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

Effective Date: 11/1/10 1

Approval Date: 12/30/10 STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT STATE CHILDREN’S HEALTH INSURANCE PROGRAM

Preamble

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

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

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

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

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Approval Date: 12/30/10 MODEL APPLICATION TEMPLATE FOR STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT STATE CHILDREN’S HEALTH INSURANCE PROGRAM

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

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

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

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

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

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

Position/Title: Administrator Division of Medical Assistance Name:

Position/Title: Name:

Position/Title:

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0707. The time required to complete this information collection is estimated to average 160 hours (or minutes) per response, including the time to review instructions, search existing data resources, gather the data needed and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, P.O. Box 26684, Baltimore, Maryland 21207 and to the Office of the Information and Regulatory Affairs, Office of Management and Budget, Washington, D.C.

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

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Approval Date: 12/30/10 20503.

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

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Approval Date: 12/30/10 Section 1. General Description and Purpose of the State Child Health Plans and State Child Health Plan Requirements (Section 2101)

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

1.1.1

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

1.1.2.

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

1.1.3.

A combination of both of the above.

1.2

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

The Division of Medical Assistance Programs (DMAP) assures that expenditures for this program will not be claimed prior to the time the State has legislative authority to operate the State plan or plan amendment as approved by CMS.

1.3

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

DMAP assures that the state complies with all applicable civil rights requirements, including those listed above.

1.4

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

Effective date: July 1, 1998

Implementation date: July 1, 1998

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

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Approval Date: 12/30/10

State Plan Amendment #2: Minor revisions to performance measures in approved XXI State Plan Submitted: May 30, 2000 CMS Approved: September 11, 2000

State Plan Amendment #3: Increase enrollment cap to 19,800 Submitted: December 12, 2000 CMS Approved: March 9, 2001

State Plan Amendment #4 Compliance with final CHIP regulations and updated program descriptions Submitted: July 31, 2002 CMS Approved: April 15, 2003

State Plan Amendment #5: Asset limit increase to $10,000 Submitted: August 19, 2004 CMS Approved: November 10, 2004 Effective date: October 1, 2004

State Plan Amendment #6: Duration of eligibility period increased to 12 months Submitted: May 16, 2006 CMS Approved: August 1, 2006 Effective Date: June 1, 2006

State Plan Amendment # 7: Unborn child expansion Submitted: July 31, 2007 Approved: April 9, 2008 Effective: April 1, 2008

State Plan Amendment #8: Require SSN on application Submitted: September 13, 2007 Approved: December 12, 2007 Effective: October 1, 2007

State Plan Amendment # 9: Transition the following targeted low income children from Section 1115 demonstration to the state plan: children ages 0 through 18 above 170 percent of the FPL up to 185 percent of the FPL. Submitted: November 30, 2007 Approved: September 16, 2008Effective: November 1, 2007 State Plan Amendment # 10: This amendment expands the income

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

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Approval Date: 12/30/10 eligibility level for CHIP children through age 18 from 185 percent of the Federal poverty level (FPL) up to and including 300 percent of the FPL under the State’s Healthy Kids initiative. This SPA is a companion amendment to the State’s section 1115 title XXI demonstration amendment. This SPA also creates a new private insurance option, referred to as Healthy KidsConnect, specifically for children from 200 up to and including 300 percent of the FPL under Secretary-approved coverage under the CHIP state plan. In addition, this SPA institutes an Application Assistance Program to assist families applying for CHIP and other child health programs in the State as part of its Healthy Kids initiative, finances an outreach and enrollment grant program designed to provide culturally-specific and targeted outreach and direct application assistance to families in racial, ethnic and language minority communities living in geographic isolation or with additional access barriers, reduces the waiting period of uninsurance for CHIP coverage from 6 months to 2 months, and eliminates the asset test in CHIP This amendment will have a retroactive effective date of October 1, 2009, for the expansion of eligibility from 185 percent of FPL up to and including 200 percent of the FPL, as well as for the application assistance program, outreach and enrollment grant program, the waiting period reduction, and elimination of the asset test. Submitted: July 27, 2009 Effective: October 1, 2009 This amendment will also have an effective date of January 1, 2010, for the expansion of eligibility above 200 percent of the FPL up to and including 300 percent of the FPL. However, the State must receive approval for its section 1115 demonstration amendment in order to permit children to enroll in its premium assistance programs. Submitted: July 27, 2009 Approved: December 18, 2009 Effective: January 1, 2010.

State Plan Amendment #11: Expand Unborn population coverage to Benton, Clackamas, Hood River, Jackson and Lincoln counties. Submitted: August 26, 2009 Effective: October 1, 2009 This amendment also closes the expansion in Lincoln County effective December 31, 2009. Submitted: December 22, 2009 Approved: September 20, 2010 Effective: January 1, 2009

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

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Approval Date: 12/30/10 State Plan Amendment # 12: CHIPRA provisions related to those who have not met the 5 year waiting period for immigrant children. Submitted: July 27, 2009 Approved: May 18, 2010 Effective: October 1, 2009

State Plan Amendment # 13: Designate express lane eligibility agencies as the Supplemental Nutritional Assistance Program (SNAP) and selected Department of Education, National School Lunch Program (NSLP). Submitted: August 9, 2010 Approved: October 21, 2010 Effective: August 1, 2010

State Plan Amendment #14: Expand Unborn population coverage to Lane county and revise the. Submitted: October 11, 2010 Effective: January 1, 2011 This Amendment also revises the budget month used for income Eligibility Approved: December 30, 2010 Effective: November 1, 2010

State Plan Amendment #15: withdrawn

State Plan Amendment #16: Expand Unborn population coverage to Columbia, Crook, Douglas, Josephine, Jefferson, Morrow, Union and Wasco county. Submitted: March 28, 2011 Effective: July 1, 2011 Approved: May 26, 2011

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

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Approval Date: 8 Section 2. General Background and Description of State Approach to Child Health Coverage and Coordination (Section 2102 (a)(1)- (3)) and (Section 2105)(c)(7)(A)-(B))

2.1. Describe the extent to which, and manner in which, children in the state including targeted low-income children and other classes of children, by income level and other relevant factors, such as race and ethnicity and geographic location, currently have creditable health coverage (as defined in 42 CFR 457.10). To the extent feasible, make a distinction between creditable coverage under public health insurance programs and public- private partnerships (See Section 10 for annual report requirements). (42 CFR 457.80(a)) Prior to implementation of CHIP in 1998, approximately 870,000 children in the state of Oregon were under the age of 19. About 92 percent of them, 800,000, had health insurance coverage of some form. Children of Hispanic or racial minority origin are more likely than their Caucasian counterparts to be uninsured. Fourteen percent of Hispanic children and 9 percent of other minority children are uninsured, compared with only 7 percent of Caucasian children. Most uninsured children live in households earning less than $25,000 per year, while median household income for all children in the state is more than $40,000 per year.

The economic conditions of the state and nation reflect an increase in the number of uninsured. The 2006 Oregon Population Survey (OPS) shows 12.6% of children under age 19 lacked health insurance coverage last year compared to 13% in 2004 and 10.6% in 2002. The table below compares number of uninsured children by Federal Poverty Level (FPL).

<100% 100-135% 135-150% 150-185% 186-200% >200% Age 0-4 Total 35,817 13,567 9,226 15,195 11,668 148,695 Age 0-4 insured 32,021 12,129 8,248 13,584 10,431 132,934 Age 0-4 uninsured 3,797 1,438 978 1,611 1,237 15,762 Age 5-9 Total 37,076 14,044 9,550 15,729 12,078 153,923 Age 5-9 insured 33,146 12,555 8,538 14,062 10,798 137,608

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

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<100% 100-135% 135-150% 150-185% 186-200% >200% Age 5-9 uninsured 3,930 1,489 1,012 1,667 1,280 16,316 Age 10-14 Total 38,818 14,704 9,999 16,468 12,645 161,155 Age 10-14 insured 34,704 13,145 8,939 14,723 11,305 144,073 Age 10-14 Uninsured 4,115 1,559 1,060 1,746 1,340 17,082 Age 15-17 Total 23,556 8,923 6,067 9,993 7,673 97,792 Age 15-17 insured 21,059 7,977 5,424 8,934 6,860 87,426 Age 15-17 Uninsured 2,497 946 643 1,059 813 10,366 Sources: Population Research Center, Portland State University data for July 2008, Bureau of Labor Statistics/ U.S. Census; Current Population Survey (CPS)

The primary source of health coverage for most children is an employer-based policy, most often sponsored by a parent’s employer. In 1998 Employer-based coverage accounted for 82 percent of all children’s health insurance coverage in the state, while public sources made up 13 percent and the remaining 5 percent was from other sources. In 2007 Employer-based coverage decreased as the unemployment rate increased.

During Oregon’s 2009 Legislative Session, HB 2116 created the Healthy Kids initiative. Healthy Kids provides coverage for uninsured children through age 18 in the State. The objective of Healthy Kids is to provide options for children at all income levels, remove barriers to accessing health care coverage and build on existing programs already available to Oregon families. HB 2116 increases the FPL from 185 percent of FPL up to and including 300 percent of FPL for children. Healthy Kids includes three different program components: 1) Existing CHIP direct coverage under OHP Plus, 2) Child only premium assistance administered by the Office of Private Health Partnerships, and 3) A new private insurance component (Healthy KidsConnect) that will be offered under the CHIP State Plan. CHIP-eligible children that select direct coverage or Healthy KidsConnect under the CHIP state plan are governed by the title XXI state plan and subject to all title XXI laws and regulations in accordance with the title XXI State plan. Children that select FHIAP or child-only Healthy Kids ESI premium assistance under the demonstration are subject to all title XXI laws and regulations in accordance with the State plan, except as expressly waived, described as non applicable, or specified in the OHP 1115 waiver demonstration STCs. Children up to and including 200 percent of the FPL have the choice between Title XXI state plan direct coverage, or premium

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

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Approval Date: 10 assistance through FHIAP or Healthy Kids ESI. Children in families over 200 percent up to and including 300 percent of the FPL have the choice between child only premium assistance under Healthy Kids ESI, or Healthy KidsConnect coverage under the CHIP state plan.

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

2.2.1. The steps the state is currently taking to identify and enroll all uncovered children who are eligible to participate in public health insurance programs (i.e., Medicaid and state-only child health insurance): As part of the outreach effort, the Office of Private Health Partnerships and the Department of Human Services plan to conduct a number of training sessions across the state. These training sessions focus on getting timely and accurate information about Healthy Kids into the hands of local community partners who have extensive contact with clients. Activities will target children eligible as the result of covering higher income levels, but also attempt to reach children at lower income levels who are eligible for but not enrolled in current programs. The Department of Human Services will develop and distribute educational materials for parents that focus on the importance of obtaining health coverage for their children and receiving preventive services

Children from birth to age 6 with family incomes less than 133% of the federal poverty level (FPL) and children 6-18 with family incomes up to 100% of the FPL are eligible for coverage under the Oregon Health Plan Medicaid Demonstration.

OHP Medicaid and CHIP applications and application assistance are available at the 64 DHS Children, Adults and Families Division (CAF) branch offices throughout the state and at 56 Senior and Disabled Services field offices. A well-publicized 800 number to the OHP Medicaid/CHIP Application Center is also available. The Application Center mails applications on request and helps callers in completing OHP applications and related forms. Applications may also be obtained and submitted on line via the Internet, through outreach locations at FQHCs, Tribal health clinics, DSH hospitals, Healthy Start, local health departments and Certified Application Assistance Organizations. Brochures outlining the services and eligibility requirements and containing the Application Center toll-free number and Web address are widely available in provider offices, libraries and other community

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

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Approval Date: 11 distribution points throughout the state. The toll-free number for the Application Center also appears in the white pages of telephone directories throughout the state. Information about OHP Medicaid/CHIP services, eligibility requirements and processes is also available on the DMAP website.

Express Lane Eligibility: The Department utilizes designated agencies (SNAP and NSLP) in order to provide a simplified eligibility determination process and expedited enrollment of eligible children in Medicaid and CHIP.

VISTA Health Links Project VISTA volunteers work in many counties throughout the state. As a part of their activities to ensure public health systems and programs work well together for the women and children they serve, these volunteers provide clients assistance and information on the Oregon Health Plan, immunizations, prenatal care and other health issues/concerns. The WIC program has the broadest client base of the VISTA Health Links partner programs, and is often the gateway service for women and children. Therefore, a good deal of the VISTA Health Links Project focus is around developing outreach efforts and systems to promote immunizations, OHP registration and early prenatal care access among WIC clients.

Community-Based Application Assistance Project This program, started in January 1998, allows local health departments, Disproportionate Share Hospitals (DSH), Federally Qualified Health Centers (FQHC) and Tribal Health Clinics to distribute OHP Medicaid/CHIP applications and to give on-site assistance with completion of the OHP application for children, pregnant women and their families. Currently DMAP has 200 outreach sites located throughout the state.

Hospital Hold-CHIP OHP Plus If an uninsured patient is admitted to a hospital, the hospital may fax a Hospital Hold form for the patient to the OHP Medicaid/CHIP Application Center within 24 hours of the admission, or by the next working day. The intent of this program is to allow people who receive care in a hospital (inpatient only) to secure a date of request for the Medicaid/CHIP program application although they cannot physically reach a phone or a DHS branch. An OHP Medicaid/CHIP application is sent to the patient. For those who complete and return the application and are determined eligible for OHP Medicaid or CHIP, their eligibility is retroactive to the

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

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Approval Date: 12 date of request. The original date of request is honored if the application is received within 45 days from the date of request.

SAFENET SAFENET is a community partnership program that provides a statewide toll free information/referral phone line for Oregonians. It is the state’s Maternal and Child Health (MCH) hotline, designed to link low-income Oregon residents with health care services within their communities, including information on the Oregon Health Plan.

OFFICE OF PRIVATE HEALTH PARTNERSHIPS (OPHP) – INFORMATION, EDUCATION AND OUTREACH (IEO) OPHP’s statutory mission is to increase access to health insurance and health care by providing, in part, a central source for information about resources for health care and health insurance. The program trains insurance agents, consumers, and agency partners on state and federal regulatory changes and reforms, as well as in-depth information on the programs of the Oregon Health Plan. Training also includes information about non-traditional and non-insurance based health care resources, such as rural or safety net clinics and public health departments. Applicants to the Family Health Insurance Assistance Program also receive informational materials about the Oregon Health Plan Medicaid and CHIP programs.

2.2.2. The steps the state is currently taking to identify and enroll all uncovered children who are eligible to participate in health insurance programs that involve a public-private partnership: • Family Health Insurance Assistance Program (FHIAP) for Families Enrolled in ESI or Individual Market: The Office of Private Health Partnerships (OPHP), Oregon Health Authority (OHA) administers FHIAP. The premium assistance program provides subsidies to help families and individuals pay for health insurance offered either through employer-sponsored insurance (ESI) or private health insurance carriers. Coverage provided by the insurance plans must meet or exceed the FHIAP benchmark criteria, which is approved at a level actuarially equivalent to federally mandated Medicaid benefits.

• FHIAP and Healthy Kids ESI Premium Assistance for children and families with incomes from zero up to and including 200 percent of FPL: Subsidies are available to children in this income category through FHIAP or Healthy Kids ESI. Children who are determined eligible for HK ESI by DHS are referred to OPHP for enrollment and subsidy payment. These families with children can also go directly to OPHP to apply for

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

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Approval Date: 13 FHIAP premium assistance for the whole family. If this option is chosen, these children are put on the FHIAP reservation list. Families are encouraged to apply for immediate coverage through Healthy Kids ESI or direct coverage under the CHIP state plan. FHIAP premium subsidies range from 50 to 95 percent for adults and 100 percent of the premium for children in this income group. Healthy Kids ESI subsidies are 100 percent for children in this income group. Individuals (adults and children) who enroll in FHIAP are subject to all other cost sharing provisions of the insurance plan. The children in this income group have the option of enrolling in FHIAP, Healthy Kids ESI or CHIP direct coverage (OHP Plus). Children enrolled who choose FHIAP or Healthy Kids ESI can move to State plan direct coverage at any time.

• Healthy Kids ESI Premium Assistance for children in families with incomes above 200 up to and including 300 percent of FPL. Children in families with incomes above 200 percent FPL are not eligible for CHIP OHP Plus. Subsidies are available to children in this income category through Healthy Kids ESI. Sliding scale subsidies are available for children who are able to enroll in the family’s ESI.  Families with incomes above 200 up to and including 250 percent of FPL will pay a maximum of 10 percent of the child’s monthly premium.  Families with incomes above 250 up to and including 300 percent of the FPL will pay a maximum of 15 percent of the child’s monthly premium.  All other cost-sharing is subject to the cost of the employer plan.

• Healthy KidsConnect: This is a private insurance option available to children under the CHIP state plan. Sliding scale subsidies are available to children who enroll in State-approved benefit packages developed and offered by private health insurers. Private insurers are selected through a competitive bid process. Approved benefit plans must be comparable to the CHIP direct coverage (OHP Plus) benefit package. Children in families with incomes above 200 percent FPL are not eligible for CHIP OHP Plus.  Families with incomes above 200 up to and including 250 percent of FPL will pay a maximum of 10 percent of the child’s monthly premium; and  Families with incomes above 250 and 300 percent of the FPL will pay a maximum of 15 percent of the child’s monthly premium.

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

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Approval Date: 14  Out of pocket costs (including premium) will not exceed the Title XXI cost-sharing cap of five percent. Another component of the overall Oregon Health Plan is the Oregon Medical Insurance Pool (OMIP), Oregon’s high risk health insurance program. The program provides health insurance to Oregon children and their families who have been denied health insurance due to health conditions. OMIP also provides a way to continue coverage for those who exhaust COBRA benefits with no other options. As of May 2009 OMIP serves approximately 15,500 individuals.

The Information, Education, and Outreach program and FHIAP marketing staff connect employers and individual consumers with OPHP-trained agents for help in purchasing a health insurance plan. Agents across the state are trained by staff on the latest state and federal regulatory changes and commercial health insurance reforms, in addition to in- depth information on the programs of the Oregon Health Plan. Marketing staff meet with employers across the state to promote employer partnerships to reduce the overall rate of uninsured in the state.

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

The Child Development and Rehabilitation Center (CDRC) administers the Oregon Services to Children with Special Health Needs (OSCSHN) Title V Program at the Oregon Health and Sciences University (OHSU). The OSCSHN Financial Assistance Program provides financial assistance to families who meet the financial eligibility criteria at three times the federal poverty level and whose child has a qualifying medical diagnosis. Financial counselors screen families to determine program eligibility and make referrals to OHP including Medicaid, CHIP and the Family Health Insurance Assistance Program (FHIAP) when appropriate. OSCSHN staff, conduct follow-up calls to families referred to the OHP to determine the status of applications and to provide assistance when needed. This effort has resulted in more families qualifying for benefits and cost savings to the OSCSHN budget.

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

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The DHS Public Health Division, Office of Family Health Services (OFHS) serves as the state Title V Agency and continues to work closely with DMAP. The OFHS maintains an agreement with DMAP for a community immunization program and to purchase vaccines for children enrolled in CHIP, for joint management of the Section 1115 Demonstration Family Planning Expansion Project, and for the MCH Hotline, SafeNet, which is contracted to the Multnomah County Health Department. Other coordination efforts include lead screening, preschool and adolescent immunization, vaccines for children, school based health centers, Oregon MothersCare, Babies First and CaCoon.

FHIAP: Applicants to the FHIAP program also receive informational materials that include the toll free telephone number for the application center and other materials about the Oregon Health Plan Medicaid and CHIP programs.

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

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Approval Date: 16 Section 3. Methods of Delivery and Utilization Controls (Section 2102)(a)(4))

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

3.1. Describe the methods of delivery of the child health assistance using Title XXI funds to targeted low-income children. Include a description of the choice of financing and the methods for assuring delivery of the insurance products and delivery of health care services covered by such products to the enrollees, including any variations. (Section 2102)(a)(4) (42CFR 457.490(a)) CHIP OHP Plus coverage: Health care services for CHIP clients are primarily provided through the managed care delivery system already established for the OHP Medicaid Demonstration. The managed care delivery system consists of prepaid health plans (PHPs) and primary care case managers (PCCMs) that manage the care of CHIP enrollees for a monthly capitated payment. The Division of Medical Assistance Programs (DMAP), within Oregon’s Department of Human Services (DHS), manages the Medicaid Demonstration Project, and has primary responsibility for operation of S-CHIP. The State of Oregon contracts with fourteen Fully Capitated Health Plans (FCHPs), one Physician Care Organization (PCO), nine Dental Care Organizations (DCOs), and nine Mental Health Organizations (MHOs). Oregon also contracts with one Chemical Dependency Organization (CDO) in Deschutes County (in all other counties, chemical dependency services are provided through the Fully Capitated Health Plans or on a fee-for-service basis). As part of OHP Medicaid and CHIP policy all plans are encouraged to incorporate safety net providers in their delivery system and most FQHCs, rural health clinics and local health departments that provide primary care are incorporated into plan networks.

CHIP enrollees have the same choice of managed care plans as OHP Medicaid enrollees in their area. CHIP clients are required to enroll in a FCHP or a PCO, and a DCO, a MHO, and, in Deschutes County only, a CDO, as a condition of eligibility. If no managed care plan is available, the CHIP client may select a PCCM from a list of available PCCMs in their service area and will receive health services on a managed fee-for- service (FFS) basis. DMAP monitors plan provider capacity quarterly and we track enrollment monthly. If it is determined that there is insufficient capacity in a geographic area, CHIP clients are not required to enroll in a managed care plan and may receive services on a fee for service basis. In service areas where DCO capacity is limited, CHIP clients are not

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

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Approval Date: 17 required to enroll in a DCO and can receive dental services on a FFS basis from any dentist enrolled with DMAP who will accept their CHIP insurance. The problem of dental care capacity in Oregon, and particularly pediatric dental capacity, is not unique to Oregon Medicaid. There is overall an insufficient supply of pediatric dentists in the state. DMAP continues to work in coordination with the Oregon Dental Association and Dental coalitions to develop strategies to encourage more dentists to practice in Oregon.

FHIAP Program:

The Office of Private Health Partnerships (OPHP) administers FHIAP; a premium assistance program for families from zero up to and including 200 percent FPL who are enrolled in ESI or Individual private market health plans. FHIAP provides subsidies to program participants to purchase Employer Sponsored Insurance Plans (ESI) or individual market plans. Insurance plans approved for subsidy must meet benefit benchmark standards.

