS approved modifications to the MAGI Conversion Plan No No No No Attachment A, Column C, Line 2 of Part 2 of the CMS approved MAGI conversion Plan, including any subsequent CMS approved modifications to the MAGI Conversion Plan No No No No Attachment A, Column C, Line 3 of Part 2 of the CMS approved MAGI conversion Plan, including any subsequent CMS approved modifications to the MAGI Conversion Plan No No No No Attachment A, Column C, Line 4 of Part 2 of the CMS approved MAGI conversion Plan, including any subsequent CMS approved modifications to the MAGI Conversion Plan No No No No Attachment A, Column C, Line 5 of Part 2 of the CMS approved MAGI conversion Plan, including any subsequent CMS approved modifications to the MAGI Conversion Plan N/A N/A N/A N/A 21-0003 12/04/2020 07/01/2021

Supplement 18 to Attachment 2.6A Page 3 3 TN – Approval Date – Effective Date – Part 2 – Population-based Adjustments to the Newly Eligible Population Based on Resource Test, Enrollment Cap or Special Circumstances A. Optional Resource Criteria Proxy Adjustment (42 CFR 433.206(d)) 1. The state: ܆Applies a resource proxy adjustment to a population group(s) that was subject to a resource test that was applicable on December 1, 2009. ܆Does NOT apply a resource proxy adjustment (Skip items 2 through 3 and go to Section B). Table 1 indicates the group or groups for which the state applies a resource proxy adjustment to the expenditures applicable for individuals eligible and enrolled under 42 CFR 435.119. A resource proxy adjustment is only permitted for a population group(s) that was subject to a resource test that was applicable on December 1, 2009. The effective date(s) for application of the resource proxy adjustment is specified and described in Attachment B. 2. Data source used for resource proxy adjustments: The state: ܆Applies existing state data from periods before January 1, 2014. ܆Applies data obtained through a post-eligibility statistically valid sample of individuals. Data used in resource proxy adjustments is described in Attachment B. 3. Resource Proxy Methodology: Attachment B describes the sampling approach or other methodology used for calculating the adjustment. B. Enrollment Cap Adjustment (42 CFR 433.206(e)) 1. ܆ An enrollment cap adjustment is applied by the state (complete items 2 through 4). ܆An enrollment cap adjustment is not applied by the state (skip items 2 through 4 and go to Section C). 21-0003 12/04/2020 07/01/2021

Supplement 18 to Attachment 2.6A Page 4 4 TN – Approval Date – Effective Date – 2. Attachment C describes any enrollment caps authorized in section 1115 demonstrations as of December 1, 2009 that are applicable to populations that the state covers in the eligibility group described at 42 CFR 435.119 and received full benefits, benchmark benefits, or benchmark equivalent benefits as determined by CMS. The enrollment cap or caps are as specified in the applicable section 1115 demonstration special terms and conditions as confirmed by CMS, or in alternative authorized cap or caps as confirmed by CMS. Attach CMS correspondence confirming the applicable enrollment cap(s). 3. The state applies a combined enrollment cap adjustment for purposes of claiming FMAP in the adult group: ܆Yes. The combined enrollment cap adjustment is described in Attachment C ܆No. 4. Enrollment Cap Methodology: Attachment C describes the methodology for calculating the enrollment cap adjustment, including the use of combined enrollment caps, if applicable. C. Special Circumstances (42 CFR 433.206(g)) and Other Adjustments to the Adult Group FMAP Methodology 1. The state: ܆Applies a special circumstances adjustment(s). ܆Does not apply a special circumstances adjustment. 2. The state: ܆Applies additional adjustment(s) to the adult group FMAP methodology (complete item 3). ܆Does not apply any additional adjustment(s) to the adult group FMAP methodology (skip item 3 and go to Part 3). 3. Attachment D describes the special circumstances and other proxy adjustment(s) that are applied, including the population groups to which the adjustments apply and the methodology for calculating the adjustments. 21-0003 12/04/2020 07/01/2021

Supplement 18 to Attachment 2.6A Page 5 5 TN – Approval Date – Effective Date – Part 3 – One-Time Transitions of Previously Covered Populations into the New Adult Group A. Transitioning Previous Section 1115 and State Plan Populations to the New Adult Group ܆Individuals previously eligible for Medicaid coverage through a section 1115 demonstration program or a mandatory or optional state plan eligibility category will be transitioned to the new adult group described in 42 CFR 435.119 in accordance with a CMS-approved transition plan and/or a section 1902(e)(14)(A) waiver. For purposes of claiming federal funding at the appropriate FMAP for the populations transitioned to new adult group, the adult group FMAP methodology is applied pursuant to and as described in Attachment E, and where applicable, is subject to any special circumstances or other adjustments described in Attachment D. ܆The state does not have any relevant populations requiring such transitions. Part 4 - Applicability of Special FMAP Rates A. Expansion State Designation The state: ܆Does NOT meet the definition of expansion state in 42 CFR 433.204(b). (Skip section B and go to Part 5) ܆Meets the definition of expansion state as defined in 42 CFR 433.204(b), determined in accordance with the CMS letter confirming expansion state status, dated __ . _______________ B. Qualification for Temporary 2.2 Percentage Point Increase in FMAP. The state: ܆Does NOT qualify for temporary 2.2 percentage point increase in FMAP under 42 CFR 433.10(c)(7). ܆Qualifies for temporary 2.2 percentage point increase in FMAP under 42 CFR 433.10(c)(7), determined in accordance with the CMS letter confirming eligibility for the temporary FMAP increase, dated ___ . The state will not claim any federal funding for individuals determined eligible under 42 CFR 435.119 at the FMAP rate described in 42 CFR 433.10(c)(6). __________ 21-0003 12/04/2020 07/01/2021

Supplement 18 to Attachment 2.6A Page 6

6

TN – Approval Date –

Effective Date –

Part 5 - State Attestations The State attests to the following: A. The application of the adult group FMAP methodology will not affect the timing or approval of any individual’s eligibility for Medicaid.

B. The application of the adult group FMAP methodology will not be biased in such a manner as to inappropriately establish the numbers of, or medical assistance expenditures for, individuals determined to be newly or not newly eligible.

ATTACHMENTS Not all of the attachments indicated below will apply to all states; some attachments may describe methodologies for multiple population groups within the new adult group. Indicate those of the following attachments which are included with this SPA:

܆ ܆ ܆ ܆ ܆ Attachment A – Conversion Plan Standards Referenced in Table 1 Attachment B – Resource Criteria Proxy Methodology Attachment C – Enrollment Cap Methodology Attachment D – Special Circumstances Adjustment and Other Adjustments to the Adult Group FMAP Methodology Attachment E – Transition Methodologies

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 4 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. 21-0003 12/04/2020 07/01/2021

CMS Approved: 5/14/2020 Population Group Net standard as of 12/1/09 Converted standard for FMAP claiming Same as converted eligibilty standard? (yes, no, or n/a) Source of information in Column C (New SIPP conversion or Part 1 of approved state MAGI conversion plan) Data source for Conversion (SIPP or state data) A B C D E F Parents/Caretaker Relatives Noninstitutionalized Disabled Persons FPL % Institutionalized Disabled Persons SSI FBR% Children Age 19-20 Childless Adults FPL % n/a: Not applicable. 2 1 New SIPP conversion SIPP n/a 100% 100% 73% AFDC need standard 1 $407 2 $521 3 $668 4 $820 5 $958 6 $1098 7 $1236 8 $1364 9 $1486 yes MAGI SIPP Conversion SIPP yes Attachment A: Most Recent Updated Summary Information for Part 2 of Modified Adjusted Gross Income (MAGI) Conversion Plan* OKLAHOMA MAGI SIPP Conversion SIPP *The contents of this table will be updated automatically in case of modifications to the CMS approved MAGI Conversion Plan. 5 3 4 ABD conversion template n/a MAGI SIPP Conversion SIPP n/a yes 212% n/a 300% 300% 200% n/a

Attachment E: Adult Population Reprocess Plan

Counts of current members as of 11/11/2020 Type of Recipient Recipients Cases Insure Oklahoma – Individual Plan 19,273 16,222 Insure Oklahoma – Employer Sponsored Insurance (ESI) with FPL 138% or less 4,055 3,312 SoonerPlan 41,377 36,639 Adults not eligible as Needy Caretakers 31,153 26,747 Not Categorically Related Adults 4,163 3,918 Totals 100,021 86,838

Any members that do not have current eligibility must have applied within the last 90 days.

Plan for Reprocess OHCA will reprocess each group in 06/2021 for an expansion eligibility start date of 07/01/2021. OHCA will reprocess each group in a manner that will create the least operational impact, most likely one per week. Some groups, depending on volume, may be reprocessed over multiple days.

Suggested Order of reprocesses: x Insure Oklahoma o Individual Plan o Individuals in the ESI plan with FPL less than 138% x SoonerPlan x Adults not eligible as Needy Caretakers x Not Categorically Related Adults

Program Definitions Insure Oklahoma – Individual Plan: Insure Oklahoma’s Public option Insure Oklahoma – ESI: Insure Oklahoma’s Employee Sponsored Insurance plan helps employers provide their eligible employees with affordable health care. SoonerPlan: benefit plan covering limited services related to family planning, to women and men ages 19 and older, in an effort to reduce unwanted pregnancies.

Table of Contents

State/Territory Name: Oklahoma State Plan Amendment (SPA) #: 20-0004 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES

Centers for Medicare & Medicaid Services 601 East 12th Street, Suite 355 Kansas City, Missouri 64106-2898

Medicaid & CHIP Operations Group September 16, 2020

Melody Anthony State Medicaid Director Oklahoma Health Care Authority Oklahoma City, OK 73105

Dear Ms. Anthony:

On June19, 2020, the Centers for Medicare & Medicaid Services (CMS) received Oklahoma State Plan (SPA) No. 20-0004. This SPA was submitted to revise Supplement 1 to Attachment 3.1-A, Pages 7 - 7c to increase the maximum age to 21 for individuals who are involved or at serious risk of involvement with the juvenile justice system and align TCM services with current evidence-based practices.

We are pleased to inform you that SPA 20-0004 was approved on September 16, 2020, with an effective date of September 1, 2020, as requested by the state. Enclosed is a copy of the CMS 179 summary form, as well as the approved pages for incorporation into the Oklahoma State Plan.

If you have any questions regarding this matter you may contact Deborah Read (816) 426-5925 or by e-mail at Deborah.read@cms.hhs.gov.

X

Enclosures

cc: Kasie McCarty, Oklahoma Health Care Authority

Megan Buck, Program Branch Manager

James G. Scott, Director Division of Program Operations Sincerely, Digitally signed by James G. Scott -S Date: 2020.09.16 16:06:59 -05'00'

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB No. 0938-0193 TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES 1. TRANSMITTAL NUMBER 2. STATE 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) 4. PROPOSED EFFECTIVE DATE TO: REGIONAL ADMINISTRATOR CENTERS FOR MEDICARE & MEDICAID SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL (Check One) NEW STATE PLAN AMENDMENT TO BE CONSIDERED AS NEW PLAN AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate transmittal for each amendment) 6. FEDERAL STATUTE/REGULATION CITATION 7. FEDERAL BUDGET IMPACT a. FFY__________________ $ __________________ b. FFY__________________ $ __________________ 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable) 10. SUBJECT OF AMENDMENT 11. GOVERNOR’S REVIEW (Check One) GOVERNOR’S OFFICE REPORTED NO COMMENT OTHER, AS SPECIFIED COMMENTS OF GOVERNOR’S OFFICE ENCLOSED NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL 12. SIGNATURE OF STATE AGENCY OFFICIAL 13. TYPED NAME 14. TITLE 15. DATE SUBMITTED 16. RETURN TO FOR REGIONAL OFFICE USE ONLY 17. DATE RECEIVED 18. DATE APPROVED PLAN APPROVED - ONE COPY ATTACHED 19. TE OF APPROVED MATERIAL 20. SIG NAL OFFICIAL 21. TYPED NAME 22. TITLE 23. REMARKS EFFECTIVE DA FORM CMS-179 (07/92) Instructions on Back 13 TYPED NAME 12. SIGNATURE OF STA T T A -XQH  6HSWHPEHU -DPHV*6FRWW 'LUHFWRU'LYLVLRQRI3URJUDP2SHUDWLRQV 2 0 0 0 04 Oklahoma September 1, 2020 42 CFR §440.169 2020 124,940 2021 1,499,283 Supplement 1 to Attachment 3.1-A, page 7 Supplement 1 to Attachment 3.1-A, page 7a Supplement 1 to Attachment 3.1-A, page 7b Supplement 1 to Attachment 3.1-A, page 7c Supplement 1 to Attachment 3.1-A, page 7; TN 08-08 Supplement 1 to Attachment 3.1-A, page 7a; TN 08-08 Supplement 1 to Attachment 3.1-A, page 7b; TN 08-08 Supplement 1 to Attachment 3.1-A, page 7c; TN 08-08 SPA to increase the maximum age to 21 for individuals who are involved in or at serious risk of involvement with the juvenile justice system; and align targeted case management services with current evidence-based practices Melody Anthony State Medicaid Director June 19, 2020 Oklahoma Health Care Authority Attn: Traylor Rains 4345 N. Lincoln Blvd. Oklahoma City, OK 73105  6HSWHPEHU Digitally signed by James G. Scott -S Date: 2020.09.16 16:08:56 -05'00'

State: Oklahoma SUPPLEMENT 1 TO ATTACHMENT 3.1-A Page 7 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT TARGETED CASE MANAGEMENT SERVICES Target Group (42 Code of Federal Regulations 441.18(a)(8)(i) and 441.18(a)(9)): The target group includes eligible individuals under age 21 who are assessed as at risk of abuse or neglect as define in Title 10A §1-1-105 of the Oklahoma Statutes and who are involved in, or at serious risk of involvement with the juvenile justice system. The target group does not include those who are involuntarily in secure custody of law enforcement or judicial systems, except individuals who meet Medicaid criteria for inpatient care as defined in 42 CFR § 435.1009; 42 CFR § 435.1010. X Target group includes individuals transitioning to a community setting. Case-management services will be made available for up to 180 consecutive days of a covered stay in a medical institution. The target group does not include individuals between ages 22 and 64 who are served in Institutions for Mental Disease or individuals who are inmates of public institutions. (State Medicaid Directors Letter (SMDL), July 25, 2000) Areas of State in which services will be provided (§1915(g)(1) of the Act): X Entire State Only in the following geographic areas: Comparability of services (§§1902(a)(10)(B) and 1915(g)(1))

Services are provided in accordance with §1902(a)(10)(B) of the Act. X Services are not comparable in amount duration and scope (§1915(g)(1)). Definition of services [42 CFR 440.169(b)]: Targeted case management services are defined as services furnished to assist individuals, eligible under the State Plan, in gaining access to needed medical, social, educational and other services. Targeted Case Management includes the following assistance: ™ Comprehensive assessment and periodic reassessment of individual needs, to determine the need for any medical, educational, social or other services. These assessment activities include: x taking client history; x identifying the individual’s needs and completing related documentation; and x gathering information from other sources such as family members, medical providers, social workers, and educators (if necessary), to form a complete assessment of the eligible individual; Each eligible individual is assessed by utilizing an evidence-based, comprehensive assessment tool at the beginning of case assignment. The tool is designed to assess levels of risk, needs, or strengths within multiple areas, and to facilitate targeted and effective interventions. Any area showing a moderate to high- risk/need/strength score could result in additional goals and action steps documented within the individualized treatment plan. Each eligible individual is reassessed and scored again, at least once every six (6) months. If behavior shifts or life-changing events occur prior to six (6) months, the eligible individual is reassessed and the Individualized Treatment Service Plan is adjusted to reflect identified needs. Any needed changes in services, service providers, treatment type, frequency, or duration may also be effected at this time. Revised 09-01-20 TN#__20-0004__ Approval Date Effective Date 09/01/2020 Supersedes TN# 08-08



State: Oklahoma SUPPLEMENT 1 TO ATTACHMENT 3.1-A Page 7a STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT Targeted Case Management (continued) Definition of services (continued) ™ Development (and periodic revision) of a specific care plan that is based on the information collected through the assessment that x specifies the goals and actions to address the medical, social, educational, and other services needed by the individual; x includes activities such as ensuring the active participation of the eligible individual, and working with the individual (or the individual’s authorized health care decision maker) and others to develop those goals; and x identifies a course of action to respond to the assessed needs of the eligible individual. ™ Referral and related activities (such as scheduling appointments for the individual) to help the eligible individual obtain needed services including x activities that help link the individual with medical, social, educational providers, or other programs and services that are capable of providing needed services to address identified needs and achieve goals specified in the care plan; and ™ Monitoring and follow-up activities: x activities and contacts that are necessary to ensure the care plan is implemented and adequately addresses the eligible individual’s needs, and which may be with the individual, family members, service providers, or other entities or individuals and conducted as frequently as necessary, and including at least one annual monitoring, to determine whether the following conditions are met: 1. services are being furnished in accordance with the individual’s care plan; 2. services in the care plan are adequate; and 3. changes in the needs or status of the individual are reflected in the care plan. Monitoring and follow-up activities include making necessary adjustments in the care plan and service arrangements with providers. The targeted case manager performs at least one documented, face-to-face encounter per month with each eligible individual to review progress towards achieving Individualized Treatment Service Plan goals and objectives. The targeted case manager also engages in at least one contact per month with the parent(s) or legal guardian(s) of the eligible individual. Weekly or monthly contacts (often by telephone) are performed by the targeted case manager with family, school personnel, medical, and other service providers to stay aware of treatment and progress, support the coordination of services, and ensure that eligible individuals are provided with necessary services in a coordinated, timely, effective, and efficient manner. Revised 09-01-20 TN#___20-0004 Approval Date Effective Date 09-01-2020 Supersedes TN# 08-08



State: Oklahoma SUPPLEMENT 1 TO ATTACHMENT 3.1-A Page 7b STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT Targeted Case Management (continued) Definition of services (continued) X Targeted case management includes contacts with non-eligible individuals that are directly related to identifying the eligible individual’s needs and care, for the purposes of helping the eligible individual access services; identifying needs and supports to assist the eligible individual in obtaining services; providing case managers with useful feedback, and alerting case managers to changes in the eligible individual’s needs. [42 CFR 440.169(e)] Qualifications of providers [42 CFR 441.18(a)(8)(v) and 42 CFR 441.18(b)]: Case Management Agency Qualifications: The provider agency must: 1. Meet applicable State and Federal laws governing the participation of providers in the Medicaid program. 2. Demonstrate that their staff has experience working with the target population. 3. Have a minimum of five years’ experience in providing all core elements of case management including: a.Individual strengths and needs assessment; b.Needs-based service planning; c. Service coordination and monitoring; and d. Ongoing assessment and treatment plan revision. 4. Have adequate administrative capacity to fulfill State and Federal requirements. 5. Have financial management capacity and system that provides documentation of services and costs in accordance with Generally Accepted Government Auditing Standards (GAGAS). 6. Have capacity to document and maintain individual case records in accordance with State and Federal requirements. 7. Have ability to meet all State and Federal laws governing the participation of providers in the State Medicaid program including, but not limited to, the ability to meet Federal and State requirements for documentation billing and audits. 8. Have a minimum of five years’ experience in providing case management services that coordinate and link to community resources required by the target population. 9. Have a minimum of five years’ experience in meeting the case management and service needs of the target population, including statewide contract management/oversight and administration of services. 10. Have responsibility for planning and coordinating statewide juvenile justice and delinquency prevention services in accordance with Oklahoma Statutes. 11. Have ability to evaluate the effectiveness, accessibility, and quality of TCM services on a community- wide basis. Revised 09-01-20 TN#_20-0004_ Approval Date Effective Date 09-01-2020 Supersedes TN# 08-08



State: Oklahoma SUPPLEMENT 1 TO ATTACHMENT 3.1-A Page 7c STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT Targeted Case Management (continued) Targeted Case Manager Qualifications: 1. Must be employed by an approved provider agency; 2. Possess a minimum of a Bachelor’s degree in a behavioral science, or a Bachelor’s degree and one year of professional experience in juvenile justice or a related field; 3. Possess knowledge of: a. Laws, rules, regulations, legislation, policies, and procedures as they pertain to the State administration of juvenile justice and the investigation of juvenile delinquency; b. Community resources; c. Human developmental stages and related dysfunctions, social work theory and practices; d. Adverse childhood experiences (ACE) and the impact of trauma on the developing brain; e. The risk and protective factors of child delinquency; f. Solution-focused practices and the critical role protective factors play in intervention planning; g. Sensitivity of cultural diversity; and, h. Clinical and counseling techniques and treatment of juvenile delinquency. 4. Possess skill in: a. Crisis intervention; b. Gathering necessary information to determine the needs of the child; c. Casework management; d. Courtroom testimony, terminology, and procedures; e. Effective communication; f. Developing, evaluating and modifying intervention plans on an ongoing basis; g. Establishing and maintaining constructive relationships with children and their families; h. Helping families become and maintain as functional family units; and i. Working with courts and law enforcement entities. 5. Have the ability to access multi-disciplinary staff, when needed. This includes, at a minimum, medical professionals as needed and a child protective services social worker. Freedom of choice [42 CFR 441.18(a)(1)]: The State assures that the provision of case management services will not restrict an individual’s free choice of providers in violation of section 1902(a)(23) of the Act. 1. Eligible individuals will have free choice of any qualified Medicaid provider within the specified geographic area identified in this plan. 2. Eligible individuals will have free choice of any qualified Medicaid providers of other medical care under the plan. Revised 09-01-20 TN#__20-0004 Approval Date Effective Date 09/01/2020 Supersedes TN# __08-08__



Table of Contents State/Territory Name: OK State Plan Amendment (SPA) #: 20-0006 This file contains the following documents in the order listed: 1) Approval Letter 2) Summary Form (with 179-like data) 3) Approved SPA Pages

DEPARTMENTOFHEALTH & HUMANSERVICES CentersforMedicare & MedicaidServices Street, Suite355 601East12th KansasCity, Missouri 64106-2898 MedicaidandCHIPOperationsGroup

EFQBSUNFOU!PG!IFBMUI!BOE!IVNBO!TFSWJDFT! GPSN!BQQSPWFE! PNC!Op/!1:49.12:4! DFOUFST!GPS!NFEJDBSF!'!NFEJDBJE!TFSWJDFT! 3/TUBUF 2/USBOTNJUUBM!OVNCFS USBOTNJUUBM!BOE!OPUJDF!PG!BQQSPWBM!PG! Oklahoma 200006 TUBUF!QMBO!NBUFSJBM! 4/QSPHSBN!JEFOUJGJDBUJPO;!UJUMF!YJY!PG!UIF!TPDJBM GPS;!DFOUFST!GPS!NFEJDBSF!'!NFEJDBJE!TFSWJDFT! TFDVSJUZ!BDU!)NFEJDBJE* UP;!SFHJPOBM!BENJOJTUSBUPS! 5/QSPQPTFE!FGGFDUJWF!EBUF DFOUFST!GPS!NFEJDBSF!'!NFEJDBJE!TFSWJDFT! September1,2020 EFQBSUNFOU!PG!IFBMUI!BOE!IVNBO!TFSWJDFT! 6/UZQF!PG!QMBO!NBUFSJBM! OFX!TUBUF!QMBO! BNFOENFOU!UP!CF!DPOTJEFSFE!BT!OFX!QMBO! BNFOENFOU! DPNQMFUF!CMPDLT!7!UISV!21!JG!UIJT!JT!BO!BNFOENFOU! 7/GFEFSBM!TUBUVUF0SFHVMBUJPO!DJUBUJPO8/GFEFSBM!CVEHFU!JNQBDU 0 2020 b/GGZ``````````````````!%!`````````````````` 42CFR§440.166 20210 c/GGZ``````````````````!%!`````````````````` 9/QBHF!OVNCFS!PG!UIF!QMBO!TFDUJPO!PS!BUUBDINFOU:/ QBHF!OVNCFS!PG!UIF!TVQFSTFEFE!QMBO!TFDUJPO PS!BUUBDINFOU! Attachment3.1-A,Page-6a-1.5;TN#15-06 Attachment3.1-A,Page6a-1.5 Attachment3.1-A,Page-6a-1.11;TN#19-0010 Attachment3.1-A,Page6a-1.11 Supplement1toAttachment3.1-A,Page1e;TN#13-13 Supplement1toAttachment3.1-A,Page1e Supplement1toAttachment3.1-A,Page8b;TN#08-09 Supplement1toAttachment3.1-A,Page8b 21/TVCKFDU!PG!BNFOENFOU ReflectingOklahoma'smembershipintheEnhancedNurseLicensureCompact(eNLC)agreement 22/HPWFSOPST!SFWJFX! PUIFS-!BT!TQFDJGJFE! HPWFSOPST!PGGJDF!SFQPSUFE!OP!DPNNFOU! DPNNFOUT!PG!HPWFSOPST!PGGJDF!FODMPTFE! OP!SFQMZ!SFDFJWFE!XJUIJO!56!EBZT!PG!TVCNJUUBM! 27/SFUVSO!UP 23/TJHOBUVSF!PG!TUBUF!BHFODZ!PGGJDJBM 23/TJHOBUVUUSF!PG!TUUBUF!BBBH OklahomaHealthCareAuthority Attn:TraylorRains 24/UZQFE!OBNF2/UZQFEBNF 4OOOOO 4345N.LincolnBlvd. MelodyAnthony OklahomaCity,OK73105 25/UJUMF StateMedicaidDirector 26/EBUF!TVCNJUUFE April24,2020 GPS!SFHJPOBM!PGGJDF!VTF!POMZ! 28/EBUF!SFDFJWFE29/EBUF!BQQSPWFE QMBO!BQQSPWFE!.!POF!DPQZ!BUUBDIFE! 2:/!UF!PG!BQQSPWFE!NBUFSJBM!31/TJHOBUVSF!PG!SFHJPOBM!PGGJDJBMFGGFDUJWF!EB 32/UZQFE!OBNF33/UJUMF 34/SFNBSLT GPSN!DNT.28:!)180:3*!