Healthy Kids ESI: OPHP also administers Healthy Kids ESI; a private insurance option available to children in families who have employer-sponsored insurance available to them. Healthy Kids ESI subsidies are available to children in families from zero up to and including 300 percent of the FPL. HK ESI plans must meet the same benchmark standards as FHIAP plans.

The benchmark for FHIAP and Healthy Kids ESI plans is approved at a level actuarially equivalent to federally mandated Medicaid benefits (as outlined in CMS approval letter, #21-W-00013/10 and 11-W-00160/10). FHIAP requires all eligible children of enrolled families insured, in order for adults to receive assistance. All eligible children in the household must be insured through public or private coverage first, and the coverage must be maintained as long as the family is enrolled. FHIAP and Healthy Kids ESI carriers are licensed and regulated by the Oregon Insurance Division. They must adhere to rules and regulations specific to commercial insurers, the plans offered by these carriers must meet the benchmark requirement. The benefits must meet a federally- approved benchmark (as outlined in CMS approval letter (#21-W- 00013/10 and 11-W-00160/10). FHIAP and Healthy Kids ESI is a “qualifying event”, so members generally have an opportunity to enroll in their health plan immediately, without waiting for open enrollment. Eligible members also have the opportunity to enroll in OHP-Plus if they

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

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Approval Date: 18 are not able to obtain health benefits through their group plan immediately, and they meet the eligibility requirements for the Medical Assistance Program or CHIP. Children with income above 200% FPL have the opportunity to enroll in Healthy KidsConnect.

Healthy KidsConnect:

OPHP also administers Healthy KidsConnect; a private insurance option for children in families above 200 % up to and including 300% FPL, who do not have access to employer-sponsored insurance or choose not to enroll in it. Healthy KidsConnect provides direct subsidies to children on a sliding scale based on family income. Children in families with incomes above 200 percent FPL are not eligible for CHIP OHP Plus.  Families with incomes above 200 up to and including 250 percent of FPL will pay a maximum of 10% of the child’s monthly premium; and  Families with incomes above 250 up to and including 300 percent of the FPL will pay a maximum of 15% of the child’s monthly premium.  Out of pocket costs (including premium) will not exceed the Title XXI cost-sharing cap of five percent. Private insurance carriers are selected through a competitive bid process. Approved benefit plans must be comparable to the CHIP OHP Plus benefit package. Carriers are licensed and regulated by the Oregon Insurance Division. They must adhere to rules and regulations specific to commercial insurers. The managed care plans that contract with the State to offer this coverage provide a private sector insurance product with potential variations in the scope of coverage that meet the State's comparability requirements, but are unique to the carrier in terms of their particular coverage and how they manage their benefits (e.g. use of prior authorization or other service limits). Enrollees of HKC will have a choice of Health plans. There is 1 insurer that is offered statewide, as well as 4 regional insurers that will be offered in various regions of the state.

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

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

Effective Date:

Approval Date: 19 consistent with the benefit package described in the approved state plan. (Section 2102)(a)(4) (42CFR 457.490(b)) Oregon Administrative rules for quality assurance and quality improvement review process require DMAP contracted prepaid health plans to have an internal utilization review infrastructure and to specifically monitor utilization of preventive care, the operation and outcome of referral procedures, and persistent or significant DMAP member complaints. DMAP staff annually reviews health plan compliance with utilization and quality assurance requirements to ensure appropriate utilization of health care services. The quality improvement process ensures services provided are appropriate and medically necessary, and approved by the state. The following are examples of administrative mechanisms required of the managed care plans in the Oregon Health Plan Medicaid Demonstration Project, which are also required under CHIP to ensure CHIP children receive appropriate and medically necessary health care.

• Plans must provide 24-hour-a-day, 7 day-a-week appropriate urgent, emergent, and triage services. Plans are required to have written policies and procedures that they communicate to providers, and plans are required to review their policies and procedures annually. • Plans must ensure and monitor the availability of an after-hours call- in system to triage urgent and emergent call from clients. • Plans must assure access to services according to the following time standards: • Immediately for emergency medical services. Within 24 hours for emergency dental, mental health, or chemical dependency services. • Within 48 hours for urgent medical, mental health, or chemical dependency services. Within one to two weeks for urgent dental services. • Within four weeks, or within the community standard, for well care for preventive or non emergent medical services. • Within two weeks of patient request for intake assessment for mental health or chemical dependency services. • Within twelve weeks, or the community standard, for dental services.

For CHIP services provided on a FFS basis, all utilization review requirements of Title XIX and the 1115 Demonstration apply. The Quality Improvement Organization (QIO) contractor reviews inpatient hospital services. DMAP requires prior authorization for certain services

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

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Approval Date: 20 according to OHP Medicaid FFS protocols and claims are subject to SURS post-payment review.

The OPHP private market carrier contract will require that the carriers have quality assurance rules and a quality improvement review process in place to ensure that the services provided are appropriate and medically necessary. It will include an internal utilization review infrastructure that monitors utilization of preventive care, the operation and outcome of referral procedures, and persistent or significant Healthy KidsConnect enrollee/guardian complaints.

Carriers require prior authorization for certain services according to the guidelines developed in accordance with its Care Management Department’s requirements.

Healthy KidsConnect quality assurance staff annually review health plan compliance against utilization and quality assurance requirements to ensure appropriate structures are in place to monitor utilization of health care services.

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

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Approval Date: 21 Section 4. Eligibility Standards and Methodology. (Section 2102(b))

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

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

4.1.1.

Geographic area served by the Plan:

The entire state of Oregon, except Unborn coverage is restricted

to Benton, Clackamas, Columbia, Crook, Deschutes, Douglas,

Hood River, Jackson, Jefferson, Josephine, Lane, Lincoln,

Morrow, Multnomah, Union and Wasco Counties (Lincoln County

expanded October 1, 2009 through December 31, 2009)

4.1.2.

Age:

Birth to age 19, except for Unborn coverage restricted to Benton,

Clackamas, Columbia, Crook, Deschutes, Douglas, Hood River,

Jackson, Jefferson, Josephine, Lane, Lincoln, Morrow,

Multnomah, Union and Wasco Counties, which is from

conception to birth. (Lincoln County expanded October 1, 2009

through December 31, 2009)

4.1.3.

Income: CHIP OHP Plus direct coverage: Birth to six, family income of 133% FPL up to and including 200% FPL, ages 6 to 19, family income 100% up to and including 200% of FPL. Except for redeterminations, we use income in the month of application for the countable income test. For redeterminations, we use the month the Department initiates the redetermination or the last month of current program eligibility. We use gross income, unless they are self employed. When they are self-employed we use adjusted income (allowing for deductions for business costs, or a 50% exclusion). If not eligible using the initial month of determination, we use the same application and reevaluate countable income using income in any calendar month in the 45 days after the date of application. For purposes of income determination the definition of a child’s family will be the same as the state’s OHP Title XIX family composition

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

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Approval Date: 22 definition, whichever applies. When we evaluate the client for eligibility under CHIP or Medicaid we begin by looking at TANF related medical. All wages paid by the Census Bureau for temporary employment related to Census activities and payments made for cash medical support are disregarded.

Unborn coverage: 0% to 185% of the FPL (and not eligible for Medicaid).

FHIAP ESI coverage: Children birth to age 19 with Income zero up to and including 200% of FPL who meet the Title XXI definition of a targeted low- income child and who choose ESI and enrolled in FHIAP. Children who opt for FHIAP are not subject to title XXI benefit and cost sharing rules, and receive waiver authority for this under the Section 1115 demonstration.

FHIAP Individual health insurance: Children birth to age 19 in families with income zero up to and including 200% FPL who meet the Title XXI definition of a targeted low-income child and who do not have employer-sponsored insurance available. Children who opt for FHIAP are not subject to title XXI benefit and cost sharing rules, and receive waiver authority for this under the Section 1115 demonstration.

Healthy Kids ESI Coverage: Children birth to age 19 with family income from zero up to and including 200% of FPL who meet the Title XXI definition of a targeted low-income child and who apply for coverage through DHS and choose employer-sponsored insurance. Also Children birth to age 19 with family income above 200% up to and including 300% of FPL who meet the Title XXI definition of a targeted low- income child and choose employer-sponsored insurance instead of Healthy KidConnect plan. Children who opt for Healthy Kids are not subject to title XXI benefit and cost sharing rules, and receive waiver authority for this under the Section 1115 demonstration.

Healthy KidsConnect Private insurance option: Birth to age 19 with family income above 200% up to and including 300% of FPL who meet the Title XXI definition of a targeted low-income child and who don’t have ESI available or have it but choose not to accept it and enroll for coverage under the private insurance option. Coverage for Healthy KidsConnect is

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

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Approval Date: 23 provided under the CHIP state plan and families have choice of ESI or HKC option.

4.1.4.

Resources (including any standards relating to spend downs and disposition of resources): No asset limit.

4.1.5.

Residency (so long as residency requirement is not based on length of time in state): Oregon requires a Social Security Number (SSN) for CHIP unless the applicant is a member of religious sect or division of a religious sect that has continuously existed since December 31, 1950 and adheres to its tenets that prohibit applying for or using an SSN.

4.1.6.

Disability Status (so long as any standard relating to disability status does not restrict eligibility): N/A

4.1.7.

Access to or coverage under other health coverage:

The CHIP child must not have been covered by any private major medical health insurance in the past two months before application. The two months of uninsurance are the two months preceding the eligibility determination. This is done at every eligibility review for CHIP, regardless if a new applicant for CHIP, or not. The two-month waiting period is waived if any of the following are true: the person has a condition that without treatment would be life-threatening or cause permanent loss of function or disability; the person’s private health insurance premium was reimbursed under the policy for reimbursement of cost-effective Employer Sponsored Health Insurance; the person’s Insurance premium was subsidized by FHIAP; or the person met the two month uninsurance period while on the FHIAP reservation list even if they have since obtained coverage; a member of the filing group was a victim of domestic violence; or the person lost coverage due to the loss of employment of a parent(e.g.reduction in hours, employer stops providing coverage, etc). Examples of life-threatening or disabling conditions are cancer, asthma, diabetes. Oregon monitors substitution under the Community Human Service’s Quality Control and Quality Assurance process to analyze the extent to which an applicant drops other health

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

Effective Date:

Approval Date: 24 plan coverage. Records are reviewed to ensure that the two-month period of ineligibility policy is applied appropriately. Action is taken as needed. Trends are monitored to ensure that the policy is consistently applied throughout the programs.

4.1.8.

Duration of eligibility: Eligibility is for 12 continuous months, unless one of the following events occurs before the annual renewal: 1) moves out of state; 2) obtains other health insurance; 3) a child turns age 19; 4) the family requests cancellation; 5) the family applies for Medicaid and the child is determined eligible for Medicaid or 6) if the child is enrolled in a HKC plan and does not pay the premium. Families with HKC children will have a minimum 30 days to pay their portion of the premium before being disenrolled. People in HKC are billed by OPHP each month for their portion of the premium. OPHP combines the member’s portion with the subsidy and pays the insurance carrier. Individuals who fail to pay their premium will be disenrolled. Members are billed approximately 45 days in advance of the date premiums are due to the carrier. Members are provided a premium grace period of at least 30 days from the billing date. Reminder notices are mailed mid-way through this grace period. Subsidy cancellation notices outlining the program’s intent to terminate, are mailed at the end of the grace period. Terminated individuals can be reinstated on a one time exception basis. Once terminated for non payment of premium members are able to re-enroll in the program. In order to do so, however, they must serve a new two-month period of uninsurance

Eligibility is redeterminded every twelve months for State Plan

children (at or below 200% FPL). No limit to duration of eligibility if

all conditions are met. The Unborn population is eligible for CHIP

benefits while in utero and redetermined at birth. Coverage for this

population is restricted to counties referenced in 4.1.1.

4.1.9.

Other standards (identify and describe): Although eligibility is retroactive to date of CHIP application, the client is not eligible if the application does not include selection of a prepaid health plan in mandatory managed care areas for OHP Plus coverage. This is the same as the current rule applied to OHP Medicaid non-categorical members. The twelve-month eligibility period for Healthy KidsConnect members begins on the date of application approval. Plan enrollment will be no earlier than the first of the month following

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

Effective Date:

Approval Date: 25 eligibility approval. Enrollment in HKC plans is the first of the month following application approval, if application approval occurs on or before the 25th of the approval month. If application approval is the 26th or after in the approval month, enrollment will be the first of the next month.

Express Lane Eligibility agencies include The Department of Human Services, Supplemental Nutritional Assistance Program (SNAP) and the Department of Education, selected districts, through the National School Lunch Program (NSLP). The Department will use SNAP income findings and apply this income to the child who is applying for medical. The state will use SNAP findings on verification of SSN and state residency. The state will then verify citizenship.

The State Department of Education prepares the application form that all schools use for NSLP Each school district will then send DHS a list of children that are found eligible for free and reduced lunch whose parents did not ‘opt-out’ and who indicated the child does not have any kind of health coverage”. DHS will then send “Express Lane” applications for health coverage to the identified families, requesting additional information. The additional information requested of families includes the names, genders, social security numbers, dates of birth, citizenship status, tribal information, availability of other insurance, disabilities, absent parent information, and managed care information for everyone applying. Applications that are returned will be processed to determine eligibility using regular methodologies including verification of citizenship. The Department will use the NSLP findings for income and household composition for initial eligibility determinations for children. The NSLP will send the Department households’ income and household group size. The Department will send the households shortened applications, and when the applications are returned, the NSLP findings of income and eligibility group size will be used to determine eligibility for children.

The Express Lane option will be applied to initial determinations only.

4.1.10

Check if the State is electing the option under section 214 of the Children’s Health Insurance Program Reauthorization Act of

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

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Approval Date: 26 2009 (CHIPRA) to provide coverage to the following otherwise eligible individuals lawfully residing in the United States:

(1) “Qualified aliens” otherwise subject to the 5-year waiting period per section 403 of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996;

(2) Citizens of a Compact of Free Association State (i.e., Federated States of Micronesia, Republic of the Marshall Islands, and the Republic of Palau) who have been admitted to the United States (U.S.) as non- immigrants and are permitted by the Department of Homeland Security to reside permanently or indefinitely in the U.S.; (3) Individuals described in 8 CFR 103.12(a)(4) who do not have a permanent residence in the country of their nationality and are in statuses that permit them to remain in the U.S. for an indefinite period of time pending adjustment of status. These individuals include: (a) Individuals currently in temporary resident status as Amnesty beneficiaries pursuant to section 210 or 245A of the Immigration and Nationality Act (INA); (b) Individuals currently under Temporary Protected Status pursuant to section 244 of the INA; (c) Family Unity beneficiaries pursuant to section 301 of Public Law 101-649 as amended, as well as pursuant to section 1504 of Pub. L. 106- 554; (d) Individuals currently under Deferred Enforced Departure pursuant to a decision made by the President; and (e) Individuals who are the spouse or child of a U.S. citizen whose visa petition has been approved and who has a pending application for adjustment of status; and (4) Individuals in non-immigrant classifications under the INA who are permitted to remain the U.S. for an indefinite period, including the following who are specified in section 101(a)(15) of the INA: • Parents or children of individuals with special immigrant status under section 101(a)(27) of the INA as permitted under section 101(a)(15)(N) of the INA; • Fiancées of a citizen as permitted under section 101(a)(15)(K) of the INA; • Religious workers under section 101(a)(15)(R); • Individuals assisting the Department of Justice in a criminal investigation as permitted under section 101(a)(15)(U) of the INA; • Battered aliens; and

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

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Approval Date: 27 • Individuals with a petition pending for 3 years or more as permitted under section 101(a)(15)(V) of the INA.

The State elects the CHIPRA section 214 option for children up to age 19.

The State elects the CHIPRA section 214 option for pregnant women through the 60 day postpartum period.

4.1.10.1 The State provides assurance that for individuals whom it enrolls in CHIP under the CHIPRA section 214 option that it has verified, both at the time of the individual’s initial eligibility determination and at the time of the eligibility redetermination, that the individual continues to be lawfully residing in the United States. The State must first attempt to verify this status using information provided at the time of initial application. If the State cannot do so from the information readily available, it must require the individual to provide documentation or further evidence to verify satisfactory immigration status in the same manner as it would for anyone else claiming satisfactory immigration status under section 1137(d) of the Act.

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

4.2.1.

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

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

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

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

Effective Date:

Approval Date: 28 4.3. Describe the methods of establishing eligibility and continuing enrollment. (Section 2102)(b)(2)) (42CFR 457.350) Oregon uses one application for CHIP and Medicaid. This application is obtained by calling the toll free application hotline number that provides application assistance and sends applications to people requesting applications. Applications may also be obtained and submitted on line via the internet, through outreach locations at FQHCs, Tribal health clinics, DSH hospitals, Healthy Start, local health departments and Certified Application Assistance Organizations, Outreach Grant Organizations and DHS branch. Potential clients that submit an application over the Internet must affirm that the information supplied is true under penalty of perjury. Applicants are informed of the Medicaid and CHIP program in the application packet. The applicant sends the application to the OHP Central Processing Center. Eligibility workers first screen the application to determine if the child is eligible for OHP Medicaid, using the initial gross income test standard and applicable resource standards. If the child is over income for OHP Medicaid, the application is then screened for CHIP eligibility. The same eligibility workers conduct this eligibility determination process, thus coordinating and streamlining the procedures. Once eligibility has been established, the applicant is notified of eligibility and they receive a new member packet. The eligibility period for all children, Medicaid and CHIP is 12 months.

To facilitate continuous health care coverage for eligible children, the OHP application processing center sends a notice and a new simplified redetermination form to enrollees notifying them that their coverage is scheduled to end soon. Enrollees receive a reapplication packet and two additional notices before coverage is terminated. However, the recipient does not need to complete a new application; they can contact their worker or local branch and establish a request for medical assistance. Once they have initiated a new date of request, an eligibility worker must review the recipient's eligibility and request verification necessary for the new eligibility determination.

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

Check here if this section does not apply to your state. Oregon’s OHP Plus CHIP program and Healthy KidsConnect does not currently have an enrollment cap. The children opting for the FHIAP ‘premium assistance’ program may have enrollment limited if enrollment numbers exceed

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

Effective Date:

Approval Date: 29 FHIAPs biennial budget. Enrollment would be allowed to reduce by attrition methods or close to new applicants. Children in families with income from zero up to and including 200 percent of the FPL currently on the FHIAP Reservation List: The State will perform targeted outreach to families on the existing reservation list to ensure they are aware that children also have the option to receive direct state plan coverage at any time under Medicaid or CHIP. Families with children will be sent information about direct coverage through Healthy Kids, along with a Healthy Kids application, and a letter encouraging families to apply for immediate coverage rather than wait on FHIAP’s reservation list. Families must either complete the application or actively decline direct coverage. All children that choose FHIAP at the point of application and choose to go on the reservation list will also receive information on direct coverage options and be informed that they can move from the FHIAP reservation list or decline CHIP or Medicaid coverage, but still be given the opportunity to choose to move to direct state plan coverage at any time.

4.4. Describe the procedures that assure that:

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

Oregon uses one application for CHIP and Medicaid. This application is obtained by calling the toll free application hotline number that provides application assistance and sends applications to people requesting applications. Applications may also be obtained and submitted on line via the Internet, through outreach locations at FQHC, Tribal health clinics, DSH hospitals, Healthy Start, local health departments and Certified Application Assistance Organizations, Outreach Grant Organizations and DHS branch offices. Potential clients that submit an application over the internet must affirm that the information supplied is true under penalty or perjury. Applicants are informed of the Medicaid and CHIP program in the application packet. The applicant sends the application to the OHP Central Processing Center. Eligibility workers first screen the application to determine if the child is eligible for OHP Medicaid, using the initial gross income test standard and applicable resource standards. If the child is over

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

Effective Date:

Approval Date: 30 income for OHP Medicaid, the application is then screened for CHIP eligibility. The same eligibility workers conduct this eligibility determination process, thus coordinating and streamlining the procedures. Once eligibility has been established, the applicant is notified and receives a new member packet. The eligibility period for Medicaid and CHIP is 12 months

The OHP Central Processing Center conducts standardized audits on an ongoing basis to review eligibility determination to ensure that children who are Medicaid eligible, or have access to a state employee health plan, or have private coverage are not enrolled in CHIP.

To facilitate continuous health care coverage for eligible children, the OHP application processing center sends a notice and a new simplified redetermination form to enrollees notifying them that their coverage is scheduled to end soon. Enrollees receive a total of three notices before coverage is terminated. However, the recipient does not need to complete a new application; they can contact their worker or local branch and establish a request for medical assistance. Once they have initiated a new date of request, an eligibility worker must review the recipient's eligibility and request verification necessary for the new eligibility determination.

In addition, children enrolled in the CHIP program are instructed to notify the program in the event they become pregnant (0-185% of FPL), in which case they will be moved to the Title XIX Poverty Level Medical Program for pregnant women until their eligibility in that category expires. Most children born to women in the Medicaid PLM program are eligible for Medicaid for one year. Before that year is up, we send notification they may be eligible for CHIP when that year is up. The Children who are eligible for CHIP because their household income is between 185-300 % of FPL and who are or become pregnant will remain in CHIP. Babies born to these CHIP children will have assumed eligible newborn status in CHIP for their first year of life. Children above 200% up to and including 300% born into subsidy families do not have assumed eligible newborn status. However, when adding the baby, the worker determines if there would be a decrease in the family's subsidy level, we add the baby for the balance of the existing 12- month eligibility period at the existing subsidy level (i.e., we would

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

Effective Date:

Approval Date: 31 not apply the decrease in benefits at that time). At the end of the 12-month period, we would redetermine eligibility, update the income information (which could affect the subsidy level) and establish a new 12-month eligibility period for everyone in the family.

Screen and enroll requirement under Express Lane Eligibility:

The State will continue to use the screen and enroll procedures required under section 2102(b)(3)(A) and (B) of the Social Security Act and 42 CFR 457.350(a) and 457.80(c). Describe this process.

The State is establishing a screening threshold set as 30 percentage of the Federal poverty level (FPL) that exceeds the highest Medicaid income threshold applicable to a child. The thresholds for all children based on 163% FPL.

The State is temporarily enrolling children in CHIP, based on the income finding from the Express Lane agency, pending the completion of the screen and enroll process.

4.4.2. The Medicaid application and enrollment process is initiated and facilitated for children found through the screening to be potentially eligible for medical assistance under the state Medicaid plan under Title XIX. (Section 2102)(b)(3)(B)) (42CFR 457.350(a)(2)) See 4.4.1 above.