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Table of Contents State/Territory Name: Oklahoma State Plan Amendment (SPA) #: 20-0009B This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form 3) Approved Page

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Table of Contents State/Territory Name: Oklahoma State Plan Amendment (SPA) #: 20-0011 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form 3) Approved Page CORRECTED

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 601 East 12th Street, Suite 0300 Kansas City, Missouri 64106-2898 Medicaid and CHIP Operations Group February 25, 2020 Melody Anthony, State Medicaid Director Oklahoma Health Care Authority Attn: Maria Maule 4345 N. Lincoln Boulevard Oklahoma City, OK 73105 Dear Ms. Anthony: On January 27, 2020, the Centers for Medicare & Medicaid Services (CMS) received Oklahoma State Plan (SPA) No. 20-0011. This SPA was submitted to include pancreas and intestinal transplants as covered organ and tissue transplant procedures. It also updated transplant standards to include donor search and procurement services and to ensure that the methods used for organ acquisition are consistent with the Medicare program. We are pleased to inform you that SPA #20-0011 was approved on February 24, 2020, with an effective date of January 1, 2020, as requested by the State. Enclosed is a copy of the CMS 179 summary form, as well as the approved page for incorporation into the Oklahoma State Plan. If you have any questions regarding this matter you may contact Deborah Read (816) 426-5925 or by e-mail at Deborah.read@cms.hhs.gov. X Signed by: James G. Scott -S Enclosures cc: Kasie McCarty, Oklahoma Health Care Authority Megan Buck, Branch Manager, DPO-North James G. Scott, Director Division of Program Operations Sincerely,

DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL 1. TRANSMITTAL NUMBER 2 0 - 0 0 11 2.STATE Oklahoma FORM APPROVED 0MB No. 0938-0193 FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) TO: REGIONAL ADMINISTRATOR CENTERS FOR MEDICARE & MEDICAID SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES 4. PROPOSED EFFECTIVE DATE January 1, 2020 5. TYPE OF PLAN MATERIAL (Check One) 0 NEW STATE PLAN O AMENDMENT TO BE CONSIDERED AS NEW PLAN liJ AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate transmittal for each amendment) 6. FEDERAL STATUTE/REGULATION CITATION 7. FEDERAL BUDGET IMPACT 42 CFR §§ 482 74 441 35· 1903(i) of the SSA a. FFY 2020 $_6 _89¼,5_ 9_ 3 _ _ _ _ . ' . ' b. FFY 2021 $ 868,763 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT Attachment 3.1-E, Page 1 10. SUBJECT OF AMENDMENT 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable) Attachment 3.1-E, Page 1, TN# 00-19 SPA to add pancreas and intestinal to the list of organ transplant procedures as well as updating the standards of organ transplant coverage. 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 liJ OTHER, AS SPECIFIED 12. SIGNATURE OF STATE AGENCY OFFICIAL 16. RETURN TO Oklahoma Health Care Authority __________ ----1 Attn: Maria Maule 13. TYPED NAME 4345 N. Lincoln Blvd. _M_ e_ l _od_ y_ A_ n_ t_h_o _ny _________________ Oklahoma City , OK 73105 14. TITLE State Medicaid Director 15. DATE SUBMITTED 1/27/2020 17. DATE RECEIVED 01/27/2020 FOR REGIONAL OFFICE USE ONLY 18. DATE APPROVED 02/24/2020 PLAN APPROVED - ONE COPY ATTACHED 19. EFFECTIVE DATE OF APPROVED MATERIAL 20. SIGNATI JRF OF RF(.;IONAL OFFICIAL Digitally signed by James G. Scott -S __ 0_1_/0_1_/2_0_2 _0 ____________________ --- Date: 2020.02.25 14:41 :21 -06'00' 21. TYPED NAME 22. TITL James G. Scott Director, Division of Program Operations 23. REMARKS FORM CMS-179 (07/92) Instructions on Back

State: OKLAHOMA Attachment 3.1-E Page 1 STANDARDS FOR THE COVERAGE OF ORGAN TRANSPLANT SERVICES The following organ and tissue transplant procedures are covered: 1. bone marrow; 2. stem cells; 3. cornea; 4. heart; 5. kidney; 6. liver; 7. lung; 8. simultaneous pancreas-kidney (SPK); 9. pancreas after kidney (PAK); 10. heart-lung; 11. pancreas (alone); 12. intestinal (multivisceral and/or intestinal); and 13. other multi-organ transplants as deemed medically necessary. The following standards apply to organ transplant services: a. similarly situated individuals are treated alike; b. any restriction, on the facilities or practitioners which may provide such procedures, is consistent with the accessibility of high quality care to individuals eligible for the procedures under the State plan; and c. services are reasonable in amount, duration, and scope to achieve their purpose. The following limitations apply to organ transplant services: a. all transplantation services, except kidney and cornea, must be prior authorized; b. all transplant procedures are reviewed and prior authorization is based upon appropriate medical criteria; c. all organ transplants must be performed at a Medicare approved transplantation center; d. procedures considered experimental or investigational are not covered; and e. donor search and procurement services are covered for transplants consistent with the methods used by the Medicare program for organ acquisition costs. For the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) population of all Medicaid eligible children under the age of 21, services are furnished based on medical necessity. TN# 20-0011 Supersedes TN# 00-19 Approval Date 02/24/2020 Effective Date 01/01/2020 Revised 01/01/20

Table of Contents State/Territory Name: Oklahoma State Plan Amendment (SPA) #: 20-0012 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form 3) Approved SPA Page

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 601 East 12th Street, Suite 355 Kansas City, Missouri 64106-2898 Medicaid & CHIP Operations Group August 17, 2020 Melody Anthony State Medicaid Director Oklahoma Health Care Authority Oklahoma City, OK 73105 Dear Ms. Anthony: On June 5, 2020, the Centers for Medicare & Medicaid Services (CMS) received Oklahoma State Plan (SPA) No. 20-0012. This SPA was submitted to increase the number of covered inpatient rehabilitation hospital days for adult SoonerCare members from 24 days per state fiscal year to 90 days per state fiscal year. We are pleased to inform you that SPA 20-0012 was approved on August 14, 2020, with an effective date of September 1, 2020, as requested by the state. Enclosed is a copy of the CMS 179 summary form, as well as the approved pages for incorporation into the Oklahoma State Plan. If you have any questions regarding this matter you may contact Deborah Read (816) 426-5925 or by e-mail at Deborah.read@cms.hhs.gov. X Enclosures cc: Kasie McCarty, Oklahoma Health Care Authority Megan Buck, Program Branch Manager James G. Scott, Director Division of Program Operations Sincerely, Digitally signed by James G. Scott -S Date: 2020.08.17 16:34:05 -05'00'

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB No. 0938-0193 TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES 1. TRANSMITTAL NUMBER 2. STATE 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) 4. PROPOSED EFFECTIVE DATE TO: REGIONAL ADMINISTRATOR CENTERS FOR MEDICARE & MEDICAID SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL (Check One) NEW STATE PLAN AMENDMENT TO BE CONSIDERED AS NEW PLAN AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate transmittal for each amendment) 6. FEDERAL STATUTE/REGULATION CITATION 7. FEDERAL BUDGET IMPACT a. FFY__________________ $ __________________ b. FFY__________________ $ __________________ 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable) 10. SUBJECT OF AMENDMENT 11. GOVERNOR’S REVIEW (Check One) GOVERNOR’S OFFICE REPORTED NO COMMENT OTHER, AS SPECIFIED COMMENTS OF GOVERNOR’S OFFICE ENCLOSED NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL 12. SIGNATURE OF STATE AGENCY OFFICIAL 13. TYPED NAME 14. TITLE 15. DATE SUBMITTED 16. RETURN TO FOR REGIONAL OFFICE USE ONLY 17. DATE RECEIVED 18. DATE APPROVED PLAN APPROVED - ONE COPY ATTACHED 19. TE OF APPROVED MATERIAL 20. SIGNATURE OF REGIONAL OFFICIAL 21. TYPED NAME 22. TITLE 23. REMARKS EFFECTIVE DA FORM CMS-179 (07/92) Instructions on Back 12 1 . S . IGNATURE OF STA T TE T AGENCY A 13. TYPED NAM A E 2 0 0 0 12 Oklahoma September 1, 2020 42 CFR § 412.604 2020 64,918 2021 779,021 Attachment 3.1-A, Page 1a-1 Attachment 3.1-A, Page 1a-1; TN# 03-10 OK SPA 20-0012 revises Attachment 3.1-A, Page 1a-1 to increase the number of covered inpatient rehabilitation hospital days for adult SoonerCare members from 24 days per state fiscal year to 90 days per state fiscal year Melody Anthony State Medicaid Director 6/5/2020 Oklahoma Health Care Authority Attn: Traylor Rains 4345 N. Lincoln Blvd. Oklahoma City, OK 73105 June 5, 2020 August 14, 2020 September 1, 2020 James G. Scott Director, Medicaid and CHIP Operations Group Digitally signed by James G. Scott -S Date: 2020.08.17 16:34:37 -05'00'

State OKLAHOMA Attachment 3.1-A Page 1a-1 AMOUNT, DURATION AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED CATEGORICALLY NEEDY 1. Inpatient hospital services other than those provided in an institution for mental diseases Payment is made for compensable inpatient medical and surgical services to those hospitals which have a contract with this Agency. Freestanding inpatient rehabilitation hospital services are limited to 90 days per individual per state fiscal year. The 90-day limitation per state fiscal year can be extended based on medical necessity. The limitation is not applicable to services received by children (see 4.b., Early and Periodic Screening, Diagnostic, and Treatment (EPSDT)). Medical necessity for hospital services is subject to review and determination that a period of hospitalization is not medically necessary will result in a non-compensable service. Revised 09/01/20 TN#_OK-20-0012____ Approval Date 8/14/20________ Effective Date 9/1/20___________ Supersedes TN# 03-10

Table of Contents State/Territory Name: Oklahoma State Plan Amendment (SPA) #: 20-0013 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form 3) Approved Page

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 1301 Young Street Dallas, Texas 75202

Regional Operations Group

December 26, 2019

Our Reference: SPA OK 20-0013

Melody Anthony State Medicaid Director Oklahoma Health Care Authority 4345 N. Lincoln Blvd. Oklahoma City, Oklahoma 73105

Dear Ms. Anthony:

Enclosed is a copy of approved Oklahoma State Plan Amendment (SPA) No. 20-0013, with an effective date of January 1, 2020. This amendment was submitted to establish Registered Behavioral Technicians (RBT) as providers of Applied Behavioral Analysis (ABA) Services.

This letter affirms that OK 20-0013 is approved effective January 1, 2020 as requested by the State.

We are including the CMS-179 and the following amended plan page:

o Attachment 3.1-A, Page 1a-6.1

If you have any questions regarding this matter you may contact Stacey Shuman at 214-767-6479, or by email at stacey.shuman@cms.hhs.gov.

Sincerely,

Bill Brooks

Director

Centers for Medicaid & CHIP Services

Regional Operations Group

Cc: Billy Bob Farrell, Branch Manager

Nancy Kirchner, CMS Baltimore

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB No. 0938-0193 TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES 1. TRANSMITTAL NUMBER 2. STATE 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) 4. PROPOSED EFFECTIVE DATE TO: REGIONAL ADMINISTRATOR CENTERS FOR MEDICARE & MEDICAID SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL (Check One) NEW STATE PLAN AMENDMENT TO BE CONSIDERED AS NEW PLAN AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate transmittal for each amendment) 6. FEDERAL STATUTE/REGULATION CITATION 7. FEDERAL BUDGET IMPACT a. FFY__________________ $ __________________ b. FFY__________________ $ __________________ 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable) 10. SUBJECT OF AMENDMENT 11. GOVERNOR’S REVIEW (Check One) GOVERNOR’S OFFICE REPORTED NO COMMENT OTHER, AS SPECIFIED COMMENTS OF GOVERNOR’S OFFICE ENCLOSED NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL 12. SIGNATURE OF STATE AGENCY OFFICIAL 13. TYPED NAME 14. TITLE 15. DATE SUBMITTED 16. RETURN TO FOR REGIONAL OFFICE USE ONLY 17. DATE RECEIVED 18. DATE APPROVED PLAN APPROVED - ONE COPY ATTACHED 19. TE OF APPROVED MATERIAL 20. SIGNATURE OF REGIONAL OFFICIAL 21. TYPED NAME 22. TITLE 23. REMARKS EFFECTIVE DA FORM CMS-179 (07/92) Instructions on Back 12. SIGNA N TURE OF S 13 TYPED NAME 2 0 0 0 13 Oklahoma January 1, 2020 42 CFR § 440.60 2020 4,184,162 2021 5,745,353 Attachment 3.1-A, Page 1a-6.1; Attachment 3.1-A, Page 1a-6.1; TN # 19-0007 Establishing Registered Behavioral Technicians as providers of Applied Behavioral Analysis Services Melody Anthony State Medicaid Director 11/26/2019 Oklahoma Health Care Authority Attn: Maria Maule 4345 N. Lincoln Blvd. Oklahoma City, OK 73105 11/27/2019 12/26/2019 01/01/2020 Bill Brooks Director, Medicaid and CHIP Services Regional Operations Group

State: OKLAHOMA Attachment 3.1-A Page 1a-6.1 AMOUNT, DURATION AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED CATEGORICALLY NEEDY 4b. Early and Periodic Screening, Diagnosis and Treatment of Conditions Found (continued) B. Diagnosis and Treatment The following diagnosis and treatment services are provided in addition to any diagnosis and treatment services covered elsewhere in the plan: 1. Medical or Other Remedial Care by Licensed Practitioners (42 CFR 440.60) (a) Optometric Services – Services for defects in vision including eyeglasses by State licensed optometrist. (b) Podiatrists Services – Payment is made for medically necessary surgical procedures and medically necessary outpatient visits and procedures generally considered as preventive foot care provided by a Doctor of Podiatric Medicine (DPM). Services beyond this limitation are available if as a result of a screening they are determined to be medically necessary and prior authorized. (c) Nursing Services – Nursing services must be provided by a registered nurse or licensed practical nurse under supervision of a registered nurse. Services may include medically necessary procedures rendered in the child’s home. (d) Licensed Behavioral Health Practitioner Services – Services provided under the scope of their licensure by clinical psychologists and master’s level behavioral practitioners who can bill independently using the appropriate Physician’s Current Procedure Terminology (CPT) codes in an outpatient setting. (e) Applied Behavior Analysis (ABA) – ABA services must be medically necessary and prior authorized by OHCA or its designated agent. Eligible ABA provider types include: i. Board Certified Behavior Analyst® (BCBA®) – A master’s or doctoral level independent practitioner who is certified by the national-accrediting Behavior Analyst Certification Board® (BACB) and licensed by Oklahoma Department of Human Services (DHS) Developmental Disabilities Services (DDS) provide behavior analysis services. A BCBA may supervise the work of a Board Certified Assistant Behavior Analyst® (BCaBA) and a Registered Behavior Technician (RBT) implementing behavior analytic interventions within their scope of practice and assumes professional responsibility for services rendered by the non-licensed practitioner. ii. Board Certified Assistant Behavior Analyst® (BCaBA®) – A bachelor’s level practitioner who is certified by the national-accrediting BACB and is certified by the Oklahoma DHS DDS to provide behavior analysis services under the supervision of a licensed BCBA. iii. Registered Behavior TechnicianTM (RBT®) – A high school level or higher paraprofessional who is certified by the national-accrediting BACB and practices under the close and ongoing supervision of a BCBA. A RBT® is primarily responsible for the direct implementation of BCBA® designed behavior-analytic services. iv. State-licensed human services professional – An Oklahoma state-licensed individual practicing within the scope of their human service profession as defined by State law and who is certified by the national- accrediting BACB, to include: (A) A licensed physical therapist; (B) A licensed occupational therapist; (C) A licensed clinical social worker or social worker candidate under the supervision of a licensed clinical social worker; (D) A licensed psychologist; (E) A licensed speech-language pathologist or licensed audiologist; (F) A licensed professional counselor or professional counselor candidate under the supervision of a licensed professional counselor; (G) A licensed marital and family therapist or marital and family therapist candidate under the supervision of a licensed marital and family therapist; or (H) A licensed behavioral practitioner or behavioral practitioner candidate under the supervision of a licensed behavioral practitioner. 2. Medical supplies, equipment, appliances and prosthetic devices (42 CFR 440.70 & 42 CFR 440.120). Services and supplies not otherwise available to Medicaid clients in the state under the state plan when prior authorized. 3. Diagnostic Services (42 440.130(a)) (a) Investigations to Determine Source of Lead. A one-time investigation to determine the source of lead for a child diagnosed with elevated blood lead levels. Reimbursement does not include testing the water, soil, or paint. In accordance with the rules established by the Oklahoma Department of Environmental Quality (DEQ), a qualified Risk Assessor must perform the service. 4. Clinic Services (42 CFR 440.90) (a) Public Health Clinic Services Revised 01-01-20 TN#___________ Approval Date___________ Effective Date ___________ Supersedes TN#__________ 20-0013 12/26/2019 01/01/2020 19-0007 State: Oklahoma Date Received: 27 November, 2019 Date Approved: 26 December, 2019 Effective Date: 1 January, 2020 Transmittal Number: 20-0013

Table of Contents State/Territory Name: OK State Plan Amendment (SPA) #: 20-0021 This file contains the following documents in the order listed: 1) Approval Letter 2) Summary Form (with 179-like data) 3) Approved SPA Pages

DEPARTMENTOFHEALTH & HUMANSERVICES CentersforMedicare & MedicaidServices Street, Suite355 601East12th KansasCity, Missouri64106-2898 MedicaidandCHIPOperationsGroup June26, 2020 MelodyAnthony StateMedicaidDirector OklahomaHealthCareAuthority 4345N. LincolnBoulevard OklahomaCity, OK 73105 DearMs. Anthony: OnMay8, 2020, theCentersforMedicare & MedicaidServices (CMS) receivedOklahoma StatePlan (SPA) No. 20-0021. ThisSPAwassubmittedtoseparateanddifferentiatebetween servicesprovidedinaschoolsettingunderEPSDTversusthoseschool-basedservicesprovided pursuanttoanIndividualEducationPlan (IEP). WearepleasedtoinformyouthatSPA20-0021wasapprovedonJune24, 2020, withan effectivedateofSeptember1, 2020, asrequestedbythestate. EnclosedisacopyoftheCMS 179summaryform, aswellastheapprovedpagesforincorporationintotheOklahomaState Plan. IfyouhaveanyquestionsregardingthismatteryoumaycontactDeborahRead (816) 426-5925 orbye-mailatDeborah.read@cms.hhs.gov. Sincerely, X JamesG. Scott, Director DivisionofProgramOperations Enclosures cc: KasieMcCarty, OklahomaHealthCareAuthority MeganBuck, ProgramBranchManager JanCovello

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State OKLAHOMA Attachment 3.1-A

Page 1a-6.6

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

CATEGORICALLY NEEDY

4b. Early and Periodic Screening, Diagnosis and Treatment of Conditions Found (continued)

B. Diagnosis and Treatment (continued)

9.

10.

11.

12.

Preventive Services — (42 CFR 440.130(c))

Outpatient Substance Abuse Prevention Counseling — Interactive, preventive counseling that may include training in life skills, such as problem-solving, responsibility, communication and decision-making skills, which enable individuals to successfully resist social and other pressures to engage in activities that are destructive to their health and future. This service must be recommended by a physician or other licensed practitioner and may be provided by aBHP. A QBHT may provide assistance. For individual provider qualifications, see Attachment 3.1-A, page 1a-6.4.

Inpatient Psychiatric Services (42 CFR 440.160) — Provided when medically necessary and prior authorized.

Personal Care Services (PCS) (42 CFR 440.167) — Services furnished to an individual who is not an inpatient or resident of a hospital, nursing facility, intermediate care facility for individuals with intellectual disabilities, or institution for mental disease that are: 1) authorized for an individual by a physician in accordance with a plan of treatment or otherwise authorized for the individual in accordance with an IEP service plan; 2) provided by registered paraprofessionals who have completed training provided by State Department of Education or Personal Care Assistants, including Licensed Practical Nurses who have completed on the job training specific to their duties and who is not a member of the individual’s family (or legally responsible relative) Provision of these services allows clients with disabilities to function safely in their activities of daily living in the home and to safely attend school. Services include, but are not limited to: dressing, eating, bathing, assistance with transferring and toileting, positioning and instrumental activities of daily living such as preparing meals and managing medications. PCS also includes assistance while riding a school bus to handle medical or physical emergencies. Services must be prior authorized. The determination of whether a client needs PCS is based on a client’s individual needs and a consideration of family resources.

School-Based Health Services (42 CFR 440.130) - School-based services are provided pursuant to a valid Individualized Education Plan (IEP) in accordance with Individuals with Disabilities Education Act (IDEA) and all relevant supporting documentation. Services provided per the IEP and supporting documentation are considered medically necessary and are provided by or through local educational agencies and/or interlocal cooperatives (schools) to eligible individuals. IEPs may only serve as the basis for medical necessity if the IEP team providers are qualified to make that determination, in accordance with their scope of practice. In addition to any other notification and/or consent requirements related to IEP evaluation and/or treatments, schools must provide sufficient notification to a child’s legal guardian and obtain adequate consent from them prior to accessing a child's or legal guardian’s public benefits or insurance for the first time, and annually thereafter, in accordance with 34 CFR 300.154.

Medically necessary services are provided in a school setting during the school day when determined that the school is an appropriate place of service performed by qualified providers as set forth in the State Plan for the services they are providing and shall meet applicable qualifications under 42 CFR Part 440. OHCA- contracted practitioners furnish medically necessary services to the Medicaid eligible child while the school is the operator of the setting, ensures that a the student’s school educational day is not unnecessarily interrupted, and that there is appropriate parental consent for the services. Schools have the right to limit outpatient visits unrelated to the IEP to before and after the school day so that interruptions the educational day are limited. Prior authorization is required for non-IEP services furnished by an independent practitioner under arrangement with the school. All beneficiaries must be allowed the freedom of choice to receive services from any qualified practitioner including in a community setting.

Revised 09-01-20

TN# 20-0021 Approval Date 06/24/2020 Effective Date 09/01/2020

Supersedes TN# 18-03

State OKLAHOMA Attachment 3.1-A Page 1a-6.9

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

Reserved

Revised 09-01-20

TN# 20-0021 Approval Date 06/24/2020 Effective Date 09/01/2020

Supersedes TN# 13-12

State OKLAHOMA Attachment 3.1-A Page 1a-6.10

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

Reserved

Revised 09-01-20

TN# 20-0021 Approval Date 06/24/2020 Effective Date 09/01/2020

Supersedes TN# 13-12

State OKLAHOMA Attachment 3.1-A Page 1a-6.11

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

Reserved

Revised 09-01-20

TN# 20-0021 Approval Date 06/24/2020 Effective Date 09/01/2020

Supersedes TN# 13-12

State OKLAHOMA Attachment 3.1-A Page 1a-6.12

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

Reserved

Revised 09-01-20

TN# 20-0021 Approval Date 06/24/2020 Effective Date 09/01/2020

Supersedes TN# 18-03

Table of Contents State/Territory Name: Oklahoma State Plan Amendment (SPA) #: 20-0032 This file contains the following documents in the order listed:

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

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-26-12 Baltimore, Maryland 21244-1850 May 11, 2020 Melody Anthony State Medicaid Director Oklahoma Health Care Authority 4345 North Lincoln Boulevard Oklahoma City, Oklahoma 73105 Re: Oklahoma State Plan Amendment (SPA) 20-0032 Dear Ms. Anthony: We have reviewed the proposed amendment to add section 7.4 Medicaid Disaster Relief for the COVID-19 National Emergency to your Medicaid state plan, as submitted under transmittal number OK 20-0032. This amendment proposes to implement temporary policies, which are different from those policies and procedures otherwise applied under your Medicaid state plan, during the period of the Presidential and Secretarial emergency declarations related to the COVID-19 outbreak (or any renewals thereof). On March 13, 2020, the President of the United States issued a proclamation that the COVID-19 outbreak in the United States constitutes a national emergency by the authorities vested in him by the Constitution and the laws of the United States, including sections 201 and 301 of the National Emergencies Act (50 U.S.C. 1601 et seq.), and consistent with section 1135 of the Social Security Act (Act). On March 13, 2020, pursuant to section 1135(b) of the Act, the Secretary of the United States Department of Health and Human Services invoked his authority to waive or modify certain requirements of titles XVIII, XIX, and XXI of the Act as a result of the consequences of the COVID-19 pandemic, to the extent necessary, as determined by the Centers for Medicare & Medicaid Services (CMS), to ensure that sufficient health care items and services are available to meet the needs of individuals enrolled in the respective programs and to ensure that health care providers that furnish such items and services in good faith, but are unable to comply with one or more of such requirements as a result of the COVID-19 pandemic, may be reimbursed for such items and services and exempted from sanctions for such noncompliance, absent any determination of fraud or abuse.

This authority took effect as of 6PM Eastern Standard Time on March 15, 2020, with a retroactive effective date of March 1, 2020. The emergency period will terminate, and this state plan provision will no longer be in effect, upon termination of the public health emergency, including any extensions. 3XUVXDQW WR VHFWLRQ  E

 RI WKH $FW IRU WKH SHULRG RI WKH SXEOLF KHDOWK HPHUJHQF\ &06 LV PRGLI\LQJ WKH UHTXLUHPHQW DW  &)5  WKDW WKH VWDWH VXEPLW 63$V UHODWHG WR WKH &29,' SXEOLF KHDOWK HPHUJHQF\ E\ WKH ILQDO GD\ RI WKH TXDUWHU WR REWDLQ D 63$ HIIHFWLYH GDWH GXULQJ WKH TXDUWHU HQDEOLQJ 63$V VXEPLWWHG DIWHU WKH ODVW GD\ RI WKH TXDUWHU WR KDYH DQ HIIHFWLYH GDWH LQ D SUHYLRXV TXDUWHU EXW QR HDUOLHU WKDQ WKH HIIHFWLYH GDWH RI WKH SXEOLF KHDOWK HPHUJHQF\ The State of Oklahoma requested a waiver of public notice requirements applicable to the state plan amendment (SPA) submission process. 3XUVXDQW WR VHFWLRQ  E



& RI WKH $FW &06 LV DOVR ZDLYLQJ SXEOLF QRWLFH UHTXLUHPHQWV DSSOLFDEOH WR WKH 63$ VXEPLVVLRQ SURFHVV Public notice for SPAs is required under 42 C.F.R §447.205 for changes in statewide methods and standards for setting Medicaid payment rates, 42 C.F.R. §447.57 for changes to premiums and cost sharing, and 42 C.F.R. §440.386 for changes to ABPs. 3XUVXDQW WR VHFWLRQ  E



& RI WKH $FW &06 LV DSSURYLQJ WKH VWDWH V UHTXHVW WR ZDLYH WKHVH QRWLFH UHTXLUHPHQWV RWKHUZLVH DSSOLFDEOH WR WKH 63$ VXEPLVVLRQ SURFHVV The State of Oklahoma also requested a waiver to modify the tribal consultation timeline applicable to this SPA submission process. Under section 1135(b)(5) of the Act, CMS is also approving the State of Oklahoma’s request for flexibility to modify the timeframes associated with tribal consultation required under section 1902(a)(73) of the Act, including shortening the number of days before submission or conducting consultation after submission of the SPA. These ZDLYHUV RU PRGLILFDWLRQV RI WKH UHTXLUHPHQWV UHODWHG WR 63$ VXEPLVVLRQ WLPHOLQHV SXEOLF QRWLFH DQG WULEDO FRQVXOWDWLRQ DSSO\ RQO\ ZLWK UHVSHFW WR 63$V WKDW PHHW WKH IROORZLQJ FULWHULD

 WKH 63$ SURYLGHV RU LQFUHDVHV EHQHILFLDU\ DFFHVV WR LWHPV DQG VHUYLFHV UHODWHG WR &29,'

VXFK DV E\ ZDLYLQJ RU HOLPLQDWLQJ FRVW VKDULQJ LQFUHDVLQJ SD\PHQW UDWHV RU DPHQGLQJ $%3V WR DGG VHUYLFHV RU SURYLGHUV

 WKH 63$ GRHV QRW UHVWULFW RU OLPLW SD\PHQW RU VHUYLFHV RU RWKHUZLVH EXUGHQ EHQHILFLDULHV DQG SURYLGHUV DQG  WKH 63$ LV WHPSRUDU\ ZLWK D VSHFLILHG VXQVHW GDWH WKDW LV QRW ODWHU WKDQ WKH ODVW GD\ RI WKH GHFODUHG &29,' SXEOLF KHDOWK HPHUJHQF\ RU DQ\ H[WHQVLRQ WKHUHRI  :H QRQHWKHOHVV HQFRXUDJH VWDWHV WR PDNH DOO UHOHYDQW LQIRUPDWLRQ DERXW WKH 63$ DYDLODEOH WR WKH SXEOLF VR WKH\ DUH DZDUH RI WKH FKDQJHV We conducted our review of your submittal according to the statutory requirements at section 1902(a) of the Act and implementing regulations. This letter is to inform you that Oklahoma’s Medicaid SPA Transmittal Number 20-0032 is approved effective March 1, 2020. Enclosed is a copy of the CMS-179 summary form and the approved state plan pages.

Please contact Deborah Read at 816-426-6363 or by email at Deborah.read@cms.hhs.gov if you have any questions about this approval. We appreciate the efforts of you and your staff in responding to the needs of the residents of the State of Oklahoma and the health care community. Sincerely, Anne Marie Costello Deputy Director Center for Medicaid & CHIP Services Enclosures Anne M. Costello -S Digitally signed by Anne M. Costello -S Date: 2020.05.11 08 54:42 -04'00'

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

FORM APPROVED OMB No. 0938-0193

1. TRANSMITTAL NUMBER 2. STATE TRANSMITTAL AND NOTICEOF APPROVALOF |) > 5, loxlanoma STATE PLAN MATERIAL FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID)

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

4. PROPOSED EFFECTIVE DATE March 1, 2020

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

(0 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 Sections 1135(b), 1902, and 1905 of the SSA

7. FEDERAL BUDGET IMPACT a. FFY.2020 $ b. FFY.2021 $ NIA

8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT

Section 7.4, Page 1 Section 7.4, Page 2 Section 7.4, Page 3 Section 7.4, Page 4 Section 7.4, Page 5 Section 7.4, Page 6 Section 7.4, Page 7 Section 7.4, Page 8 Section 7.4, Page 9 Section 7.4, Page 10

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

Section 7.4, Page 1; New Section 7.4, Page 2; New Section 7.4, Page 3; New Section 7.4, Page 4; New Section 7.4, Page 5; New Section 7.4, Page 6; New Section 7.4, Page 7; New Section 7.4, Page 8; New Section 7.4, Page 9; New Section 7.4, Page 10; New

10. SUBJECT OF AMENDMENT

Medicaid disaster relief due to the COVID-19 public health emergency

11. GOVERNOR'S REVIEW (Check One)

(J Governor's OFFICE REPORTED NO COMMENT (0 CoMMENTS OF GOVERNOR'S OFFICE ENCLOSED (1 No REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL

fl OTHER, AS SPECIFIED

———————————————

13. TYPED NAME Melody Anthony

14. TITLE State Medicaid Director

15. DATE SUBMITTED 4/24/20

16. RETURN TO

Oklahoma Health Care Authority Attn: Traylor Rains

4345 N. Lincoln Blvd.

Oklahoma City, OK 73105

FOR REGIONAL OFFICE USE ONLY

17. DATE RECEIVED April 24, 2020

18. DATE APPROVED May 11, 2020

PLAN APPROVED - ONE COPY ATTACHED

19. EFFECTIVE DATE OF APPROVED MATERIAL March 1, 2020

20. SIGNATURE OF REGIONAL OFFICIAL signed by Anne M.

Digtaly Anne M. Costello -S costetio-s Date: 2020.06.11 08:56:22 -0400

21. TYPED NAME

Anne Marie Costello

22. TITLE

Deputy Director, CMCS

23. REMARKS

FORM CMS-179 (07/92)

Instructions on Back

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

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

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

^ƚĂƚĞͬdĞƌƌŝƚŽƌLJ͗ K<>,KD dE͗ ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ ƉƉƌŽǀĂů ĂƚĞ͗ ͺͺͺͺͺͺͺͺͺͺ ^ƵƉĞƌƐĞĚĞƐ dE͗ ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ

ĨĨĞĐƚŝǀĞ ĂƚĞ͗ ͺͺͺͺͺͺͺͺͺͺ Đ͘ ͺͺy ͺ dƌŝďĂů ĐŽŶƐƵůƚĂƚŝŽŶ ƌĞƋƵŝƌĞŵĞŶƚƐ ʹ ƚŚĞ ĂŐĞŶĐLJ ƌĞƋƵĞƐƚƐ ŵŽĚŝĨŝĐĂƚŝŽŶ ŽĨ ƚƌŝďĂů ĐŽŶƐƵůƚĂƚŝŽŶ ƚŝŵĞůŝŶĞƐ ƐƉĞĐŝĨŝĞĚ ŝŶ ΀ŝŶƐĞƌƚ ŶĂŵĞ ŽĨ ƐƚĂƚĞ΁ DĞĚŝĐĂŝĚ ƐƚĂƚĞ ƉůĂŶ͕ ĂƐ ĚĞƐĐƌŝďĞĚ ďĞůŽǁ͗ dŚĞ ^ƚĂƚĞ DĞĚŝĐĂŝĚ ŐĞŶĐLJ ǁŝůů ŶŽƚŝĨLJ ƚƌŝďĂů ƉĂƌƚŶĞƌƐ ŽĨ Ăůů ^W ĐŚĂŶŐĞƐ ŽŶ Žƌ ďĞĨŽƌĞ ƐƵďŵŝƐƐŝŽŶ ƚŽ D^ ĂŶĚ ǁŝůů ĞŝƚŚĞƌ ŽĨĨĞƌ Ă ƚĞůĞƉŚŽŶŝĐ ŵĞĞƚŝŶŐ ƚŽ ĚŝƐĐƵƐƐ Žƌ ĐŽŶƐƵůƚ ǁŝƚŚ dƌŝďĞƐ Ăƚ ƚŚĞ ŶĞdžƚ ƌĞŐƵůĂƌůLJ ƐĐŚĞĚƵůĞ ďŝͲŵŽŶƚŚůLJ ĐŽŶƐƵůƚĂƚŝŽŶ ŵĞĞƚŝŶŐ͘ ^ĞĐƚŝŽŶ  ʹ ůŝŐŝďŝůŝƚLJ ϭ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ĨƵƌŶŝƐŚĞƐ ŵĞĚŝĐĂů ĂƐƐŝƐƚĂŶĐĞ ƚŽ ƚŚĞ ĨŽůůŽǁŝŶŐ ŽƉƚŝŽŶĂů ŐƌŽƵƉƐ ŽĨ ŝŶĚŝǀŝĚƵĂůƐ ĚĞƐĐƌŝďĞĚ ŝŶ ƐĞĐƚŝŽŶ ϭϵϬϮ;ĂͿ;ϭϬͿ;Ϳ;ŝŝͿ Žƌ ϭϵϬϮ;ĂͿ;ϭϬͿ;ĐͿ ŽĨ ƚŚĞ Đƚ͘ dŚŝƐ ŵĂLJ ŝŶĐůƵĚĞ ƚŚĞ ŶĞǁ ŽƉƚŝŽŶĂů ŐƌŽƵƉ ĚĞƐĐƌŝďĞĚ Ăƚ ƐĞĐƚŝŽŶ ϭϵϬϮ;ĂͿ;ϭϬͿ;Ϳ;ŝŝͿ;yy///Ϳ ĂŶĚ ϭϵϬϮ;ƐƐͿ ŽĨ ƚŚĞ Đƚ ƉƌŽǀŝĚŝŶŐ ĐŽǀĞƌĂŐĞ ĨŽƌ ƵŶŝŶƐƵƌĞĚ ŝŶĚŝǀŝĚƵĂůƐ͘ /ŶĐůƵĚĞ ŶĂŵĞ ŽĨ ƚŚĞ ŽƉƚŝŽŶĂů ĞůŝŐŝďŝůŝƚLJ ŐƌŽƵƉ ĂŶĚ ĂƉƉůŝĐĂďůĞ ŝŶĐŽŵĞ ĂŶĚ ƌĞƐŽƵƌĐĞ ƐƚĂŶĚĂƌĚ͘ Ϯ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ĨƵƌŶŝƐŚĞƐ ŵĞĚŝĐĂů ĂƐƐŝƐƚĂŶĐĞ ƚŽ ƚŚĞ ĨŽůůŽǁŝŶŐ ƉŽƉƵůĂƚŝŽŶƐ ŽĨ ŝŶĚŝǀŝĚƵĂůƐ ĚĞƐĐƌŝďĞĚ ŝŶ ƐĞĐƚŝŽŶ ϭϵϬϮ;ĂͿ;ϭϬͿ;Ϳ;ŝŝͿ;yyͿ ŽĨ ƚŚĞ Đƚ ĂŶĚ ϰϮ &Z ϰϯϱ͘Ϯϭϴ͗ Ă͘ ͺͺͺͺͺ ůů ŝŶĚŝǀŝĚƵĂůƐ ǁŚŽ ĂƌĞ ĚĞƐĐƌŝďĞĚ ŝŶ ƐĞĐƚŝŽŶ ϭϵϬϱ;ĂͿ;ϭϬͿ;Ϳ;ŝŝͿ;yyͿ /ŶĐŽŵĞ ƐƚĂŶĚĂƌĚ͗ ͺͺͺͺͺͺͺͺͺͺͺͺͺ ͲŽƌͲ ď͘ ͺͺͺͺͺ /ŶĚŝǀŝĚƵĂůƐ ĚĞƐĐƌŝďĞĚ ŝŶ ƚŚĞ ĨŽůůŽǁŝŶŐ ĐĂƚĞŐŽƌŝĐĂů ƉŽƉƵůĂƚŝŽŶƐ ŝŶ ƐĞĐƚŝŽŶ ϭϵϬϱ;ĂͿ ŽĨ ƚŚĞ Đƚ͗ /ŶĐŽŵĞ ƐƚĂŶĚĂƌĚ͗ ͺͺͺͺͺͺͺͺͺͺͺͺͺ ϯ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ĂƉƉůŝĞƐ ůĞƐƐ ƌĞƐƚƌŝĐƚŝǀĞ ĨŝŶĂŶĐŝĂů ŵĞƚŚŽĚŽůŽŐŝĞƐ ƚŽ ŝŶĚŝǀŝĚƵĂůƐ ĞdžĐĞƉƚĞĚ ĨƌŽŵ ĨŝŶĂŶĐŝĂů ŵĞƚŚŽĚŽůŽŐŝĞƐ ďĂƐĞĚ ŽŶ ŵŽĚŝĨŝĞĚ ĂĚũƵƐƚĞĚ ŐƌŽƐƐ ŝŶĐŽŵĞ ;D'/Ϳ ĂƐ ĨŽůůŽǁƐ͘ >ĞƐƐ ƌĞƐƚƌŝĐƚŝǀĞ ŝŶĐŽŵĞ ŵĞƚŚŽĚŽůŽŐŝĞƐ͗ ϮϬͲϬϬϯϮ ϱͬϭϭͬϮϬ E t ϯͬϭͬϮϬ Ϯ

^ƚĂƚĞͬdĞƌƌŝƚŽƌLJ͗ K<>,KD dE͗ ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ ƉƉƌŽǀĂů ĂƚĞ͗ ͺͺͺͺͺͺͺͺͺͺ ^ƵƉĞƌƐĞĚĞƐ dE͗ ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ

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

ƉĞƌŝŽĚƐ͘ ϯ͘ ͺͺ dŚĞ ĂŐĞŶĐLJ ĚĞƐŝŐŶĂƚĞƐ ƚŚĞ ĨŽůůŽǁŝŶŐ ĞŶƚŝƚŝĞƐ ĂƐ ƋƵĂůŝĨŝĞĚ ĞŶƚŝƚŝĞƐ ĨŽƌ ƉƵƌƉŽƐĞƐ ŽĨ ŵĂŬŝŶŐ ƉƌĞƐƵŵƉƚŝǀĞ ĞůŝŐŝďŝůŝƚLJ ĚĞƚĞƌŵŝŶĂƚŝŽŶƐ Žƌ ĂĚĚƐ ĂĚĚŝƚŝŽŶĂů ƉŽƉƵůĂƚŝŽŶƐ ĂƐ ĚĞƐĐƌŝďĞĚ ďĞůŽǁ ŝŶ ϮϬͲϬϬϯϮ ϱͬϭϭͬϮϬ E t ϯͬϭͬϮϬ ϯ

^ƚĂƚĞͬdĞƌƌŝƚŽƌLJ͗ K<>,KD dE͗ ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ ƉƉƌŽǀĂů ĂƚĞ͗ ͺͺͺͺͺͺͺͺͺͺ ^ƵƉĞƌƐĞĚĞƐ dE͗ ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ

ĨĨĞĐƚŝǀĞ ĂƚĞ͗ ͺͺͺͺͺͺͺͺͺͺ ĂĐĐŽƌĚĂŶĐĞ ǁŝƚŚ ƐĞĐƚŝŽŶƐ ϭϵϮϬ͕ ϭϵϮϬ͕ ϭϵϮϬ͕ ĂŶĚ ϭϵϮϬ ŽĨ ƚŚĞ Đƚ ĂŶĚ ϰϮ &Z WĂƌƚ ϰϯϱ ^ƵďƉĂƌƚ >͘ /ŶĚŝĐĂƚĞ ŝĨ ĂŶLJ ĚĞƐŝŐŶĂƚĞĚ ĞŶƚŝƚŝĞƐ ĂƌĞ ƉĞƌŵŝƚƚĞĚ ƚŽ ŵĂŬĞ ƉƌĞƐƵŵƉƚŝǀĞ ĞůŝŐŝďŝůŝƚLJ ĚĞƚĞƌŵŝŶĂƚŝŽŶƐ ŽŶůLJ ĨŽƌ ƐƉĞĐŝĨŝĞĚ ƉŽƉƵůĂƚŝŽŶƐ͘ WůĞĂƐĞ ĚĞƐĐƌŝďĞ ƚŚĞ ĚĞƐŝŐŶĂƚĞĚ ĞŶƚŝƚŝĞƐ Žƌ ĂĚĚŝƚŝŽŶĂů ƉŽƉƵůĂƚŝŽŶƐ ĂŶĚ ĂŶLJ ůŝŵŝƚĂƚŝŽŶƐ ƌĞůĂƚĞĚ ƚŽ ƚŚĞ ƐƉĞĐŝĨŝĞĚ ƉŽƉƵůĂƚŝŽŶƐ Žƌ ŶƵŵďĞƌ ŽĨ ĂůůŽǁĂďůĞ W ƉĞƌŝŽĚƐ͘ ϰ͘ ͺͺyͺͺ dŚĞ ĂŐĞŶĐLJ ĂĚŽƉƚƐ Ă ƚŽƚĂů ŽĨ ͺϭϮ ŵŽŶƚŚƐ ;ŶŽƚ ƚŽ ĞdžĐĞĞĚ ϭϮ ŵŽŶƚŚƐͿ ĐŽŶƚŝŶƵŽƵƐ ĞůŝŐŝďŝůŝƚLJ ĨŽƌ ĐŚŝůĚƌĞŶ ƵŶĚĞƌ ĂŐĞ ŽĨ ͺϭϵ ;ŶŽƚ ƚŽ ĞdžĐĞĞĚ ĂŐĞ ϭϵͿ ƌĞŐĂƌĚůĞƐƐ ŽĨ ĐŚĂŶŐĞƐ ŝŶ ĐŝƌĐƵŵƐƚĂŶĐĞƐ ŝŶ ĂĐĐŽƌĚĂŶĐĞ ǁŝƚŚ ƐĞĐƚŝŽŶ ϭϵϬϮ;ĞͿ;ϭϮͿ ŽĨ ƚŚĞ Đƚ ĂŶĚ ϰϮ &Z ϰϯϱ͘ϵϮϲ͘ ϱ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ĐŽŶĚƵĐƚƐ ƌĞĚĞƚĞƌŵŝŶĂƚŝŽŶƐ ŽĨ ĞůŝŐŝďŝůŝƚLJ ĨŽƌ ŝŶĚŝǀŝĚƵĂůƐ ĞdžĐĞƉƚĞĚ ĨƌŽŵ D'/Ͳ ďĂƐĞĚ ĨŝŶĂŶĐŝĂů ŵĞƚŚŽĚŽůŽŐŝĞƐ ƵŶĚĞƌ ϰϮ &Z ϰϯϱ͘ϲϬϯ;ũͿ ŽŶĐĞ ĞǀĞƌLJ ͺͺͺͺͺ ŵŽŶƚŚƐ ;ŶŽƚ ƚŽ ĞdžĐĞĞĚ ϭϮ ŵŽŶƚŚƐͿ ŝŶ ĂĐĐŽƌĚĂŶĐĞ ǁŝƚŚ ϰϮ &Z ϰϯϱ͘ϵϭϲ;ďͿ͘ ϲ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ƵƐĞƐ ƚŚĞ ĨŽůůŽǁŝŶŐ ƐŝŵƉůŝĨŝĞĚ ĂƉƉůŝĐĂƚŝŽŶ;ƐͿ ƚŽ ƐƵƉƉŽƌƚ ĞŶƌŽůůŵĞŶƚ ŝŶ ĂĨĨĞĐƚĞĚ ĂƌĞĂƐ Žƌ ĨŽƌ ĂĨĨĞĐƚĞĚ ŝŶĚŝǀŝĚƵĂůƐ ;Ă ĐŽƉLJ ŽĨ ƚŚĞ ƐŝŵƉůŝĨŝĞĚ ĂƉƉůŝĐĂƚŝŽŶ;ƐͿ ŚĂƐ ďĞĞŶ ƐƵďŵŝƚƚĞĚ ƚŽ D^Ϳ͘ Ă͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ƵƐĞƐ Ă ƐŝŵƉůŝĨŝĞĚ ƉĂƉĞƌ ĂƉƉůŝĐĂƚŝŽŶ͘ ď͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ƵƐĞƐ Ă ƐŝŵƉůŝĨŝĞĚ ŽŶůŝŶĞ ĂƉƉůŝĐĂƚŝŽŶ͘ Đ͘ ͺͺͺͺͺ dŚĞ ƐŝŵƉůŝĨŝĞĚ ƉĂƉĞƌ Žƌ ŽŶůŝŶĞ ĂƉƉůŝĐĂƚŝŽŶ ŝƐ ŵĂĚĞ ĂǀĂŝůĂďůĞ ĨŽƌ ƵƐĞ ŝŶ ĐĂůůͲĐĞŶƚĞƌƐ Žƌ ŽƚŚĞƌ ƚĞůĞƉŚŽŶĞ ĂƉƉůŝĐĂƚŝŽŶƐ ŝŶ ĂĨĨĞĐƚĞĚ ĂƌĞĂƐ͘ ^ĞĐƚŝŽŶ  ʹ WƌĞŵŝƵŵƐ ĂŶĚ ŽƐƚ ^ŚĂƌŝŶŐ ϭ͘ ͺͺͺͺ y ͺͺ dŚĞ ĂŐĞŶĐLJ ƐƵƐƉĞŶĚƐ ĚĞĚƵĐƚŝďůĞƐ͕ ĐŽƉĂLJŵĞŶƚƐ͕ ĐŽŝŶƐƵƌĂŶĐĞ͕ ĂŶĚ ŽƚŚĞƌ ĐŽƐƚ ƐŚĂƌŝŶŐ ĐŚĂƌŐĞƐ ĂƐ ĨŽůůŽǁƐ͗ WůĞĂƐĞ ĚĞƐĐƌŝďĞ ǁŚĞƚŚĞƌ ƚŚĞ ƐƚĂƚĞ ƐƵƐƉĞŶĚƐ Ăůů ĐŽƐƚ ƐŚĂƌŝŶŐ Žƌ ƐƵƐƉĞŶĚƐ ŽŶůLJ ƐƉĞĐŝĨŝĞĚ ĚĞĚƵĐƚŝďůĞƐ͕ ĐŽƉĂLJŵĞŶƚƐ͕ ĐŽŝŶƐƵƌĂŶĐĞ͕ Žƌ ŽƚŚĞƌ ĐŽƐƚ ƐŚĂƌŝŶŐ ĐŚĂƌŐĞƐ ĨŽƌ ƐƉĞĐŝĨŝĞĚ ŝƚĞŵƐ ĂŶĚ ƐĞƌǀŝĐĞƐ Žƌ ĨŽƌ ƐƉĞĐŝĨŝĞĚ ĞůŝŐŝďŝůŝƚLJ ŐƌŽƵƉƐ ĐŽŶƐŝƐƚĞŶƚ ǁŝƚŚ ϰϮ &Z ϰϰϳ͘ϱϮ;ĚͿ Žƌ ĨŽƌ ƐƉĞĐŝĨŝĞĚ ŝŶĐŽŵĞ ůĞǀĞůƐ ĐŽŶƐŝƐƚĞŶƚ ǁŝƚŚ ϰϮ &Z ϰϰϳ͘ϱϮ;ŐͿ͘ dŚĞ ^ƚĂƚĞ ǁĂŝǀĞƐ ĐŽƐƚͲƐŚĂƌŝŶŐ ĨŽƌ ƚĞƐƚŝŶŐ ƐĞƌǀŝĐĞƐ ;ŝŶĐůƵĚŝŶŐ ŝŶ ǀŝƚƌŽ ĚŝĂŐŶŽƐƚŝĐ ƉƌŽĚƵĐƚƐͿ͕ ƚĞƐƚŝŶŐͲƌĞůĂƚĞĚ ƐĞƌǀŝĐĞƐ͕ ĂŶĚ ƚƌĞĂƚŵĞŶƚƐ ĨŽƌ Ks/Ͳϭϵ͕ ŝŶĐůƵĚŝŶŐ ǀĂĐĐŝŶĞƐ͕ ƐƉĞĐŝĂůŝnjĞĚ ĞƋƵŝƉŵĞŶƚ ĂŶĚ ƚŚĞƌĂƉŝĞƐ ;ŝŶĐůƵĚŝŶŐ ĚƌƵŐƐͿ͕ ĨŽƌ ĂŶLJ ƋƵĂƌƚĞƌ ŝŶ ǁŚŝĐŚ ƚŚĞ ƚĞŵƉŽƌĂƌLJ ŝŶĐƌĞĂƐĞĚ &DW ŝƐ ĐůĂŝŵĞĚ͘ Ϯ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ƐƵƐƉĞŶĚƐ ĞŶƌŽůůŵĞŶƚ ĨĞĞƐ͕ ƉƌĞŵŝƵŵƐ ĂŶĚ ƐŝŵŝůĂƌ ĐŚĂƌŐĞƐ ĨŽƌ͗ Ă͘ ͺͺͺ ůů ďĞŶĞĨŝĐŝĂƌŝĞƐ ϮϬͲϬϬϯϮ ϱͬϭϭͬϮϬ E t ϯͬϭͬϮϬ ϰ

^ƚĂƚĞͬdĞƌƌŝƚŽƌLJ͗ K<>,KD dE͗ ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ ƉƉƌŽǀĂů ĂƚĞ͗ ͺͺͺͺͺͺͺͺͺͺ ^ƵƉĞƌƐĞĚĞƐ dE͗ ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ

ĨĨĞĐƚŝǀĞ ĂƚĞ͗ ͺͺͺͺͺͺͺͺͺͺ ď͘ ͺͺͺͺ dŚĞ ĨŽůůŽǁŝŶŐ ĞůŝŐŝďŝůŝƚLJ ŐƌŽƵƉƐ Žƌ ĐĂƚĞŐŽƌŝĐĂů ƉŽƉƵůĂƚŝŽŶƐ͗ WůĞĂƐĞ ůŝƐƚ ƚŚĞ ĂƉƉůŝĐĂďůĞ ĞůŝŐŝďŝůŝƚLJ ŐƌŽƵƉƐ Žƌ ƉŽƉƵůĂƚŝŽŶƐ͘ ϯ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ĂůůŽǁƐ ǁĂŝǀĞƌ ŽĨ ƉĂLJŵĞŶƚ ŽĨ ƚŚĞ ĞŶƌŽůůŵĞŶƚ ĨĞĞ͕ ƉƌĞŵŝƵŵƐ ĂŶĚ ƐŝŵŝůĂƌ ĐŚĂƌŐĞƐ ĨŽƌ ƵŶĚƵĞ ŚĂƌĚƐŚŝƉ͘ WůĞĂƐĞ ƐƉĞĐŝĨLJ ƚŚĞ ƐƚĂŶĚĂƌĚ;ƐͿ ĂŶĚͬŽƌ ĐƌŝƚĞƌŝĂ ƚŚĂƚ ƚŚĞ ƐƚĂƚĞ ǁŝůů ƵƐĞ ƚŽ ĚĞƚĞƌŵŝŶĞ ƵŶĚƵĞ ŚĂƌĚƐŚŝƉ͘ ^ĞĐƚŝŽŶ  ʹ ĞŶĞĨŝƚƐ ĞŶĞĨŝƚƐ͗ ϭ͘ yͺͺͺ dŚĞ ĂŐĞŶĐLJ ĂĚĚƐ ƚŚĞ ĨŽůůŽǁŝŶŐ ŽƉƚŝŽŶĂů ďĞŶĞĨŝƚƐ ŝŶ ŝƚƐ ƐƚĂƚĞ ƉůĂŶ ;ŝŶĐůƵĚĞ ƐĞƌǀŝĐĞ ĚĞƐĐƌŝƉƚŝŽŶƐ͕ ƉƌŽǀŝĚĞƌ ƋƵĂůŝĨŝĐĂƚŝŽŶƐ͕ ĂŶĚ ůŝŵŝƚĂƚŝŽŶƐ ŽŶ ĂŵŽƵŶƚ͕ ĚƵƌĂƚŝŽŶ Žƌ ƐĐŽƉĞ ŽĨ ƚŚĞ ďĞŶĞĨŝƚͿ͗ WĞƌ ϰϮ &Z ϰϰϬ͘ϲϬ͕ DĞĚŝĐĂů Žƌ ŽƚŚĞƌ ƌĞŵĞĚŝĂů ĐĂƌĞ ƉƌŽǀŝĚĞĚ ďLJ ůŝĐĞŶƐĞĚ ƉƌĂĐƚŝƚŝŽŶĞƌƐ͕ ƚŚĞ ŐĞŶĐLJ ƐĞĞŬƐ ƚŽ ĂůůŽǁ ŝŶĚĞƉĞŶĚĞŶƚůLJ ĐŽŶƚƌĂĐƚĞĚ ƉƐLJĐŚŽůŽŐŝƐƚƐ ƚŽ ƐĞƌǀĞ ^ŽŽŶĞƌĂƌĞ ĂĚƵůƚƐ ŽŶůLJ ĨŽƌ ĐƌŝƐŝƐ ŝŶƚĞƌǀĞŶƚŝŽŶ ƐĞƌǀŝĐĞƐ ĚƵƌŝŶŐ ƚŚĞ ĞŵĞƌŐĞŶĐLJ ƉĞƌŝŽĚ͘ /ŶĚĞƉĞŶĚĞŶƚůLJ ĐŽŶƚƌĂĐƚĞĚ ƉƐLJĐŚŽůŽŐŝƐƚƐ ĂƌĞ ůŝĐĞŶƐĞĚ ĂŶĚ ƉƌĂĐƚŝĐŝŶŐ ǁŝƚŚŝŶ ƐƚĂƚĞ ƐĐŽƉĞ ŽĨ ƉƌĂĐƚŝĐĞ͕ ĂƐ ǁĞůů ĂƐ ƚŚĞ ůŝŵŝƚĂƚŝŽŶ ƚŚĂƚ ŽŶůLJ ĐƌŝƐŝƐ ŝŶƚĞƌǀĞŶƚŝŽŶ ƐĞƌǀŝĐĞƐ ŵĂLJ ďĞ ƉƌŽǀŝĚĞĚ ďLJ ůŝĐĞŶƐĞĚ ƉƐLJĐŚŽůŽŐŝƐƚƐ ĚƵƌŝŶŐ ƚŚĞ ĚŝƐĂƐƚĞƌ ƉĞƌŝŽĚ͘ Ϯ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ŵĂŬĞƐ ƚŚĞ ĨŽůůŽǁŝŶŐ ĂĚũƵƐƚŵĞŶƚƐ ƚŽ ďĞŶĞĨŝƚƐ ĐƵƌƌĞŶƚůLJ ĐŽǀĞƌĞĚ ŝŶ ƚŚĞ ƐƚĂƚĞ ƉůĂŶ͗ ϯ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ĂƐƐƵƌĞƐ ƚŚĂƚ ŶĞǁůLJ ĂĚĚĞĚ ďĞŶĞĨŝƚƐ Žƌ ĂĚũƵƐƚŵĞŶƚƐ ƚŽ ďĞŶĞĨŝƚƐ ĐŽŵƉůLJ ǁŝƚŚ Ăůů ĂƉƉůŝĐĂďůĞ ƐƚĂƚƵƚŽƌLJ ƌĞƋƵŝƌĞŵĞŶƚƐ͕ ŝŶĐůƵĚŝŶŐ ƚŚĞ ƐƚĂƚĞǁŝĚĞŶĞƐƐ ƌĞƋƵŝƌĞŵĞŶƚƐ ĨŽƵŶĚ Ăƚ ϭϵϬϮ;ĂͿ;ϭͿ͕ ĐŽŵƉĂƌĂďŝůŝƚLJ ƌĞƋƵŝƌĞŵĞŶƚƐ ĨŽƵŶĚ Ăƚ ϭϵϬϮ;ĂͿ;ϭϬͿ;Ϳ͕ ĂŶĚ ĨƌĞĞ ĐŚŽŝĐĞ ŽĨ ƉƌŽǀŝĚĞƌ ƌĞƋƵŝƌĞŵĞŶƚƐ ĨŽƵŶĚ Ăƚ ϭϵϬϮ;ĂͿ;ϮϯͿ͘ ϰ͘ ͺͺͺͺͺ ƉƉůŝĐĂƚŝŽŶ ƚŽ ůƚĞƌŶĂƚŝǀĞ ĞŶĞĨŝƚ WůĂŶƐ ;WͿ͘ dŚĞ ƐƚĂƚĞ ĂĚŚĞƌĞƐ ƚŽ Ăůů W ƉƌŽǀŝƐŝŽŶƐ ŝŶ ϰϮ &Z WĂƌƚ ϰϰϬ͕ ^ƵďƉĂƌƚ ͘ dŚŝƐ ƐĞĐƚŝŽŶ ŽŶůLJ ĂƉƉůŝĞƐ ƚŽ ƐƚĂƚĞƐ ƚŚĂƚ ŚĂǀĞ ĂŶ ĂƉƉƌŽǀĞĚ W;ƐͿ͘ Ă͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ĂƐƐƵƌĞƐ ƚŚĂƚ ƚŚĞƐĞ ŶĞǁůLJ ĂĚĚĞĚ ĂŶĚͬŽƌ ĂĚũƵƐƚĞĚ ďĞŶĞĨŝƚƐ ǁŝůů ďĞ ŵĂĚĞ ĂǀĂŝůĂďůĞ ƚŽ ŝŶĚŝǀŝĚƵĂůƐ ƌĞĐĞŝǀŝŶŐ ƐĞƌǀŝĐĞƐ ƵŶĚĞƌ WƐ͘ ϮϬͲϬϬϯϮ ϱͬϭϭͬϮϬ E t ϯͬϭͬϮϬ ϱ

^ƚĂƚĞͬdĞƌƌŝƚŽƌLJ͗ K<>,KD dE͗ ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ ƉƉƌŽǀĂů ĂƚĞ͗ ͺͺͺͺͺͺͺͺͺͺ ^ƵƉĞƌƐĞĚĞƐ dE͗ ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ

ĨĨĞĐƚŝǀĞ ĂƚĞ͗ ͺͺͺͺͺͺͺͺͺͺ ď͘ ͺͺͺͺͺ /ŶĚŝǀŝĚƵĂůƐ ƌĞĐĞŝǀŝŶŐ ƐĞƌǀŝĐĞƐ ƵŶĚĞƌ WƐ ǁŝůů ŶŽƚ ƌĞĐĞŝǀĞ ƚŚĞƐĞ ŶĞǁůLJ ĂĚĚĞĚ ĂŶĚͬŽƌ ĂĚũƵƐƚĞĚ ďĞŶĞĨŝƚƐ͕ Žƌ ǁŝůů ŽŶůLJ ƌĞĐĞŝǀĞ ƚŚĞ ĨŽůůŽǁŝŶŐ ƐƵďƐĞƚ͗ WůĞĂƐĞ ĚĞƐĐƌŝďĞ͘ dĞůĞŚĞĂůƚŚ͗ ϱ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ƵƚŝůŝnjĞƐ ƚĞůĞŚĞĂůƚŚ ŝŶ ƚŚĞ ĨŽůůŽǁŝŶŐ ŵĂŶŶĞƌ͕ ǁŚŝĐŚ ŵĂLJ ďĞ ĚŝĨĨĞƌĞŶƚ ƚŚĂŶ ŽƵƚůŝŶĞĚ ŝŶ ƚŚĞ ƐƚĂƚĞ͛Ɛ ĂƉƉƌŽǀĞĚ ƐƚĂƚĞ ƉůĂŶ͗ WůĞĂƐĞ ĚĞƐĐƌŝďĞ͘ ƌƵŐ ĞŶĞĨŝƚ͗ ϲ͘ ͺͺ y dŚĞ ĂŐĞŶĐLJ ŵĂŬĞƐ ƚŚĞ ĨŽůůŽǁŝŶŐ ĂĚũƵƐƚŵĞŶƚƐ ƚŽ ƚŚĞ ĚĂLJ ƐƵƉƉůLJ Žƌ ƋƵĂŶƚŝƚLJ ůŝŵŝƚ ĨŽƌ ĐŽǀĞƌĞĚ ŽƵƚƉĂƚŝĞŶƚ ĚƌƵŐƐ͘ dŚĞ ĂŐĞŶĐLJ ƐŚŽƵůĚ ŽŶůLJ ŵĂŬĞ ƚŚŝƐ ŵŽĚŝĨŝĐĂƚŝŽŶ ŝĨ ŝƚƐ ĐƵƌƌĞŶƚ ƐƚĂƚĞ ƉůĂŶ ƉĂŐĞƐ ŚĂǀĞ ůŝŵŝƚƐ ŽŶ ƚŚĞ ĂŵŽƵŶƚ ŽĨ ŵĞĚŝĐĂƚŝŽŶ ĚŝƐƉĞŶƐĞĚ͘ WůĞĂƐĞ ĚĞƐĐƌŝďĞ ƚŚĞ ĐŚĂŶŐĞ ŝŶ ĚĂLJƐ Žƌ ƋƵĂŶƚŝƚŝĞƐ ƚŚĂƚ ĂƌĞ ĂůůŽǁĞĚ ĨŽƌ ƚŚĞ ĞŵĞƌŐĞŶĐLJ ƉĞƌŝŽĚ ĂŶĚ ĨŽƌ ǁŚŝĐŚ ĚƌƵŐƐ͘ dŚĞ ^ƚĂƚĞ ǁŝůů ĐŚĂŶŐĞ ƚŚĞ ϯϰͲĚĂLJ ƐƵƉƉůLJ ƉƌĞƐĐƌŝƉƚŝŽŶ ƋƵĂŶƚŝƚLJ ůŝŵŝƚ ƚŽ ĂůůŽǁ ĨŽƌ Ă ϵϬͲĚĂLJ ƐƵƉƉůLJ͘ ϳ͘ y WƌŝŽƌ ĂƵƚŚŽƌŝnjĂƚŝŽŶ ĨŽƌ ŵĞĚŝĐĂƚŝŽŶƐ ŝƐ ĞdžƉĂŶĚĞĚ ďLJ ĂƵƚŽŵĂƚŝĐ ƌĞŶĞǁĂů ǁŝƚŚŽƵƚ ĐůŝŶŝĐĂů ƌĞǀŝĞǁ͕ Žƌ ƚŝŵĞͬƋƵĂŶƚŝƚLJ ĞdžƚĞŶƐŝŽŶƐ͘ ϴ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ŵĂŬĞƐ ƚŚĞ ĨŽůůŽǁŝŶŐ ƉĂLJŵĞŶƚ ĂĚũƵƐƚŵĞŶƚ ƚŽ ƚŚĞ ƉƌŽĨĞƐƐŝŽŶĂů ĚŝƐƉĞŶƐŝŶŐ ĨĞĞ ǁŚĞŶ ĂĚĚŝƚŝŽŶĂů ĐŽƐƚƐ ĂƌĞ ŝŶĐƵƌƌĞĚ ďLJ ƚŚĞ ƉƌŽǀŝĚĞƌƐ ĨŽƌ ĚĞůŝǀĞƌLJ͘ ^ƚĂƚĞƐ ǁŝůů ŶĞĞĚ ƚŽ ƐƵƉƉůLJ ĚŽĐƵŵĞŶƚĂƚŝŽŶ ƚŽ ũƵƐƚŝĨLJ ƚŚĞ ĂĚĚŝƚŝŽŶĂů ĨĞĞƐ͘ WůĞĂƐĞ ĚĞƐĐƌŝďĞ ƚŚĞ ŵĂŶŶĞƌ ŝŶ ǁŚŝĐŚ ƉƌŽĨĞƐƐŝŽŶĂů ĚŝƐƉĞŶƐŝŶŐ ĨĞĞƐ ĂƌĞ ĂĚũƵƐƚĞĚ͘ ϵ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ŵĂŬĞƐ ĞdžĐĞƉƚŝŽŶƐ ƚŽ ƚŚĞŝƌ ƉƵďůŝƐŚĞĚ WƌĞĨĞƌƌĞĚ ƌƵŐ >ŝƐƚ ŝĨ ĚƌƵŐ ƐŚŽƌƚĂŐĞƐ ŽĐĐƵƌ͘ dŚŝƐ ǁŽƵůĚ ŝŶĐůƵĚĞ ŽƉƚŝŽŶƐ ĨŽƌ ĐŽǀĞƌŝŶŐ Ă ďƌĂŶĚ ŶĂŵĞ ĚƌƵŐ ƉƌŽĚƵĐƚ ƚŚĂƚ ŝƐ Ă ŵƵůƚŝͲƐŽƵƌĐĞ ĚƌƵŐ ŝĨ Ă ŐĞŶĞƌŝĐ ĚƌƵŐ ŽƉƚŝŽŶ ŝƐ ŶŽƚ ĂǀĂŝůĂďůĞ͘ ^ĞĐƚŝŽŶ ʹ WĂLJŵĞŶƚƐ KƉƚŝŽŶĂů ďĞŶĞĨŝƚƐ ĚĞƐĐƌŝďĞĚ ŝŶ ^ĞĐƚŝŽŶ ͗ ϭ͘ ͺͺyͺͺ EĞǁůLJ ĂĚĚĞĚ ďĞŶĞĨŝƚƐ ĚĞƐĐƌŝďĞĚ ŝŶ ^ĞĐƚŝŽŶ  ĂƌĞ ƉĂŝĚ ƵƐŝŶŐ ƚŚĞ ĨŽůůŽǁŝŶŐ ŵĞƚŚŽĚŽůŽŐLJ͗ ϮϬͲϬϬϯϮ ϱͬϭϭͬϮϬ E t ϯͬϭͬϮϬ ϲ

^ƚĂƚĞͬdĞƌƌŝƚŽƌLJ͗ K<>,KD dE͗ ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ ƉƉƌŽǀĂů ĂƚĞ͗ ͺͺͺͺͺͺͺͺͺͺ ^ƵƉĞƌƐĞĚĞƐ dE͗ ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ

ĨĨĞĐƚŝǀĞ ĂƚĞ͗ ͺͺͺͺͺͺͺͺͺͺ ƒǤ ̴̴̴̴̴ —„Ž‹•Š‡† ˆ‡‡ • Š‡†—Ž‡• Ȃ

ĨĨĞĐƚŝǀĞ ĚĂƚĞ ;ĞŶƚĞƌ ĚĂƚĞ ŽĨ ĐŚĂŶŐĞͿ͗ ͺͺͺͺͺͺͺͺͺͺͺͺͺ >ŽĐĂƚŝŽŶ ;ůŝƐƚ ƉƵďůŝƐŚĞĚ ůŽĐĂƚŝŽŶͿ͗ ͺͺͺͺͺͺͺͺͺͺͺͺͺ ď͘ ͺͺyͺͺ KƚŚĞƌ͗ ĞƐĐƌŝďĞ ŵĞƚŚŽĚŽůŽŐLJ ŚĞƌĞ͘ 3D\PHQW LV PDGH IRU ĐƌŝƐŝƐ ŝŶƚĞƌǀĞŶƚŝŽŶ ƐĞƌǀŝĐĞƐ ƉƌŽǀŝĚĞĚ ďLJ ŝŶĚĞƉĞŶĚĞŶƚůLJ ĐŽŶƚƌĂĐƚĞĚ ƉƐLJĐŚŽůŽŐŝƐƚƐ VHUYLFHV LQ DFFRUGDQFH ZLWK WKH PHWKRGRORJ\ GHVFULEHG LQ $WWDFKPHQW  % 3DJH 

džĐĞƉƚ ĂƐ ŽƚŚĞƌǁŝƐĞ ŶŽƚĞĚ ŝŶ ƚŚĞ ƉůĂŶ͕ ƐƚĂƚĞͲĚĞǀĞůŽƉĞĚ ĨĞĞ ƐĐŚĞĚƵůĞ ƌĂƚĞƐ ĂƌĞ ƚŚĞ ƐĂŵĞ ĨŽƌ ďŽƚŚ ŐŽǀĞƌŶŵĞŶƚĂů ĂŶĚ ƉƌŝǀĂƚĞ ƉƌŽǀŝĚĞƌƐ ŽĨ ĐƌŝƐŝƐ ŝŶƚĞƌǀĞŶƚŝŽŶ ƐĞƌǀŝĐĞƐ͘ dŚĞ ĂŐĞŶĐLJ͛Ɛ ĨĞĞ ƐĐŚĞĚƵůĞ ƌĂƚĞ ǁĂƐ ƐĞƚ ĂƐ ŽĨ :ƵůLJ ϭ͕ ϮϬϭϴ ĂŶĚ ŝƐ ĞĨĨĞĐƚŝǀĞ ĨŽƌ ƐĞƌǀŝĐĞƐ ƉƌŽǀŝĚĞĚ ŽŶ Žƌ ĂĨƚĞƌ ƚŚĂƚ ĚĂƚĞ͘ ůů ƌĂƚĞƐ ĂƌĞ ƉƵďůŝƐŚĞĚ ƚŚĞ ĂŐĞŶĐLJ͛Ɛ ǁĞďƐŝƚĞ Ăƚ ǁǁǁ͘ŽŬŚĐĂ͘ŽƌŐͬĨĞĞƐĐŚĞĚƵůĞƐ͘ /ŶĐƌĞĂƐĞƐ ƚŽ ƐƚĂƚĞ ƉůĂŶ ƉĂLJŵĞŶƚ ŵĞƚŚŽĚŽůŽŐŝĞƐ͗ Ϯ͘ ͺͺ dŚĞ ĂŐĞŶĐLJ ŝŶĐƌĞĂƐĞƐ ƉĂLJŵĞŶƚ ƌĂƚĞƐ ĨŽƌ ƚŚĞ ĨŽůůŽǁŝŶŐ ƐĞƌǀŝĐĞƐ͗ WůĞĂƐĞ ůŝƐƚ Ăůů ƚŚĂƚ ĂƉƉůLJ͘ Ă͘ ͺͺͺͺͺ WĂLJŵĞŶƚ ŝŶĐƌĞĂƐĞƐ ĂƌĞ ƚĂƌŐĞƚĞĚ ďĂƐĞĚ ŽŶ ƚŚĞ ĨŽůůŽǁŝŶŐ ĐƌŝƚĞƌŝĂ͗ WůĞĂƐĞ ĚĞƐĐƌŝďĞ ĐƌŝƚĞƌŝĂ͘ ď͘ WĂLJŵĞŶƚƐ ĂƌĞ ŝŶĐƌĞĂƐĞĚ ƚŚƌŽƵŐŚ͗ ‹Ǥ ̴̴̴̴̴  •—’’Ž‡‡–ƒŽ ’ƒ›‡– ‘” ƒ††Ǧ‘ ™‹–Š‹ ƒ’’Ž‹ ƒ„Ž‡ —’’‡” ’ƒ›‡– Ž‹‹–•ǣ WůĞĂƐĞ ĚĞƐĐƌŝďĞ͘ ‹‹Ǥ ̴̴̴̴̴  ‹ ”‡ƒ•‡ –‘ ”ƒ–‡• ƒ• †‡• ”‹„‡† „‡Ž‘™Ǥ ZĂƚĞƐ ĂƌĞ ŝŶĐƌĞĂƐĞĚ͗ ϮϬͲϬϬϯϮ ϱͬϭϭͬϮϬ E t ϯͬϭͬϮϬ ϳ

^ƚĂƚĞͬdĞƌƌŝƚŽƌLJ͗ K<>,KD dE͗ ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ ƉƉƌŽǀĂů ĂƚĞ͗ ͺͺͺͺͺͺͺͺͺͺ ^ƵƉĞƌƐĞĚĞƐ dE͗ ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ

ĨĨĞĐƚŝǀĞ ĂƚĞ͗ ͺͺͺͺͺͺͺͺͺͺ ͺͺͺͺͺ hŶŝĨŽƌŵůLJ ďLJ ƚŚĞ ĨŽůůŽǁŝŶŐ ƉĞƌĐĞŶƚĂŐĞ͗ ͺͺͺͺͺͺͺͺͺͺ ͺͺͺͺͺ dŚƌŽƵŐŚ Ă ŵŽĚŝĨŝĐĂƚŝŽŶ ƚŽ ƉƵďůŝƐŚĞĚ ĨĞĞ ƐĐŚĞĚƵůĞƐ ʹ

ĨĨĞĐƚŝǀĞ ĚĂƚĞ ;ĞŶƚĞƌ ĚĂƚĞ ŽĨ ĐŚĂŶŐĞͿ͗ ͺͺͺͺͺͺͺͺͺͺͺͺͺ >ŽĐĂƚŝŽŶ ;ůŝƐƚ ƉƵďůŝƐŚĞĚ ůŽĐĂƚŝŽŶͿ͗ ͺͺͺͺͺͺͺͺͺͺͺͺͺ ͺͺͺͺͺ hƉ ƚŽ ƚŚĞ DĞĚŝĐĂƌĞ ƉĂLJŵĞŶƚƐ ĨŽƌ ĞƋƵŝǀĂůĞŶƚ ƐĞƌǀŝĐĞƐ͘ ͺͺͺͺͺ LJ ƚŚĞ ĨŽůůŽǁŝŶŐ ĨĂĐƚŽƌƐ͗ WůĞĂƐĞ ĚĞƐĐƌŝďĞ͘ WĂLJŵĞŶƚ ĨŽƌ ƐĞƌǀŝĐĞƐ ĚĞůŝǀĞƌĞĚ ǀŝĂ ƚĞůĞŚĞĂůƚŚ͗ ϯ͘ ͺͺͺͺͺ &Žƌ ƚŚĞ ĚƵƌĂƚŝŽŶ ŽĨ ƚŚĞ ĞŵĞƌŐĞŶĐLJ͕ ƚŚĞ ƐƚĂƚĞ ĂƵƚŚŽƌŝnjĞƐ ƉĂLJŵĞŶƚƐ ĨŽƌ ƚĞůĞŚĞĂůƚŚ ƐĞƌǀŝĐĞƐ ƚŚĂƚ͗ ƒǤ ̴̴̴̴̴ ”‡ ‘– ‘–Š‡”™‹•‡ ’ƒ‹† —†‡” –Š‡ ‡†‹ ƒ‹† •–ƒ–‡ ’ŽƒǢ „Ǥ ̴̴̴̴̴ ‹ˆˆ‡” ˆ”‘ ’ƒ›‡–• ˆ‘” –Š‡ •ƒ‡ •‡”˜‹ ‡• ™Š‡ ’”‘˜‹†‡† ˆƒ ‡ –‘ ˆƒ ‡Ǣ

Ǥ ̴̴̴̴̴ ‹ˆˆ‡” ˆ”‘ —””‡– •–ƒ–‡ ’Žƒ ’”‘˜‹•‹‘• ‰‘˜‡”‹‰ ”‡‹„—”•‡‡– ˆ‘” –‡Ž‡Š‡ƒŽ–ŠǢ ĞƐĐƌŝďĞ ƚĞůĞŚĞĂůƚŚ ƉĂLJŵĞŶƚ ǀĂƌŝĂƚŝŽŶ͘ †Ǥ ̴̴̴̴̴  Ž—†‡ ’ƒ›‡– ˆ‘” ƒ ‹ŽŽƒ”› ‘•–• ƒ••‘ ‹ƒ–‡† ™‹–Š –Š‡ †‡Ž‹˜‡”› ‘ˆ ‘˜‡”‡† •‡”˜‹ ‡• ˜‹ƒ –‡Ž‡Š‡ƒŽ–Šǡ ȋ‹ˆ ƒ’’Ž‹ ƒ„Ž‡Ȍǡ ƒ• ˆ‘ŽŽ‘™•ǣ ‹Ǥ ̴̴̴̴̴  ‹ŽŽƒ”› ‘•– ƒ••‘ ‹ƒ–‡† ™‹–Š –Š‡ ‘”‹‰‹ƒ–‹‰ •‹–‡ ˆ‘” –‡Ž‡Š‡ƒŽ–Š ‹• ‹ ‘”’‘”ƒ–‡† ‹–‘ ˆ‡‡Ǧˆ‘”Ǧ•‡”˜‹ ‡ ”ƒ–‡•Ǥ ‹‹Ǥ ̴̴̴̴̴  ‹ŽŽƒ”› ‘•– ƒ••‘ ‹ƒ–‡† ™‹–Š –Š‡ ‘”‹‰‹ƒ–‹‰ •‹–‡ ˆ‘” –‡Ž‡Š‡ƒŽ–Š ‹• •‡’ƒ”ƒ–‡Ž› ”‡‹„—”•‡† ƒ• ƒ ƒ†‹‹•–”ƒ–‹˜‡ ‘•– „› –Š‡ •–ƒ–‡ ™Š‡ ƒ ‡†‹ ƒ‹† •‡”˜‹ ‡ ‹• †‡Ž‹˜‡”‡†Ǥ KƚŚĞƌ͗ ϰ͘ ͺͺyͺͺ KƚŚĞƌ ƉĂLJŵĞŶƚ ĐŚĂŶŐĞƐ͗ WůĞĂƐĞ ĚĞƐĐƌŝďĞ͘ &Žƌ ƚŚĞ ĚƵƌĂƚŝŽŶ ŽĨ ƚŚĞ ƉƵďůŝĐ ŚĞĂůƚŚ ĞŵĞƌŐĞŶĐLJ͕ ƌƵƌĂůͬŝŶĚĞƉĞŶĚĞŶƚ DĞĚŝĐĂŝĚͲĞŶƌŽůůĞĚ ŚŽƐƉŝƚĂůƐ ŵĂLJ ƌĞƋƵĞƐƚ ĂŶ ŝŶƚĞƌŝŵ ƉĂLJŵĞŶƚ͘ /Ĩ ĂƉƉƌŽǀĞĚ͕ ƚŚĞ ƌĞƋƵĞƐƚŝŶŐ ƉƌŽǀŝĚĞƌ ǁŝůů ƌĞĐĞŝǀĞ ϮϬͲϬϬϯϮ ϱͬϭϭͬϮϬ E t ϯͬϭͬϮϬ ϴ

^ƚĂƚĞͬdĞƌƌŝƚŽƌLJ͗ K<>,KD dE͗ ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ ƉƉƌŽǀĂů ĂƚĞ͗ ͺͺͺͺͺͺͺͺͺͺ ^ƵƉĞƌƐĞĚĞƐ dE͗ ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ