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

Oregon uses one application for CHIP and Medicaid. This application is obtained by calling the toll free application hotline number that provides application assistance and sends applications to people requesting applications. Applications may also be obtained and submitted on line via the Internet, through outreach locations at FQHCs, Tribal health clinics, DSH hospitals, Healthy Start, local health departments and Certified Application Assistance Organizations, Outreach Grant Organizations and DHS branch offices. Potential clients that submit an application over the internet must affirm that the information supplied is true under penalty or perjury Applicants are informed of the Medicaid and

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

Effective Date:

Approval Date: 32 CHIP program in the application packet. The applicant sends the application to the OHP Central Processing Center. Eligibility workers first screen the application to determine if the child is eligible for OHP Medicaid, using the initial gross income test standard and applicable resource standards. If the child is over income for OHP Medicaid, the application is then screened for CHIP eligibility. The same eligibility workers conduct this eligibility determination process, thus coordinating and streamlining the procedures. Once eligibility has been established, the applicant is notified and receives a new member packet. The eligibility period for Medicaid and CHIP is 12 months.

In an effort to maximize enrollment of CHIP children the Application Assistance Program (AAP). Certified Application Assistance Organizations (CAAO) will provide application assistance to potential CHIP eligibles. An organization is certified as a CAAO if they are doing business in the state of Oregon and registered with the Secretary of State. Upon completion of an application with DHS and signing an agreement to use trained application assisters and conduct criminal background checks on application assisters the entity is certified as a CAAO. Oregon will not limit the number of organizations that are certified as a CAAO. Organizations, existing or new may not participate in both the AAP and Outreach and Enrollment grant programs. Organizations that provide medical services are not eligible to be CAAO certified, these include clinics, hospitals, FQHCs, MCO or Public health departments. These non certified CAAO organizations are currently in a program which allows them to use a “date stamp” in order to establish a date of request for client’s presenting themselves for medical care. We do not provide compensation to these providers.

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

4.4.4.1. Coverage provided to children in families at or below 200% FPL: describe the methods of monitoring substitution. DHS has specific measures to prevent the clients from substituting CHIP

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

Effective Date:

Approval Date: 33 coverage for group health coverage. The first measure is that persons covered by private health insurance are not eligible for benefits under CHIP. Another measure to prevent substitution is that children are ineligible if they have been covered by a group health plan two months immediately preceding the application for CHIP. There are exceptions to the two-month rule, such as when the child has a life threatening or disabling conditions.

DHS also requires that insurance information on the persons seeking medical assistance coverage be provided on the application for CHIP as a measure to avoid substitution for group health coverage. DHS enrollees’ TPR information is maintained in the MMIS system. In addition to self reported insurance information, the OHP Central Processing Center receives TPR insurance information from providers which is verified by Central Processing staff. Eligibility staff also reviews pay stub information that may also indicate whether dependent health insurance is being deducted from the employee paycheck. The State monitors substitution under its Quality Control and Quality Assurance process to analyze the extent to which an applicant drops other health plan coverage. Records are reviewed to ensure that the two- month period of ineligibility is applied appropriately. Action is taken as needed. Trends are monitored to ensure that the policy is consistently applied throughout the program.

Targeted, low-income children of employees of the State of Oregon, who are eligible for employer sponsored insurance benefits, are not eligible for CHIP coverage since the State provides coverage of dependents.

The OHP Central Processing Center conducts standardized audits on an ongoing basis to review eligibility determinations to ensure that children who are Medicaid eligible, or who have private coverage are not enrolled in CHIP. The Quality Assurance Unit at OHP Central Processing conducts random audits on an ongoing basis of eligibility determinations to monitor the integrity of determinations. All eligibility elements are reviewed during this process, including assessment of the client’s access to TPR and the substitution of coverage.

4.4.4.2. Coverage provided to children in families over 200% and up to 250% FPL: describe how substitution is monitored and identify specific strategies to limit substitution if levels become unacceptable. Same as listed under 4.4.4.1

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

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

Effective Date:

Approval Date: 34 specific strategies in place to prevent substitution. Same as listed under 4.4.4.1

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

The FHIAP program is described throughout this state plan. Only the aspects which are different from direct coverage children are referenced. The employer contributions and benefits are outlined in the Medicaid Section 1115 demonstration project.

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

Targeted low-income children who are American Indian or Alaska Native are subject to the same eligibility determination protocol as other targeted low-income children. Due to the unique characteristics of this population, DMAP works with representatives of the tribes in the state through the American Indian/Alaska Native Forum and the N.W. Portland Area Indian Health Board (PAIHB) to develop outreach protocols that specifically target low income children in the state who are American Indians or Alaska Natives. Representatives of the Department of Human Services meet quarterly with representatives of the nine federally recognized tribes in the state, the PAIHB and the Portland Indian Health Service. CHIP has been and continues to be a recurring agenda item at these meetings. CHIP policy will mirror OHP Medicaid policy for children in the state who are American Indians or Alaska Natives. Children of recognized Indian heritage will not be required to enroll in managed care and may receive services on a FFS basis, if they choose. Options for tribal participation in CHIP are open. There is a possibility of future Title XXI State Plan amendments if the tribes decide they want to do something different for their children.

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

Effective Date:

Approval Date: 35 Section 5. Outreach (Section 2102(c))

Describe the procedures used by the state to accomplish:

Outreach to families of children likely to be eligible for child health assistance or other public or private health coverage to inform them of the availability of the programs, and to assist them in enrolling their children in such a program: (Section 2102(c)(1)) (42CFR 457.90) Outreach for CHIP will be incorporated into existing OHP Medicaid outreach activities, including: ♦ VISTA Health Links; ♦ DSHs Hospitals, FQHCs and tribal health clinics local health departments. ♦ Hospital hold; ♦ SAFENET; ♦ Outreach through Healthy Start.

These programs are described in more detail in Section 2.2.1 Application Assistance:

An additional program starting in October 2009 to maximize enrollment of children is the Application Assistance Program (AAP). Certified Application Assistance Organizations (CAAO) will provide application assistance to potential CHIP eligibes. In order to become a CAAO an organization must be registered with the Secretary of State and be free from a conflict of interest. The CAAO must complete an application with DHS and sign an agreement to use trained application assisters and conduct criminal background checks on application assisters the entity is certified as a CAAO. Oregon will not limit the number of organizations that are certified as a CAAO. Organizations, existing or new may not participate in both the AAP and Outreach and Enrollment grant programs. The types of organizations that can be CAAO are health advocacy groups, Boys and Girls Clubs, Faith based groups and insurance agents. Application Assistance Program contracts will be renewed within state contract schedules. There will be no competitive bid process as the program is available to any organizations that qualify to participate.

Organizations that provide medical services are not eligible to be CAAO certified, these include clinics, hospitals, FQHCs, MCO, schools, individuals, Public health departments or anyone that may have a conflict of interest. These non-certified CAAO organizations are currently in a program which allows them to use a “date stamp” in order to establish a date of request for client’s presenting themselves for medical care. We do not provide compensation to these providers.

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

Effective Date:

Approval Date: 36

The Application Assistance Program is used for both CHIP and Medicaid enrollees. Only after an application is processed and the client is enrolled in OHP will DHS pay $50 to the CAAO. The method developed to account for this payment is that each CAAOs will have a date stamp that will include their own unique code. They will stamp each application or type it on for applications submitted electronically. Once the application is received at the OHP processing center that code will be entered into their case file along with the other client date. Our system has the ability to report the status (Approved, denied or pended) of applications by CAAO. We will run a monthly report and pay the organization for each application approved during the past month. The amount per application was determined by information provided by other states using this method and approved by DHS executive staff and the Governors Health Policy Advisor. The role of a CAAO is to assist families in applying for Healthy Kids. They are expected to find uninsured kids, educate them on the Oregon Health Plan, assist the family in completing an application, assist the family in obtaining necessary documents and ensure the application is submitted. CAAO staff will also assist the family on any necessary follow up, if needed.

Outreach and Enrollment Grants: The Targeted Outreach and Enrollment Grant Program is designed to provide culturally-specific and targeted outreach and direct application assistance to aid families in racial, ethnic and language minority communities, living in geographic isolation or with additional access barriers to enroll their children into the Healthy Kids program. The Outreach and Enrollment Grantee will target geographic areas with high rates of eligible but unenrolled children, including rural areas; racial, ethnic and language minority communities and populations with additional barriers to accessing health care, such as those with physical, cognitive, sensory or mental disabilities or chemical dependency and those experiencing homelessness. Grant funds are intended for staff time, local travel, and other expenses necessary to reach and provide assistance to targeted families with children. DHS will provide technical assistance and training, publications and other promotional materials

The targeted Outreach and Enrollment Grant program will provide funding opportunities to community organizations that apply and are selected for an award. The funds must be used for activities that will lead to enrollment of children into the Oregon Health Plan for both Medicaid and CHIP. Activities funded may include, but are not limited to, community education, application assistance, and participation in community events. Outreach grants will be awarded to community organizations specifically targeting enrollment of children in racial, ethnic and language minority communities; living in geographic isolation; and/or with additional barriers to accessing health care, such as those with physical, cognitive, sensory or mental

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Approval Date: 37 disabilities or chemical dependency; and those experiencing homelessness.

The criteria used to award an outreach and enrollment grant are: (1) Ability to Target geographic areas with high rates of eligible but unenrolled children, including rural areas; racial, ethnic and language minority communities and populations with additional barriers to accessing health care, such as those with physical, cognitive, sensory or mental disabilities or chemical dependency and those experiencing homelessness; (2) Demonstrate that they have access to, and credibility with, target populations; and (3) Demonstrate that they have the ability to address barriers to enrollment, such as a lack of awareness, stigma concerns and punitive fears or cultural barriers. (4) Are not currently a CAAO participating in the AAP.

Outreach and Enrollment Grants will begin effective upon CMS approval on or after October 1, 2009. The grant will be for the balance of state fiscal year 2010 and renewable for a second year, based on performance. Grants will range from $20,000 to $80,000 a year. We anticipate awarding approximately 20 to 40 grants in the first biennium. Each grantee will have enrollment targets that they have proposed in their application and will have been approved by Office of Healthy Kids. Grantees will be required to provide monthly reports on their progress. Fund disbursement will be contingent upon demonstrating progress toward their goals. The Office of Healthy Kids will be fully staffed with at least one FTE monitoring their progress and providing technical assistance.

Outreach and Enrollment Grant agreement statement of work includes, but is not limited to: Identifying its target population(s); • Distributing DHS-approved promotional, educational and marketing materials to its targeted population • Completing application assistance training, provided by DHS; • Participating in meetings and conferences as requested by DHS; • Assisting its targeted population in completing the enrollment process into the Healthy Kids program, in accordance with the application assistance training; • Collaborating with local community organizations and establishing information-sharing processes as needed. • Submitting its progress to DHS on monthly and annual basis according to reporting requirements specified by DHS, including the number of families contacted and the number of children enrolled successfully;

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Approval Date: 38 • Conducting outreach that is results driven and connected to actual enrollment and retention of children; and • Developing strategies to overcome barriers that families in the target population may have, and establishing relationships of trust to effectively support enrollment;

Express Lane Eligibility: The DHS utilizes SNAP and NSLP as indicated in section 1.4 in order to provide a simplified eligibility determination process and expedited enrollment of eligible children in Medicaid and CHIP. For initial determinations the Department will utilize income findings from these designated agencies to automatically enroll children in Healthy Kids if they meet the other eligibility criteria. Families will be contacted by phone and children will be enrolled if their parents give verbal or written approval.

The Department has ongoing outreach activities as indicated above, to increase enrollment for the health kids programs and have worked with the Department of Education and statewide education organizations to facilitate the express lane eligibility through the NSLP. Agency staff has been trained and will have access to ongoing training.

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Approval Date: 39 Section 6. Coverage Requirements for Children’s Health Insurance (Section 2103)

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

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

6.1.1.

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

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

6.1.2.

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

6.1.3.

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

6.1.4.

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

6.1.4.1. Coverage the same as Medicaid State plan

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Approval Date: 40 6.1.4.2. Comprehensive coverage for children under a Medicaid Section 1115 demonstration project

Program rules are available at http://www.dhs.state.or.us/policy/healthplan/gu ides/main.html 6.1.4.3. Coverage that either includes the full EPSDT benefit or that the state has extended to the entire Medicaid population 6.1.4.4. Coverage that includes benchmark coverage plus additional coverage 6.1.4.5. Coverage that is the same as defined by existing comprehensive state-based coverage 6.1.4.6. Coverage under a group health plan that is substantially equivalent to or greater than benchmark coverage through a benefit by benefit comparison (Please provide a sample of how the comparison will be done) 6.1.4.7. Other (Describe) Healthy KidsConnect: This is a private insurance option available to children under the CHIP state plan. Sliding scale subsidies are available to children who enroll in State-approved benefit packages developed and offered by private health insurers. Private insurers are selected through a competitive bid process. Approved benefit plans are comparable, but not identical to OHP Plus benefit package.

6.2. The state elects to provide the following forms of coverage to children: (Check all that apply. If an item is checked, describe the coverage with respect to the amount, duration and scope of services covered, as well as any exclusions or limitations) (Section 2110(a)) (42CFR 457.490) As long as the Section 1115 waiver authority is effective, children who opt to take up premium assistance are not subject to title XXI benefit rules. Healthy KidsConnect participants receive benefits that are comparable, but not identical to OHP Plus benefits and are delivered through the private insurance marketplace. The insurer’s contract identifies services not covered as benefit limitations and exclusions rather than by use of the prioritized List, which defines the CHIP OHP Plus benefit package. Both CHIP OHP Plus and HKC contain the benefit elements listed below.

*Applicable for Unborn population only- When any grouping below is

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Approval Date: 41 provided only if medically necessary and/or limited to emergency for the Unborn population it is identified with *L/MN.

Services for the Unborn population are the same benefits, regardless of county, (subject to section 4.1.8) as identified in items 6.2.1 through 6.2.28.

Section Benefit description Eligibility Groups covered by the state plan Conception to birth

6.2.1. Inpatient services (Section 2110(a)(1))

6.2.2. Outpatient services (Section 2110(a)(2))

6.2.3. Physician services (Section 2110(a)(3))

6.2.4. Surgical services (Section 2110(a)(4))

*L/MN 6.2.5. Clinic services (including health center

services) and other Ambulatory health

care services. (Section 2110(a)(5))

6.2.6. Prescription drugs (Section 2110(a)(6))

6.2.7. Over-the-counter medications (Section 2110(a)(7))

6.2.8. Laboratory and radiological services

(Section 2110(a)(8)) 6.2.9. Prenatal care and prepregnancy family

services and supplies (Section 2110(a)(9)) 6.2.10.Inpatient mental health services, other than services

described in 6.2.18., but including services furnished

in a state-operated mental hospital and including

residential or other 24-hour therapeutically planned

structural services (Section 2110(a)(10)) 6.2.11.Outpatient mental health services, other than services

described in 6.2.19, but including services furnished in

a state-operated mental hospital and including

community-based services (Section 2110(a)(11) 6.2.12.Durable medical equipment and other medically-related

*L/MN

or remedial devices (such as prosthetic devices, implants,

eyeglasses, hearing aids, dental devices, and adaptive

devices) (Section 2110(a)(12)) 6.2.13. Disposable medical supplies (Section 2110(a)(13))

*L/MN 6.2.14 .Home and community-based health care services

(See instructions) (Section 2110(a)(14)) 6.2.15. Nursing care services (See instructions)

(Section 2110(a)(15)) 6.2.16.Abortion only if necessary to save the life of the

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mother or if the pregnancy is the result of an act

of rape or incest (Section 2110(a)(16) ** state only -funded abortion services are available to CHIP OHP Plus and HKC 6.2.17. Dental services (Section 2110(a)(17))

*L/MN 6.2.18. Inpatient substance abuse treatment services

*L/MN

and residential substance abuse treatment

services (Section 2110(a)(18)) 6.2.19. Outpatient substance abuse treatment

*L/MN

services (Section 2110(a)(19)) 6.2.20. Case management services (Section 2110(a)(20))

6.2.21. Care coordination services (Section 2110(a)(21))

6.2.22. Physical therapy, occupational therapy, and services

*L/MN

for individuals with speech, hearing, and language

disorders (Section 2110(a)(22)) 6.2.23. Hospice care (Section 2110(a)(23))

6.2.24. Any other medical, diagnostic, screening, preventive,

*L/MN

restorative, remedial, therapeutic, or rehabilitative

services. (See instructions) (Section 2110(a)(24)) 6.2.25. Premiums for private health care insurance

coverage (Section 2110(a)(25))(HKC and ESI) 6.2.26. Medical transportation (Section 2110(a)(26))

*L/MN 6.2.27.Enabling services (such as transportation, translation,

and outreach services (See instructions)

(Section 2110(a)(27))(except those enrolled in HKC) 6.2.28.Any other health care services or items specified by the

Secretary and not included under this

section (Section 2110(a)(28))

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

6.3.1.

The state shall not permit the imposition of any pre-existing medical condition exclusion for covered services (Section 2102(b)(1)(B)(ii)); OR 6.3.2.

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

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Approval Date: 43 6.4. Additional Purchase Options. If the state wishes to provide services under the plan through cost effective alternatives or the purchase of family coverage, it must request the appropriate option. To be approved, the state must address the following: (Section 2105(c)(2) and (3)) (42 CFR 457.1005 and 457.1010)

6.4.1.

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

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

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

6.4.1.3. The coverage must be provided through the use of a community-based health delivery system, such as through contracts with health centers receiving funds under section 330 of the Public Health Service Act or with hospitals such as those that receive disproportionate share payment adjustments under section 1886(c)(5)(F) or 1923 of the Social Security Act. Describe the community-based delivery system. (Section 2105(c)(2)(B)(iii)) (42CFR 457.1005(a))

6.4.2.

Purchase of Family Coverage. Describe the plan to purchase family coverage. Payment may be made to a state for the purpose of family coverage under a group health plan or health insurance coverage that includes coverage of targeted low-

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Approval Date: 44 income children, if it demonstrates the following: (Section 2105(c)(3)) (42CFR 457.1010)

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

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Approval Date: 45 Section 7. Quality and Appropriateness of Care

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

7.1. Describe the methods (including external and internal monitoring) used to assure the quality and appropriateness of care, particularly with respect to well-baby care, well-child care, and immunizations provided under the plan. (2102(a)(7)(A)) (42CFR 457.495(a)) For CHIP OHP Plus, DMAP contracted prepaid managed care plans results of consumer satisfaction surveys, EQRO and site review identify areas that need system improvements in quality of or access to care. DMAP measures well-baby care/child/adolescent care and childhood immunizations through the use of HEDIS performance measures. The results of these measures are reported by FCHP, as well as fee-for- service. In addition, access to primary care provider and measures of early childhood cavities prevention efforts are measured. Health KidsConnect private option plans are licensed and regulated by the Department of Consumer and Business Services (DCBS), Oregon’s insurance division. The regulations for Health insurers require the carriers to report annually to DCBS on grievance and appeals, utilization review policies, quality assessments activities and health promotion and disease prevention activities, including a summary of screening and prevention health care activities covered by the insurer, as well as the scope of the insurers network and to the accessibility of services. Health insurers measure well-baby care/child/adolescent care and childhood immunizations through the use of HEDIS performance measures.

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

Quality standards 7.1.2.

Performance measurement 7.1.3.

Information strategies 7.1.4.

Quality improvement strategies

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

7.2.1 Access to well-baby care, well-child care, well-adolescent care and childhood and adolescent immunizations. (Section 2102(a)(7)) (42CFR 457.495(a)) CHIP OHP Plus: CHIP services will be provided through Oregon’s existing OHP Medicaid Demonstration delivery system. The managed

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Approval Date: 46 care plans are contracted directly with DMAP (described in Section 3.1).Since 1994, health plans that contract with the state to provide Title XIX services have been required to adhere to established quality assurance methods and protocols. As the state of the art of managed care quality assurance has changed and become more sophisticated, so have Oregon’s requirements for plan participation. Activities of the OHP Medicaid Demonstration quality improvement program extend to CHIP OHP Plus coverage. This assures CHIP OHP Plus members will receive the same quality of care and access to care currently provided to OHP Medicaid members. Specific studies of the quality of care and access to care of CHIP OHP Plus members are conducted within the context of ongoing DMAP quality improvement and evaluation efforts. As described in DMAPs Oregon Health Plan Administrative Rules and the General Rules, Prepaid Health Plans (PHPs) that contract with DMAP must meet specific mandatory obligations designed to assure quality, medically appropriate care for all OHP enrollees. The data specifications and reporting requirements outlined in the Rules are consistent with CMS’s quality initiatives for Medicaid managed care. All services provided to children enrolled in Oregon’s CHIP OHP Plus program will meet the same standards of quality assurance and medically appropriate care as currently provided by OHP Medicaid. With respect to health care delivery systems, DMAP has many contractual requirements for plan participation. PHPs must meet various quality assurance reporting requirements, including the following:

Reporting Area Quality Assurance Requirement

Plan Infrastructure and Management Solvency plan and financial reporting ♦ Medical and dental record keeping system ♦ Utilization control requirements and review procedures ♦ Credentialing and recredentialing procedures ♦ Information materials for the orientation of new members and the continuing education of existing members ♦ Provider compensation and turnover rates

Access/Availability Utilization of Medically Appropriate Covered Services, including: ♦ Inpatient/Outpatient care; ♦ Maternity and newborn care; ♦ Ambulatory care; ♦ Preventive care; and

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Approval Date: 47 ♦ Emergency services ♦ Sufficient quantity of providers to ensure adequate capacity ♦ 24-hour-a-day, 7-day-a-week emergency and urgent care services ♦ Language and transportation services ♦ Medical Case Management services ♦ ADA compliant physical access to facilities and providers ♦ Community Standards governing scheduling, rescheduling and waiting time for scheduled appointments ♦ Client Referral system

Reporting Area Quality Assurance Requirement Quality of Care ♦ Documented policies and procedures for member care ♦ External review of policies and procedures relating to member care and medical record review for quality of care ♦ Internal Quality Assurance and Quality Improvement programs based on written policies, standards and procedures ♦ Quality assurance committee structure and membership guidelines

Member Rights ♦ Due process rights; including a formal complaints and hearings process ♦ Rights to informed consent ♦ Rights to treatment with dignity and respect ♦ Other processes establishing and maintaining rights to adequate medical care

Clinical Measures and Utilization The Health Plan Employers Data Information Set (HEDIS) and statewide goals described in Oregon Shines II, the state’s 20-year strategic plan, serves as the basis on which CHIP OHP Plus health care is assessed for quality and appropriateness of care. DMAP collects the following health measures specific to the population of OHP clients under 19 years of age:

♦ Access to Primary Care Provider ♦ Childhood Immunizations ♦ Well-Baby, Child and Adolescent Visits ♦ Annual dental visit

Over 85 percent of CHIP OHP Plus children are enrolled in managed care. DMAP evaluates and monitors the measures listed above for each

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Approval Date: 48 health plan. These measures are used as part of our periodic on-site reviews of each health plan to promote access to necessary services. DMAP does not currently sanction plans for not meeting minimum performance levels for these measures. However, DMAP has both a Quality Improvement Coordinator and a Prepaid Health Plan coordinator assigned to each plan to monitor access to services and performance on these critical indicators. If problems are encountered, these staff members work with the health plans to establish and monitor corrective action plans in order to achieve acceptable performance.

Contracted health plans are required to have written policies and procedures and monitoring systems that provide for emergency and urgent services for all DMAP Members on a 24-hour, 7-day-a-week basis.

Contracted health plans are required to have written policies, procedures and monitoring systems that ensure the provision of Case Management Services for all OHP clients, to coordinate and manage services, and to ensure that referrals made are noted in the patient’s clinical record. Plans are required to develop and maintain a formal referral system consisting of a network of consultation and referral providers, including applicable Alternative Care Settings, for all services covered by agreements with DHS. Health plans must ensure that access to and quality of care provided in all referral settings is monitored.

Other Efforts to Improve Quality of and Access to OHP Services:

Quality DMAP coordinates the activities of the Department of Human Services' Oregon Health Plan Quality Improvement Committee (OHPQIC). The OHPQIC is responsible for advising and guiding the quality improvement efforts of all administrative components of the OHP and will serve a similar role in assessing the CHIP OHP Plus. The overall mechanism for quality improvement, administered by DMAP requires PHPs to have an active Quality Improvement Process (QIP) in place and integrated with other management functions. QIP performance is evaluated annually and involves review against standards in the following areas:

♦ Member Care is measured against current, relevant, criteria for care. ♦ Medical and Dental Records are reviewed for structure and completeness. ♦ Quality Improvement Program Policies and Standards are reviewed and refined to meet changing conditions and needs. ♦ Comorbidities and Special Needs are reviewed before denial of a

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Approval Date: 49 service and review of notices of denials. ♦ Member Access to Service and Utilization of Service is evaluated by site examination of PHP policies and practices and encounter data claim validation.

♦ Member Educational Plans and Provider Information are evaluated by site examination of PHP policies, practices and materials. ♦ Preventive care, adequacy of medical or dental record keeping; ♦ Operation and outcome of referral procedures; ♦ Medication reviews; ♦ Appointment systems; ♦ After-hours call-in system; ♦ Emergency services; ♦ Denials of service; ♦ PHP-initiated disenrollments; ♦ The access plan and out-of-plan access; ♦ Encounter data management; and ♦ Timeliness and appropriateness of referrals. ♦ DMAP also reviews for compliance with its Administrative Rules which set standards for access, provider credentialling and other structural measures of quality.

Oregon's PHPs have adopted selected elements of NCQA standards as the basis for their quality improvement programs, credentialing systems, record keeping, and utilization review. DMAP also contracts with an External Quality Review Organization (EQRO) for medical record review of a representative sample of OHP Medicaid clients to determine the quality of care they receive. Recent EQRO studies include prenatal care, diabetes management and depression.

Access and Member Satisfaction DMAP conducts surveys of members to determine satisfaction with access to medical services in terms of distance and appointment availability. Americans with Disabilities Act (ADA) access is reviewed in the survey of adult populations and children’s access to service with the children's form of the Consumer Assessment of Health Plans Study (CAHPS) survey. Oregon has established a biennial member satisfaction survey using the nationally standardized CAHPS instrument to assess members experiences of access, satisfaction, and system performance.

Quality Assurance and Utilization Review Oregon has built on the successful design, implementation, and improvement of the OHP Quality Improvement Program for CHIP OHP

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Approval Date: 50 Plus. PHPs monitor the quality of care using a number of aspects of care, including outcomes of selected procedures. Each PHP is responsible for the maintenance of the organizational and methodological structures (such as Quality Improvement Committees and reviews of adverse events) necessary to ensure the quality and appropriateness of care.

Preventive Care Oregon’s emphasis on primary prevention is best demonstrated through the activities of Project: PREVENTION! a management and quality initiative developed by DMAP in the Spring of 1996 in partnership with the Public Health Division and the OHP managed care plans. The goal of Project: PREVENTION! is to assure the presence and effectiveness of preventive health care services for OHP clients. A task force identified and recommended appropriate preventive health practice measures for individual plans to target and accelerate. In addition, Project: PREVENTION! developed a joint-venture partnership with OHP plans, the Public Health Division, non-OHP plans and county health departments on one unified statewide measure, an electronic pediatric immunization registry, Immunization ALERT. Immunization ALERT is a comprehensive immunization registry designed to give providers access to current and complete childhood immunization records despite changes in family residence, health insurance and choice of health provider if the child remains in Oregon.

Project: PREVENTION! supports a statewide tobacco cessation effort that involves partnership with medical and dental managed care plans, the Public Health Division and the Tobacco Free Coalition of Oregon. Central to the tobacco cessation project is the collective identification, education, and treatment of tobacco users. Medical and dental providers developed programs to help prevent children and adults from starting to use tobacco and have increased their efforts to help them quit. Project: PREVENTION! also adopted HEDIS technical standards for use in the measurement of childhood and adolescent immunization status, diabetes and asthma.

In 2001 Project: PREVENTION! adopted Early Childhood Cavities Prevention as the focus for prevention efforts. These efforts are ongoing with the FCHPs and DCOs.

Healthy KidsConnect: Plans are licensed and regulated by the Department of Consumer and Business Services. The Insurance division’s administrative rules contain many of the

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Approval Date: 51 Elements described above for DMAP’s contracts with prepaid health plans. These include but are not limited to, benefit design, reporting quality assurance, enrollee rights, screening and prevention health care activities and the accessibility of services.

7.2.2 Access to covered services, including emergency services as defined in 42 CFR 457.10. (Section 2102(a)(7)) 42CFR 457.495(b)) CHIP OHP Plus: PHPs that contract with DMAP are required to follow established rules concerning access and availability of covered services outlined in the Oregon Health Plan Administrative Rules under rule OAR 410-141-0220: Oregon Health Plan Prepaid Health Plan Accessibility. Requirements of this rule include:

♦ Written policies and procedures that establish standards for access, capacity, risk assessment, interpreter services, and ADA compliant accommodation to ensure access to health care services to all OHP members ♦ Geographic proximity of facilities and appointment wait times as determined by the prevailing Community Standard ♦ Sufficient provider panels and networks to ensure adequate service capacity to provide availability of, and timely access to, medically appropriate services ♦ Professional expertise among providers to treat or otherwise accommodate the full range of medical, dental or mental health conditions experienced by OHP members ♦ Monitoring systems to assure access to services according to time standards as indicated by the nature of the appointment including: ♦ Emergency care – Immediately for physical. Within 24 hours for dental, mental, or chemical dependency. ♦ Urgent care – Within 48 hours for physical, mental or chemical dependency, as indicated. Within one to two weeks for dental. ♦ Well Care, Routine, Preventive or Non-urgent – Within four weeks or the Community Standard for physical. Intake assessment for mental or chemical dependency within two weeks of patient request. Within twelve weeks for dental. ♦ Maintenance of 24-hour telephone coverage with a live operator (not a recording) guided by established standards pertaining to Primary Care Provider (PCP) call-back and back-up in the areas of: • Emergency, urgent, and routine issues • Internal Medicine, Family Practice, OB/Gyn, and Pediatrics • Interpretive services after office hours

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Approval Date: 52 DMAP and the PHPs monitor all access issues from both the planning and implementation perspective. Regular reports, site inspections, internal and external audits, and consumer satisfaction surveys serve to validate the effectiveness and timeliness of access to covered medical services.

Healthy KidsConnect: Plans are licensed and regulated by the Department of Consumer and Business Services (DCBS), Oregon’s Insurance division. The Insurance division’s administrative rule contain many of the elements described for DMAPs contracts managed care plans above, such as benefit design, reporting quality assurance, enrollee rights, screening and prevention health care activities and the accessibility of services. Health insurers in Oregon are required to provide the enrollee with information relating to covered services, access, scheduling as well as how emergency medical conditions are covered and accessed including a statement of prudent layperson standards for emergency treatment.

7.2.3 Appropriate and timely procedures to monitor and treat enrollees with chronic, complex, or serious medical conditions, including access to an adequate number of visits to specialists experienced in treating the specific medical condition and access to out-of-network providers when the network is not adequate for the enrollee’s medical condition. (Section 2102(a)(7)) (42CFR 457.495(c)) CHIP OHP Plus: PHPs are required to assure access to the services they provide including: specialists, pharmacy, hospital, vision and ancillary services, as accessible to DMAP Members in terms of timeliness, amount, duration and scope as those services are to non-DMAP persons within the same service area. If the PHP is unable to provide those services locally, it must so demonstrate to DMAP and provide reasonable alternatives for Members to access care that must be approved by DMAP. PHPs have a monitoring system that demonstrates to DHS, as applicable, that the plan has surveyed and monitored for equal access of DMAP Members to referral providers pharmacy, hospital, vision and ancillary services. Healthy KidsConnect: Plans are private insurers and regulated by the Oregon Insurance Division. The Insurance Division requires that commercial group health insurers submit their benefit plan designs and premium rates through an approval process. The HKC plans are considered Discretionary group plans and will be reviewed by the Insurance Division. This review by the Division helps assure that the Healthy KidsConnect benefit plans meets all Division requirements. The ultimate focus of the Insurance Division approval process is to protect

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Approval Date: 53 the consumer.

Benefit plans need not include an out-of-network benefit except for emergencies. The Healthy KidsConnect benefit plan excludes any out- of-network benefit except for emergencies or in cases for which the insurer provides a prior authorization. When out-of-network providers are authorized or emergent, the insurers will cover them as in network services.

7.2.4 Decisions related to the prior authorization of health services are completed in accordance with state law or, in accordance with the medical needs of the patient, within 14 days after the receipt of a request for services. (Section 2102(a)(7)) (42CFR 457.495(d)) CHIP OHP Plus: DMAP requires PHPs to make a determination on authorization requests within two working days of receipt of an authorization or reauthorization request related to urgent services; alcohol and drug services; and/or care required while in skilled nursing facility. Authorizations for prescription drugs must be completed and the pharmacy notified within 24 hours. If an authorization for a prescription cannot be completed within the 24 hours, the PHP must provide for the dispensing of at least a 72 hour supply if the medical need for the drug is immediate.

For all other pre-authorization requests, PHPs shall notify providers of an approval, a denial or a need for further information within 14 calendar working days of receipt of the request.

Healthy KidsConnect: private Plans are required by DCBS OAR to respond to requests for prior authorization of nonemergency services within two business days and must have qualified health care personnel available for same day telephone responses to inquiries concerning certification of continued length of stay. Emergency services do not require prior authorization.

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Approval Date: 54 Section 8. Cost Sharing and Payment (Section 2103(e))

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

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

8.1.1.

YES, Cost sharing applies to Healthy KidsConnect, FHIAP and Healthy Kids ESI. As long as the Section 1115 waiver authority is effective, children who opt to take up premium assistance under FHIAP and Healthy Kids ESI are not subject to Title XXI cost sharing rules. These children are subject to cost sharing rules through ESI plans. Healthy KidsConnect children are subject to the 5% cap.

8.1.2.

NO, skip to question 8.8. CHIP OHP Plus children have no cost sharing requirement.

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

8.2.1. Premiums: Member premiums will be a maximum of 10% of the overall premium for members over 200 up to and including 250% of the FPL. Member premiums will be a maximum of 15% of the overall premium for members over 250 up to and including 300% of the FPL. Members will be sent an enrollment confirmation letter at the time of initial plan enrollment and each eligibility redetermination. This notice will include, but is not limited to monthly premium, the member’s premium cost and the state paid portion. The notice will also include the maximum cost-sharing allowed for the family, including premiums, co- insurance and copayments and will clearly state that the carrier will track the out of pocket costs. Under Express Lane Eligibility when a child is found eligible for HKC which require premiums, the Department sends a notice informing the client that the child may be eligible for lower or no premiums using our regular eligibility methods. If a child were found to be ineligible using an ELE finding the Department would do a full eligibility determination.

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Approval Date: 55 8.2.2. Deductibles: None 8.2.3. Coinsurance or copayments: Coinsurance or copayments: Each carrier will offer one or two plan options, described as follows: Option A has a combination of copayments and coinsurance. Each benefit or service will have either a copayment or coinsurance percentage associated with it. In no case will there be both a copayment and coinsurance applied to the benefit. Option B has copayments only for each benefit or service. 8.2.4. Other: Medical out of pocket maximums are the same for both Options A & B: $900 for families with 1 child and $1800 for families with 2 or more children. Prescription out of pocket maximum is the same for both options A&B: $100 for families with 1 child and $200 for families with 2 or more children; Dental out of pocket maximums are also the same: families with 1 child are $200 and families with 2 or more children are $400. In no case will total out of costs exceed 5 percent of the family’s annual income.

8.3. Describe how the public will be notified, including the public schedule, of this cost sharing (including the cumulative maximum) and changes to these amounts and any differences based on income. (Section 2103(e)((1)(B)) (42CFR 457.505(b)) Benefits and cost-sharing information will be available to the public through the Office of Healthy Kids website at: www.oregonhealthykids.gov as well as the Office of Private Health Partnerships website: www.oregon.gov/ophp. Outreach and marketing materials will also include the information. Additionally, Oregon Administrative Rules will reference the HKC benefits and cost sharing. The rule filing process includes public notification in writing, public advisory committee review, rule posting on the agency website and a public feedback hearing prior to rule implementation. As indicated in sec 8.2.1 Members will receive an enrollment confirmation letter at the time of initial plan enrollment and each eligibility redetermination. This notice will include, but is not limited to monthly premium, the member’s premium cost and the portion paid by OPHP. The notice will also include the maximum cost-sharing allowed for the family, including premiums, co-insurance and copayments and will clearly state that the carrier will track the out of pocket costs.

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

8.4.1.

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

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Approval Date: 56 457.530) 8.4.2.

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

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

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Approval Date: 57 8.5. Describe how the state will ensure that the annual aggregate cost-sharing for a family does not exceed 5 percent of such family’s income for the length of the child’s eligibility period in the State. Include a description of the procedures that do not primarily rely on a refund given by the state for overpayment by an enrollee: (Section 2103(e)(3)(B)) (42CFR 457.560(b) and 457.505(e)) During the first contract year the carriers’ premiums were not adjusted to reflect the cost share cap of 5%. Therefore the state will employ one or more of the following three methods to ensure enrollees do not exceed the yearly 5% out of pocket maximum:

(1) The state will establish an arrangement with each carrier to track copayments and coinsurance. DHS will provide OPHP with income information (used for eligibility determination) for each family. This will give OPHP the basis for the family’s 5 percent threshold.

OPHP will then calculate the 5 percent maximum for each family approved for Healthy KidsConnect using the family’s annual income. The state will subtract the family’s yearly premium share from this amount. The difference between the 5% maximum and the yearly premium share will be the family’s net liability for cost sharing. Using this calculation, OPHP will determine which enrolled families might exceed their 5% maximum.

The state and carrier will then establish a mechanism to track actual coinsurance and copayments. Oregon will require that all carriers work to ensure that claim payment systems are updated in real time, so that out of pocket costs are not exceeded inadvertently. Carriers will send OPHP a regular accounting of actual family out of pocket costs for tracking purposes;

(2) Insurers will include the enrollee cost sharing maximum in their actuarial calculations and adjust premium costs to account for the increased risk;

(3) The state will adjust subsidy levels to offset the enrollee cost sharing limits.

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Approval Date: 58 8.6. Describe the procedures the state will use to ensure American Indian (as defined by the Indian Health Care Improvement Act of 1976) and Alaska Native children will be excluded from cost-sharing. (Section 2103(b)(3)(D)) (42CFR 457.535) DHS will provide a PERC code to identify members of a Federally recognized Indian tribe. the carrier systems will be adjusted to ensure that the identified children pay no out of pocket costs or premiums subject to 42 CFR 457.535.

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

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

State has established a process that gives enrollees reasonable notice of and an opportunity to pay past due premiums, copayments, coinsurance, deductibles or similar fees prior to disenrollment. (42CFR 457.570(a))

The disenrollment process affords the enrollee an opportunity to show that the enrollee’s family income has declined prior to disenrollment for non-payment of cost-sharing charges. (42CFR 457.570(b))

In the instance mentioned above, that the state will facilitate enrolling the child in Medicaid or adjust the child’s cost-sharing category as appropriate. (42CFR 457.570(b))

The state provides the enrollee with an opportunity for an impartial review to address disenrollment from the program. (42CFR 457.570(c))

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

8.8.1.

No Federal funds will be used toward state matching requirements. (Section 2105(c)(4)) (42CFR 457.220) 8.8.2.

No cost-sharing (including premiums, deductibles, copays, coinsurance and all other types) will be used toward state matching requirements. (Section 2105(c)(5) (42CFR 457.224) (Previously 8.4.5) 8.8.3.

No funds under this title will be used for coverage if a private insurer would have been obligated to provide such assistance except for a provision limiting this obligation because the child is eligible under the this title. (Section 2105(c)(6)(A)) (42CFR 457.626(a)(1))

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Approval Date: 59 8.8.4.

Income and resource standards and methodologies for determining Medicaid eligibility are not more restrictive than those applied as of June 1, 1997. (Section 2105(d)(1)) (42CFR 457.622(b)(5)) 8.8.5.

No funds provided under this title or coverage funded by this title will include coverage of abortion except if necessary to save the life of the mother or if the pregnancy is the result of an act of rape or incest. (Section 2105)(c)(7)(B)) (42CFR 457.475)

8.8.6.

No funds provided under this title will be used to pay for any abortion or to assist in the purchase, in whole or in part, for coverage that includes abortion (except as described above). (Section 2105)(c)(7)(A)) (42CFR 457.475)

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Approval Date: 60 Section 9. Strategic Objectives and Performance Goals and Plan Administration (Section 2107)

9.1. Describe strategic objectives for increasing the extent of creditable health coverage among targeted low-income children and other low-income children: (Section 2107(a)(2)) (42CFR 457.710(b)) The strategic objective for Oregon’s Children’s Health Insurance Program (CHIP) is to expand coverage of the Oregon Health Plan (OHP) to include eligible low income children. The current OHP delivery system assures quality medical care to the Medicaid and CHIP population by removing financial barriers and providing access to inpatient, outpatient, primary and preventive health care services. Specific strategic objectives include:

Objective 1 Expand OHP eligibility rules to include uninsured children: • Birth through age 5. Living in households with gross income between 133% and 200% of the federal poverty level (FPL) . Age 6 through 18. Living in households with two months average gross income between 100% and 200% of the FPL.

Objective 2 Identify CHIP eligibles through coordinated and ongoing outreach activities.

Objective 3 Enroll CHIP eligibles in the OHP Plus, FHIAP ESI, Healthy Kids ESI or Healthy KidsConnect health care delivery system to assure a usual source of health care coverage.

Objective 4 Monitor access and utilization patterns among DHS CHIP OHP Plus and Healthy KidsConnect enrollees.

Objective 5 Improve the health status of CHIP enrollees through provider and client programs specific to the needs of this population.

9.2. Specify one or more performance goals for each strategic objective identified: (Section 2107(a)(3)) (42CFR 457.710(c)) The following performance goals and measures will be utilized to measure the effectiveness of Oregon’s identified strategic objectives for CHIP:

Performance Goals for Objective 1 Since July 1, 1998, the Division of Medical Assistance Programs (DMAP)

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Approval Date: 61 has expanded the capacity of the OHP to meet the needs of 48,000 CHIP eligibles. DMAP’s data and operational systems are structured to accommodate CHIP criteria in the areas of eligibility determination, enrollment, client information, and utilization of health care services. DMAP staff and Department of Human Services (DHS) field personnel have and continue to receive CHIP-related training.

Performance Goals for Objective 2 Since January 1, 1999, DMAP has developed and implemented outreach efforts among current Medicaid OHP channels to identify, enroll, and meet the health care needs of the CHIP population.

Performance Goals for Objective 3 As of May 2009, 48,000 low income children are enrolled in Oregon’s CHIP. They have access to a usual source of health care coverage in the form of a stable health care plan and a primary care provider (PCP).

Performance Goals for Objective 4 DHS CHIP enrollees are assigned a unique code that will enable DMAP analysts to distinguish CHIP clients from the OHP Medicaid population. DMAP monitors CHIP utilization patterns to help assure access to health care and the delivery of medically appropriate care.

Performance Goals for Objective 5 Health status and health care system measures for Oregon’s DHS CHIP program enrollees are collected and analyzed to demonstrate acceptable utilization in the following areas: access to a primary care provider, childhood immunization status, and well-child and -adolescent visits.

9.3. Describe how performance under the plan will be measured through objective, independently verifiable means and compared against performance goals in order to determine the state’s performance, taking into account suggested performance indicators as specified below or other indicators the state develops: (Section 2107(a)(4)(A),(B)) (42CFR 457.710(d)) Oregon’s performance relative to its stated goals is objectively and independently verified through DMAP analysis of DHS CHIP population and utilization data. The ongoing analysis of data obtained through the Medicaid Management Information System (MMIS) is used to measure the state’s progress toward its goals and objectives.

As previously noted, health plan oversight occurs as clinical data review, desktop medical chart audits, and on-site inspection of PHPs.

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Approval Date: 62 Health plans are notified when areas of deficiency are discovered and of corrective actions needed. PHPs are required to give DMAP medical and dental service utilization reports, provider capacity reports and access to service statistics and various semiannual and annual financial reports. In addition to administering client satisfaction surveys, DMAP produces monthly enrollment reports, quarterly disenrollment reports and reports profiling the demographic characteristics of enrollees.

DMAP staff directly responsible for the implementation and monitoring of CHIP, continuously monitor program administration and take necessary action to ensure the program meets strategic objectives.