ĨĨĞĐƚŝǀĞ ĂƚĞ͗ ͺͺͺͺͺͺͺͺͺͺ ĂŶ ĂŵŽƵŶƚ ĞƋƵĂů ƚŽ ƚǁŽ ŵŽŶƚŚƐ͛ ƉĂLJŵĞŶƚ Ăƚ ƚŚĞ ŚŝƐƚŽƌŝĐĂů ĂǀĞƌĂŐĞ ŵŽŶƚŚůLJ DĞĚŝĐĂŝĚ ƉĂLJŵĞŶƚ͕ ďĂƐĞĚ ŽŶ ƚŚĞ ŵŽŶƚŚƐ ŽĨ :ĂŶƵĂƌLJ ĂŶĚ &ĞďƌƵĂƌLJ ϮϬϮϬ͘ ƌŝƚŝĐĂů ĂĐĐĞƐƐ ŚŽƐƉŝƚĂůƐ ǁŽƵůĚ ďĞ ĞůŝŐŝďůĞ ƚŽ ƌĞĐĞŝǀĞ ƵƉ ƚŽ ϭϮϱй ŽĨ ƚŚĞ ŚŝƐƚŽƌŝĐĂů ƉĂLJŵĞŶƚ ĂŵŽƵŶƚ͘ dŚĞ ^ƚĂƚĞ ǁŝůů ƐƵďƐĞƋƵĞŶƚůLJ ƌĞĐŽŶĐŝůĞ ƚŚĞ ŝŶƚĞƌŝŵ ƉĂLJŵĞŶƚƐ ǁŝƚŚ ĨŝŶĂů ƉĂLJŵĞŶƚƐ ƚŚĂƚ ƚŚĞ ƉƌŽǀŝĚĞƌ ŝƐ ĞůŝŐŝďůĞ ĨŽƌ ďĂƐĞĚ ŽŶ ďŝůůĞĚ ĐůĂŝŵƐ͘ ĨƚĞƌ ƌĞĐŽŶĐŝůŝĂƚŝŽŶ͕ ƉĂLJŵĞŶƚƐ ǁŝůů ďĞ ĞƋƵĂů ƚŽ ƚŚĞ ĂĐƚƵĂů ƵƚŝůŝnjĂƚŝŽŶ ĚƵƌŝŶŐ ƚŚĞ ƉĞƌŝŽĚ Ăƚ ĐƵƌƌĞŶƚ DĞĚŝĐĂŝĚ ƌĂƚĞƐ͘ dŚĞ ƌĞĐŽŶĐŝůŝĂƚŝŽŶ ǁŝůů ŽĐĐƵƌ ďĞŐŝŶŶŝŶŐ ϯ ŵŽŶƚŚƐ ĂĨƚĞƌ ƚŚĞ ĞŶĚ ŽĨ ƚŚĞ ĨĞĚĞƌĂů ĞŵĞƌŐĞŶĐLJ ĚĞĐůĂƌĂƚŝŽŶ ĂŶĚ ďĞ ƌĞƉĂŝĚ ďLJ ƚŚĞ ĞŶĚ ŽĨ ƚŚĞ ĨŝƐĐĂů LJĞĂƌ ƚŚĞ ĚĞĐůĂƌĂƚŝŽŶ ĞŶĚƐ͘ dŚĞ ^ƚĂƚĞ ĂƐƐƵƌĞƐ ƚŚĂƚ &&W ƌĞůĂƚĞĚ ƚŽ ƚŚĞ ŽǀĞƌƉĂŝĚ ŝŶƚĞƌŝŵ ƉĂLJŵĞŶƚƐ ǁŝůů ďĞ ƌĞƚƵƌŶĞĚ ƚŽ D^͖ ƚŚĞ ^ƚĂƚĞ ǁŝůů ƌĞƚƵƌŶ ƚŚĞ ĨĞĚĞƌĂů ƐŚĂƌĞ ŽĨ ƐƵĐŚ ŽǀĞƌƉĂLJŵĞŶƚƐ ƚŽ D^ ŝŶ ĂĐĐŽƌĚĂŶĐĞ ǁŝƚŚ ƚŚĞ ŽǀĞƌƉĂLJŵĞŶƚ ƌƵůĞƐ Ăƚ ϰϮ &Z WĂƌƚ ϰϯϯ͕ ^ƵďƉĂƌƚ &͘ &Žƌ ƚŚĞ ĚƵƌĂƚŝŽŶ ŽĨ ƚŚĞ ƉƵďůŝĐ ŚĞĂůƚŚ ĞŵĞƌŐĞŶĐLJ͕ ƉƌŝǀĂƚĞ ĚƵƚLJ ŶƵƌƐŝŶŐ ;WEͿ ƉƌŽǀŝĚĞƌƐ ǁŝůů ƌĞĐĞŝǀĞ ĂŶ ŝŶĐƌĞĂƐĞ ĨŽƌ WE ŚŽƵƌƐ ƚŚĂƚ ƌĞƐƵůƚ ŝŶ ŽǀĞƌͲƚŝŵĞ ƌĂƚĞ ŽĨ ƉĂLJ ĨŽƌ ŶƵƌƐŝŶŐ ƐƚĂĨĨ͘ dŚĞ ŝŶĐƌĞĂƐĞ ĨƌŽŵ ΨϯϮͬŚŽƵƌ ƚŽ ΨϰϬͬŚŽƵƌ ŝƐ ƚŽ ďĞ ĂƉƉůŝĞĚ ŽŶůLJ ĨŽƌ ƉĞƌƐŽŶƐ ǁŝƚŚ ƚƌĂĐŚĞŽƐƚŽŵŝĞƐ Žƌ ǁŚŽ ĂƌĞ ǀĞŶƚŝůĂƚŽƌ ĚĞƉĞŶĚĞŶƚ͘ ƉƉůŝĐĂďůĞ UHLPEXUVHPHQW PHWKRGRORJ\ SDJHV IRU 3'1 VHUYLFHV \ DUH ZLWKLQ LQ $WWDFKPHQW  % 3DJH  $WWDFKPHQW  % 3DJH  DQG $WWDFKPHQW  % ,QWURGXFWLRQ 3DJH 

džĐĞƉƚ ĂƐ ŽƚŚĞƌǁŝƐĞ ŶŽƚĞĚ ŝŶ ƚŚĞ ƉůĂŶ͕ ƐƚĂƚĞͲĚĞǀĞůŽƉĞĚ ĨĞĞ ƐĐŚĞĚƵůĞ ƌĂƚĞƐ ĂƌĞ ƚŚĞ ƐĂŵĞ ĨŽƌ ďŽƚŚ ŐŽǀĞƌŶŵĞŶƚĂů ĂŶĚ ƉƌŝǀĂƚĞ ƉƌŽǀŝĚĞƌƐ ŽĨ WE ƐĞƌǀŝĐĞƐ͘ dŚĞ ĂŐĞŶĐLJ͛Ɛ ĨĞĞ ƐĐŚĞĚƵůĞ ƌĂƚĞ ǁĂƐ ƐĞƚ ĂƐ ŽĨ KĐƚŽďĞƌ ϭ͕ ϮϬϭϵ ĂŶĚ ŝƐ ĞĨĨĞĐƚŝǀĞ ĨŽƌ ƐĞƌǀŝĐĞƐ ƉƌŽǀŝĚĞĚ ŽŶ Žƌ ĂĨƚĞƌ ƚŚĂƚ ĚĂƚĞ͘ ůů ƌĂƚĞƐ ĂƌĞ ƉƵďůŝƐŚĞĚ ƚŚĞ ĂŐĞŶĐLJ͛Ɛ ǁĞďƐŝƚĞ Ăƚ ǁǁǁ͘ŽŬŚĐĂ͘ŽƌŐͬĨĞĞƐĐŚĞĚƵůĞƐ͘ ^ĞĐƚŝŽŶ & ʹ WŽƐƚͲ ůŝŐŝďŝůŝƚLJ dƌĞĂƚŵĞŶƚ ŽĨ /ŶĐŽŵĞ ͳǤ ̴̴̴̴̴ Š‡ •–ƒ–‡ ‡Ž‡ –• –‘ ‘†‹ˆ› –Š‡ „ƒ•‹ ’‡”•‘ƒŽ ‡‡†• ƒŽŽ‘™ƒ ‡ ˆ‘” ‹•–‹–—–‹‘ƒŽ‹œ‡† ‹†‹˜‹†—ƒŽ•Ǥ Š‡ „ƒ•‹ ’‡”•‘ƒŽ ‡‡†• ƒŽŽ‘™ƒ ‡ ‹• ‡“—ƒŽ –‘ ‘‡ ‘ˆ –Š‡ ˆ‘ŽŽ‘™‹‰ ƒ‘—–•ǣ ƒǤ ̴̴̴̴̴ Š‡ ‹†‹˜‹†—ƒŽǯ• –‘–ƒŽ ‹ ‘‡ „Ǥ ̴̴̴̴̴ ͵ͲͲ ’‡” ‡– ‘ˆ –Š‡  ˆ‡†‡”ƒŽ „‡‡ˆ‹– ”ƒ–‡

Ǥ ̴̴̴̴̴ –Š‡” ”‡ƒ•‘ƒ„Ž‡ ƒ‘—–ǣ ̴̴̴̴̴̴̴̴̴̴̴̴̴̴̴̴̴ ʹǤ ̴̴̴̴̴ Š‡ •–ƒ–‡ ‡Ž‡ –• ƒ ‡™ ˜ƒ”‹ƒ ‡ –‘ –Š‡ „ƒ•‹ ’‡”•‘ƒŽ ‡‡†• ƒŽŽ‘™ƒ ‡Ǥ ȋ‘–‡ǣ Ž‡ –‹‘ ‘ˆ –Š‹• ‘’–‹‘ ‹• ‘– †‡’‡†‡– ‘ ƒ •–ƒ–‡ ‡Ž‡ –‹‰ –Š‡ ‘’–‹‘ †‡• ”‹„‡† –Š‡ ‘’–‹‘ ‹ ǤͳǤ ƒ„‘˜‡ǤȌ dŚĞ ƐƚĂƚĞ ƉƌŽƚĞĐƚƐ ĂŵŽƵŶƚƐ ĞdžĐĞĞĚŝŶŐ ƚŚĞ ďĂƐŝĐ ƉĞƌƐŽŶĂů ŶĞĞĚƐ ĂůůŽǁĂŶĐĞ ĨŽƌ ŝŶĚŝǀŝĚƵĂůƐ ǁŚŽ ŚĂǀĞ ƚŚĞ ĨŽůůŽǁŝŶŐ ŐƌĞĂƚĞƌ ƉĞƌƐŽŶĂů ŶĞĞĚƐ͗ WůĞĂƐĞ ĚĞƐĐƌŝďĞ ƚŚĞ ŐƌŽƵƉ Žƌ ŐƌŽƵƉƐ ŽĨ ŝŶĚŝǀŝĚƵĂůƐ ǁŝƚŚ ŐƌĞĂƚĞƌ ŶĞĞĚƐ ĂŶĚ ƚŚĞ ĂŵŽƵŶƚ;ƐͿ ƉƌŽƚĞĐƚĞĚ ĨŽƌ ĞĂĐŚ ŐƌŽƵƉ Žƌ ŐƌŽƵƉƐ͘ ϮϬͲϬϬϯϮ ϱͬϭϭͬϮϬ E t ϯͬϭͬϮϬ ϵ

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DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-26-12 Baltimore, Maryland 21244-1850 December 3, 2020 Melody Anthony State Medicaid Director Oklahoma Health Care Authority 4345 North Lincoln Boulevard Oklahoma City, OK 73105 Re: Oklahoma State Plan Amendment (SPA) 20-0043 Dear Ms. Anthony: We have reviewed the proposed amendment to add section 7.4 Medicaid Disaster Relief for the COVID-19 National Emergency to your Medicaid state plan, as submitted under transmittal number (TN) 20-0043. This amendment proposes to implement temporary policies, which are different from those policies and procedures otherwise applied under your Medicaid state plan, during the period of the Presidential and Secretarial emergency declarations related to the COVID-19 outbreak (or any renewals thereof). On March 13, 2020, the President of the United States issued a proclamation that the COVID-19 outbreak in the United States constitutes a national emergency by the authorities vested in him by the Constitution and the laws of the United States, including sections 201 and 301 of the National Emergencies Act (50 U.S.C. 1601 et seq.), and consistent with section 1135 of the Social Security Act (Act). On March 13, 2020, pursuant to section 1135(b) of the Act, the Secretary of the United States Department of Health and Human Services invoked his authority to waive or modify certain requirements of titles XVIII, XIX, and XXI of the Act as a result of the consequences of the COVID-19 pandemic, to the extent necessary, as determined by the Centers for Medicare & Medicaid Services (CMS), to ensure that sufficient health care items and services are available to meet the needs of individuals enrolled in the respective programs and to ensure that health care providers that furnish such items and services in good faith, but are unable to comply with one or more of such requirements as a result of the COVID-19 pandemic, may be reimbursed for such items and services and exempted from sanctions for such noncompliance, absent any determination of fraud or abuse. This authority took effect as of 6PM Eastern Standard Time on March 15, 2020, with a retroactive effective date of March 1, 2020. The emergency period will terminate, and this state plan provision will no longer be in effect, upon termination of the public health emergency, including any extensions. 3XUVXDQW WR VHFWLRQ  E

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The State of Oklahoma also requested a waiver of public notice requirements applicable to the SPA submission process. Pursuant to section 1135(b)(1)(C) of the Act, CMS is waiving public notice requirements applicable to the SPA submission process. Public notice for SPAs is required under 42 C.F.R. §447.205 for changes in statewide methods and standards for setting Medicaid payment rates, 42 C.F.R. §447.57 for changes to premiums and cost sharing, and 42 C.F.R. §440.386 for changes to Alternative Benefit Plans (ABPs). Pursuant to section 1135(b)(1)(C) of the Act, CMS is approving the state’s request to waive these notice requirements otherwise applicable to SPA submissions. The State of Oklahoma also requested a waiver to modify the tribal consultation timeline applicable to this SPA submission process. Pursuant to section 1135(b)(5) of the Act, CMS is also allowing states to modify the timeframes associated with tribal consultation required under section 1902(a)(73) of the Act, including shortening the number of days before submission or conducting consultation after submission of the SPA. These waivers of the requirements related to SPA submission timelines, public notice, and tribal consultation apply only with respect to SPAs that meet the following criteria: (1) the SPA provides or increases beneficiary access to items and services related to COVID-19 (such as by waiving or eliminating cost sharing, increasing payment rates or amending ABPs to add services or providers); (2) the SPA does not restrict or limit payment or services or otherwise burden beneficiaries and providers; and (3) the SPA is temporary, with a specified sunset date that is not later than the last day of the declared COVID-19 public health emergency (or any extension thereof). We nonetheless encourage states to make all relevant information about the SPA available to the public so they are aware of the changes. We conducted our review of your submittal according to the statutory requirements at section 1902(a) of the Act and implementing regulations. This letter is to inform you that Oklahoma’s Medicaid SPA Transmittal Number 20-0043 is approved effective December 14, 2020. This SPA is in addition to Oklahoma’s Disaster Relief SPAs approved on May 11, 2020, August 18, 2020, and October 15, 2020 and does not supersede any requests in those SPAs. Enclosed is a copy of the CMS-179 summary form and the approved state plan pages. Please contact Deborah Read at 816-426-6363 or by email at deborah.read@cms.hhs.gov if you have any questions about this approval. We appreciate the efforts of you and your staff in responding to the needs of the residents of the State of Oklahoma and the health care community. Sincerely, Alissa Mooney DeBoy On Behalf of Anne Marie Costello, Acting Director Center for Medicaid and CHIP Services Enclosures Alissa M. Deboy -S Digitally signed by Alissa M. Deboy -S Date: 2020.12.31 08:25:40 -05'00'

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

FORM APPROVED OMB No. 0938-0193

TRANSMITTAL AND NOTICE OF APPROVAL OF

STATE PLAN MATERIAL FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES

1. TRANSMITTAL NUMBER 2. STATE 2 0—0 0 4 Oklahoma 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID)

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

4. PROPOSED EFFECTIVE DATE December 14, 2020

5. TYPE OF PLAN MATERIAL (Check One) OO NEw STATE PLAN

(0 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 Sections 1135(b) and 1902 of the SSA; Title XIX of the SSA

7. FEDERAL BUDGET IMPACT a. FFY2021 $ 36,552 b. FFY.2022 $ 42,214

8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT

Section 7.4, Pages 30-89 20-29*

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

10. SUBJECT OF AMENDMENT

Disaster relief request to allow hospitals to make hospital presumptive eligibility (HPE) determinations for the non-MAGI

populations to facilitate discharge into LTC facilities.

11. GOVERNOR'S REVIEW (Check One)

(J Governor's OFFICE REPORTED NO COMMENT (J ComMENTS OF GOVERNOR'S OFFICE ENCLOSED (1 No REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL

fl OTHER, AS SPECIFIED

OFFICIAL 16. RETURN TO

Oklahoma Health Care Authority - Attn: Traylor Rains

4345 N. Lincoln Blvd. Melody Anthony Oklahoma City, OK 73105 14. TITLE State Medicaid Director 15. DATE SUBMITTED 12/14/2020

FOR REGIONAL OFFICE USE ONLY 17. DATE RECEIVED 18. DATE APPROVED 12/14/2020 12/31/2020

PLAN APPROVED - ONE COPY ATTACHED

19. EFFECTIVE DATE OF APPROVED MATERIAL

12/14/2020

20. SIGNATURE OF REGIONAL OFFICIAL Alissa M. Deboy -S Ba=seet ny isas pes

21. TYPED NAME

Alissa Mooney DeBoy

22. TITLE On Behalf of Anne Marie Costello, Acting Director

23. REMARKS

*Per state email dated 12/22/20 giving permission for pen and ink change to page numbers

FORM CMS-179 (07/92)

Instructions on Back

State/Territory: Oklahoma TN: _20-0043_ Approval Date: __________ Supersedes TN: _NEW_ Effective Date: __________ This SPA is in addition to Oklahoma’s Disaster Relief SPAs approved on 5/11/2020, 8/18/2020, and 10/15/2020 and does not supersede any requests in the aforementioned SPAs. Section 7 – General Provisions 7.4. Medicaid Disaster Relief for the COVID-19 National Emergency On March 13, 2020, the President of the United States issued a proclamation that the COVID-19 outbreak in the United States constitutes a national emergency by the authorities vested in him by the Constitution and the laws of the United States, including sections 201 and 301 of the National Emergencies Act (50 U.S.C. 1601 et seq.), and consistent with section 1135 of the Social Security Act (Act). On March 13, 2020, pursuant to section 1135(b) of the Act, the Secretary of the United States Department of Health and Human Services invoked his authority to waive or modify certain requirements of titles XVIII, XIX, and XXI of the Act as a result of the consequences COVID-19 pandemic, to the extent necessary, as determined by the Centers for Medicare & Medicaid Services (CMS), to ensure that sufficient health care items and services are available to meet the needs of individuals enrolled in the respective programs and to ensure that health care providers that furnish such items and services in good faith, but are unable to comply with one or more of such requirements as a result of the COVID-19 pandemic, may be reimbursed for such items and services and exempted from sanctions for such noncompliance, absent any determination of fraud or abuse. This authority took effect as of 6PM Eastern Standard Time on March 15, 2020, with a retroactive effective date of March 1, 2020. The emergency period will terminate, and waivers will no longer be available, upon termination of the public health emergency, including any extensions. The State Medicaid agency (agency) seeks to implement the policies and procedures described below, which are different than the policies and procedures otherwise applied under the Medicaid state plan, during the period of the Presidential and Secretarial emergency declarations related to the COVID-19 outbreak (or any renewals thereof), or for any shorter period described below: This request will last through the termination of the public health emergency declaration. NOTE: States may not elect a period longer than the Presidential or Secretarial emergency declaration (or any renewal thereof). States may not propose changes on this template that restrict or limit payment, services, or eligibility, or otherwise burden beneficiaries and providers. Request for Waivers under Section 1135 _X_ The agency seeks the following under section 1135(b)(1)(C) and/or section 1135(b)(5) of the Act: a. __ SPA submission requirements – the agency requests modification of the requirement to submit the SPA by March 31, 2020, to obtain a SPA effective date during the first calendar quarter of 2020, pursuant to 42 CFR 430.20. b. _X_ Public notice requirements – the agency requests waiver of public notice requirements that would otherwise be applicable to this SPA submission. These requirements may include those specified in 42 CFR 440.386 (Alternative Benefit Plans), 42 CFR 447.57(c) (premiums and cost sharing), and 42 CFR 447.205 (public notice of changes in statewide methods and standards for setting payment rates). 12/31/2020 12/14/2020

State/Territory: Oklahoma

TN: _20-0043_ Approval Date: __________ Supersedes TN: _NEW_

Effective Date: __________ This SPA is in addition to Oklahoma’s Disaster Relief SPAs approved on 5/11/2020, 8/18/2020, and 10/15/2020 and does not supersede any requests in the aforementioned SPAs. c. _X_ Tribal consultation requirements – the agency requests modification of tribal consultation timelines specified in [insert name of state] Medicaid state plan, as described below: The State Medicaid Agency will notify tribal partners of all SPA changes on or before submission to CMS and will either offer a telephonic meeting to discuss or consult with Tribes at the next regularly schedule bi-monthly consultation meeting. Section A – Eligibility 1. _____ The agency furnishes medical assistance to the following optional groups of individuals described in section 1902(a)(10)(A)(ii) or 1902(a)(10)(c) of the Act. This may include the new optional group described at section 1902(a)(10)(A)(ii)(XXIII) and 1902(ss) of the Act providing coverage for uninsured individuals.

Include name of the optional eligibility group and applicable income and resource standard.

2. _____ The agency furnishes medical assistance to the following populations of individuals described in section 1902(a)(10)(A)(ii)(XX) of the Act and 42 CFR 435.218:

a. _____ All individuals who are described in section 1905(a)(10)(A)(ii)(XX)

Income standard: _____________

-or-

b. _____ Individuals described in the following categorical populations in section 1905(a) of the Act:

Income standard: _____________

3. _____ The agency applies less restrictive financial methodologies to individuals excepted from financial methodologies based on modified adjusted gross income (MAGI) as follows.

Less restrictive income methodologies:

12/31/2020 12/14/2020

State/Territory: Oklahoma

TN: _20-0043_ Approval Date: __________ Supersedes TN: _NEW_

Effective Date: __________ This SPA is in addition to Oklahoma’s Disaster Relief SPAs approved on 5/11/2020, 8/18/2020, and 10/15/2020 and does not supersede any requests in the aforementioned SPAs.

Less restrictive resource methodologies:

4. _____ The agency considers individuals who are evacuated from the state, who leave the state for medical reasons related to the disaster or public health emergency, or who are otherwise absent from the state due to the disaster or public health emergency and who intend to return to the state, to continue to be residents of the state under 42 CFR 435.403(j)(3).

5. _____ The agency provides Medicaid coverage to the following individuals living in the state, who are non-residents:

6. _____ The agency provides for an extension of the reasonable opportunity period for non- citizens declaring to be in a satisfactory immigration status, if the non-citizen is making a good faith effort to resolve any inconsistences or obtain any necessary documentation, or the agency is unable to complete the verification process within the 90-day reasonable opportunity period due to the disaster or public health emergency. Section B – Enrollment 1. __X__ The agency elects to allow hospitals to make presumptive eligibility determinations for the following additional state plan populations, or for populations in an approved section 1115 demonstration, in accordance with section 1902(a)(47)(B) of the Act and 42 CFR 435.1110, provided that the agency has determined that the hospital is capable of making such determinations.

Please describe the applicable eligibility groups/populations and any changes to reasonable limitations, performance standards or other factors. The Agency elects to allow hospitals to make presumptive eligibility (PE) determinations for non- MAGI individuals, including: • Individuals Eligible for But Not Receiving Cash Assistance, 1902(a)((10)(A)(ii)(I); • Individuals Eligible for Cash Except Institutionalization, 1902(a)(10)(A)(ii)(IV); • Optional State Supplemental Beneficiaries, 1902(a)(10)(A)(ii)(XI); • Individuals in Institutions Eligible under a Special Income Level, aged, blind and disabled individuals, 1902(a)(10)(A)(ii)(V) and 1905(a)(iii), (iv) and (v); and • Age and Disability-Related Poverty Level, 1902(a)(10)(ii)(X) and 1902(m).

During the PHE, the OHCA will comport with current State plan requirements for HPE with certain exceptions. The exceptions include: 12/31/2020 12/14/2020

State/Territory: Oklahoma

TN: _20-0043_ Approval Date: __________ Supersedes TN: _NEW_

Effective Date: __________ This SPA is in addition to Oklahoma’s Disaster Relief SPAs approved on 5/11/2020, 8/18/2020, and 10/15/2020 and does not supersede any requests in the aforementioned SPAs.

The OHCA will waive HPE performance standards in the current State Plan.

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

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

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

Please describe the designated entities or additional populations and any limitations related to the specified populations or number of allowable PE periods.

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

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

6. _____ The agency uses the following simplified application(s) to support enrollment in affected areas or for affected individuals (a copy of the simplified application(s) has been submitted to CMS). a. _____ The agency uses a simplified paper application. b. _____ The agency uses a simplified online application. c. _____ The simplified paper or online application is made available for use in call-centers or other telephone applications in affected areas. Section C – Premiums and Cost Sharing 1. _____ The agency suspends deductibles, copayments, coinsurance, and other cost sharing charges as follows: 12/31/2020 12/14/2020

State/Territory: Oklahoma

TN: _20-0043_ Approval Date: __________ Supersedes TN: _NEW_

Effective Date: __________ This SPA is in addition to Oklahoma’s Disaster Relief SPAs approved on 5/11/2020, 8/18/2020, and 10/15/2020 and does not supersede any requests in the aforementioned SPAs.

Please describe whether the state suspends all cost sharing or suspends only specified deductibles, copayments, coinsurance, or other cost sharing charges for specified items and services or for specified eligibility groups consistent with 42 CFR 447.52(d) or for specified income levels consistent with 42 CFR 447.52(g).

2. _____ The agency suspends enrollment fees, premiums and similar charges for: a. _____ All beneficiaries b. _____ The following eligibility groups or categorical populations: Please list the applicable eligibility groups or populations.

3. _____ The agency allows waiver of payment of the enrollment fee, premiums and similar charges for undue hardship.

Please specify the standard(s) and/or criteria that the state will use to determine undue hardship.

Section D – Benefits Benefits: 1. _____ The agency adds the following optional benefits in its state plan (include service descriptions, provider qualifications, and limitations on amount, duration or scope of the benefit):

2. _____ The agency makes the following adjustments to benefits currently covered in the state plan:

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

4. _____ Application to Alternative Benefit Plans (ABP). The state adheres to all ABP provisions in 42 CFR Part 440, Subpart C. This section only applies to states that have an approved ABP(s). 12/31/2020 12/14/2020

State/Territory: Oklahoma

TN: _20-0043_ Approval Date: __________ Supersedes TN: _NEW_

Effective Date: __________ This SPA is in addition to Oklahoma’s Disaster Relief SPAs approved on 5/11/2020, 8/18/2020, and 10/15/2020 and does not supersede any requests in the aforementioned SPAs. a. _____ The agency assures that these newly added and/or adjusted benefits will be made available to individuals receiving services under ABPs. b. _____ Individuals receiving services under ABPs will not receive these newly added and/or adjusted benefits, or will only receive the following subset:

Please describe.

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

Please describe.

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

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

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

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

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

9. _____ The agency makes exceptions to their published Preferred Drug List if drug shortages occur. This would include options for covering a brand name drug product that is a multi-source drug if a generic drug option is not available. 12/31/2020 12/14/2020

State/Territory: Oklahoma

TN: _20-0043_ Approval Date: __________ Supersedes TN: _NEW_

Effective Date: __________ This SPA is in addition to Oklahoma’s Disaster Relief SPAs approved on 5/11/2020, 8/18/2020, and 10/15/2020 and does not supersede any requests in the aforementioned SPAs. Section E – Payments Optional benefits described in Section D: 1. _____ Newly added benefits described in Section D are paid using the following methodology:

a. __ Published fee schedules –

Effective date (enter date of change): _______________

Location (list published location):

b. _____ Other:

Increases to state plan payment methodologies: 2. ____ The agency increases payment rates for the following services:

a. _____ Payment increases are targeted based on the following criteria:

b. Payments are increased through: i. _____ A supplemental payment or add-on within applicable upper payment limits:

ii. _____ An increase to rates as described below.

Rates are increased:

_____ Uniformly by the following percentage: _____________

_____ Through a modification to published fee schedules –

Effective date (enter date of change): _____________

12/31/2020 12/14/2020

State/Territory: Oklahoma

TN: _20-0043_ Approval Date: __________ Supersedes TN: _NEW_

Effective Date: __________ This SPA is in addition to Oklahoma’s Disaster Relief SPAs approved on 5/11/2020, 8/18/2020, and 10/15/2020 and does not supersede any requests in the aforementioned SPAs. Location (list published location): _____________

_____ Up to the Medicare payments for equivalent services.

_____ By the following factors:

Please describe.

Payment for services delivered via telehealth: 3. _____ For the duration of the emergency, the state authorizes payments for telehealth services that: a. _____ Are not otherwise paid under the Medicaid state plan; b. _____ Differ from payments for the same services when provided face to face; c. _____ Differ from current state plan provisions governing reimbursement for telehealth;

Describe telehealth payment variation.

d. _____ Include payment for ancillary costs associated with the delivery of covered services via telehealth, (if applicable), as follows: i. _____ Ancillary cost associated with the originating site for telehealth is incorporated into fee-for-service rates. ii. _____ Ancillary cost associated with the originating site for telehealth is separately reimbursed as an administrative cost by the state when a Medicaid service is delivered. Other: 4. _____ Other payment changes:

Please describe.

Section F – Post-Eligibility Treatment of Income 1. _____ The state elects to modify the basic personal needs allowance for institutionalized individuals. The basic personal needs allowance is equal to one of the following amounts: a. _____ The individual’s total income 12/31/2020 12/14/2020

State/Territory: Oklahoma

TN: _20-0043_ Approval Date: __________ Supersedes TN: _NEW_

Effective Date: __________ This SPA is in addition to Oklahoma’s Disaster Relief SPAs approved on 5/11/2020, 8/18/2020, and 10/15/2020 and does not supersede any requests in the aforementioned SPAs. b. _____ 300 percent of the SSI federal benefit rate c. _____ Other reasonable amount: _________________ 2. _____ The state elects a new variance to the basic personal needs allowance. (Note: Election of this option is not dependent on a state electing the option described the option in F.1. above.)

The state protects amounts exceeding the basic personal needs allowance for individuals who have the following greater personal needs:

Please describe the group or groups of individuals with greater needs and the amount(s) protected for each group or groups.

Section G – Other Policies and Procedures Differing from Approved Medicaid State Plan /Additional Information

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148 (Expires 03/31/2021). The time required to complete this information collection is estimated to average 1 to 2 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. Your response is required to receive a waiver under Section 1135 of the Social Security Act. All responses are public and will be made available on the CMS web site. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. ***CMS Disclosure*** Please do not send applications, claims, payments, medical records or any documents containing sensitive information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information collection burden approved under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please contact the Centers for Medicaid & CHIP Services at 410-786-3870. 12/31/2020 12/14/2020

Records / Submission Packages - View All OK - Submission Package - OK2020MS0008O - (OK-21-0001) - Eligibility CMS-10434 OMB 0938-1188 Package Information Package ID OK2020MS0008O Program Name N/A SPA ID OK-21-0001 Version Number 2 Submitted By Sandra Puebla Package Disposition Priority Code P2 Submission Type OŰcial State OK Region Dallas, TX Package Status Approved Submission Date 9/8/2020 Approval Date 12/4/2020 2:38 PM EST Summary Reviewable Units Versions Correspondence Log Compare Doc Change Report Analyst Notes Review Assessment Report Approval Letter Transaction Logs News Related Actions

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Medicaid and CHIP Operations Group 601 E 12th Street, Room 355 Kansas City, MO 64106 Center for Medicaid & CHIP Services December 04, 2020 Melody Anthony State Medicaid Director Oklahoma Health Care Authority 4345 N Lincoln Blvd Oklahoma City, OK 73105 Re: Approval of State Plan Amendment OK-21-0001 Dear Melody Anthony: On September 08, 2020, the Centers for Medicare and Medicaid Services (CMS) received Oklahoma State Plan Amendment (SPA) OK-21-0001 to add the adult group described in Section 1902(a)(10)(A)(i)(VIII) of the Social Security Act and Title 42 of the Code of Federal Regulations (CFR) §435.119, eſective July 1, 2021. The adult group will include non-pregnant individuals who: are age 19 or older and under 65; not otherwise mandatorily eligible for Medicaid; not entitled to or enrolled in Medicare Parts A or B Medicare; and have income at or below 133 percent of the federal poverty level (FPL).. We approve Oklahoma State Plan Amendment (SPA) OK-21-0001 on December 04, 2020 with an eſective date(s) of July 01, 2021. CMS appreciated the opportunity to discuss our informal questions and recommendations related to Oklahoma’s Eligibility and FMAP SPA submissions. The additional information has provided CMS with valuable insight into Oklahoma’s program integrity function and Medicaid expansion oversight activities.

CMS plans to maintain regular communications and a collaborative partnership with the state, including the provision of program integrity-related technical assistance and guidance throughout the Medicaid expansion implementation process as needed. As part of this partnership, CMS will continue to work with the state to ensure that it demonstrates and provide evidence of its systems performance, via a systems testing strategy as deţned in Appendix A of CMCS Informational Bulletin dated June 20, 2019, “Oversight of State Medicaid Claiming and Program Integrity Expectations.”

Further, CMS looks forward to receiving the staſ training materials for the adult group, which will help ensure beneţciary eligibility and other determinations are accurate, and appropriate FMAP claiming occurs. As discussed with the state, please provide the training materials no later than February 1, 2021. Name Date Created No items available If you have any questions regarding this amendment, please contact Deborah Read at deborah.read@cms.hhs.gov. Sincerely, James G. Scott Director, Division of Program Operations Center for Medicaid & CHIP Services Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | OK2020MS0008O | OK-21-0001 Package Header Package ID OK2020MS0008O Submission Type OŰcial Approval Date 12/4/2020 Superseded SPA ID N/A SPA ID OK-21-0001 Initial Submission Date 9/8/2020 Eſective Date N/A State Information State/Territory Name: Oklahoma Medicaid Agency Name: Oklahoma Health Care Authority

Submission Component State Plan Amendment Medicaid CHIP

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | OK2020MS0008O | OK-21-0001 Package Header Package ID OK2020MS0008O Submission Type OŰcial Approval Date 12/4/2020 Superseded SPA ID N/A SPA ID OK-21-0001 Initial Submission Date 9/8/2020 Eſective Date N/A SPA ID and Eſective Date SPA ID OK-21-0001 Reviewable Unit Proposed Eſective Date Superseded SPA ID Eligibility Determinations of Individuals Age 65 or Older or Who Have Blindness or a Disability 7/1/2021 N/A Mandatory Eligibility Groups 7/1/2021 OK-13-0017 Adult Group 7/1/2021 OK-13-0017 Page Number of the Superseded Plan Section or Attachment (If Applicable):

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | OK2020MS0008O | OK-21-0001 Package Header Package ID OK2020MS0008O Submission Type OŰcial Approval Date 12/4/2020 Superseded SPA ID N/A SPA ID OK-21-0001 Initial Submission Date 9/8/2020 Eſective Date N/A Executive Summary Summary Description Including Goals and Objectives Adding eligibility for adults 19-64 years of age and up to 133% FPL Federal Budget Impact and Statute/Regulation Citation Federal Budget Impact Federal Fiscal Year Amount First 2021 $254412286 Second 2022 $1071430098 Federal Statute / Regulation Citation 42 CFR 435.119; 1902(a)(10)(A)(i)(VIII) Supporting documentation of budget impact is uploaded (optional). Name Date Created No items available

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | OK2020MS0008O | OK-21-0001 Package Header Package ID OK2020MS0008O Submission Type OŰcial Approval Date 12/4/2020 Superseded SPA ID N/A SPA ID OK-21-0001 Initial Submission Date 9/8/2020 Eſective Date N/A Governor's OŰce Review Describe The Governor does not review State Plan materials/submissions. No comment Comments received No response within 45 days Other

Submission - Public Comment MEDICAID | Medicaid State Plan | Eligibility | OK2020MS0008O | OK-21-0001 Package Header Package ID OK2020MS0008O Submission Type OŰcial Approval Date 12/4/2020 Superseded SPA ID N/A SPA ID OK-21-0001 Initial Submission Date 9/8/2020 Eſective Date N/A Indicate whether public comment was solicited with respect to this submission. Indicate how public comment was solicited: Select the type of website Date of Posting: Jul 31, 2020 Website URL: http://okhca.org/WorkArea/linkit.aspx? LinkIdentiţer=id&ItemID=24995&libID= 23981 Upload copies of public notices and other documents used Name Date Created Adult Expansion Public Notice 7.31.20 8/25/2020 1:21 AM EDT Upload with this application a written summary of public comments received (optional) Name Date Created Adult Expansion Tribal Consultation Comments Received 8.26.20 9/8/2020 4:42 PM EDT Indicate the key issues raised during the public comment period (optional) Public notice was not federally required and comment was not solicited Public notice was not federally required, but comment was solicited Public notice was federally required and comment was solicited Newspaper Announcement Publication in state's administrative record, in accordance with the administrative procedures requirements Email to Electronic Mailing List or Similar Mechanism Website Notice Website of the State Medicaid Agency or Responsible Agency Website for State Regulations Other Public Hearing or Meeting Other method Access Quality Cost Payment methodology Eligibility Beneţts Service delivery Other issue

Submission - Tribal Input MEDICAID | Medicaid State Plan | Eligibility | OK2020MS0008O | OK-21-0001 Package Header Package ID OK2020MS0008O Submission Type OŰcial Approval Date 12/4/2020 Superseded SPA ID N/A SPA ID OK-21-0001 Initial Submission Date 9/8/2020 Eſective Date N/A One or more Indian Health Programs or Urban Indian Organizations furnish health care services in this state This state plan amendment is likely to have a direct eſect on Indians, Indian Health Programs or Urban Indian Organizations, as described in the state consultation plan. Complete the following information regarding any solicitation of advice and/or tribal consultation conducted with respect to this submission: Solicitation of advice and/or Tribal consultation was conducted in the following manner: States are not required to consult with Indian tribal governments, but if such consultation was conducted voluntarily, provide information about such consultation below: Date of consultation: Method of consultation: 7/7/2020 Tribal partners were sent a tribal public notice for the request to expand Medicaid for eligible adults as per 42 CFR 435.119 on 6/23/2020. Due to the current public health emergency, the State conducted a virtual tribal consultation on July 7, 2020. The state must upload copies of documents that support the solicitation of advice in accordance with statutory requirements, including any notices sent to Indian Health Programs and/or Urban Indian Organizations, as well as attendee lists if face-to-face meetings were held. Also upload documents with comments received from Indian Health Programs or Urban Indian Organizations and the state's responses to any issues raised. Alternatively indicate the key issues and summarize any comments received below and describe how the state incorporated them into the design of its program. Name Date Created July ITU Notice & Agenda 8/26/2020 4:53 PM EDT 7.7.20 ITU Consulation List of Attendees 8/26/2020 4:53 PM EDT Adult Expansion Tribal Consultation Comments Received 8.26.20 8/26/2020 4:53 PM EDT Indicate the key issues raised (optional) Yes No Yes No The state has solicited advice from Indian Health Programs and/or Urban Indian Organizations, as required by section 1902(a)(73) of the Social Security Act, and in accordance with the state consultation plan, prior to submission of this SPA. All Indian Health Programs All Urban Indian Organizations All Indian Tribes Access Quality Cost Payment methodology Eligibility Beneţts

Name of issue: Summarize comments: Summarize response: Medicaid Expansion to Adult Group Tribal consultation was held virtually on July 7th, 2020; 51 stakeholders were in attendance. Sign-in sheets are enclosed with the state plan amendment (SPA) submission package. There were no comments/questions received by attendees for OK SPA 21-001, 21-002 and 21-0003. However, a participant inquired about the status of the Healthy Adult Opportunity (HAO) waiver; the State responded that the direction of HAO was unknown at the time and was pending guidance from OHCA executive leadership.

The SPA was also posted on the State’s public policy change blog website from July 31, 2020 through August 30, 2020; no written comments were received during the 30-day public comment period. Tribal consultation was held virtually on July 7th, 2020; 51 stakeholders were in attendance. Sign-in sheets are enclosed with the state plan amendment (SPA) submission package. There were no comments/questions received by attendees for OK SPA 21-001, 21-002 and 21- 0003. However, a participant inquired about the status of the Healthy Adult Opportunity (HAO) waiver; the State responded that the direction of HAO was unknown at the time and was pending guidance from OHCA executive leadership.

The SPA was also posted on the State’s public policy change blog website from July 31, 2020 through August 30, 2020; no written comments were received during the 30-day public comment period. Service delivery Other issue

Medicaid State Plan Eligibility Income/Resource Methodologies Eligibility Determinations of Individuals Age 65 or Older or Who Have Blindness or a Disability MEDICAID | Medicaid State Plan | Eligibility | OK2020MS0008O | OK-21-0001 Package Header Package ID OK2020MS0008O Submission Type OŰcial Approval Date 12/4/2020 Superseded SPA ID N/A User-Entered SPA ID OK-21-0001 Initial Submission Date 9/8/2020 Eſective Date 7/1/2021 A. Eligibility Determinations of Individuals Who Are Age 65 or Older or Who Have Blindness or a Disability Eligibility determinations of individuals who are age 65 or older or who have blindness or a disability are based on one of the following: The state has an agreement under section 1634 of the Social Security Act for the Social Security Administration to determine Medicaid eligibility of SSI beneţciaries. For all other individuals who seek Medicaid eligibility on the basis of being age 65 or older or having blindness or a disability, the state requires a separate Medicaid application and determines ţnancial eligibility based on SSI income and resource methodologies. The state requires all individuals who seek Medicaid eligibility on the basis of being age 65 or older or having blindness or a disability, including SSI beneţciaries, to ţle a separate Medicaid application, and determines ţnancial eligibility based on SSI income and resource methodologies. The state requires all individuals who seek Medicaid eligibility on the basis of being age 65 or older or having blindness or a disability, including SSI beneţciaries, to ţle a separate Medicaid application, and determines ţnancial eligibility using income and resource methodologies more restrictive than SSI. B. Additional information (optional) 1. SSA Eligibility Determination State (1634 State) 2. State Eligibility Determination (SSI Criteria State) 3. State Eligibility Determination (209(b) State)

Medicaid State Plan Eligibility Mandatory Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | OK2020MS0008O | OK-21-0001 Package Header Package ID OK2020MS0008O Submission Type OŰcial Approval Date 12/4/2020 Superseded SPA ID OK-13-0017 System-Derived SPA ID OK-21-0001 Initial Submission Date 9/8/2020 Eſective Date 7/1/2021 Mandatory Coverage A. The state provides Medicaid to mandatory groups of individuals. The mandatory groups covered are: Families and Adults Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Infants and Children under Age 19 CONVERTED Parents and Other Caretaker Relatives CONVERTED Pregnant Women CONVERTED Deemed Newborns NEW Children with Title IV-E Adoption Assistance, Foster Care or Guardianship Care NEW Former Foster Care Children NEW Transitional Medical Assistance NEW Extended Medicaid due to Spousal Support Collections NEW Aged, Blind and Disabled Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  SSI Beneţciaries NEW Closed Eligibility Groups NEW Individuals Deemed To Be Receiving SSI NEW Working Individuals under 1619(b) NEW Qualiţed Medicare Beneţciaries NEW Qualiţed Disabled and Working Individuals NEW Speciţed Low Income Medicare Beneţciaries NEW

Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Qualifying Individuals NEW

Mandatory Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | OK2020MS0008O | OK-21-0001 Package Header Package ID OK2020MS0008O Submission Type OŰcial Approval Date 12/4/2020 Superseded SPA ID OK-13-0017 System-Derived SPA ID OK-21-0001 Initial Submission Date 9/8/2020 Eſective Date 7/1/2021 B. The state elects the Adult Group, described at 42 CFR 435.119. Families and Adults Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Adult Group APPROVED C. Additional Information (optional) Eligibility Groups Deselected from Coverage The following eligibility groups were previously covered in the source approved version of the state plan and deselected from coverage as part of this submission package: N/A Yes No

Medicaid State Plan Eligibility Eligibility Groups - Mandatory Coverage Adult Group MEDICAID | Medicaid State Plan | Eligibility | OK2020MS0008O | OK-21-0001 Non-pregnant individuals age 19 through 64, not otherwise mandatorily eligible, with income at or below 133% FPL. Package Header Package ID OK2020MS0008O Submission Type OŰcial Approval Date 12/4/2020 Superseded SPA ID OK-13-0017 User-Entered SPA ID OK-21-0001 Initial Submission Date 9/8/2020 Eſective Date 7/1/2021 The state covers the Adult Group in accordance with the following provisions: A. Characteristics Individuals qualifying under this eligibility group must meet the following criteria: 1. Have attained age 19 but not age 65

2. Are not pregnant

3. Are not entitled to or enrolled for Part A or B Medicare beneţts

4. Are not otherwise eligible for and enrolled for mandatory coverage under the state plan in accordance with 42 CFR 435, subpart B. B. Financial Methodologies MAGI-based methodologies are used in calculating household income. Please refer as necessary to MAGI-Based Methodologies, completed by the state. C. Income Standard Used The amount of the income standard for this group is 133% FPL. D. Coverage of Dependent Children Parents or caretaker relatives living with a child under the age speciţed below are not covered unless the child is receiving beneţts under Medicaid, CHIP or through the Exchange or otherwise enrolled in minimum essential coverage, as deţned in 42 CFR 435.4. Not Started In Progress Complete 1. Under age 19, or 2. A higher age of children, if any covered under the Reasonable Classiţcations of Children eligibility group (42 CFR 435.222) on March 23, 2010:

MEDICAID | Medicaid State Plan | Eligibility | OK2020MS0008O | OK-21-0001 Package Header Package ID OK2020MS0008O Submission Type OŰcial Approval Date N/A Superseded SPA ID N/A SPA ID OK-21-0001 Initial Submission Date N/A Eſective Date N/A E. Additional Information (optional) PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format deţned by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reŤects the characteristics of the particular state’s program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in eſorts to boost program integrity eſorts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance OŰcer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. This view was generated on 12/4/2020 4:30 PM EST

Table of Contents State/Territory Name: Oklahoma State Plan Amendment (SPA) #: 21-0028 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-26-12 Baltimore, Maryland 21244-1850 July 2, 2021 Melody Anthony State Medicaid Director Oklahoma Health Care Authority 4345 N. Lincoln Boulevard Oklahoma City, OK 73105 Re: Oklahoma State Plan Amendment (SPA) 21-0028 Dear Ms. Anthony: We have reviewed the proposed amendment to add section 7.4 Medicaid Disaster Relief for the COVID-19 National Emergency to your Medicaid state plan, as submitted under transmittal number (TN) OK 21-0028. This amendment proposes to implement temporary policies, which are different from those policies and procedures otherwise applied under your Medicaid state plan, during the period of the Presidential and Secretarial emergency declarations related to the COVID-19 outbreak (or any renewals thereof). On March 13, 2020, the President of the United States issued a proclamation that the COVID-19 outbreak in the United States constitutes a national emergency by the authorities vested in him by the Constitution and the laws of the United States, including sections 201 and 301 of the National Emergencies Act (50 U.S.C. 1601 et seq.), and consistent with section 1135 of the Social Security Act (Act). On March 13, 2020, pursuant to section 1135(b) of the Act, the Secretary of the United States Department of Health and Human Services invoked his authority to waive or modify certain requirements of titles XVIII, XIX, and XXI of the Act as a result of the consequences of the COVID-19 pandemic, to the extent necessary, as determined by the Centers for Medicare & Medicaid Services (CMS), to ensure that sufficient health care items and services are available to meet the needs of individuals enrolled in the respective programs and to ensure that health care providers that furnish such items and services in good faith, but are unable to comply with one or more of such requirements as a result of the COVID-19 pandemic, may be reimbursed for such items and services and exempted from sanctions for such noncompliance, absent any determination of fraud or abuse. This authority took effect as of 6PM Eastern Standard Time on March 15, 2020, with a retroactive effective date of March 1, 2020. The emergency period will terminate, and this state plan provision will no longer be in effect, upon termination of the public health emergency, including any extensions. The State of Oklahoma requested a waiver of public notice requirements applicable to the SPA submission process. Pursuant to section 1135(b)(1)(C) of the Act, CMS is waiving public notice requirements applicable to the SPA submission process. Public notice for SPAs is required under 42 C.F.R. §447.205 for changes in statewide methods and standards for setting Medicaid payment rates, 42 C.F.R. §447.57 for changes to premiums and cost sharing, and 42 C.F.R. §440.386 for changes to Alternative Benefit Plans (ABPs). Pursuant to section 1135(b)(1)(C) to waive of the Act, CMS is approving the state’s request to waive these notice requirements otherwise applicable to SPA submissions.

The State of Oklahoma also requested a waiver to modify the tribal consultation timeline applicable to this SPA submission process. Pursuant to section 1135(b)(5) of the Act, CMS is also allowing states to modify the timeframes associated with tribal consultation required under section 1902(a)(73) of the Act, including shortening the number of days before submission or conducting consultation after submission of the SPA. These waivers or modifications of the requirements related to SPA submission timelines, public notice, and tribal consultation apply only with respect to SPAs that meet the following criteria: (1) the SPA provides or increases beneficiary access to items and services related to COVID-19 (such as by waiving or eliminating cost sharing, increasing payment rates or amending ABPs to add services or providers); (2) the SPA does not restrict or limit payment or services or otherwise burden beneficiaries and providers; and (3) the SPA is temporary, with a specified sunset date that is not later than the last day of the declared COVID-19 public health emergency (or any extension thereof). We nonetheless encourage states to make all relevant information about the SPA available to the public so they are aware of the changes. We conducted our review of your submittal according to the statutory requirements at section 1902(a) of the Act and implementing regulations. This letter is to inform you that Oklahoma’s Medicaid SPA Transmittal Number 21-0028 is approved effective July 1, 2021. This SPA is in addition to Oklahoma’s Disaster Relief SPA 20-0032, approved on May 11, 2020; Oklahoma’s Disaster Relief SPA 20-0040, approved on August 18, 2020; Oklahoma’s Disaster Relief SPA 20-0041, approved on October 15, 2020; Oklahoma’s Disaster Relief SPA 20-0043 approved on December 31, 2020; Oklahoma’s Disaster Relief SPA 20-0042, approved on March 10, 2021; Oklahoma’s Disaster Relief SPA 21-0011, approved on April 1, 2021, Oklahoma’s Disaster Relief SPA 21-0024, approved on April 8, 2021and Oklahoma’s Disaster Relief SPA 21-0021 approved on May 12, 2021, and does not supersede anything approved in those SPAs. Enclosed is a copy of the CMS-179 summary form and the approved state plan pages. Please contact Deborah Read at 816-426-6363 or by email at Deborah.Read@cms.hhs.gov if you have any questions about this approval. We appreciate the efforts of you and your staff in responding to the needs of the residents of the State of Oklahoma and the health care community. Sincerely, Alissa Mooney DeBoy On Behalf of Anne Marie Costello, Deputy Director Center for Medicaid DQG CHIP Services Enclosures Alissa M. Deboy -S Digitally signed by Alissa M. Deboy -S Date: 2021.07.28 07 55:57 -04'00'

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

FORM APPROVED OMB No. 0938-0193

TRANSMITTAL AND NOTICE OF APPROVAL OF

STATE PLAN MATERIAL FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES

2. STATE 2 1—0 0 2 8 |Oklahoma

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

1. TRANSMITTAL NUMBER

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

4. PROPOSED EFFECTIVE DATE

July 1, 2021

5. TYPE OF PLAN MATERIAL (Check One) (0 NEw STATE PLAN

(0 AMENDMENT TO BE CONSIDERED AS NEW PLAN

(H]) AMENDMENT

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

6. FEDERAL STATUTE/REGULATION CITATION Sections 1135(b) and 1902 of the SSA; Title XIX of the SSA

7. FEDERAL BUDGET IMPACT a. FFY 2021 $ 1,298,571.00 b. FFY 2022 $5,200,371.00

8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT

Section 7.4, Pages 70-78

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

10. SUBJECT OF AMENDMENT

DRSPA to align the Expansion Adult ABP with previously approved DRSPAS 20-0032, 20-0040, 20-0042, and 21-0011.