The Office for Oregon Health Policy and Research will analyze and evaluate the implementation of the Healthy Kids, including FHIAP Healthy Kids ESI, CHIP OHP Plus and Healthy KidsConnect expansion. The office will report on information using a variety of data sources including a statewide health insurance survey, program administrative data and other quantitative and qualitative data sources. Unless otherwise noted, the program will be evaluated annually. • Biennial estimates of the number of children who are eligible for but not enrolled in the program; • The number of children enrolled in the program; • The number of children disenrolled from the program; • A description of any identified barriers to enrolling or maintaining enrollment of children in the program; • The quality of care received using nationally accepted HEDIS measures for children; • Biennial estimates of the number children voluntarily not enrolling in employer-sponsored health coverage and enroll in the program.

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

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

The reduction in the percentage of uninsured children. 9.3.3.

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

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

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

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

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Approval Date: 63 9.3.7.

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

Performance measures for special targeted populations.

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Approval Date: 64 9.4.

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

9.5.

The state assures it will comply with the annual assessment and evaluation required under Section 10. Briefly describe the state’s plan for these annual assessments and reports. (Section 2107(b)(2)) (42CFR 457.750) Oregon provides an annual report to the Secretary, as required. The report includes evaluation of CHIP program components, coordination with other state-sponsored health insurance programs and an evaluation of the progress made toward increasing health insurance coverage for children in Oregon.

9.6.

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

9.7.

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

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

9.8.1.

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

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

Section 1903(w) (relating to limitations on provider donations and taxes) 9.8.4.

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

9.9. Describe the process used by the state to accomplish involvement of the public in the design and implementation of the plan and the method for insuring ongoing public involvement. (Section 2107(c)) (42CFR 457.120(a) and (b)) Policy guidance for the development of Oregon's response to Title XXI includes substantial public comment and participation. The Oregon Legislature established the Oregon Health Council as the body responsible for providing a forum for public debate on the policy framework for the state's CHIP program. The Health Council is the

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Approval Date: 65 policy-recommending body for health planning in the state. It consists of nine public members appointed by the Governor. The Health Council held a public hearing on Oregon's response to CHIP on October 18, 1997 in Salem, Oregon. At this meeting, approximately 30 interested parties, including consumers and consumer advocates, providers, managed care plans, insurance carriers, and educators, delivered testimony. Besides this focused, three-hour public hearing, the Health Council also solicited public comment at its regular meetings. At each of the six Council meetings held September 1997 through January 1998, written and oral public comment about CHIP was provided and discussed. On January 15, 1998, there were four additional public hearings around the state; Portland and Eugene in the Willamette Valley, Medford in Southern Oregon, and Bend in Central Oregon. Approximately 70 additional parties presented testimony at these hearings. There were comments on both general program policy issues and the proposed administrative rules for the Family Health Insurance Assistance Program (FHIAP). Program staff then summarized this public input and presented to a joint meeting of the Health Council and the Insurance Pool Governing Board that will oversee the operations of the FHIAP program. DMAP staff was also represented at this meeting, because Oregon is attempting to ensure consistent policies for the two complementary programs, the state-funded FHIAP commercial health insurance subsidy program and the CHIP program. Additional opportunities to receive public input around CHIP design and implementation have occurred and continue. A draft of the initial Title XXI State Plan document was circulated for comment internally to state agencies and externally to providers, consumer advocates, and to a broad array of other interested parties. When the original Title XXI State Plan was submitted to CMS, DMAP submitted a notice for publication in Oregon’s major newspapers. All interested Oregonians were notified on how to obtain a copy of this document and had timely opportunity to comment on CHIP

Oregon Health Decisions conducted a series of approximately 200 meetings around the state. "Health Decisions '98" continued ongoing efforts by Oregon Health Decisions to engage Oregonians at the grass- roots level in a democratic approach to developing health policy. A similar series of "town hall meetings" in 1990 informed the setting of health service priorities by the Health Services Commission, information upon which they developed the Prioritized List of Health Services. A subsequent set of focus groups in 1995 addressed questions designed to identify the most sensible "next steps" for the Oregon Health Plan following implementation of the Medicaid expansion with benefits based on those priorities. "Health Decisions '98" focused on issues of how we

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Approval Date: 66 finance health care, who ultimately pays for it, and how we can build more equity into the financing of health care while improving access and quality. As in the past with the Oregon Health Plan, public input on CHIP and more general health care policy questions is being used to inform debate, set policy, and develop concepts for program development and proposed legislation. Public comment is a continuing part of Oregon's design, implementation, and refinement of its CHIP program and other expansions of the Oregon Health Plan.

9.9.1 Describe the process used by the state to ensure interaction with Indian Tribes and organizations in the state on the development and implementation of the procedures required in 42 CFR 457.125. (Section 2107(c)) (42CFR 457.120(c)) The Department engages Tribal consultation prior to submission of state plan amendments, waiver requests, proposed demonstration waivers, and rule-making likely to have a cost or direct impact on Oregon Native Americans, Indian Health Programs, or Urban Indian Organizations. To the extent practical and permitted by law, the state consults with Tribal governments as early as possible in the consultation process. This policy applies to the Children’s Health Insurance Program in the same manner in which it applies to Medicaid.

A representative from the Division of Medical Assistance Programs attends quarterly “770” meetings to discuss proposed State Plan Amendments, waiver proposals or amendments, demonstration project proposals or amendments, and rule-making that may have a direct impact on American Indians and Tribal entities. Face-to-face consultation is the preferred method of communication and consultation prior to submission of documents to the Centers for Medicare and Medicaid Services. In the event a deadline is out of the control of the Division, the communication and consultation will be handled by mail distributed through the Department Tribal Liaison to Tribal designees. A monthly written Division of Medical Assistance Program Update is also provided to the DHS Tribal Liaison, who forwards it to Tribal designees. This update includes the status of State Plan Amendments, waiver or demonstration project proposals or amendments, and rule filings.

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Approval Date: 67 9.9.2 For an amendment relating to eligibility or benefits (including cost sharing and enrollment procedures), please describe how and when prior public notice was provided as required in §457.65(b) through (d).

Prior to an amendment being submitted, DHS coordinates with the Oregon Health Policy Committee and Tribal organizations, Medicaid Advisory Committee or Legislative Committees as appropriate. Oregon Administrative Rules are filed and at a minimum DMAP gives a public notice 45 days prior to any changes or closure of the program .

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Approval Date: 68 9.10. Provide a one year projected budget. A suggested financial form for the budget is attached. The budget must describe: (Section 2107(d)) (42CFR 457.140) • Planned use of funds, including -- - Projected amount to be spent on health services; - Projected amount to be spent on administrative costs, such as outreach, child health initiatives, and evaluation; and - Assumptions on which the budget is based, including cost per child and expected enrollment. • Projected sources of non-Federal plan expenditures, including any requirements for cost-sharing by enrollees. Budget included as an attachment

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Approval Date: 69 Section 10. Annual Reports and Evaluations (Section 2108)

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

10.1.1.

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

10.2.

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

10.3.

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

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Approval Date: 70 Section 11. Program Integrity (Section 2101(a))

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

11.1.

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

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

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

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

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

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

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

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

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Approval Date: 71 Section 12. Applicant and Enrollee Protections (Sections 2101(a))

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

12.1. Eligibility and Enrollment Matters

Please describe the review process for eligibility and enrollment matters that complies with 42 CFR 457.1120. DHS CHIP applicants and members have the same rights as OHP Medicaid members with respect to eligibility and enrollment matters. Clients and applicants have a right to a timely, written, impartial external review through the administrative hearing process that complies with 42 CFR 457.1120.

Under Express Lane Eligibility when a child is found eligible for HKC which require premiums, the Department sends a notice informing the client that the child may be eligible for lower or no premiums using our regular eligibility methods. If a child were found to be ineligible using an ELE finding the Department would do a full eligibility determination. 12.2. Health Services Matters

Please describe the review process for health services matters that comply with 42 CFR 457.1120. DHS CHIP members have the same rights as OHP Medicaid members with respect to denials, reductions and termination of services. Clients have a right to a timely, written, impartial external review through the DMAP administrative hearing process that complies with 42 CFR 457.1120. Additionally Healthy KidsConnect plan are regulated by private insurance rules which also guide how insurance appeals and grievances are handled,.

12.3. Premium Assistance Programs

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

1

Date Last Updated: CMCS, CAHPG, DCHIP, June 09, 2011 OREGON TITLE XXI STATE PROGRAM FACT SHEET

Name of Plan:

Oregon CHIP

Date Plan Submitted:

March 2, 1998 Date Plan Approved:

June 12, 1998 Effective Date:

July 1, 1998

Date Amendment #1 Submitted: August 13, 1999 Date Amendment #1 Withdrawn: July 2, 2001

Date Amendment #2 Submitted: May 30, 2000 Date Amendment #2 Approved: September 11, 2000 Date Amendment #2 Effective:

January 1, 2000

Date Amendment #3 Submitted: December 20, 2000 Date Amendment #3 Approved: March 9, 2001 Date Amendment #3 Effective:

January 1, 2001

Date Amendment #4 Submitted: July 31, 2002 Date Amendment #4 Approved: May 5, 2003

Date Amendment #5 Submitted: August 19, 2004 Date Amendment #5 Approved: November 10, 2004 Date Amendment #5 Effective:

October 1, 2004

Date Amendment #6 Submitted: May 16, 2006 Date Amendment #6 Approved:

August 1, 2006 Date Amendment#6 Effective:

June 1, 2006

Date Amendment #7 Submitted: July 27, 2007 Date Amendment #7 Approved:

April 9, 2008 Date Amendment #7 Effective:

April 1, 2008

Date Amendment #8 Submitted: September 13, 2007 Date Amendment #8 Approved:

December 12, 2007

Date Amendment #8 Effective:

October 1, 2007

Date Amendment #9 Submitted: December 4, 2007 Date Amendment #9 Approved:

September 16, 2008 Date Amendment #9 Effective:

November 1, 2007

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Date Last Updated: CMCS, CAHPG, DCHIP, June 09, 2011 Date Amendment #10 Submitted: July 27, 2009 Date Amendment #10 Approved: December 18, 2009

Date Amendment #10 Effective: October 1, 2009

Date Amendment #11 Submitted: August 27, 2009 Date Amendment #11 Approved: September 20, 2010 Date Amendment #11 Effective: October 1, 2009

Date Amendment #12 Submitted: September 30, 2009 Date Amendment #12 Approved: May 14, 2010 Date Amendment #12 Effective: October 1, 2009

Date Amendment #13 Submitted: August 10, 2009 Date Amendment #13 Approved: October 21, 2010 Date Amendment #13 Effective: August 1, 2010

Date Amendment #14 Submitted: October 25, 2010 Date Amendment #14 Approved: December 30, 2010 Date Amendment #14 Effective: November 1, 2010 (income eligibility

methodology)

January 1, 2011 (unborn expansion)

Date Amendment #15 Submitted: November 5, 2010 Date Amendment #15 Withdrawn: November 30, 2010

Date Amendment #16 Submitted: March 28, 2011 Date Amendment #16 Approved: May 26, 2011 Date Amendment #16 Effective: July 1, 2011

Background

• On March 2, 1998, Oregon submitted a Title XXI State Plan to expand health insurance coverage to infants and children through a separate program.

• The program provides coverage to children from birth to age 6 with family incomes between 133 percent and 170 percent of the Federal Poverty Level (FPL) and to children from age 6 to age 19 with incomes between 100 percent and 170 percent of the FPL.

Amendments

• On August 13, 1999, the State submitted an amendment to allow employer sponsored coverage through its Family Health Insurance Assistance Program via a

3

Date Last Updated: CMCS, CAHPG, DCHIP, June 09, 2011 Health Insurance Purchasing Cooperative, and to request a family coverage waiver. This request was withdrawn.

• On May 30, 2000, the State submitted a second amendment to revise several of its performance measures.

• On December 20, 2000, the State submitted a third amendment to increase the number of children permitted under the State’s enrollment cap from 16,800 (as stated in the original State plan) to approximately 19,800 children.

• On July 31, 2002, the State submitted its fourth amendment. This amendment updates and amends the CHIP state plan to indicate the State’s compliance with the final CHIP regulations.

• On August 19, 2004, the State submitted its fifth amendment to expand coverage to children with family incomes through 170 percent of the FPL by increasing the assets limit for determining CHIP eligibility from $5,000 to $10,000.

• On May 16, 2006, Oregon submitted its sixth amendment to its Title XXI State Plan to extend the CHIP continuous eligibility period from 6 months to 12 months.

• On July 27, 2007, Oregon submitted its seventh amendment to extend health care coverage to unborn children with family income up to 185 percent of the FPL in Multnomah County.

• On September 13, 2007, Oregon submitted its eight amendment to require applicants to provide a Social Security Number (SSN) on SCIHP applications for the purpose of making eligibility determinations. Applicants who are members of a religious sect or division of a religious sect that has continuously existed since December 31, 1950 and adhere to its tenets or teachings that prohibit applying for or using an SSN are exempt.

• On December 3, 2007, Oregon submitted its ninth amendment to its Title XXI State Plan. This amendment allows Oregon to transition children from birth through age 18, with family income above 170 percent of the Federal poverty level (FPL) up to 185 percent of the FPL, from eligibility through the Section 1115 demonstration to the State Children’s Health Insurance Program (CHIP) state plan.

• On July 27, 2009, Oregon submitted its tenth amendment to its Title XXI State Plan. This amendment proposes to expand the income eligibility level for CHIP children through age 18 from 185 percent of the Federal poverty level (FPL) through 300 percent of the FPL under its Healthy Kids initiative and provides for the reduction of the waiting period of uninsurance for CHIP coverage from 6 months to 2 month and eliminates the asset test.

4

Date Last Updated: CMCS, CAHPG, DCHIP, June 09, 2011

Additionally, the amendment allows Oregon to institute an Application Assistance Program (AAP) to assist families applying for CHIP and other child health programs in the State as part of its Health Kids initiative and finance an Outreach and Enrollment Grant Program designed to provide culturally-specific and targeted outreach and direct application assistance to families in racial, ethnic and language minority communities living in geographic isolation or with additional access barriers.

• On August 27, 2009, Oregon submitted its eleventh amendment to its Title XXI State Plan. This amendment proposes to expand unborn coverage in additional counties.

• A twelfth amendment was submitted by the State on June 30, 2009 to implement the legal immigrant funding option as listed in CHIPRA section 214.

• On August 10, 2009, Oregon submitted its thirteenth amendment to its Title XXI State Plan. This amendment allows Oregon to implement the Express Lane Eligibility (ELE) option under the title XXI State plan, per section 203 of Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA), using the Supplemental Nutritional Assistance Program (SNAP) and the National School Lunch Program (NSLP) as the express lane eligibility agencies that will be operating to perform a simplified eligibility determination process and expedited enrollment of eligible children in CHIP.

• On October 25, 2010, Oregon submitted its fourteenth amendment to its Title XXI State Plan. This amendment allows Oregon to expand coverage to unborn children with family income up to 185 percent of the Federal poverty level (FPL) in Lane County and to simplify income eligibility by using the income in the month of application for the income test.

• On March 28, 2011, Oregon submitted its sixteenth amendment to its Title XXI State Plan. This amendment allows Oregon to expand coverage to unborn children with family income up to 185 percent of the Federal poverty level (FPL) in Columbia, Crook, Douglas, Jefferson, Josephine, Morrow, Union and Wasco counties.

Children Covered under the Program

• The State reported that there were 62,121 children ever enrolled in CHIP during Federal fiscal year (FFY) 2009.

5

Date Last Updated: CMCS, CAHPG, DCHIP, June 09, 2011 Administration

• The program is administered by the State’s Division of Medical Assistance Programs (DMAP) within the Department of Human Resources.

Health Care Delivery System

• The State utilizes the same delivery system for CHIP as it uses for its section 1115 Medicaid managed care delivery system, the Oregon Health Plan (OHP), to deliver services. The delivery system is comprised of prepaid health plans and primary care case managers.

Benefit Package

• The separate child health program offers Secretary-approved coverage that is the same as coverage offered under the State’s Medicaid program. The State’s benefit package is based on the OHP Prioritized List of Health Services which is a modified Medicaid benefit package as allowed under Oregon’s section 1115 Medicaid demonstration waiver for its entire Medicaid population. Medically necessary services are defined in the Prioritized List.

• The comprehensive benefit package includes case-management, preventive health care, interpreter, and non-emergency transportation services at no additional cost.

• Benefits for the unborn population include prenatal care and associated health care services. The program will cover medically necessary services including, but not limited to: physician, surgical, prescription drug, inpatient, outpatient, prenatal care, radiology, and laboratory services.

Cost Sharing

• There are no premiums, copayments, or deductibles for enrollees.

State Action to Avoid Crowd-Out

• Information on current or previous health insurance is gathered on the application. Children are not eligible if they have been enrolled in private insurance within the past 6 months, except in cases of a life-threatening or disabling condition. The State monitors substitution under its Quality Control and Quality Assurance process to analyze the extent to which an applicant drops other health plan coverage.

6

Date Last Updated: CMCS, CAHPG, DCHIP, June 09, 2011

Outreach Activities

• Outreach for CHIP has been incorporated into existing OHP Medicaid outreach activities, which includes the following activities:

• In May 2009, Oregon’s legislature appropriated state funds to cover all children in Oregon with health insurance. The legislation combined existing children’s health programs (Medicaid and CHIP) into a new consolidated program, referred to as Healthy Kids.

Oregon is instituting an Application Assistance Program (AAP) to assist families applying for CHIP and other child health programs in the State as part of its Healthy Kids initiative. Certified Application Assistance Organizations will receive a $50 fee for each application that results in new coverage in the Oregon Health Plan, which includes CHIP and Medicaid children.

• Oregon is instituting an Outreach and Enrollment Grant Program designed to provide culturally-specific and targeted outreach and direct application assistance to families in racial, ethnic and language minority communities living in geographic isolation or with additional access barriers. Outreach and Enrollment Grants will range from $20,000 to $80,000 per grantee per year. The State anticipates awarding approximately 20 to 40 grants in the first biennium. Each grantee will have enrollment targets that they have proposed in their application. Grants will begin effective upon CMS approval on or after October 1, 2009. The grants will be awarded during State fiscal year 2010 and renewable for a second year, based on performance.

Coordination between CHIP and Medicaid

• Oregon’s CHIP program was designed to be seamless with the State’s section 1115 Medicaid demonstration waiver. A single application and eligibility determination process, as well as the same quality improvement program, are used for both CHIP and Medicaid.

Financial Information

Total FFY '11 CHIP Allotment -- $91 million FFY '11 Enhanced Federal Matching Rate – 74.00%

_____________________________________________________________________________

Table of Contents

State/Territory Name: Oregon

State Plan Amendment (SPA) #: OR-13-0120

This file contains the following documents in the order listed:

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

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

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

Baltimore, Maryland 21244-1850 NNER bon MEDICAID E Chip SeNvIC

‘CENTER FOR MEDICAID & CHIP SERVICES

Children and Adults Health Programs Group

Ms. Judy Mohr Peterson FEB 1 0 2014 Administrator

Division of Medical Assistance Programs

Oregon Health Authority

500 Summer Street Northeast, E-49

Salem, OR 97301-1079

Dear Ms. Mohr Peterson:

I am pleased to inform you that your Title XXI Children’s Health Insurance Program (CHIP) state plan amendment (SPA) numbers OR 13-0120 and OR-13-0123, related to Modified Adjusted Gross Income (MAGI) Eligibility, have been approved with an effective date of January 1, 2014.

MAGI Eligibility & Methods:

SPA number OR-13-0120 provides assurance on page CS15 that the state will apply methodologies based on MAGI for all separate CHIP covered groups, using the approved MAGI conversion plan income thresholds. The state indicates on page CS7 that it will cover targeted low-income children, and indicates on page CS9 that it will cover children from conception to birth when the mother is not eligible for Medicaid. Page CS13 indicates that the state elects to cover as deemed newborns children born to mothers enrolled as targeted low-income children in CHIP or enrolled in the section 1115 demonstration, Oregon Health Plan. A copy of the approved CS15 is attached and should be incorporated within a separate subsection under Section 4.3 of the state’s approved CHIP state plan. A copy of the approved CS7 and CS9 are attached and together supersede the current Geographic Area, Age and Income Sections 4.1.1, 4.1.2 and 4.1.3 of the current CHIP state plan. A copy of the approved CS13 is attached and should be incorporated under Section 4.3 of the state’s approved CHIP state plan.

Non-Financial Eligibility:

SPA number OR-13-0123 is approved to clarify the state’s non-financial eligibility policies on residency, citizenship, social security numbers, non-payment of premiums, continuous eligibility and presumptive eligibility. Copies of the approved state plan pages are attached and these approved pages supersede sections of Oregon's current state plan as detailed below:

logged in as TONIABROWN(CMS CO Staff) read only mode application rev p01 Children's Health Insurance Program Eligibility OR.0500.R00.00 - Jan 01, 2014 Home Logout Finder Save Validate Print Help Control Panel General Information File Management Tribal Input Summary State/Territory name: Oregon State Funds: $ Federal Funds: $ Submitted By: Jesse Anderson Last Revision Date: Jan 28, 2014 Submit Date: Nov 12, 2013 Children's Health Insurance Program Eligibility: Summary Page Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. OR-13-0120 Type of SPA: MAGI Eligibility & Methods XXI Medicaid Expansion Establish 2101(f) Group Eligibility Processing Non-Financial Eligibility Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation 2102(b)(1)(B)(v) of the SSA Federal Budget Impact This SPA has a budget impact. Total budget impact: Subject of Amendment Please provide a brief summary of SPA changes. Character Count:130 out of 2000 This transmittal is being submitted to reflect the ACA eligibility templates SPAs which include MAGI eligibility income standards. Signature of State Agency Official Page 1 of 2 Children's Health Insurance Program Eligibility: CMS 179 08/28/2014 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

FAQs | Site Map | Contact | Medicaid.gov | CMS.gov Page 2 of 2 Children's Health Insurance Program Eligibility: CMS 179 08/28/2014 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

Page 2 — Ms. Judy Mohr Peterson

New State Plan Page Impact on Current State Plan Section CS17: Non-Financial Eligibility — Residency | Section 4.1.5 CS18: Non-Financial Eligibility — Citizenship | Section 4.1.0; 4.1-LR; 4.1.1-LR CS19: Non-Financial Eligibility — Social Section 4.1.9.1 Security Number C821: Non-Payment of Premiums Section 8.7 C827: General Eligibility —- Continuous Section 4.1.8 Eligibility CS28: General Eligibility - Presumptive Section 4.4.3 Eligibility for Children

Your title XX] project officer is Ms. Victoria Collins. She is available to answer questions concerning this amendment and other CHIP-related issues. Ms. Collins’ contact information is as follows:

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

7500 Security Boulevard

Baltimore, MD 21244-1850

Telephone: (410) 786-2167

Facsimile: (410) 786-5943

E-mail: Victoria.Collins@cms.hhs.gov

Official communications regarding program matters should be sent simultaneously to Ms. Collins and to Ms. Carol Peverly, Associate Regional Administrator (ARA) in our Seattle Regional Office. Ms. Peverly’s address is:

Centers for Medicare & Medicaid Services

Division of Medicaid and Children’s Health Operations 2201 6" Avenue, Mail Stop RX-43

Seattle, Washington 98121

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

Sincerely,

Eliot Fishman Director

Enclosures ce: Ms. Carol Peverly, ARA, CMS Region X, Seattle ‘

Cems CHIP Eligibility

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

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

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

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

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

In determining family size for the eligibility determination of the other individuals in a household that includes a pregnant woman: C The pregnant woman is counted just as herself. C The pregnant woman is counted just as herself, plus one. (@ The pregnant woman is counted as herself, plus the number of children she is expected to deliver. Financial eligibility is determined consistent with the following provisions: When determining eligibility for new applicants, financial eligibility is based on current monthly income and family size. When determining eligibility for current beneficiaries, financial eligibility is based on: @ Current monthly household income and family size. C Projected annual household income for the remaining months of the current calendar year and family size. In determining current monthly or projected annual household income, the state will use reasonable methods to: (7 Include a prorated portion of the reasonably predictable increase in future income and/or family size. Account for a reasonably predictable decrease in future income and/or family size.