11. GOVERNOR'S REVIEW (Check One)

(J Governor's OFFICE REPORTED NO COMMENT (J CoMMENTS OF GOVERNOR'S OFFICE ENCLOSED (1 No REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL

I OTHER, AS SPECIFIED

OFFICIAL 13. TYPED os

Melody Anthony

14. TITLE State Medicaid Director

15. DATE SUBMITTED 7/15/2021

16. RETURN TO

Oklahoma Health Care Authority Attn: Traylor Rains

4345 N. Lincoln Blvd.

Oklahoma City, OK 73105

FOR REGIONAL OFFICE USE ONLY

17. DATE RECEIVED July 15, 2021

18. DATE APPROVED July 28, 2021

PLAN APPROVED - ONE COPY ATTACHED

19. EFFECTIVE DATE OF APPROVED MATERIAL July 1, 2021

20. SIGNATURE OF REGIONAL OFFICIAL Dares So by Alissa M.

Alissa M. Deboy -S Detoy

21. TYPED NAME

Alissa Mooney DeBoy

22. TITLE On Behalf of Anne Marie Costello, Deputy Director, CMCS

23. REMARKS

FORM CMS-179 (07/92)

Instructions on Back

State/Territory: OKLAHOMA TN: _21-0028 Supersedes TN: _NEW_ Approval Date: Effective Date: _07/01/21_ Page 70 This SPA is in addition to Oklahoma’s Disaster Relief SPAs approved on 5/11/20, 8/18/20, 10/15/2020, 12/31/20, 3/10/21, 4/1/21, 4/8/21, and 5/12/20, and does not supersede any items approved in those SPAs. Section 7 – General Provisions 7.4. Medicaid Disaster Relief for the COVID-19 National Emergency On March 13, 2020, the President of the United States issued a proclamation that the COVID-19 outbreak in the United States constitutes a national emergency by the authorities vested in him by the Constitution and the laws of the United States, including sections 201 and 301 of the National Emergencies Act (50 U.S.C. 1601 et seq.), and consistent with section 1135 of the Social Security Act (Act). On March 13, 2020, pursuant to section 1135(b) of the Act, the Secretary of the United States Department of Health and Human Services invoked his authority to waive or modify certain requirements of titles XVIII, XIX, and XXI of the Act as a result of the consequences COVID-19 pandemic, to the extent necessary, as determined by the Centers for Medicare & Medicaid Services (CMS), to ensure that sufficient health care items and services are available to meet the needs of individuals enrolled in the respective programs and to ensure that health care providers that furnish such items and services in good faith, but are unable to comply with one or more of such requirements as a result of the COVID-19 pandemic, may be reimbursed for such items and services and exempted from sanctions for such noncompliance, absent any determination of fraud or abuse. This authority took effect as of 6PM Eastern Standard Time on March 15, 2020, with a retroactive effective date of March 1, 2020. The emergency period will terminate, and waivers will no longer be available, upon termination of the public health emergency, including any extensions. The State Medicaid agency (agency) seeks to implement the policies and procedures described below, which are different than the policies and procedures otherwise applied under the Medicaid state plan, during the period of the Presidential and Secretarial emergency declarations related to the COVID-19 outbreak (or any renewals thereof), or for any shorter period described below: NOTE: States may not elect a period longer than the Presidential or Secretarial emergency declaration (or any renewal thereof). States may not propose changes on this template that restrict or limit payment, services, or eligibility, or otherwise burden beneficiaries and providers. Request for Waivers under Section 1135 X The agency seeks the following under section 1135(b)(1)(C) and/or section 1135(b)(5) of the Act: a. _ SPA submission requirements – the agency requests modification of the requirement to submit the SPA by March 31, 2020, to obtain a SPA effective date during the first calendar quarter of 2020, pursuant to 42 CFR 430.20. b. _ X Public notice requirements – the agency requests waiver of public notice requirements that would otherwise be applicable to this SPA submission. These requirements may include those specified in 42 CFR 440.386 (Alternative Benefit Plans), 42 CFR 447.57(c) (premiums and cost sharing), and 42 CFR 447.205 (public notice of changes in statewide methods and standards for setting payment rates). Describe shorter period here. ϬϳͬϮϴͬϮϭ

State/Territory: OKLAHOMA TN: _21-0028 Supersedes TN: _NEW_ Approval Date: Effective Date: _07/01/21_ Page 71 This SPA is in addition to Oklahoma’s Disaster Relief SPAs approved on 5/11/20, 8/18/20, 10/15/2020, 12/31/20, 3/10/21, 4/1/21, 4/8/21, and 5/12/20, and does not supersede any items approved in those SPAs. c. X _ Tribal consultation requirements – the agency requests modification of tribal consultation timelines specified in Oklahoma Medicaid state plan, as described below: Section A – Eligibility 1. The agency furnishes medical assistance to the following optional groups of individuals described in section 1902(a)(10)(A)(ii) or 1902(a)(10)(c) of the Act. This may include the new optional group described at section 1902(a)(10)(A)(ii)(XXIII) and 1902(ss) of the Act providing coverage for uninsured individuals. 2. The agency furnishes medical assistance to the following populations of individuals described in section 1902(a)(10)(A)(ii)(XX) of the Act and 42 CFR 435.218: a. All individuals who are described in section 1905(a)(10)(A)(ii)(XX) Income standard: -or-

b. Individuals described in the following categorical populations in section 1905(a) of the Act: Income standard: 3. The agency applies less restrictive financial methodologies to individuals excepted from financial methodologies based on modified adjusted gross income (MAGI) as follows. Less restrictive income methodologies: The State Medicaid Agency will notify tribal partners of all SPA changes on or before submission to CMS and will either offer a telephonic meeting to discuss or consult with Tribes at the next regularly scheduled bi-monthly consultation meeting. Include name of the optional eligibility group and applicable income and resource standard. ϬϳͬϮϴͬϮϭ

State/Territory: OKLAHOMA TN: _21-0028 Supersedes TN: _NEW_ Approval Date: Effective Date: _07/01/21_ Page 72 This SPA is in addition to Oklahoma’s Disaster Relief SPAs approved on 5/11/20, 8/18/20, 10/15/2020, 12/31/20, 3/10/21, 4/1/21, 4/8/21, and 5/12/20, and does not supersede any items approved in those SPAs. Less restrictive resource methodologies: 4. The agency considers individuals who are evacuated from the state, who leave the state for medical reasons related to the disaster or public health emergency, or who are otherwise absent from the state due to the disaster or public health emergency and who intend to return to the state, to continue to be residents of the state under 42 CFR 435.403(j)(3). 5. The agency provides Medicaid coverage to the following individuals living in the state, who are non-residents: 6. The agency provides for an extension of the reasonable opportunity period for non- citizens declaring to be in a satisfactory immigration status, if the non-citizen is making a good faith effort to resolve any inconsistences or obtain any necessary documentation, or the agency is unable to complete the verification process within the 90-day reasonable opportunity period due to the disaster or public health emergency. Section B – Enrollment 1. The agency elects to allow hospitals to make presumptive eligibility determinations for the following additional state plan populations, or for populations in an approved section 1115 demonstration, in accordance with section 1902(a)(47)(B) of the Act and 42 CFR 435.1110, provided that the agency has determined that the hospital is capable of making such determinations. 2. _ _ The agency designates itself as a qualified entity for purposes of making presumptive eligibility determinations described below in accordance with sections 1920, 1920A, 1920B, and 1920C of the Act and 42 CFR Part 435 Subpart L. 3. The agency designates the following entities as qualified entities for purposes of making presumptive eligibility determinations or adds additional populations as described below in accordance with sections 1920, 1920A, 1920B, and 1920C of the Act and 42 CFR Part 435 Please describe the applicable eligibility groups/populations and any changes to reasonable limitations, performance standards or other factors. Please describe any limitations related to the populations included or the number of allowable PE periods. ϬϳͬϮϴͬϮϭ

State/Territory: OKLAHOMA TN: _21-0028 Supersedes TN: _NEW_ Approval Date: Effective Date: _07/01/21_ Page 73 This SPA is in addition to Oklahoma’s Disaster Relief SPAs approved on 5/11/20, 8/18/20, 10/15/2020, 12/31/20, 3/10/21, 4/1/21, 4/8/21, and 5/12/20, and does not supersede any items approved in those SPAs. Subpart L. Indicate if any designated entities are permitted to make presumptive eligibility determinations only for specified populations. 4. The agency adopts a total of months (not to exceed 12 months) continuous eligibility for children under age of (not to exceed age 19) regardless of changes in circumstances in accordance with section 1902(e)(12) of the Act and 42 CFR 435.926. 5. The agency conducts redeterminations of eligibility for individuals excepted from MAGI- based financial methodologies under 42 CFR 435.603(j) once every months (not to exceed 12 months) in accordance with 42 CFR 435.916(b). 6. The agency uses the following simplified application(s) to support enrollment in affected areas or for affected individuals (a copy of the simplified application(s) has been submitted to CMS). a. The agency uses a simplified paper application. b. The agency uses a simplified online application. c. The simplified paper or online application is made available for use in call-centers or other telephone applications in affected areas. Section C – Premiums and Cost Sharing 1.

The agency suspends deductibles, copayments, coinsurance, and other cost sharing charges as follows: 2. The agency suspends enrollment fees, premiums and similar charges for: a. All beneficiaries b. The following eligibility groups or categorical populations: 3. The agency allows waiver of payment of the enrollment fee, premiums and similar charges for undue hardship. Please list the applicable eligibility groups or populations. Please specify the standard(s) and/or criteria that the state will use to determine undue hardship. ϬϳͬϮϴͬϮϭ

State/Territory: OKLAHOMA TN: _21-0028 Supersedes TN: _NEW_ Approval Date: Effective Date: _07/01/21_ Page 74 This SPA is in addition to Oklahoma’s Disaster Relief SPAs approved on 5/11/20, 8/18/20, 10/15/2020, 12/31/20, 3/10/21, 4/1/21, 4/8/21, and 5/12/20, and does not supersede any items approved in those SPAs. Section D – Benefits Benefits: 1. The agency adds the following optional benefits in its state plan (include service descriptions, provider qualifications, and limitations on amount, duration or scope of the benefit): 2. The agency makes the following adjustments to benefits currently covered in the state plan: 3. The agency assures that newly added benefits or adjustments to benefits comply with all applicable statutory requirements, including the statewideness requirements found at 1902(a)(1), comparability requirements found at 1902(a)(10)(B), and free choice of provider requirements found at 1902(a)(23). 4. X Application to Alternative Benefit Plans (ABP). The state adheres to all ABP provisions in 42 CFR Part 440, Subpart C. This section only applies to states that have an approved ABP(s). a. X The agency assures that these newly added and/or adjusted benefits will be made available to individuals receiving services under ABPs. b. Individuals receiving services under ABPs will not receive these newly added and/or adjusted benefits, or will only receive the following subset: Telehealth: 5. The agency utilizes telehealth in the following manner, which may be different than outlined in the state’s approved state plan: Drug Benefit: 6. The agency makes the following adjustments to the day supply or quantity limit for covered outpatient drugs. The agency should only make this modification if its current state plan pages have limits on the amount of medication dispensed. Please describe. Please describe. ϬϳͬϮϴͬϮϭ

State/Territory: OKLAHOMA TN: _21-0028 Supersedes TN: _NEW_ Approval Date: Effective Date: _07/01/21_ Page 75 This SPA is in addition to Oklahoma’s Disaster Relief SPAs approved on 5/11/20, 8/18/20, 10/15/2020, 12/31/20, 3/10/21, 4/1/21, 4/8/21, and 5/12/20, and does not supersede any items approved in those SPAs. 7. Prior authorization for medications is expanded by automatic renewal without clinical review, or time/quantity extensions. 8. The agency makes the following payment adjustment to the professional dispensing fee when additional costs are incurred by the providers for delivery. States will need to supply documentation to justify the additional fees. 9. The agency makes exceptions to their published Preferred Drug List if drug shortages occur. This would include options for covering a brand name drug product that is a multi-source drug if a generic drug option is not available. Section E – Payments Optional benefits described in Section D: 1. Newly added benefits described in Section D are paid using the following methodology: a. Published fee schedules – Effective date (enter date of change): Location (list published location): b. Other: Increases to state plan payment methodologies: 2. The agency increases payment rates for the following services: a. Payment increases are targeted based on the following criteria: Please describe the change in days or quantities that are allowed for the emergency period and for which drugs. Please describe the manner in which professional dispensing fees are adjusted. Please list all that apply. ϬϳͬϮϴͬϮϭ

State/Territory: OKLAHOMA TN: _21-0028 Supersedes TN: _NEW_ Approval Date: Effective Date: _07/01/21_ Page 76 This SPA is in addition to Oklahoma’s Disaster Relief SPAs approved on 5/11/20, 8/18/20, 10/15/2020, 12/31/20, 3/10/21, 4/1/21, 4/8/21, and 5/12/20, and does not supersede any items approved in those SPAs. b. Payments are increased through: i. A supplemental payment or add-on within applicable upper payment limits: ii. An increase to rates as described below. Rates are increased: Uniformly by the following percentage: Through a modification to published fee schedules – Effective date (enter date of change): Location (list published location): Up to the Medicare payments for equivalent services. _ By the following factors: Payment for services delivered via telehealth: 3. For the duration of the emergency, the state authorizes payments for telehealth services that: a. Are not otherwise paid under the Medicaid state plan; b. Differ from payments for the same services when provided face to face; c. Differ from current state plan provisions governing reimbursement for telehealth; d. Include payment for ancillary costs associated with the delivery of covered services via telehealth, (if applicable), as follows: Please describe criteria. Please describe. Please describe. Describe telehealth payment variation. ϬϳͬϮϴͬϮϭ

State/Territory: OKLAHOMA TN: _21-0028 Supersedes TN: _NEW_ Approval Date: Effective Date: _07/01/21_ Page 77 This SPA is in addition to Oklahoma’s Disaster Relief SPAs approved on 5/11/20, 8/18/20, 10/15/2020, 12/31/20, 3/10/21, 4/1/21, 4/8/21, and 5/12/20, and does not supersede any items approved in those SPAs. i. Ancillary cost associated with the originating site for telehealth is incorporated into fee-for-service rates. ii. Ancillary cost associated with the originating site for telehealth is separately reimbursed as an administrative cost by the state when a Medicaid service is delivered. Other: 4. Other payment changes: Section F – Post-Eligibility Treatment of Income 1. The state elects to modify the basic personal needs allowance for institutionalized individuals. The basic personal needs allowance is equal to one of the following amounts: a. The individual’s total income b. 300 percent of the SSI federal benefit rate c. Other reasonable amount: 2. The state elects a new variance to the basic personal needs allowance. (Note: Election of this option is not dependent on a state electing the option described the option in F.1. above.) The state protects amounts exceeding the basic personal needs allowance for individuals who have the following greater personal needs: Section G – Other Policies and Procedures Differing from Approved Medicaid State Plan /Additional Information PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this Please describe. Please describe the group or groups of individuals with greater needs and the amount(s) protected for each group or groups. Aligning the Expansion Adult ABP with the previously approved DRSPAs: 20-0032, 20-0040, 20-0042, and 21-0011. ϬϳͬϮϴͬϮϭ

State/Territory: OKLAHOMA TN: _21-0028 Supersedes TN: _NEW_ Approval Date: Effective Date: _07/01/21_ Page 78 This SPA is in addition to Oklahoma’s Disaster Relief SPAs approved on 5/11/20, 8/18/20, 10/15/2020, 12/31/20, 3/10/21, 4/1/21, 4/8/21, and 5/12/20, and does not supersede any items approved in those SPAs. information collection is 0938-1148 (Expires 03/31/2021). The time required to complete this information collection is estimated to average 1 to 2 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. Your response is required to receive a waiver under Section 1135 of the Social Security Act. All responses are public and will be made available on the CMS web site. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. ***CMS Disclosure*** Please do not send applications, claims, payments, medical records or any documents containing sensitive information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information collection burden approved under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please contact the Centers for Medicaid & CHIP Services at 410-786-3870. ϬϳͬϮϴͬϮϭ

Table of Contents State/Territory Name: Oklahoma State Plan Amendment (SPA) #: 21-0036 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS Form 179 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-26-12 Baltimore, Maryland 21244-1850 October , 2021 Melody Anthony State Medicaid Director Oklahoma Health Care Authority 4345 N. Lincoln Boulevard Oklahoma City, OK 73105 Re: Oklahoma State Plan Amendment (SPA) 21-0036 Dear Ms. Anthony: We have reviewed the proposed amendment to add section 7.4 Medicaid Disaster Relief for the COVID-19 National Emergency to your Medicaid state plan, as submitted under transmittal number (TN) OK 21-0036. This amendment proposes to implement temporary policies, which are different from those policies and procedures otherwise applied under your Medicaid state plan, during the period of the Presidential and Secretarial emergency declarations related to the COVID- 19 outbreak (or any renewals thereof). On March 13, 2020, the President of the United States issued a proclamation that the COVID- 19 outbreak in the United States constitutes a national emergency by the authorities vested in him by the Constitution and the laws of the United States, including sections 201 and 301 of the National Emergencies Act (50 U.S.C. 1601 et seq.), and consistent with section 1135 of the Social Security Act (Act). On March 13, 2020, pursuant to section 1135(b) of the Act, the Secretary of the United States Department of Health and Human Services invoked his authority to waive or modify certain requirements of titles XVIII, XIX, and XXI of the Act as a result of the consequences of the COVID-19 pandemic, to the extent necessary, as determined by the Centers for Medicare & Medicaid Services (CMS), to ensure that sufficient health care items and services are available to meet the needs of individuals enrolled in the respective programs and to ensure that health care providers that furnish such items and services in good faith, but are unable to comply with one or more of such requirements as a result of the COVID- 19 pandemic, may be reimbursed for such items and services and exempted from sanctions for such noncompliance, absent any determination of fraud or abuse. This authority took effect as of 6PM Eastern Standard Time on March 15, 2020, with a retroactive effective date of March 1, 2020. The emergency period will terminate, and this state plan provision will no longer be in effect, upon termination of the public health emergency, including any extensions.

Pursuant to section 1135(b)(5) of the Act, for the period of the public health emergency, CMS is modifying the requirement at 42 C.F.R. 430.20 that the state submit SPAs related to the COVID- 19 public health emergency by the final day of the quarter, to obtain a SPA effective date during the quarter, enabling SPAs submitted after the last day of the quarter to have an effective date in a previous quarter, but no earlier than the effective date of the public health emergency. The State of Oklahoma also requested a waiver of public notice requirements applicable to the SPA submission process. Pursuant to section 1135(b)(1)(C) of the Act, CMS is waiving public notice requirements applicable to the SPA submission process. Public notice for SPAs is required under 42 C.F.R. §447.205 for changes in statewide methods and standards for setting Medicaid payment rates, 42 C.F.R. §447.57 for changes to premiums and cost sharing, and 42 C.F.R. §440.386 for changes to Alternative Benefit Plans (ABPs). Pursuant to section 1135(b)(1)(C) to waive of the Act, CMS is approving the state’s request to waive these notice requirements otherwise applicable to SPA submissions. The State of Oklahoma also requested a waiver to modify the tribal consultation timeline applicable to this SPA submission process. Pursuant to section 1135(b)(5) of the Act, CMS is also allowing states to modify the timeframes associated with tribal consultation required under section 1902(a)(73) of the Act, including shortening the number of days before submission or conducting consultation after submission of the SPA. These waivers or modifications of the requirements related to SPA submission timelines, public notice, and tribal consultation apply only with respect to SPAs that meet the following criteria: (1) the SPA provides or increases beneficiary access to items and services related to COVID-19 (such as by waiving or eliminating cost sharing, increasing payment rates or amending ABPs to add services or providers); (2) the SPA does not restrict or limit payment or services or otherwise burden beneficiaries and providers; and (3) the SPA is temporary, with a specified sunset date that is not later than the last day of the declared COVID-19 public health emergency (or any extension thereof). We nonetheless encourage states to make all relevant information about the SPA available to the public so they are aware of the changes. We conducted our review of your submittal according to the statutory requirements at section 1902(a) of the Act and implementing regulations. This letter is to inform you that Oklahoma’s Medicaid SPA Transmittal Number 21-0036 is approved effective March 1, 2020. This SPA is in addition to Oklahoma’s Disaster Relief SPA 20-0032, approved on May 11, 2020; Oklahoma’s Disaster Relief SPA 20-0040, approved on August 18, 2020; Oklahoma’s Disaster Relief SPA 20- 0041, approved on October 15, 2020; Oklahoma’s Disaster Relief SPA 20-0043 approved on December 31, 2020; Oklahoma’s Disaster Relief SPA 20-0042, approved on March 10, 2021; Oklahoma’s Disaster Relief SPA 21-0011, approved on April 1, 2021, Oklahoma’s Disaster Relief SPA 21-0024, approved on April 8, 202, Oklahoma’s Disaster Relief SPA 21-0021 approved on May 12, 2021, and Oklahoma’s Disaster Relief SPA 21-0028 approved on July 28, 2021and does not supersede anything approved in those SPAs. Enclosed is a copy of the CMS-179 summary form and the approved state plan pages.

Please contact Deborah Read at 816-426-6363 or by email at Deborah.Read@cms.hhs.gov if you have any questions about this approval. We appreciate the efforts of you and your staff in responding to the needs of the residents of the State of Oklahoma and the health care community. Sincerely, Alissa Mooney DeBoy On Behalf of Anne Marie Costello, Deputy Director Center for Medicaid & CHIP Services Enclosures Alissa M. Deboy -S Digitally signed by Alissa M. Deboy -S Date: 2021.10.06 07:52 33 -04'00'

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

FORM APPROVED OMB No. 0938-0193

1. TRANSMITTAL NUMBER 2. STATE TRANSMITTAL AND NOTICEOFAPPROVALOF |) a. loxlahoma STATE PLAN MATERIAL FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID)

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

4. PROPOSED EFFECTIVE DATE March 1, 2020

5. TYPE OF PLAN MATERIAL (Check One) (0 NEW STATE PLAN

(0 AMENDMENT TO BE CONSIDERED AS NEW PLAN

fH) AMENDMENT

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

6. FEDERAL STATUTE/REGULATION CITATION Sections 1135(b) and 1902 of the SSA

7. FEDERAL BUDGET IMPACT a. FFY.21 $ 0.00 b. FFY.22 $ 0.00

8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT

Section 7.4, Pages 79-88

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

10. SUBJECT OF AMENDMENT

Disaster relief request to disregard income, resources, and a build-up of assets as a result of pandemic assistance from a federal, state, local or tribal government for aged, blind and disabled populations.

11. GOVERNOR'S REVIEW (Check One)

(J Governor's OFFICE REPORTED NO COMMENT (J CoMMENTS OF GOVERNOR'S OFFICE ENCLOSED (1 No REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL

I OTHER, AS SPECIFIED

AGENCY OFFICIAL

13. TYPED NAME Melody Anthony

14. TITLE State Medicaid Director

15. DATE SUBMITTED 07/15/2021

16. RETURN TO

Oklahoma Health Care Authority Attn: Traylor Rains

4345 N. Lincoln Blvd.

Oklahoma City, OK 73105

FOR REGIONAL OFFICE USE ONLY

17.DATE RECEIVED 7/45/2021

18. DATE APPROVED October 6, 2021

PLAN APPROVED - ONE COPY ATTACHED

19. EFFECTIVE DATE OF APPROVED MATERIAL 3/1/2020

Digitally signed by Alissa M. Deboy -S

Date: 2021.10.06 07:52:57 -04'00"

20. SIGNATURE OF REGIONAL ARSE2AM. Deboy -S

21.TYPEDNAME Alissa Mooney DeBoy

22. TITLE On behalf of Anne Marie Costello, Deputy Director, CMCS

23. REMARKS

FORM CMS-179 (07/92)

Instructions on Back

State/Territory: Oklahoma TN: _21Ͳ0036_ Supersedes TN: _NEW_ Approval Date: ϭϬͬϲͬϮϭ Effective Date: ϯͬϭͬϮϬ This SPA is in addition to Oklahoma’s Disaster Relief SPAs approved on 5/11/2020, 8/18/2020, 10/15/2020, 12/31/20, 3/10/21, 4/1/21, 4/8/21, and 5/12/21 and does not supersede any items approved in those SPAs. 79 Section 7 – General Provisions 7.4. Medicaid Disaster Relief for the COVIDͲ19 National Emergency On March 13, 2020, the President of the United States issued a proclamation that the COVIDͲ19 outbreak in the United States constitutes a national emergency by the authorities vested in him by the Constitution and the laws of the United States, including sections 201 and 301 of the National Emergencies Act (50 U.S.C. 1601 et seq.), and consistent with section 1135 of the Social Security Act (Act). On March 13, 2020, pursuant to section 1135(b) of the Act, the Secretary of the United States Department of Health and Human Services invoked his authority to waive or modify certain requirements of titles XVIII, XIX, and XXI of the Act as a result of the consequences COVIDͲ19 pandemic, to the extent necessary, as determined by the Centers for Medicare & Medicaid Services (CMS), to ensure that sufficient health care items and services are available to meet the needs of individuals enrolled in the respective programs and to ensure that health care providers that furnish such items and services in good faith, but are unable to comply with one or more of such requirements as a result of the COVIDͲ19 pandemic, may be reimbursed for such items and services and exempted from sanctions for such noncompliance, absent any determination of fraud or abuse. This authority took effect as of 6PM Eastern Standard Time on March 15, 2020, with a retroactive effective date of March 1, 2020. The emergency period will terminate, and waivers will no longer be available, upon termination of the public health emergency, including any extensions. The State Medicaid agency (agency) seeks to implement the policies and procedures described below, which are different than the policies and procedures otherwise applied under the Medicaid state plan, during the period of the Presidential and Secretarial emergency declarations related to the COVIDͲ19 outbreak (or any renewals thereof), or for any shorter period described below: Describe shorter period here. NOTE: States may not elect a period longer than the Presidential or Secretarial emergency declaration (or any renewal thereof). States may not propose changes on this template that restrict or limit payment, services, or eligibility, or otherwise burden beneficiaries and providers. Request for Waivers under Section 1135 _X_ The agency seeks the following under section 1135(b)(1)(C) and/or section 1135(b)(5) of the Act: a. _ X_ SPA submission requirements – the agency requests modification of the requirement to submit the SPA by March 31, 2020, to obtain a SPA effective date during the first calendar quarter of 2020, pursuant to 42 CFR 430.20. b. _X_ Public notice requirements – the agency requests waiver of public notice requirements that would otherwise be applicable to this SPA submission. These requirements may include those specified in 42 CFR 440.386 (Alternative Benefit Plans),

State/Territory: Oklahoma TN: _21Ͳ0036_ Supersedes TN: _NEW_ Approval Date: ϭϬͬϲͬϮϭ Effective Date: ϯͬϭͬϮϬ This SPA is in addition to Oklahoma’s Disaster Relief SPAs approved on 5/11/2020, 8/18/2020, 10/15/2020, 12/31/20, 3/10/21, 4/1/21, 4/8/21, and 5/12/21 and does not supersede any items approved in those SPAs. 80 42 CFR 447.57(c) (premiums and cost sharing), and 42 CFR 447.205 (public notice of changes in statewide methods and standards for setting payment rates). c. _X_ Tribal consultation requirements – the agency requests modification of tribal consultation timelines specified in [insert name of state] Medicaid state plan, as described below: The State Medicaid Agency will notify tribal partners of all SPA changes on or before submission to CMS and will either offer a telephonic meeting to discuss or consult with Tribes at the next regularly schedule biͲmonthly consultation meeting. Section A – Eligibility 1. _____ The agency furnishes medical assistance to the following optional groups of individuals described in section 1902(a)(10)(A)(ii) or 1902(a)(10)(c) of the Act. This may include the new optional group described at section 1902(a)(10)(A)(ii)(XXIII) and 1902(ss) of the Act providing coverage for uninsured individuals. Include name of the optional eligibility group and applicable income and resource standard. 2. _____ The agency furnishes medical assistance to the following populations of individuals described in section 1902(a)(10)(A)(ii)(XX) of the Act and 42 CFR 435.218: a. _____ All individuals who are described in section 1905(a)(10)(A)(ii)(XX) Income standard: _____________ ͲorͲ b. _____ Individuals described in the following categorical populations in section 1905(a) of the Act: Income standard: _____________ 3. _X __ The agency applies less restrictive financial methodologies to individuals excepted from financial methodologies based on modified adjusted gross income (MAGI) as follows.