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

Household income includes actually available cash support, exceeding nominal amounts, provided

by the person claiming an individual described at §435.603(f)(2)(i) as a tax dependent. No

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

An attachment is submitted.

PRA Disclosure Statement

SPA# OR-13-0120 Approval Date: FEB { 0 2014 Effective Date: January 1, 2014 Page 1 of 2

Oe

CEmMs. CHIP Eligibility

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB contro! number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

FEB 10 2014

SPA# OR-13-0120 Approval Date: Effective Date: January 1, 2014 Page 2 of 2

A Cems. CHIP Eligibility

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

2102(b)(1)(B)(v) of the SSA and 42 CFR 457.310, 315 and 320

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

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

Must be under age 19.

Income Standards

Income standards are applied statewide.

Are there any exceptions, e.g. populations in a county which may qualify under either a statewide income No standard or a county income standard?

Statewide Income Standards

Begin with lowest age range first.

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

From Age To Age Above (% FPL) Up to & including (% FPL) # |b 1 185 300 x +i 19 133 300 x

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

Special Program for Children with Disabilities

Does the state have a special program for children with disabilities?

PRA Disclosure Statement

SPA# OR-13-0120 Approval Date: FEB 1 0 2014 Effective Date: January 1, 2014 Page 1 of 2

a

Cems. CHIP Eligibility

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1 148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

V.20130709

FEB 10 2014

SPA# OR-13-0120 Approval Date: Effective Date: January 1, 2014 Page 2 of 2

a

Cems. CHIP Eligibility

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

42 CFR 457.10

[lM] Coverage From Conception to Birth - Coverage from conception to birth when the mother is not eligible for Medicaid. The CHIP Agency operates this covered group in accordance with the following provisions:

Age Standard

From conception through birth.

Does the state have an additional age definition or other age-related conditions? [No

Income Standards

Income standards are applied statewide. |Yes

Are there any exceptions, e.g. populations in a county which may qualify under either a statewide income standard or a No county income standard?

Statewide Income Standard

The statewide income standard is: From zero up to }185 | % FPL

[]) Exempted from requirement of providing or applying for a Social Security Number.

[i] Exempted from requirement of verifying citizenship status.

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

FEB 10 2014

SPA# OR-13-0120 Approval Date: Effective Date: January 1, 2014

Page 1 of 1

Cems CHIP Eligibility

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

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

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

The state operates this covered group in accordance with the following provisions: Pp [li] The child was born to an eligible targeted low-income pregnant woman under section 2112 of the SSA.

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

The state elects the following option(s):

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

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

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

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of

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

SPA# OR-13-0120 Approval Date: FEB 1 0 2014

Effective Date: January 1, 2014 Page 1 of 1

Oe

Cems. CHIP Eligibility

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

Non-Fii

42 CFR 457.320

Residency

The CHIP Agency provides CHIP to otherwise eligible residents of the state, including residents who are absent from the state under certain conditions. A child is considered to be a resident of the state under the following conditions: ry A non-institutionalized child, if capable of indicating intent and who is emancipated or married, if the child is living in the state and: 1. Intends to reside in the state, including without a fixed address, or

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

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

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

resides. An institutionalized child, who is not a ward of the state, if the state is the state of residence of the child's custodial parent or

Cy caretaker at the time of placement, or [ll] A child who is a ward of the state regardless of where the child lives, or A child physically located in the state when there is a dispute with one or more states as to the child's actual state of

Cy residence.

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

[lj A non-institutionalized pregnant woman who is living in the state and:

1. Intends to reside in the state, including without a fixed address, or if incapable of indicating intent, is living in the state, or

2. Entered with a job commitment or seeking employment, whether or not currently employed. rl An institutionalized pregnant woman placed in an out-of-state-institution, as defined in 42 CFR 435.1010, including foster care homes, by an agency of the state, or rl An institutionalized pregnant woman residing in an in-state-institution, as defined in 42 CFR 435.1010, whether or not the individual established residency in the state prior to entering the institution, or A pregnant woman physically located in the state when there is a dispute with one or more states as to the pregnant woman's

Cy actual state of residence.

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

FEB 1 u Zuid Effective Date: January 1, 2014 Page 1 of 2

SPA# OR-13-0123 Approval Date:

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Cems. CHIP Eligibility

One or more interstate agreement(s). No

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

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of

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

SPA# OR-13-0123 Approval Date: FEB i 0 2018 Effective Date: January 1, 2014 Page 2 of 2

ccmMs. CHIP Eligibility

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

git

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

Citizenship

The CHIP Agency provides CHIP eligibility to otherwise eligible citizens and nationals of the United States and certain non-citizens,

including the time period during which they are provided with reasonable opportunity to submit verification of their citizenship, national status or satisfactory immigration status.

[Mi] The CHIP Agency provides eligibility under the Plan to otherwise eligible individuals:

Who are citizens or nationals of the United States; or

Who are qualified non-citizens as defined in section 431 of the Personal Responsibility and Work Opportunity Reconciliation

Act (PRWORA) (8 U.S.C. §1641), or whose eligibility is required by section 402(b) of PRWORA (8 U.S.C. §1612(b)) and is not prohibited by section 403 of PRWORA (8 U.S.C. §1613); or

Who have declared themselves to be citizens or nationals of the United States, or an individual having satisfactory immigration| status, during a reasonable opportunity period pending verification of their citizenship, nationality, or satisfactory immigration status consistent with requirements of 1903(x), 1137(d), and 1902(ee) of the Act, and 42 CFR 435.406, 407, 956 and 457.380.

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

The agency provides for an extension of the reasonable opportunity period if the individual is making a good faith effort

to resolve any inconsistencies or obtain any necessary documentation, or the agency needs more time to complete the Yes verification process.

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

The date benefits are furnished is: @ The date of application containing the declaration of citizenship or immigration status. C The date the reasonable opportunity notice is sent.

C Other date, as described:

The CHIP Agency elects the option to provide CHIP coverage to otherwise eligible children up to age 19, lawfully residing Yes in the United States, as provided in Section 2107(e)(1)(J) of the SSA (Section 214 of CHIPRA 2009, P.L. 111-3).

Otherwise eligible children means children meeting the eligibility requirements of targeted low-income children with the exception of non-citizen status.

The CHIP Agency provides assurance that lawfully residing children are also covered under the state's Medicaid program. Prep 4 ff ag SPA# OR-13-0123 Approval Date: tEO 7 U 2014 Effective Date: January 1, 2014

Page 1 of 3

Cems CHIP Eligibility

The CHIP Agency elects the option to provide CHIP coverage to otherwise eligible pregnant women, lawfully residing in the United States, as provided in Section 214 of CHIPRA 2009, P.L. 111-3. The state may not select this option unless the state also elects to cover lawfully residing children. A state may not select this option unless the state also covers Targeted Low- Income Pregnant Women.

aw An individual is considered to be lawfully residing in the United States if he or she is lawfully present and meets state residency requirements.

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

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

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

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

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

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

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

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

(vii) Granted an administrative stay of removal under 8 CFR 241;

(viii) Beneficiary of approved visa petition who has a pending application for adjustment of status;

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

(i) Has been granted employment authorization; or

(ii) Is under the age of 14 and has had an application pending for at least 180 days; 6. Has been granted withholding of removal under the Convention Against Torture; 7. 1s a child who has a pending application for Special Immigrant Juvenile status as described in 8 U.S.C.1 101(ay(27)(N); 8. Is lawfully present in American Samoa under the immigration laws of American Samoa; or

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

SPA# OR-13-0123 Approval Date: EER 4 fe Hts Effective Date: January 1, 2014

Page 2 of 3

Cems CHIP Eligibility

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

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

SPA# OR-13-0123 Approval Date: FER 4 i] ons Effective Date: January 1, 2014

Page 3 of 3

Cems. CHIP Eligibility

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

42 CFR 457.340(b)

Social Security Number As acondition of eligibility, the CHIP Agency must require individuals who have a social security number or are eligible for one as determined by the Social Security Administration, to furnish their social security number, or numbers if they have more than one number.

The CHIP Agency requires individuals, as a condition of eligibility, to furnish their social security number(s), with the following exceptions:

Individuals refusing to obtain a social security number (SSN) because of well established religious objections, or Individuals who are not eligible for an SSN, or

Individuals who are issued an SSN only for a valid non-work purpose.

ry The CHIP Agency assists individuals, who are required to provide their SSN, to apply for or obtain an SSN from the Social Security Administration if the individual does not have or forgot their SSN.

{M] The CHIP Agency informs individuals required to provide their SSN: By what statutory authority the number is solicited; and

How the state will use the SSN.

The CHIP Agency provides assurance that it will verify each SSN furnished by an applicant or beneficiary with the Social Security Administration, not deny or delay services to an otherwise eligible applicant pending issuance or verification of the individual's SSN by the Social Security Administration and that the state's utilization of the SSNs is consistent with sections 205 and 1137 of the Social Security Act and the Privacy Act of 1974.

The state may request non-applicant household members to voluntarily provide their SSN, if the state meets the requirements below.

The state requests non-applicant household members to voluntarily provide their Ves SSN.

When requesting an SSN for non-applicant household members, the state assures that:

Ir At the time such SSN is requested, the state informs the non-applicant that this information is voluntary and provides information regarding how the SSN will be used; and

rT The state only uses the SSN for determination of eligibility for CHIP or other insurance affordability programs, or for a purpose directly connected with the administration of the state plan.

PRA Disclosure Statement

SPA# OR-13-0123 Approval Date: FEB i Q 2014 Effective Date: January 1, 2014

Page | of 2

a

Cems. CHIP Eligibility

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB contro! number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1 850.

SPA# OR-13-0123 Approval Date EB 4 0 2016 Effective Date: January 1, 2014 Page 2 of 2

ne

Cems. CHIP Eligibility

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

42 CFR 457.570

Non-Payment of Premiums

Does the state impose premiums or enrollment fees? No

PRA Disclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop 4-26-05, Baltimore, Maryland 21244-1850.

V.20130709

FEB 1 0 2016

SPA# OR-13-0123 Approval Date: Effective Date: January 1, 2014 Page | of 1

Cems. CHIP Eligibility

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

2105(a)(4)(A) of the SSA and 42 CFR 457.342 and 435.926

The CHIP Agency may provide that children who have been determined eligible under the state plan shall remain eligible, regardless of any changes in the family’s circumstances, during a continuous eligibility period up to 12 months, or until the time the child reaches an age specified by the state (not to exceed age 19), whichever is earlier. .

The CHIP Agency elects to provide continuous eligibility to children under this provision. |Yes

@ For children up to age 19

C For children up to age

The continuous eligibility period begins on the effective date of the child's most recent determination or redetermination of eligibility, and ends:

[Ml Atthe end ofthe |12 | months continuous eligibility period.

Exceptions to the continuous eligibility period: [ll The child attains the age specified by the state Agency or age 19. [| The child or child's representative requests voluntary disenrollment. [Ml] The child is no longer a resident of the state.

i The Agency determines that eligibility was erroneously granted at the most recent determination or renewal of eligibility because of Agency error or fraud, abuse, or perjury attributed to child or child's representative.

{i The child dies.

[ There is a failure to pay required premiums or enrollment fees on behalf of a child, as provided for in the state plan.

(7) Other

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance

Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. V.20130717

SPA# OR-13-0123 Approval Date: FEB 1 Q 2014 . Effective Date: January 1, 2014

Page 1 of 1

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

42 CFR 457.355 and 435.1102, 2107(e)(1)(L) and 1920A of the SSA

The CHIP Agency covers children when determined presumptively eligible by a qualified entity. |Yes

[ll Describe the population of children to whom presumptive eligibility applies:

Targeted Low-income Children (2102(b)(1)(B)(v) of the SSA and 42 CFR 457.310, 315 and 320)

{M Describe the duration of the presumptive eligibility period and any limitations:

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

[ii] Describe the application process and eligibility determination factors used:

The Hospital is responsible for making immediate eligibility determinations that:

Are initiated using the OHA Hospital Presumptive Medical application (OHP 7260) and are based only on information provided by the applicant or his/her representative in Part 1 of the OHP 7260. No additional documentation or verification may be required at the time of the Hospital Presumptive Medical eligibility determination. Information required in order for the hospital to make the determinations are: Applicant’s full legal name; Household’s gross monthly income and size; citizenship; state residency; and previous period of Hospital Presumptive Medical Assistance.

At the time of the presumptive determination, the Hospital gives the applicant immediate written notice of whether s/he is eligible, or ineligible, for Hospital Presumptive Medical coverage.

Within 2 working days of each Hospital Presumptive Medical eligibility determination, the Hospital is responsible for submitting the a copy of the completed Approval or Denial Notice issued to the applicant, and A copy of the applicant’s completed Hospital Presumptive Medical application to OHP Customer Service.

[l) The CHIP Agency uses qualified entities, as defined in section 1920A, to determine eligibility presumptively for children.

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

oO Furnishes health care items and services covered under the approved plan and is eligible to receive payments under the approved plan

SPA# OR-13-0123 Approval Date: FEB { y ANI Effective Date: January 1, 2014

Page 1 of 3

CccMs. CHIP Eligibility

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

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

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

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

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

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

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

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

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

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

Any other entity the state so deems, as approved by the Secretary

Name of entity Description

A qualified hospital 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 : oe consistent with state policies and procedures. xX 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.

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

An attachment is submitted.

SPA# OR-13-0123 Approval Date: FER 4 it] BIT Effective Date: January 1, 2014

Page 2 of 3

Cems. CHIP Eligibility

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of

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

V.20130709

SPA# OR-13-0123 Approval Date: FEB i 0 204 Effective Date: January 1, 2014

Page 3 of 3

_____________________________________________________________________________

Table of Contents

State/Territory Name: Oregon

State Plan Amendment (SPA) #: OR-13-0122

This file contains the following documents in the order listed:

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

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

DEPARTMENT OF HEALTH & HUMAN SERVICES

Centers for Medicare & Medicaid Services (CMs

7500 Security Boulevard, Mail Stop: S2-26-12 or M Ss CENTERS FOR MEDICARE & MEDICAID SERVICES.

Baltimore, Maryland 21244-1850

CENTER FOR MEDICAID & CHIP SERVICES

Children and Adults Health Programs Group

FEB 0 3 2014

Ms. Judy Mohr Peterson

Administrator

Division of Medical Assistance Programs Oregon Health Authority

500 Summer Street Northeast, E-49 Salem, Oregon 97301-1079

Dear Ms. Mohr Peterson:

I am pleased to inform you that your Title XXI Children’s Health Insurance Program (CHIP) state plan amendment (SPA) numbers OR 13-0124 and OR-13-0122, related to Modified Adjusted Gross Income (MAGI) Eligibility, have been approved with an effective date of January 1, 2014.

XXI Medicaid Expansion

SPA number OR 13-0124 converts the state’s existing income eligibility standards to modified adjusted gross income (MAGI)-equivalent standards, by age group, for children covered in its title XXI-funded Medicaid program. A copy of the approved state plan page (CS3) is attached, and should be incorporated into the state’s approved CHIP state plan. This page supersedes the current Medicaid expansion Section (4.0) of the current CHIP state plan.

Establish 2101(f) Group:

SPA number OR-13-0122 describes the state’s plan to provide coverage in its separate CHIP, as specified in the state’s submission of CS14: Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards. A copy of the approved state plan page (CS14) is attached, and should be incorporated within a separate subsection under Section 4.1 of Oregon’s approved CHIP state plan.

Your title XXI project officer is Ms. Victoria Collins. She is available to answer questions concerning this amendment and other CHIP-related issues. Ms. Collins’ contact information is as follows:

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

7500 Security Boulevard

Baltimore, MD 21244-1850

Telephone: (410) 786-2167

Facsimile: (410) 786-5943

Page 2 — Ms. Judy Mohr Peterson

E-mail: Victoria.Collins@cms.hhs.gov

Official communications regarding program matters should be sent simultaneously to Ms. Collins and to Ms. Carol Peverly, Associate Regional Administrator (ARA) in our Seattle Regional Office. Ms. Peverly’s address is:

Centers for Medicare & Medicaid Services

Division of Medicaid and Children’s Health Operations 2201 6" Avenue, Mail Stop RX-43

Seattle, Washington 98121

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

Sincerely,

Eliot Fishman Director

Enclosures ce: Ms. Carol Peverly, CMS Region X, Seattle

logged in as TONIABROWN(CMS CO Staff) read only mode application rev p01 Children's Health Insurance Program Eligibility OR.0502.R00.00 - Jan 01, 2014 Home Logout Finder Save Validate Print Help Control Panel General Information File Management Tribal Input Summary State/Territory name: Oregon State Funds: $ Federal Funds: $ Submitted By: Jesse Anderson Last Revision Date: Nov 12, 2013 Submit Date: Nov 12, 2013 Children's Health Insurance Program Eligibility: Summary Page Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. OR-13-0122 Type of SPA: MAGI Eligibility & Methods XXI Medicaid Expansion Establish 2101(f) Group Eligibility Processing Non-Financial Eligibility Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation Section 2101(f) of the ACA Federal Budget Impact This SPA has a budget impact. Total budget impact: Subject of Amendment Please provide a brief summary of SPA changes. Character Count:154 out of 2000 This transmittal is being submitted to reflect the ACA eligibility templates SPAs which include single streamlined application process, screen and enroll. Signature of State Agency Official Page 1 of 2 Children's Health Insurance Program Eligibility: CMS 179 08/28/2014 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

FAQs | Site Map | Contact | Medicaid.gov | CMS.gov Page 2 of 2 Children's Health Insurance Program Eligibility: CMS 179 08/28/2014 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

CHIP Eligibility

OMB Control Number: 0938-1148 0/31/2014

42 CFR 457.320(a)(2) and (3)

Age and Household Income Ranges

There should be no overlaps or gaps for the ages entered.

Income eligibility for children under the Medicaid Expansion is determined in accordance with the following income standards:

From Age To Age Above (% FPL) Up to & including (% FPL) 19 100 133 1 133 185

PRA Disclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

SPA# OR 13-0124

Approval Date:

FEB 0 3 2014

Effective Date: January 1, 2014 Page 1 of 1

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

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

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

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

The state assures that separate CHIP coverage will be provided for children ineligible for Medicaid due to the elimination of

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

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

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

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

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

(% FPL

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

C Other.

Describe the benefits provided to this population:

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

C Other (consistent with Section 2103 of the SSA and 42 CFR 457 Subpart D).

Describe premiums and cost sharing required of this population:

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

FEB 0 3 2014

SPA# OR-13-0122 Approval Date: Effective Date: January 1, 2014

Page 1 of 2

CHIP Eligibility

C:Premiums and cost sharing are the same as for targeted low-income children in the state's separate CHIP. (No premiums, copayments, deductibles, coinsurance or other cost sharing is required.

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

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

SPA# OR-13-0122 Approval Date: FEB 0 3 2014 Effective Date: January 1, 2014 Page 2 of 2

_____________________________________________________________________________

Table of Contents

State/Territory Name: Oregon

State Plan Amendment (SPA) #: OR-13-0123

This file contains the following documents in the order listed:

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

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

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

Baltimore, Maryland 21244-1850 NNER bon MEDICAID E Chip SeNvIC

‘CENTER FOR MEDICAID & CHIP SERVICES

Children and Adults Health Programs Group

Ms. Judy Mohr Peterson FEB 1 0 2014 Administrator

Division of Medical Assistance Programs

Oregon Health Authority

500 Summer Street Northeast, E-49

Salem, OR 97301-1079

Dear Ms. Mohr Peterson:

I am pleased to inform you that your Title XXI Children’s Health Insurance Program (CHIP) state plan amendment (SPA) numbers OR 13-0120 and OR-13-0123, related to Modified Adjusted Gross Income (MAGI) Eligibility, have been approved with an effective date of January 1, 2014.

MAGI Eligibility & Methods:

SPA number OR-13-0120 provides assurance on page CS15 that the state will apply methodologies based on MAGI for all separate CHIP covered groups, using the approved MAGI conversion plan income thresholds. The state indicates on page CS7 that it will cover targeted low-income children, and indicates on page CS9 that it will cover children from conception to birth when the mother is not eligible for Medicaid. Page CS13 indicates that the state elects to cover as deemed newborns children born to mothers enrolled as targeted low-income children in CHIP or enrolled in the section 1115 demonstration, Oregon Health Plan. A copy of the approved CS15 is attached and should be incorporated within a separate subsection under Section 4.3 of the state’s approved CHIP state plan. A copy of the approved CS7 and CS9 are attached and together supersede the current Geographic Area, Age and Income Sections 4.1.1, 4.1.2 and 4.1.3 of the current CHIP state plan. A copy of the approved CS13 is attached and should be incorporated under Section 4.3 of the state’s approved CHIP state plan.

Non-Financial Eligibility:

SPA number OR-13-0123 is approved to clarify the state’s non-financial eligibility policies on residency, citizenship, social security numbers, non-payment of premiums, continuous eligibility and presumptive eligibility. Copies of the approved state plan pages are attached and these approved pages supersede sections of Oregon's current state plan as detailed below:

Page 2 — Ms. Judy Mohr Peterson

New State Plan Page Impact on Current State Plan Section CS17: Non-Financial Eligibility — Residency | Section 4.1.5 CS18: Non-Financial Eligibility — Citizenship | Section 4.1.0; 4.1-LR; 4.1.1-LR CS19: Non-Financial Eligibility — Social Section 4.1.9.1 Security Number C821: Non-Payment of Premiums Section 8.7 C827: General Eligibility —- Continuous Section 4.1.8 Eligibility CS28: General Eligibility - Presumptive Section 4.4.3 Eligibility for Children

Your title XX] project officer is Ms. Victoria Collins. She is available to answer questions concerning this amendment and other CHIP-related issues. Ms. Collins’ contact information is as follows:

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

7500 Security Boulevard

Baltimore, MD 21244-1850

Telephone: (410) 786-2167

Facsimile: (410) 786-5943

E-mail: Victoria.Collins@cms.hhs.gov

Official communications regarding program matters should be sent simultaneously to Ms. Collins and to Ms. Carol Peverly, Associate Regional Administrator (ARA) in our Seattle Regional Office. Ms. Peverly’s address is:

Centers for Medicare & Medicaid Services

Division of Medicaid and Children’s Health Operations 2201 6" Avenue, Mail Stop RX-43

Seattle, Washington 98121

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

Sincerely,

Eliot Fishman Director

Enclosures ce: Ms. Carol Peverly, ARA, CMS Region X, Seattle ‘

logged in as TONIABROWN(CMS CO Staff) read only mode application rev p01 Children's Health Insurance Program Eligibility OR.0503.R00.00 - Jan 01, 0014 Home Logout Finder Save Validate Print Help Control Panel General Information File Management Tribal Input Summary State/Territory name: Oregon State Funds: $ Federal Funds: $ Submitted By: Siani Kayani Last Revision Date: Feb 4, 2014 Submit Date: Nov 12, 2013 Children's Health Insurance Program Eligibility: Summary Page Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. OR-13-0123 Type of SPA: MAGI Eligibility & Methods XXI Medicaid Expansion Establish 2101(f) Group Eligibility Processing Non-Financial Eligibility Proposed Effective Date 01/01/0014 (mm/dd/yyyy) Federal Statute/Regulation Citation 42 CFR 457.320, 457.340, 457.310, 457.570, 457.342, 435.926, 457.355 and 435.1102 Federal Budget Impact This SPA has a budget impact. Total budget impact: Subject of Amendment Please provide a brief summary of SPA changes. Character Count:234 out of 2000 This transmittal is being submitted to reflect the ACA eligibility templates SPAs which include such things as the income levels, single streamlined application process, residency and citizenship and Hospital presumptive eligibility. Signature of State Agency Official Page 1 of 2 Children's Health Insurance Program Eligibility: CMS 179 08/28/2014 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

FAQs | Site Map | Contact | Medicaid.gov | CMS.gov Page 2 of 2 Children's Health Insurance Program Eligibility: CMS 179 08/28/2014 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

Cems CHIP Eligibility

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

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

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

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

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

In determining family size for the eligibility determination of the other individuals in a household that includes a pregnant woman: C The pregnant woman is counted just as herself. C The pregnant woman is counted just as herself, plus one. (@ The pregnant woman is counted as herself, plus the number of children she is expected to deliver. Financial eligibility is determined consistent with the following provisions: When determining eligibility for new applicants, financial eligibility is based on current monthly income and family size. When determining eligibility for current beneficiaries, financial eligibility is based on: @ Current monthly household income and family size. C Projected annual household income for the remaining months of the current calendar year and family size. In determining current monthly or projected annual household income, the state will use reasonable methods to: (7 Include a prorated portion of the reasonably predictable increase in future income and/or family size. Account for a reasonably predictable decrease in future income and/or family size.

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

Household income includes actually available cash support, exceeding nominal amounts, provided

by the person claiming an individual described at §435.603(f)(2)(i) as a tax dependent. No

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

An attachment is submitted.

PRA Disclosure Statement

SPA# OR-13-0120 Approval Date: FEB { 0 2014 Effective Date: January 1, 2014 Page 1 of 2

Oe

CEmMs. CHIP Eligibility

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB contro! number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

FEB 10 2014

SPA# OR-13-0120 Approval Date: Effective Date: January 1, 2014 Page 2 of 2

A Cems. CHIP Eligibility

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

2102(b)(1)(B)(v) of the SSA and 42 CFR 457.310, 315 and 320

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

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

Must be under age 19.

Income Standards

Income standards are applied statewide.

Are there any exceptions, e.g. populations in a county which may qualify under either a statewide income No standard or a county income standard?

Statewide Income Standards

Begin with lowest age range first.

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

From Age To Age Above (% FPL) Up to & including (% FPL) # |b 1 185 300 x +i 19 133 300 x

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

Special Program for Children with Disabilities

Does the state have a special program for children with disabilities?

PRA Disclosure Statement

SPA# OR-13-0120 Approval Date: FEB 1 0 2014 Effective Date: January 1, 2014 Page 1 of 2

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Cems. CHIP Eligibility

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1 148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

V.20130709

FEB 10 2014

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

42 CFR 457.10

[lM] Coverage From Conception to Birth - Coverage from conception to birth when the mother is not eligible for Medicaid. The CHIP Agency operates this covered group in accordance with the following provisions:

Age Standard

From conception through birth.

Does the state have an additional age definition or other age-related conditions? [No

Income Standards

Income standards are applied statewide. |Yes

Are there any exceptions, e.g. populations in a county which may qualify under either a statewide income standard or a No county income standard?

Statewide Income Standard

The statewide income standard is: From zero up to }185 | % FPL

[]) Exempted from requirement of providing or applying for a Social Security Number.

[i] Exempted from requirement of verifying citizenship status.

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

FEB 10 2014

SPA# OR-13-0120 Approval Date: Effective Date: January 1, 2014

Page 1 of 1

Cems CHIP Eligibility

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

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

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

The state operates this covered group in accordance with the following provisions: Pp [li] The child was born to an eligible targeted low-income pregnant woman under section 2112 of the SSA.

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

The state elects the following option(s):

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

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

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

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of

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

SPA# OR-13-0120 Approval Date: FEB 1 0 2014

Effective Date: January 1, 2014 Page 1 of 1

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

Non-Fii

42 CFR 457.320

Residency

The CHIP Agency provides CHIP to otherwise eligible residents of the state, including residents who are absent from the state under certain conditions. A child is considered to be a resident of the state under the following conditions: ry A non-institutionalized child, if capable of indicating intent and who is emancipated or married, if the child is living in the state and: 1. Intends to reside in the state, including without a fixed address, or

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

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

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

resides. An institutionalized child, who is not a ward of the state, if the state is the state of residence of the child's custodial parent or

Cy caretaker at the time of placement, or [ll] A child who is a ward of the state regardless of where the child lives, or A child physically located in the state when there is a dispute with one or more states as to the child's actual state of

Cy residence.

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

[lj A non-institutionalized pregnant woman who is living in the state and:

1. Intends to reside in the state, including without a fixed address, or if incapable of indicating intent, is living in the state, or

2. Entered with a job commitment or seeking employment, whether or not currently employed. rl An institutionalized pregnant woman placed in an out-of-state-institution, as defined in 42 CFR 435.1010, including foster care homes, by an agency of the state, or rl An institutionalized pregnant woman residing in an in-state-institution, as defined in 42 CFR 435.1010, whether or not the individual established residency in the state prior to entering the institution, or A pregnant woman physically located in the state when there is a dispute with one or more states as to the pregnant woman's

Cy actual state of residence.

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

FEB 1 u Zuid Effective Date: January 1, 2014 Page 1 of 2

SPA# OR-13-0123 Approval Date:

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Cems. CHIP Eligibility

One or more interstate agreement(s). No

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

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of

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

SPA# OR-13-0123 Approval Date: FEB i 0 2018 Effective Date: January 1, 2014 Page 2 of 2

ccmMs. CHIP Eligibility

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

git

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

Citizenship

The CHIP Agency provides CHIP eligibility to otherwise eligible citizens and nationals of the United States and certain non-citizens,

including the time period during which they are provided with reasonable opportunity to submit verification of their citizenship, national status or satisfactory immigration status.

[Mi] The CHIP Agency provides eligibility under the Plan to otherwise eligible individuals:

Who are citizens or nationals of the United States; or

Who are qualified non-citizens as defined in section 431 of the Personal Responsibility and Work Opportunity Reconciliation

Act (PRWORA) (8 U.S.C. §1641), or whose eligibility is required by section 402(b) of PRWORA (8 U.S.C. §1612(b)) and is not prohibited by section 403 of PRWORA (8 U.S.C. §1613); or

Who have declared themselves to be citizens or nationals of the United States, or an individual having satisfactory immigration| status, during a reasonable opportunity period pending verification of their citizenship, nationality, or satisfactory immigration status consistent with requirements of 1903(x), 1137(d), and 1902(ee) of the Act, and 42 CFR 435.406, 407, 956 and 457.380.

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

The agency provides for an extension of the reasonable opportunity period if the individual is making a good faith effort

to resolve any inconsistencies or obtain any necessary documentation, or the agency needs more time to complete the Yes verification process.

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

The date benefits are furnished is: @ The date of application containing the declaration of citizenship or immigration status. C The date the reasonable opportunity notice is sent.

C Other date, as described:

The CHIP Agency elects the option to provide CHIP coverage to otherwise eligible children up to age 19, lawfully residing Yes in the United States, as provided in Section 2107(e)(1)(J) of the SSA (Section 214 of CHIPRA 2009, P.L. 111-3).

Otherwise eligible children means children meeting the eligibility requirements of targeted low-income children with the exception of non-citizen status.

The CHIP Agency provides assurance that lawfully residing children are also covered under the state's Medicaid program. Prep 4 ff ag SPA# OR-13-0123 Approval Date: tEO 7 U 2014 Effective Date: January 1, 2014

Page 1 of 3

Cems CHIP Eligibility

The CHIP Agency elects the option to provide CHIP coverage to otherwise eligible pregnant women, lawfully residing in the United States, as provided in Section 214 of CHIPRA 2009, P.L. 111-3. The state may not select this option unless the state also elects to cover lawfully residing children. A state may not select this option unless the state also covers Targeted Low- Income Pregnant Women.

aw An individual is considered to be lawfully residing in the United States if he or she is lawfully present and meets state residency requirements.

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

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

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

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

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

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

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

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

(vii) Granted an administrative stay of removal under 8 CFR 241;

(viii) Beneficiary of approved visa petition who has a pending application for adjustment of status;

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

(i) Has been granted employment authorization; or

(ii) Is under the age of 14 and has had an application pending for at least 180 days; 6. Has been granted withholding of removal under the Convention Against Torture; 7. 1s a child who has a pending application for Special Immigrant Juvenile status as described in 8 U.S.C.1 101(ay(27)(N); 8. Is lawfully present in American Samoa under the immigration laws of American Samoa; or

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

SPA# OR-13-0123 Approval Date: EER 4 fe Hts Effective Date: January 1, 2014

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Cems CHIP Eligibility

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

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

SPA# OR-13-0123 Approval Date: FER 4 i] ons Effective Date: January 1, 2014

Page 3 of 3

Cems. CHIP Eligibility

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

42 CFR 457.340(b)

Social Security Number As acondition of eligibility, the CHIP Agency must require individuals who have a social security number or are eligible for one as determined by the Social Security Administration, to furnish their social security number, or numbers if they have more than one number.

The CHIP Agency requires individuals, as a condition of eligibility, to furnish their social security number(s), with the following exceptions:

Individuals refusing to obtain a social security number (SSN) because of well established religious objections, or Individuals who are not eligible for an SSN, or

Individuals who are issued an SSN only for a valid non-work purpose.

ry The CHIP Agency assists individuals, who are required to provide their SSN, to apply for or obtain an SSN from the Social Security Administration if the individual does not have or forgot their SSN.

{M] The CHIP Agency informs individuals required to provide their SSN: By what statutory authority the number is solicited; and

How the state will use the SSN.

The CHIP Agency provides assurance that it will verify each SSN furnished by an applicant or beneficiary with the Social Security Administration, not deny or delay services to an otherwise eligible applicant pending issuance or verification of the individual's SSN by the Social Security Administration and that the state's utilization of the SSNs is consistent with sections 205 and 1137 of the Social Security Act and the Privacy Act of 1974.

The state may request non-applicant household members to voluntarily provide their SSN, if the state meets the requirements below.

The state requests non-applicant household members to voluntarily provide their Ves SSN.

When requesting an SSN for non-applicant household members, the state assures that:

Ir At the time such SSN is requested, the state informs the non-applicant that this information is voluntary and provides information regarding how the SSN will be used; and

rT The state only uses the SSN for determination of eligibility for CHIP or other insurance affordability programs, or for a purpose directly connected with the administration of the state plan.

PRA Disclosure Statement

SPA# OR-13-0123 Approval Date: FEB i Q 2014 Effective Date: January 1, 2014

Page | of 2

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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 contro! number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1 850.

SPA# OR-13-0123 Approval Date EB 4 0 2016 Effective Date: January 1, 2014 Page 2 of 2

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Cems. CHIP Eligibility

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

42 CFR 457.570

Non-Payment of Premiums

Does the state impose premiums or enrollment fees? No

PRA Disclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop 4-26-05, Baltimore, Maryland 21244-1850.

V.20130709

FEB 1 0 2016

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Cems. CHIP Eligibility

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

2105(a)(4)(A) of the SSA and 42 CFR 457.342 and 435.926

The CHIP Agency may provide that children who have been determined eligible under the state plan shall remain eligible, regardless of any changes in the family’s circumstances, during a continuous eligibility period up to 12 months, or until the time the child reaches an age specified by the state (not to exceed age 19), whichever is earlier. .

The CHIP Agency elects to provide continuous eligibility to children under this provision. |Yes

@ For children up to age 19

C For children up to age

The continuous eligibility period begins on the effective date of the child's most recent determination or redetermination of eligibility, and ends:

[Ml Atthe end ofthe |12 | months continuous eligibility period.

Exceptions to the continuous eligibility period: [ll The child attains the age specified by the state Agency or age 19. [| The child or child's representative requests voluntary disenrollment. [Ml] The child is no longer a resident of the state.

i The Agency determines that eligibility was erroneously granted at the most recent determination or renewal of eligibility because of Agency error or fraud, abuse, or perjury attributed to child or child's representative.

{i The child dies.

[ There is a failure to pay required premiums or enrollment fees on behalf of a child, as provided for in the state plan.

(7) Other

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance

Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. V.20130717

SPA# OR-13-0123 Approval Date: FEB 1 Q 2014 . Effective Date: January 1, 2014

Page 1 of 1

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

42 CFR 457.355 and 435.1102, 2107(e)(1)(L) and 1920A of the SSA

The CHIP Agency covers children when determined presumptively eligible by a qualified entity. |Yes

[ll Describe the population of children to whom presumptive eligibility applies:

Targeted Low-income Children (2102(b)(1)(B)(v) of the SSA and 42 CFR 457.310, 315 and 320)

{M Describe the duration of the presumptive eligibility period and any limitations:

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

[ii] Describe the application process and eligibility determination factors used:

The Hospital is responsible for making immediate eligibility determinations that:

Are initiated using the OHA Hospital Presumptive Medical application (OHP 7260) and are based only on information provided by the applicant or his/her representative in Part 1 of the OHP 7260. No additional documentation or verification may be required at the time of the Hospital Presumptive Medical eligibility determination. Information required in order for the hospital to make the determinations are: Applicant’s full legal name; Household’s gross monthly income and size; citizenship; state residency; and previous period of Hospital Presumptive Medical Assistance.

At the time of the presumptive determination, the Hospital gives the applicant immediate written notice of whether s/he is eligible, or ineligible, for Hospital Presumptive Medical coverage.

Within 2 working days of each Hospital Presumptive Medical eligibility determination, the Hospital is responsible for submitting the a copy of the completed Approval or Denial Notice issued to the applicant, and A copy of the applicant’s completed Hospital Presumptive Medical application to OHP Customer Service.

[l) The CHIP Agency uses qualified entities, as defined in section 1920A, to determine eligibility presumptively for children.

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

oO Furnishes health care items and services covered under the approved plan and is eligible to receive payments under the approved plan

SPA# OR-13-0123 Approval Date: FEB { y ANI Effective Date: January 1, 2014

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

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

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

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

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

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

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

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

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

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

Any other entity the state so deems, as approved by the Secretary

Name of entity Description

A qualified hospital 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 : oe consistent with state policies and procedures. xX 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.

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

An attachment is submitted.

SPA# OR-13-0123 Approval Date: FER 4 it] BIT Effective Date: January 1, 2014

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PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of

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

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_____________________________________________________________________________

Table of Contents

State/Territory Name: Oregon

State Plan Amendment (SPA) #: OR-13-0124

This file contains the following documents in the order listed:

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

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

DEPARTMENT OF HEALTH & HUMAN SERVICES

Centers for Medicare & Medicaid Services (CMs

7500 Security Boulevard, Mail Stop: S2-26-12 or M Ss CENTERS FOR MEDICARE & MEDICAID SERVICES.

Baltimore, Maryland 21244-1850

CENTER FOR MEDICAID & CHIP SERVICES

Children and Adults Health Programs Group

FEB 0 3 2014

Ms. Judy Mohr Peterson

Administrator

Division of Medical Assistance Programs Oregon Health Authority

500 Summer Street Northeast, E-49 Salem, Oregon 97301-1079

Dear Ms. Mohr Peterson:

I am pleased to inform you that your Title XXI Children’s Health Insurance Program (CHIP) state plan amendment (SPA) numbers OR 13-0124 and OR-13-0122, related to Modified Adjusted Gross Income (MAGI) Eligibility, have been approved with an effective date of January 1, 2014.

XXI Medicaid Expansion

SPA number OR 13-0124 converts the state’s existing income eligibility standards to modified adjusted gross income (MAGI)-equivalent standards, by age group, for children covered in its title XXI-funded Medicaid program. A copy of the approved state plan page (CS3) is attached, and should be incorporated into the state’s approved CHIP state plan. This page supersedes the current Medicaid expansion Section (4.0) of the current CHIP state plan.

Establish 2101(f) Group:

SPA number OR-13-0122 describes the state’s plan to provide coverage in its separate CHIP, as specified in the state’s submission of CS14: Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards. A copy of the approved state plan page (CS14) is attached, and should be incorporated within a separate subsection under Section 4.1 of Oregon’s approved CHIP state plan.

Your title XXI project officer is Ms. Victoria Collins. She is available to answer questions concerning this amendment and other CHIP-related issues. Ms. Collins’ contact information is as follows:

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

7500 Security Boulevard

Baltimore, MD 21244-1850

Telephone: (410) 786-2167

Facsimile: (410) 786-5943

Page 2 — Ms. Judy Mohr Peterson

E-mail: Victoria.Collins@cms.hhs.gov

Official communications regarding program matters should be sent simultaneously to Ms. Collins and to Ms. Carol Peverly, Associate Regional Administrator (ARA) in our Seattle Regional Office. Ms. Peverly’s address is:

Centers for Medicare & Medicaid Services

Division of Medicaid and Children’s Health Operations 2201 6" Avenue, Mail Stop RX-43

Seattle, Washington 98121

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

Sincerely,

Eliot Fishman Director

Enclosures ce: Ms. Carol Peverly, CMS Region X, Seattle

logged in as TONIABROWN(CMS CO Staff) read only mode application rev p01 Children's Health Insurance Program Eligibility OR.0504.R00.00 - Jan 01, 2014 Home Logout Finder Save Validate Print Help Control Panel General Information File Management Tribal Input Summary State/Territory name: Oregon State Funds: $ Federal Funds: $ Submitted By: Jesse Anderson Last Revision Date: Jan 14, 2014 Submit Date: Nov 12, 2013 Children's Health Insurance Program Eligibility: Summary Page Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. OR-13-0124 Type of SPA: MAGI Eligibility & Methods XXI Medicaid Expansion Establish 2101(f) Group Eligibility Processing Non-Financial Eligibility Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation 42 CFR 457.320(a)(2) and (3) Federal Budget Impact This SPA has a budget impact. Total budget impact: Subject of Amendment Please provide a brief summary of SPA changes. Character Count:168 out of 2000 This transmittal is being submitted to reflect the ACA eligibility templates SPAs which include The movement of current CHIP children to Medicaid between 100%-133%FPL. Signature of State Agency Official Page 1 of 2 Children's Health Insurance Program Eligibility: CMS 179 08/28/2014 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

FAQs | Site Map | Contact | Medicaid.gov | CMS.gov Page 2 of 2 Children's Health Insurance Program Eligibility: CMS 179 08/28/2014 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

CHIP Eligibility

OMB Control Number: 0938-1148 0/31/2014

42 CFR 457.320(a)(2) and (3)

Age and Household Income Ranges

There should be no overlaps or gaps for the ages entered.

Income eligibility for children under the Medicaid Expansion is determined in accordance with the following income standards:

From Age To Age Above (% FPL) Up to & including (% FPL) 19 100 133 1 133 185

PRA Disclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

SPA# OR 13-0124

Approval Date:

FEB 0 3 2014

Effective Date: January 1, 2014 Page 1 of 1

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

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

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

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

The state assures that separate CHIP coverage will be provided for children ineligible for Medicaid due to the elimination of

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

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

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

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

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

(% FPL

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

C Other.

Describe the benefits provided to this population:

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

C Other (consistent with Section 2103 of the SSA and 42 CFR 457 Subpart D).

Describe premiums and cost sharing required of this population:

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

FEB 0 3 2014

SPA# OR-13-0122 Approval Date: Effective Date: January 1, 2014

Page 1 of 2

CHIP Eligibility

C:Premiums and cost sharing are the same as for targeted low-income children in the state's separate CHIP. (No premiums, copayments, deductibles, coinsurance or other cost sharing is required.