State/Territory: Oklahoma TN: _21Ͳ0036_ Supersedes TN: _NEW_ Approval Date: ϭϬͬϲͬϮϭ Effective Date: ϯͬϭͬϮϬ This SPA is in addition to Oklahoma’s Disaster Relief SPAs approved on 5/11/2020, 8/18/2020, 10/15/2020, 12/31/20, 3/10/21, 4/1/21, 4/8/21, and 5/12/21 and does not supersede any items approved in those SPAs. 81 Less restrictive income methodologies: Less restrictive resource methodologies: Disregard resources or builtͲup assets that result from any payment made by the federal, state, local, or tribal government to relieve the adverse economic impacts of the COVIDͲ19 pandemic that would have otherwise been part of an individual’s liability for his or her institutional services based on application of the postͲeligibility treatmentͲof income (PETI) rules but which became countable resources on or after March 1, 2020 and/or retained through the end of the COVIDͲrelated public health emergency for individuals who are 65 years of age or older or are disabled individuals under section 1902(a)(10)(A)(ii)(X). 4. _____ The agency considers individuals who are evacuated from the state, who leave the state for medical reasons related to the disaster or public health emergency, or who are otherwise absent from the state due to the disaster or public health emergency and who intend to return to the state, to continue to be residents of the state under 42 CFR 435.403(j)(3). 5. _____ The agency provides Medicaid coverage to the following individuals living in the state, who are nonͲresidents: 6. _____ The agency provides for an extension of the reasonable opportunity period for nonͲ citizens declaring to be in a satisfactory immigration status, if the nonͲcitizen is making a good faith effort to resolve any inconsistences or obtain any necessary documentation, or the agency is unable to complete the verification process within the 90Ͳday reasonable opportunity period due to the disaster or public health emergency. Section B – Enrollment 1. _____ The agency elects to allow hospitals to make presumptive eligibility determinations for the following additional state plan populations, or for populations in an approved section 1115 demonstration, in accordance with section 1902(a)(47)(B) of the Act and 42 CFR 435.1110, provided that the agency has determined that the hospital is capable of making such determinations. Please describe the applicable eligibility groups/populations and any changes to reasonable limitations, performance standards or other factors.

State/Territory: Oklahoma TN: _21Ͳ0036_ Supersedes TN: _NEW_ Approval Date: ϭϬͬϲͬϮϭ Effective Date: ϯͬϭͬϮϬ This SPA is in addition to Oklahoma’s Disaster Relief SPAs approved on 5/11/2020, 8/18/2020, 10/15/2020, 12/31/20, 3/10/21, 4/1/21, 4/8/21, and 5/12/21 and does not supersede any items approved in those SPAs. 82 2. _____ The agency designates itself as a qualified entity for purposes of making presumptive eligibility determinations described below in accordance with sections 1920, 1920A, 1920B, and 1920C of the Act and 42 CFR Part 435 Subpart L. Please describe any limitations related to the populations included or the number of allowable PE periods. 3. _____ The agency designates the following entities as qualified entities for purposes of making presumptive eligibility determinations or adds additional populations as described below in accordance with sections 1920, 1920A, 1920B, and 1920C of the Act and 42 CFR Part 435 Subpart L. Indicate if any designated entities are permitted to make presumptive eligibility determinations only for specified populations. Please describe the designated entities or additional populations and any limitations related to the specified populations or number of allowable PE periods. 4. _____ The agency adopts a total of _____ months (not to exceed 12 months) continuous eligibility for children under age enter age _____ (not to exceed age 19) regardless of changes in circumstances in accordance with section 1902(e)(12) of the Act and 42 CFR 435.926. 5. _____ The agency conducts redeterminations of eligibility for individuals excepted from MAGIͲ based financial methodologies under 42 CFR 435.603(j) once every _____ months (not to exceed 12 months) in accordance with 42 CFR 435.916(b). 6. _____ The agency uses the following simplified application(s) to support enrollment in affected areas or for affected individuals (a copy of the simplified application(s) has been submitted to CMS). a. _____ The agency uses a simplified paper application. b. _____ The agency uses a simplified online application. c. _____ The simplified paper or online application is made available for use in callͲcenters or other telephone applications in affected areas. Section C – Premiums and Cost Sharing 1. _____ The agency suspends deductibles, copayments, coinsurance, and other cost sharing charges as follows:

State/Territory: Oklahoma TN: _21Ͳ0036_ Supersedes TN: _NEW_ Approval Date: ϭϬͬϲͬϮϭ Effective Date: ϯͬϭͬϮϬ This SPA is in addition to Oklahoma’s Disaster Relief SPAs approved on 5/11/2020, 8/18/2020, 10/15/2020, 12/31/20, 3/10/21, 4/1/21, 4/8/21, and 5/12/21 and does not supersede any items approved in those SPAs. 83 Please describe whether the state suspends all cost sharing or suspends only specified deductibles, copayments, coinsurance, or other cost sharing charges for specified items and services or for specified eligibility groups consistent with 42 CFR 447.52(d) or for specified income levels consistent with 42 CFR 447.52(g). 2. _____ The agency suspends enrollment fees, premiums and similar charges for: a. _____ All beneficiaries b. _____ The following eligibility groups or categorical populations: Please list the applicable eligibility groups or populations. 3. _____ The agency allows waiver of payment of the enrollment fee, premiums and similar charges for undue hardship. Please specify the standard(s) and/or criteria that the state will use to determine undue hardship. Section D – Benefits Benefits: 1. _ The agency adds the following optional benefits in its state plan (include service descriptions, provider qualifications, and limitations on amount, duration or scope of the benefit): 2. ___ The agency makes the following adjustments to benefits currently covered in the state plan: 3. _ _ The agency assures that newly added benefits or adjustments to benefits comply with all applicable statutory requirements, including the statewideness requirements found at 1902(a)(1), comparability requirements found at 1902(a)(10)(B), and free choice of provider requirements found at 1902(a)(23).

State/Territory: Oklahoma TN: _21Ͳ0036_ Supersedes TN: _NEW_ Approval Date: ϭϬͬϲͬϮϭ Effective Date: ϯͬϭͬϮϬ This SPA is in addition to Oklahoma’s Disaster Relief SPAs approved on 5/11/2020, 8/18/2020, 10/15/2020, 12/31/20, 3/10/21, 4/1/21, 4/8/21, and 5/12/21 and does not supersede any items approved in those SPAs. 84 4. _____ Application to Alternative Benefit Plans (ABP). The state adheres to all ABP provisions in 42 CFR Part 440, Subpart C. This section only applies to states that have an approved ABP(s). a. _____ The agency assures that these newly added and/or adjusted benefits will be made available to individuals receiving services under ABPs. b. _____ Individuals receiving services under ABPs will not receive these newly added and/or adjusted benefits, or will only receive the following subset: Please describe. Telehealth: 5. _____ The agency utilizes telehealth in the following manner, which may be different than outlined in the state’s approved state plan: Please describe. Drug Benefit: 6. _____ The agency makes the following adjustments to the day supply or quantity limit for covered outpatient drugs. The agency should only make this modification if its current state plan pages have limits on the amount of medication dispensed. Please describe the change in days or quantities that are allowed for the emergency period and for which drugs. 7. _____ Prior authorization for medications is expanded by automatic renewal without clinical review, or time/quantity extensions. 8. _____ The agency makes the following payment adjustment to the professional dispensing fee when additional costs are incurred by the providers for delivery. States will need to supply documentation to justify the additional fees. Please describe the manner in which professional dispensing fees are adjusted.

State/Territory: Oklahoma TN: _21Ͳ0036_ Supersedes TN: _NEW_ Approval Date: ϭϬͬϲͬϮϭ Effective Date: ϯͬϭͬϮϬ This SPA is in addition to Oklahoma’s Disaster Relief SPAs approved on 5/11/2020, 8/18/2020, 10/15/2020, 12/31/20, 3/10/21, 4/1/21, 4/8/21, and 5/12/21 and does not supersede any items approved in those SPAs. 85 9. _____ The agency makes exceptions to their published Preferred Drug List if drug shortages occur. This would include options for covering a brand name drug product that is a multiͲsource drug if a generic drug option is not available. Section E – Payments Optional benefits described in Section D: 1. ___ Newly added benefits described in Section D are paid using the following methodology: a. _ _ Published fee schedules – Effective date (enter date of change): __ Location (list published location): b. Other: Increases to state plan payment methodologies: 2. _ _ The agency increases payment rates for the following services: a. _____ Payment increases are targeted based on the following criteria: b. Payments are increased through: i. _____ A supplemental payment or add-on within applicable upper payment limits: ii. __ __ An increase to rates as described below. Rates are increased:

State/Territory: Oklahoma TN: _21Ͳ0036_ Supersedes TN: _NEW_ Approval Date: ϭϬͬϲͬϮϭ Effective Date: _03/01/20_ This SPA is in addition to Oklahoma’s Disaster Relief SPAs approved on 5/11/2020, 8/18/2020, 10/15/2020, 12/31/20, 3/10/21, 4/1/21, 4/8/21, and 5/12/21 and does not supersede any items approved in those SPAs. 86 _____ Uniformly by the following percentage: _____________ _____ Through a modification to published fee schedules – Effective date (enter date of change): _____________ Location (list published location): _____________ __ __ Up to the Medicare payments for equivalent services. _____ By the following factors: Please describe. Payment for services delivered via telehealth: 3. _____ For the duration of the emergency, the state authorizes payments for telehealth services that: a. _____ Are not otherwise paid under the Medicaid state plan; b. _____ Differ from payments for the same services when provided face to face; c. _____ Differ from current state plan provisions governing reimbursement for telehealth; Describe telehealth payment variation. d. _____ Include payment for ancillary costs associated with the delivery of covered services via telehealth, (if applicable), as follows: i. _____ Ancillary cost associated with the originating site for telehealth is incorporated into fee-for-service rates. ii. _____ Ancillary cost associated with the originating site for telehealth is separately reimbursed as an administrative cost by the state when a Medicaid service is delivered. Other: 4. _ _ Other payment changes:

State/Territory: Oklahoma TN: _21Ͳ0036_ Supersedes TN: _NEW_ Approval Date: ϭϬͬϲͬϮϭ Effective Date: ϯͬϭͬϮϬ This SPA is in addition to Oklahoma’s Disaster Relief SPAs approved on 5/11/2020, 8/18/2020, 10/15/2020, 12/31/20, 3/10/21, 4/1/21, 4/8/21, and 5/12/21 and does not supersede any items approved in those SPAs. 87 Section F – PostͲEligibility Treatment of Income 1. _____ The state elects to modify the basic personal needs allowance for institutionalized individuals. The basic personal needs allowance is equal to one of the following amounts: a. _____ The individual’s total income b. _____ 300 percent of the SSI federal benefit rate c. _ ___ Other reasonable amount: _________________ 2. _____ The state elects a new variance to the basic personal needs allowance. (Note: Election of this option is not dependent on a state electing the option described the option in F.1. above.) The state protects amounts exceeding the basic personal needs allowance for individuals who have the following greater personal needs: Please describe the group or groups of individuals with greater needs and the amount(s) protected for each group or groups. Section G – Other Policies and Procedures Differing from Approved Medicaid State Plan /Additional Information PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938Ͳ1148 (Expires 03/31/2021). The time required to complete this information collection is estimated to average 1 to 2 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. Your response is required to receive a waiver under Section 1135 of the Social Security Act. All responses are public and will be made available on the CMS web site. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4Ͳ26Ͳ05,

State/Territory: Oklahoma TN: _21Ͳ0036_ Supersedes TN: _NEW_ Approval Date: ϭϬͬϲͬϮϭ Effective Date: ϯͬϭͬϮϬ This SPA is in addition to Oklahoma’s Disaster Relief SPAs approved on 5/11/2020, 8/18/2020, 10/15/2020, 12/31/20, 3/10/21, 4/1/21, 4/8/21, and 5/12/21 and does not supersede any items approved in those SPAs. 88 Baltimore, Maryland 21244Ͳ1850. ***CMS Disclosure*** Please do not send applications, claims, payments, medical records or any documents containing sensitive information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information collection burden approved under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please contact the Centers for Medicaid & CHIP Services at 410Ͳ786Ͳ3870.

Table of Contents

State/Territory Name: Oklahoma State Plan Amendment (SPA) #: 21-0038 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS Form 179 3) Approved SPA Pages

Records / Submission Packages - View All OK - Submission Package - OK2021MS0005O - (OK-21-0038) - Eligibility Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter RAI Transaction Logs News Related Actions DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Medicaid and CHIP Operations Group (MCOG) 601 E. 12th St., Room 355 Kansas City, KS 64106 Center for Medicaid & CHIP Services July 25, 2023 Traylor Rains Chief Executive Officer / State Medicaid Director Oklahoma Health Care Authority 4345 N Lincoln Blvd Oklahoma City, OK 73105 Re: Approval of State Plan Amendment OK-21-0038 Dear Traylor Rains, The Centers for Medicare & Medicaid Services (CMS) has completed its review of Oklahoma’s State Plan Amendment (SPA) 21-0038. This amendment proposes changes to Hospital Presumptive Eligibility (HPE) to include the adult group in the eligibility groups for which hospitals may conduct HPE determinations. We approve Oklahoma State Plan Amendment (SPA) OK-21-0038 with an effective date(s) of October 01, 2021. We understand Oklahoma currently uses a paper application for HPE determinations. As part of the submission, the state provided copies of the paper HPE application and provider training materials. CMS has reviewed all submitted materials and the HPE Reviewable Unit (RU). If you have any questions regarding this amendment, please contact Stacey Steiner at (469) 904-1068 or via email at stacey.steiner@cms.hhs.gov. Sincerely, James G. Scott Director, Division of Program Operations Center for Medicaid & CHIP Services - MS CENTEIIS JOR MEDICARE & MEDICAID SERVICIS

Records / Submission Packages - View All OK - Submission Package - OK2021MS0005O - (OK-21-0038) - Eligibility Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter RAI Transaction Logs News Related Actions Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | OK2021MS0005O | OK-21-0038 CMS-10434 OMB 0938-1188 Package Header Package ID OK2021MS0005O Submission Type Official Approval Date 07/25/2023 Superseded SPA ID N/A SPA ID OK-21-0038 Initial Submission Date 9/16/2021 Effective Date N/A State Information State/Territory Name: Oklahoma Medicaid Agency Name: Oklahoma Health Care Authority Submission Component State Plan Amendment Medicaid CHIP 0 0 0

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | OK2021MS0005O | OK-21-0038 Package Header Package ID OK2021MS0005O Submission Type Official Approval Date 07/25/2023 Superseded SPA ID N/A SPA ID OK-21-0038 Initial Submission Date 9/16/2021 Effective Date N/A SPA ID and Effective Date SPA ID OK-21-0038 Reviewable Unit Proposed Effective Date Superseded SPA ID Presumptive Eligibility 10/1/2021 N/A Presumptive Eligibility by Hospitals 10/1/2021 16-0015 Page Number of the Superseded Plan Section or Attachment (If Applicable):

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | OK2021MS0005O | OK-21-0038 Package Header Package ID OK2021MS0005O Submission Type Official Approval Date 07/25/2023 Superseded SPA ID N/A SPA ID OK-21-0038 Initial Submission Date 9/16/2021 Effective Date N/A Executive Summary Summary Description Including Goals and Objectives State plan amendment to update the hospital presumptive eligibility (HPE) training materials and application to include expansion adults. Federal Budget Impact and Statute/Regulation Citation Federal Budget Impact Federal Fiscal Year Amount First 2021 $0 Second 2022 $0 Federal Statute / Regulation Citation 42 CFR 435.1110 Supporting documentation of budget impact is uploaded (optional). Name Date Created No items available

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | OK2021MS0005O | OK-21-0038 Package Header Package ID OK2021MS0005O Submission Type Official Approval Date 07/25/2023 Superseded SPA ID N/A SPA ID OK-21-0038 Initial Submission Date 9/16/2021 Effective Date N/A Governor's Office Review Describe The Governor does not review state plan amendments. PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state’s program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. This view was generated on 8/17/2023 9:33 PM EDT No comment Comments received No response within 45 days Other 0 0 0 0

Records / Submission Packages - View All OK - Submission Package - OK2021MS0005O - (OK-21-0038) - Eligibility Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter RAI Transaction Logs News Related Actions Medicaid State Plan Eligibility Eligibility and Enrollment Processes Presumptive Eligibility MEDICAID | Medicaid State Plan | Eligibility | OK2021MS0005O | OK-21-0038 CMS-10434 OMB 0938-1188 Package Header Package ID OK2021MS0005O Submission Type Official Approval Date 07/25/2023 Superseded SPA ID N/A User-Entered SPA ID OK-21-0038 Initial Submission Date 9/16/2021 Effective Date 10/1/2021 The state provides Medicaid services to individuals during a presumptive eligibility period following a determination by a qualified entity. Presumptive eligibility covered in the state plan includes: Eligibility Groups Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Presumptive Eligibility for Children under Age 19 NEW Parents and Other Caretaker Relatives - Presumptive Eligibility NEW Presumptive Eligibility for Pregnant Women NEW Adult Group - Presumptive Eligibility NEW Individuals above 133% FPL under Age 65 - Presumptive Eligibility NEW Individuals Eligible for Family Planning Services - Presumptive Eligibility NEW Former Foster Care Children - Presumptive Eligibility NEW Individuals Needing Treatment for Breast or Cervical Cancer - Presumptive Eligibility NEW Hospitals Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Presumptive Eligibility by APPROVED

□ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ 0 0 0 0 0 0 0 0 0

Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Hospitals

Presumptive Eligibility MEDICAID | Medicaid State Plan | Eligibility | OK2021MS0005O | OK-21-0038 Package Header Package ID OK2021MS0005O Submission Type Official Approval Date 07/25/2023 Superseded SPA ID N/A User-Entered SPA ID OK-21-0038 Initial Submission Date 9/16/2021 Effective Date 10/1/2021 Eligibility Groups Deselected from Coverage The following eligibility groups were previously covered in the source approved version of the state plan and deselected from coverage as part of this submission package: N/A PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state’s program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. This view was generated on 8/17/2023 9:34 PM EDT

Records / Submission Packages - View All OK - Submission Package - OK2021MS0005O - (OK-21-0038) - Eligibility Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter RAI Transaction Logs News Related Actions Medicaid State Plan Eligibility Presumptive Eligibility Presumptive Eligibility by Hospitals MEDICAID | Medicaid State Plan | Eligibility | OK2021MS0005O | OK-21-0038 CMS-10434 OMB 0938-1188 Package Header Package ID OK2021MS0005O Submission Type Official Approval Date 07/25/2023 Superseded SPA ID 16-0015 User-Entered SPA ID OK-21-0038 Initial Submission Date 9/16/2021 Effective Date 10/1/2021 A. Qualifications of Hospitals A qualified hospital is a hospital that: 1. Participates as a provider under the state plan or a Medicaid 1115 Demonstration, notifies the Medicaid agency of its election to make presumptive eligibility determinations and agrees to make presumptive eligibility determinations consistent with state policies and procedures. 2. Has not been disqualified by the Medicaid agency for failure to make presumptive eligibility determinations in accordance with applicable state policies and procedures or for failure to meet any standards that may have been established by the Medicaid agency. 3. Assists individuals in completing and submitting the full application and understanding any documentation requirements. The state provides an assurance that it has policies and procedures in place to enable qualified hospitals to determine presumptive eligibility under 42 CFR 435.1110, and the state is providing Medicaid coverage for individuals determined presumptively eligible under this provision. The state attests that presumptive eligibility by hospitals is administered in accordance with the following provisions: Yes No 0 0

Presumptive Eligibility by Hospitals MEDICAID | Medicaid State Plan | Eligibility | OK2021MS0005O | OK-21-0038 Package Header Package ID OK2021MS0005O Submission Type Official Approval Date 07/25/2023 Superseded SPA ID 16-0015 User-Entered SPA ID OK-21-0038 Initial Submission Date 9/16/2021 Effective Date 10/1/2021 B. Eligibility Groups or Populations Included The eligibility groups or populations for which hospitals determine eligibility presumptively are: 1. Pregnant Women 2. Infants and Children under Age 19 3. Parents and Other Caretaker Relatives 4. Adult Group, if covered by the state 5. Individuals above 133% FPL under Age 65, if covered by the state 6. Individuals Eligible for Family Planning Services, if covered by the state 7. Former Foster Care Children 8. Certain Individuals Needing Treatment for Breast or Cervical Cancer, if covered by the state The state limits qualified hospitals for this group to providers who conduct screenings for breast and cervical cancer under the state’s Centers for Disease Control and Prevention’s National Breast and Cervical Cancer Early Detection Program. Yes No 9. Other Medicaid state plan eligibility groups: 10. Demonstration populations covered under section 1115 0 0 □ □

Presumptive Eligibility by Hospitals MEDICAID | Medicaid State Plan | Eligibility | OK2021MS0005O | OK-21-0038 Package Header Package ID OK2021MS0005O Submission Type Official Approval Date 07/25/2023 Superseded SPA ID 16-0015 User-Entered SPA ID OK-21-0038 Initial Submission Date 9/16/2021 Effective Date 10/1/2021 C. Standards for Participating Hospitals The state establishes reasonable standards for qualified hospitals making presumptive eligibility determinations. Percentage of individuals submitting a regular application: 95.00% Percentage of individuals found eligible for Medicaid 95.00% D. Presumptive Eligibility Period 1. The presumptive period begins on the date the determination is made. 2. The end date of the presumptive period is the earlier of: The date the eligibility determination for regular Medicaid is made, if an application for Medicaid is filed by the last day of the month following the month in which the determination of presumptive eligibility is made; or The last day of the month following the month in which the determination of presumptive eligibility is made, if no application for Medicaid is filed by that date. 3. Periods of presumptive eligibility are limited as follows: Name of limitation Description Number of non-pregnancy-related PE periods allowed The number of PE periods that may be authorized is one (1) period within 12 calendar months. Number of pregnancy-related PE periods allowed Individuals applying for pregnancy-related PE are limited to one PE period per pregnancy. Yes No The state has a standard requiring that a percentage of individuals who are determined presumptively eligible submit a regular application, as described at 42 CFR 435.907, before the end of the presumptive eligibility period. The state has a standard requiring that a percentage of individuals who are determined presumptively eligible be determined eligible for Medicaid based on the submission of an application before the end of the presumptive eligibility period. The state has elected one or more other reasonable standard(s). a. No more than one period within a calendar year. b. No more than one period within two calendar years. c. No more than one period within a six-month period, starting with the effective date of the initial presumptive eligibility period. d. No more than one period within a twelve-month period, starting with the effective date of the initial presumptive eligibility period. e. Other reasonable limitation: 0 0 ~ 0 0 0 0 0

Presumptive Eligibility by Hospitals MEDICAID | Medicaid State Plan | Eligibility | OK2021MS0005O | OK-21-0038 Package Header Package ID OK2021MS0005O Submission Type Official Approval Date 07/25/2023 Superseded SPA ID 16-0015 User-Entered SPA ID OK-21-0038 Initial Submission Date 9/16/2021 Effective Date 10/1/2021 E. Application for Presumptive Eligibility Name Date Created HPE Application 12.12.22 4/27/2023 8:05 PM EDT 5. Describe the presumptive eligibility screening process: At the individual’s initial visit to a Hospital Presumptive Eligibility (HPE) Qualified Entity, an Authorized Hospital Employee takes the following steps to screen a participants enrollment: 1. Verifies the applicant is not currently enrolled in Medicaid through the Provider Portal Eligibility Verification System (EVS). 2. Assists the individual in completing all the required questions of the HPE application. 3. Determine if individual meets the reasonable estimate of Modified Adjusted Gross Income (MAGI) methodology. 4. Provide the eligibility notice to the member. 5. Summarize benefits and answer any questions. 6. Email the individual’s application and benefits eligibility to the State Medicaid Agency within 5 days of the application date . 7. Assist the individual with completing the full Medicaid application within 15 days of the start of the HPE determination date. F. Presumptive Eligibility Determination The presumptive eligibility determination is based on the following factors: 1. The individual’s categorical or non-financial eligibility for the group for which the individual’s presumptive eligibility is being determined (e.g., based on age, pregnancy status, status as a parent/caretaker relative, disability, or other requirements specified in the Medicaid state plan or a Medicaid 1115 demonstration for that group) 2. Household income must not exceed the applicable income standard for the group for which the individual's presumptive eligibility is being determined, if an income standard is applicable for this group. 1. The state uses a standardized screening process for determining presumptive eligibility. 2. The state uses the single streamlined paper and/or online application form for Medicaid and Presumptive Eligibility, approved by CMS. A copy of the single streamlined paper and/or online application with questions necessary for a PE determination highlighted or denoted is included. 3. The state uses a separate paper application form for presumptive eligibility, approved by CMS. A copy of the application form is included. 4. The state uses an online portal or electronic screening tool for presumptive eligibility approved by CMS. Screenshots of the tool included. a. A reasonable estimate of MAGI-based income is used to determine household income. b. Gross income is used to determine household size. c. Other income methodology 3. State residency 4. Citizenship, status as a national, or satisfactory immigration status ~ □ □ I

Presumptive Eligibility by Hospitals MEDICAID | Medicaid State Plan | Eligibility | OK2021MS0005O | OK-21-0038 Package Header Package ID OK2021MS0005O Submission Type Official Approval Date 07/25/2023 Superseded SPA ID 16-0015 User-Entered SPA ID OK-21-0038 Initial Submission Date 9/16/2021 Effective Date 10/1/2021 G. Qualified Entity Requirements 2. A copy of the training materials has been uploaded for review during the submission process. Name Date Created HPE Attestation 5/27/2022 11:36 AM EDT HPE MAGI Training 4/27/2023 8:09 PM EDT HPE Training 4/27/2023 8:09 PM EDT HPE Application 12.12.22 4/27/2023 8:09 PM EDT HPE Applicant Approval Notice 11.09.22 4/27/2023 8:09 PM EDT HPE Applicant Denial Notice 11.09.22 4/27/2023 8:09 PM EDT 1 – 6 of 6 H. Additional Information (optional) PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state’s program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. This view was generated on 8/17/2023 9:35 PM EDT 1. The state assures that it has communicated the requirements for qualified hospitals, and has provided adequate training to the hospitals. I I I I

Table of Contents State/Territory Name: OK State Plan Amendment (SPA) #: 22-0031 This file contains the following documents in the order listed: 1) Approval Letter 2) Summary Form (with 179-like data) 3) Approved SPA Pages



  

 

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