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

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

SPA# OR-13-0122 Approval Date: FEB 0 3 2014 Effective Date: January 1, 2014 Page 2 of 2

_____________________________________________________________________________ Table of Contents State/Territory Name: Oregon State Plan Amendments (SPA) #: OR-18-0128 This file contains the following documents in the order listed: 1) Approval Letter 2) State Plan Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES

Centers for Medicare & Medicaid Services

7500 Security Boulevard, Mail Stop S2-01-16 « ea Sam, Baltimore, MD 21244-1850

CENTERS FOR MEDICARE & MEDICAID SERVICES CENTER FOR MEDICAID & CHIP SERVICES

Children and Adults Health Programs Group

SEP 12 2019

Lori Coyner

Medicaid Director

Oregon Health Authority

500 Summer Street Northeast, E-49 Salem, OR 97301-1079

Dear Ms. Coyner:

Your title XXI Children’s Health Insurance Program (CHIP) state plan amendment (SPA) OR- 18-0128 submitted on June 29, 2018, with additional information submitted on September 9, 2019, has been approved. Through this SPA, Oregon implements mental health parity requirements to ensure that treatment limitations applied to mental health (MH) and substance use disorder (SUD) benefits are no more restrictive than those applied to medical/surgical (M/S) benefits. This SPA has an effective date of October 1, 2017 with the exception of the changes described below. ;

Section 2103(c)(7)(A) of the Social Security Act (the Act), as implemented through regulations at 42 CFR 457.496(d)(3)-(5), requires states that provide both M/S and MH/SUD benefits to ensure that treatment limitations applied to MH/SUD benefits covered under the state child health plan are consistent with the mental health parity requirements of section 2705(a) of the Public Health Service Act, in the same manner that such requirements apply to a group health plan. Oregon demonstrated compliance by providing the necessary assurances and supporting documentation that the state’s application of non-quantitative treatment limitations (NQTLs) to MH/SUD benefits are consistent with section 2103(c)(7)(A) of the Act.

In order to comply with parity requirements, Oregon identified several issues during its parity analysis process that required modifications to NQTL policies by some of its health plans. Key changes related to the following: 1) ensuring behavioral health medical necessity is based on evidence-based criteria; 2) standardizing frequency and timelines for utilization management and appeals processes across behavioral and medical/surgical services; 3) requiring that denial decisions only be made by professional peers for behavioral health services; and 4) creating consistent policies for out-of-network and out-of-state limits across all types of services. The majority of these issues were remedied by Oregon’s health plans by January 1, 2019, but no later than March 31, 2019.

This approval relates only to benefits provided under the CHIP state plan; Medicaid benefits will be analyzed separately.

Page 2 - Ms. Lori Coyner Your title XXI project officer is Ms. Janice Adams. She is available to answer questions concerning this amendment and other CHIP-related issues. Her contact information is as follows: Centers for Medicare & Medicaid Services Center for Medicaid and CHIP Services 701 Fifth Avenue, Suite 1600, Mail Stop: RX-200 Seattle, WA 98104 Telephone: (206) 615-2541 E-mail: Janice.Adams@cms.hhs.gov . Official communications regarding program matters should be sent simultaneously to Ms. Adams and to Mr. David Meacham, Deputy Director in our Division of Medicaid Field Operations West. Mr. Meacham's address is: Centers for Medicare & Medicaid Services Division of Medicaid Field Operations West 701 Fifth Avenue, Suite 1600, Mail Stop: RX-200 Seattle, WA 98104 If you have additional questions or concerns, please contact Ms. Amy Lutzky, Director, Division of State Coverage Programs (410)786-0721. Sincerely, /signed Anne Marie Costello/ Anne Mane Costello - - Director cc: Mr. David Meacham, Deputy Director, Division of Medicaid Field Operations West

1

CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT CHILDREN’S HEALTH INSURANCE PROGRAM

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

State/Territory: Oregon

As a condition for receipt of Federal funds under Title XXI of the Social Security Act, (42 CFR 457.40(b)) Designee-Medicaid Director (Signature of Governor, or designee, of State/Territory, Date Signed)

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

The following State officials are responsible for program administration and financial oversight (42 CFR 457.40(c)):

Name: Patrick Allen

Position/Title: Director, OHA Name: David Simnitt

Position/Title: Director, Medicaid/CHIP

Name:

Position/Title:

*Disclosure. 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 (CMS-10398 #34). The time required to complete this information collection is estimated to average 80 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 any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, write to: CMS, 7500 Security Blvd., Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

2 Introduction: Section 4901 of the Balanced Budget Act of 1997 (BBA), public law 105-33 amended the Social Security Act (the Act) by adding a new title XXI, the Children’s Health Insurance Program (CHIP). In February 2009, the Children’s Health Insurance Program Reauthorization Act (CHIPRA) renewed the program. The Patient Protection and Affordable Care Act of 2010 further modified the program. This template outlines the information that must be included in the state plans and the state plan amendments (SPAs). It reflects the regulatory requirements at 42 CFR Part 457 as well as the previously approved SPA templates that accompanied guidance issued to States through State Health Official (SHO) letters. Where applicable, we indicate the SHO number and the date it was issued for your reference. The CHIP SPA template includes the following changes: • Combined the instruction document with the CHIP SPA template to have a single document. Any modifications to previous instructions are for clarification only and do not reflect new policy guidance. • Incorporated the previously issued guidance and templates (see the Key following the template for information on the newly added templates), including: • Prenatal care and associated health care services (SHO #02-004, issued November 12, 2002) • Coverage of pregnant women (CHIPRA #2, SHO # 09-006, issued May 11, 2009) • Tribal consultation requirements (ARRA #2, CHIPRA #3, issued May 28, 2009) • Dental and supplemental dental benefits (CHIPRA # 7, SHO # #09-012, issued October 7, 2009) • Premium assistance (CHIPRA # 13, SHO # 10-002, issued February 2, 2010) • Express lane eligibility (CHIPRA # 14, SHO # 10-003, issued February 4, 2010) • Lawfully Residing requirements (CHIPRA # 17, SHO # 10-006, issued July 1, 2010) • Moved sections 2.2 and 2.3 into section 5 to eliminate redundancies between sections 2 and 5. • Removed crowd-out language that had been added by the August 17 letter that later was repealed. The Centers for Medicare & Medicaid Services (CMS) is developing regulations to implement the CHIPRA requirements. When final regulations are published in the Federal Register, this template will be modified to reflect those rules and States will be required to submit SPAs illustrating compliance with the new regulations. States are not required to resubmit their State plans based on the updated template. However, States must use the updated template when submitting a State Plan Amendment. Federal Requirements for Submission and Review of a Proposed SPA. (42 CFR Part 457 Subpart A) In order to be eligible for payment under this statute, each State must submit a Title XXI plan for approval by the Secretary that details how the State intends to use the funds and fulfill other requirements under the law and regulations at 42 CFR Part 457. A SPA is approved in 90 days unless the Secretary notifies the State in writing that the plan is disapproved or that specified additional information is needed. Unlike Medicaid SPAs, there is only one 90 day review period, or clock for CHIP SPAs, that may be stopped by a request for additional information and restarted after a complete response is received. More information on the SPA review process is found at 42 CFR 457 Subpart A.

3

When submitting a State plan amendment, states should redline the changes that are being made to the existing State plan and provide a “clean” copy including changes that are being made to the existing state plan.

The template includes the following sections: 1. General Description and Purpose of the Children’s Health Insurance Plans and the Requirements- This section should describe how the State has designed their program. It also is the place in the template that a State updates to insert a short description and the proposed effective date of the SPA, and the proposed implementation date(s) if different from the effective date. (Section 2101); (42 CFR 457.70) 2. General Background and Description of State Approach to Child Health Coverage and Coordination- This section should provide general information related to the special characteristics of each state’s program. The information should include the extent and manner to which children in the State currently have creditable health coverage, current State efforts to provide or obtain creditable health coverage for uninsured children and how the plan is designed to be coordinated with current health insurance, public health efforts, or other enrollment initiatives. This information provides a health insurance baseline in terms of the status of the children in a given State and the State programs currently in place. (Section 2103); (42 CFR 457.410(A)) 3. Methods of Delivery and Utilization Controls- This section requires a description that must include both proposed methods of delivery and proposed utilization control systems. This section should fully describe the delivery system of the Title XXI program including the proposed contracting standards, the proposed delivery systems and the plans for enrolling providers. (Section 2103); (42 CFR 457.410(A)) 4. Eligibility Standards and Methodology- The plan must include a description of the standards used to determine the eligibility of targeted low-income children for child health assistance under the plan. This section includes a list of potential eligibility standards the State can check off and provide a short description of how those standards will be applied. All eligibility standards must be consistent with the provisions of Title XXI and may not discriminate on the basis of diagnosis. In addition, if the standards vary within the state, the State should describe how they will be applied and under what circumstances they will be applied. In addition, this section provides information on income eligibility for Medicaid expansion programs (which are exempt from Section 4 of the State plan template) if applicable. (Section 2102(b)); (42 CFR 457.305 and 457.320) 5. Outreach- This section is designed for the State to fully explain its outreach activities. Outreach is defined in law as outreach to families of children likely to be eligible for child health assistance under the plan or under other public or private health coverage programs. The purpose is to inform these families of the availability of, and to assist them in enrolling their children in, such a program. (Section 2102(c)(1)); (42 CFR 457.90) 6. Coverage Requirements for Children’s Health Insurance- Regarding the required scope of health insurance coverage in a State plan, the child health assistance provided must consist of any of the four types of coverage outlined in Section 2103(a) (specifically, benchmark coverage;

4 benchmark-equivalent coverage; existing comprehensive state-based coverage; and/or Secretary- approved coverage). In this section States identify the scope of coverage and benefits offered under the plan including the categories under which that coverage is offered. The amount, scope, and duration of each offered service should be fully explained, as well as any corresponding limitations or exclusions. (Section 2103); (42 CFR 457.410(A)) 7. Quality and Appropriateness of Care- This section includes a description of the methods (including monitoring) to be used to assure the quality and appropriateness of care and to assure access to covered services. A variety of methods are available for State’s use in monitoring and evaluating the quality and appropriateness of care in its child health assistance program. The section lists some of the methods which states may consider using. In addition to methods, there are a variety of tools available for State adaptation and use with this program. The section lists some of these tools. States also have the option to choose who will conduct these activities. As an alternative to using staff of the State agency administering the program, states have the option to contract out with other organizations for this quality of care function. (Section 2107); (42 CFR 457.495) 8. Cost Sharing and Payment- This section addresses the requirement of a State child health plan to include a description of its proposed cost sharing for enrollees. Cost sharing is the amount (if any) of premiums, deductibles, coinsurance and other cost sharing imposed. The cost-sharing requirements provide protection for lower income children, ban cost sharing for preventive services, address the limitations on premiums and cost-sharing and address the treatment of pre- existing medical conditions. (Section 2103(e)); (42 CFR 457, Subpart E) 9. Strategic Objectives and Performance Goals and Plan Administration- The section addresses the strategic objectives, the performance goals, and the performance measures the State has established for providing child health assistance to targeted low income children under the plan for maximizing health benefits coverage for other low income children and children generally in the state. (Section 2107); (42 CFR 457.710) 10. Annual Reports and Evaluations- Section 2108(a) requires the State to assess the operation of the Children’s Health Insurance Program plan and submit to the Secretary an annual report which includes the progress made in reducing the number of uninsured low income children. The report is due by January 1, following the end of the Federal fiscal year and should cover that Federal Fiscal Year. In this section, states are asked to assure that they will comply with these requirements, indicated by checking the box. (Section 2108); (42 CFR 457.750) 11. Program Integrity- In this section, the State assures that services are provided in an effective and efficient manner through free and open competition or through basing rates on other public and private rates that are actuarially sound. (Sections 2101(a) and 2107(e); (42 CFR 457, subpart I) 12. Applicant and Enrollee Protections- This section addresses the review process for eligibility and enrollment matters, health services matters (i.e., grievances), and for states that use premium assistance a description of how it will assure that applicants and enrollees are given the opportunity at initial enrollment and at each redetermination of eligibility to obtain health benefits coverage other than through that group health plan. (Section 2101(a)); (42 CFR 457.1120)

5 Program Options. As mentioned above, the law allows States to expand coverage for children through a separate child health insurance program, through a Medicaid expansion program, or through a combination of these programs. These options are described further below: • Option to Create a Separate Program- States may elect to establish a separate child health program that are in compliance with title XXI and applicable rules. These states must establish enrollment systems that are coordinated with Medicaid and other sources of health coverage for children and also must screen children during the application process to determine if they are eligible for Medicaid and, if they are, enroll these children promptly in Medicaid. • Option to Expand Medicaid- States may elect to expand coverage through Medicaid. This option for states would be available for children who do not qualify for Medicaid under State rules in effect as of March 31, 1997. Under this option, current Medicaid rules would apply.

Medicaid Expansion- CHIP SPA Requirements In order to expedite the SPA process, states choosing to expand coverage only through an expansion of Medicaid eligibility would be required to complete sections: • 1 (General Description) • 2 (General Background) They will also be required to complete the appropriate program sections, including: • 4 (Eligibility Standards and Methodology) • 5 (Outreach) • 9 (Strategic Objectives and Performance Goals and Plan Administration including the budget) • 10 (Annual Reports and Evaluations).

Medicaid Expansion- Medicaid SPA Requirements States expanding through Medicaid-only will also be required to submit a Medicaid State Plan Amendment to modify their Title XIX State plans. These states may complete the first check-off and indicate that the description of the requirements for these sections are incorporated by reference through their State Medicaid plans for sections: • 3 (Methods of Delivery and Utilization Controls) • 4 (Eligibility Standards and Methodology) • 6 (Coverage Requirements for Children’s Health Insurance) • 7 (Quality and Appropriateness of Care) • 8 (Cost Sharing and Payment) • 11 (Program Integrity) • 12 (Applicant and Enrollee Protections)

• Combination of Options- CHIP allows states to elect to use a combination of the Medicaid program and a separate child health program to increase health coverage for children. For example, a State may cover optional targeted-low income children in families with incomes of up to 133 percent of poverty through Medicaid and a targeted group of children above that level through a separate child

6 health program. For the children the State chooses to cover under an expansion of Medicaid, the description provided under “Option to Expand Medicaid” would apply. Similarly, for children the State chooses to cover under a separate program, the provisions outlined above in “Option to Create a Separate Program” would apply. States wishing to use a combination of approaches will be required to complete the Title XXI State plan and the necessary State plan amendment under Title XIX. Proposed State plan amendments should be submitted electronically and one signed hard copy to the Centers for Medicare & Medicaid Services at the following address: Name of Project Officer Centers for Medicare & Medicaid Services 7500 Security Blvd Baltimore, Maryland 21244 Attn: Children and Adults Health Programs Group Center for Medicaid and CHIP Services Mail Stop - S2-01-16

7 Section 1. General Description and Purpose of the Children’s Health Insurance Plans and the Requirements

1.1. The state will use funds provided under Title XXI primarily for (Check appropriate box) (Section 2101)(a)(1)); (42 CFR 457.70):

Guidance: Check below if child health assistance shall be provided primarily through the development of a separate program that meets the requirements of Section 2101, which details coverage requirements and the other applicable requirements of Title XXI.

1.1.1. Obtaining coverage that meets the requirements for a separate child health program (Sections 2101(a)(1) and 2103); OR

Guidance: Check below if child health assistance shall be provided primarily through providing expanded eligibility under the State’s Medicaid program (Title XIX). Note that if this is selected the State must also submit a corresponding Medicaid SPA to CMS for review and approval. 1.1.2. Providing expanded benefits under the State’s Medicaid plan (Title XIX) (Section 2101(a)(2)); OR

Guidance: Check below if child health assistance shall be provided through a combination of both 1.1.1. and 1.1.2. (Coverage that meets the requirements of Title XXI, in conjunction with an expansion in the State’s Medicaid program). Note that if this is selected the state must also submit a corresponding Medicaid state plan amendment to CMS for review and approval. 1.1.3. A combination of both of the above. (Section 2101(a)(2))

1.1-DS

The State will provide dental-only supplemental coverage. Only States operating a separate CHIP program are eligible for this option. States choosing this option must also complete sections 4.1-DS, 4.2-DS, 6.2-DS, 8.2-DS, and 9.10 of this SPA template. (Section 2110(b)(5))

1.2.

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

1.3.

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

8 Guidance: The effective date as specified below is defined as the date on which the State begins to incur costs to implement its State plan or amendment. (42 CFR 457.65) The implementation date is defined as the date the State begins to provide services; or, the date on which the State puts into practice the new policy described in the State plan or amendment. For example, in a State that has increased eligibility, this is the date on which the State begins to provide coverage to enrollees (and not the date the State begins outreach or accepting applications).

1.4. Provide the effective (date costs begin to be incurred) and implementation (date services begin to be provided) dates for this SPA (42 CFR 457.65). A SPA may only have one effective date, but provisions within the SPA may have different implementation dates that must be after the effective date.

Original Plan Effective Date: July 1, 1998

Implementation Date: July 1, 1998

State Plan Amendment #2: Minor revisions to performance measures in approved XXI State Plan Submitted: May 30, 2000 CMS Approved: September 11, 2000

State Plan Amendment #3: Increase enrollment cap to 19,800 Submitted: December 12, 2000 CMS Approved: March 9, 2001

State Plan Amendment #4 Compliance with final CHIP regulations and updated program descriptions Submitted: July 31, 2002 CMS Approved: April 15, 2003

State Plan Amendment #5: Asset limit increase to $10,000 Submitted: August 19, 2004 CMS Approved: November 10, 2004 Effective date: October 1, 2004

State Plan Amendment #6: Duration of eligibility period increased to 12 months Submitted: May 16, 2006 CMS Approved: August 1, 2006 Effective Date: June 1, 2006

9 State Plan Amendment # 7: Unborn child expansion Submitted: July 31, 2007 Approved: April 9, 2008 Effective: April 1, 2008

State Plan Amendment #8: Require SSN on application Submitted: September 13, 2007 Approved: December 12, 2007 Effective: October 1, 2007

State Plan Amendment # 9: Transition the following targeted low income children from Section 1115 demonstration to the state plan: children ages 0 through 18 above 170 percent of the FPL up to 185 percent of the FPL. Submitted: November 30, 2007 Approved: September 16, 2008 Effective: November 1, 2007

State Plan Amendment # 10: This amendment expands the income eligibility level for CHIP children through age 18 from 185 percent of the Federal poverty level (FPL) up to and including 300 percent of the FPL under the State’s Healthy Kids initiative. This SPA is a companion amendment to the State’s section 1115 title XXI demonstration amendment. This SPA also creates a new private insurance option, referred to as Healthy KidsConnect, specifically for children from 200 up to and including 300 percent of the FPL under Secretary-approved coverage under the CHIP state plan. In addition, this SPA institutes an Application Assistance Program to assist families applying for CHIP and other child health programs in the State as part of its Healthy Kids initiative, finances an outreach and enrollment grant program designed to provide culturally-specific and targeted outreach and direct application assistance to families in racial, ethnic and language minority communities living in geographic isolation or with additional access barriers, reduces the waiting period of uninsurance for CHIP coverage from 6 months to 2 months, and eliminates the asset test in CHIP This amendment will have a retroactive effective date of October 1, 2009, for the expansion of eligibility from 185 percent of FPL up to and including 200 percent of the FPL, as well as for the application assistance program, outreach and enrollment grant program, the waiting period reduction, and elimination of the asset test. Submitted: July 27, 2009 Effective: October 1, 2009

This amendment will also have an effective date of January 1, 2010, for the expansion of eligibility above 200 percent of the FPL up to and including 300 percent of the FPL. However, the State must receive approval for its section 1115 demonstration amendment in order to permit children to enroll in its premium

10 assistance programs. Submitted: July 27, 2009 Approved: December 18, 2009 Effective: January 1, 2010.

State Plan Amendment #11: Expand Unborn population coverage to Benton, Clackamas, Hood River, Jackson and Lincoln counties. Submitted: August 26, 2009 Effective: October 1, 2009 This amendment also closes the expansion in Lincoln County effective December 31, 2009. Submitted: December 22, 2009 Approved: September 20, 2010 Effective: January 1, 2009

State Plan Amendment # 12: CHIPRA provisions related to those who have not met the 5 year waiting period for immigrant children. Submitted: July 27, 2009 Approved: May 18, 2010 Effective: October 1, 2009

State Plan Amendment # 13: Designate express lane eligibility agencies as the Supplemental Nutritional Assistance Program (SNAP) and selected Department of Education, National School Lunch Program (NSLP). Submitted: August 9, 2010 Approved: October 21, 2010 Effective: August 1, 2010

State Plan Amendment #14: Expand Unborn population coverage to Lane county. Submitted: October 11, 2010 Effective: January 1, 2011 This Amendment also revises the budget month used for income eligibility Approved: December 30, 2010 Effective: November 1, 2010

State Plan Amendment #15: withdrawn

State Plan Amendment #16: Expand Unborn population coverage to Columbia, Crook, Douglas, Josephine, Jefferson, Morrow, Union and Wasco county. Submitted: March 28, 2011 Effective: July 1, 2011

Approved: May 26, 2011

11

State Plan Amendment #17: (a) Expand Unborn population coverage to Umatilla county. (b) Provisions implementing temporary adjustments to enrollment and redetermination policies and cost sharing requirements for children in families living and/or working in Governor or FEMA declared disaster areas. In the event of a natural disaster, the State will notify CMS that it intends to provide temporary adjustments to its enrollment and/or redetermination policies and cost sharing requirements, the effective and duration date of such adjustments, and the applicable Governor or FEMA declared disaster areas. (c) This amendment also closes the expansion in Josephine county effective July 1, 2011. Submitted: March 29, 2012 Effective: April 1, 2012

Approved: April 30, 2012

State Plan Amendment # 18: This amendment is to provide federal funding for the Oregon Poison Center (OPC) under a health services initiative. Submitted: May 4, 2012 Effective: April 1, 2012

Approved: September 27, 2012

State Plan Amendment # 19: Children currently enrolled in Healthy KidsConnect with incomes between 200 and 300% FPL will be converted to CHIP direct coverage. Expand OHP Plus direct coverage to children to at or below 300% and reduce the period of uninsurance from 2 months to zero. Submitted: 8/29/13 Effective: 8/23/13

This Amendment also expands the unborn population coverage statewide. Submitted: 8/29/13 Effective: 10/1/13

Approved: 11/22/13

State Plan Amendment # 120 (13-0120) ACA MAGI elig. Form CS15 Adds new subsection 4.3.4, CS13 adds new subsection 4.3.5. CS7, CS8 supersede section 4.1.1, 4.1.2 and 4.1.3. Submitted: 11/12/13 Effective: 1/1/14

Approved: 2/10/14

12

State Plan Amendment # 121 (13-0121) ACA elig process. Form CS24 supersedes section 4.3 & 4.4. Submitted: 11/12/13 Effective: 1/1/14

Approved: 5/5/14

State Plan Amendment # 122 (13-0122) ACA established 2101(f). Form CS14 adds new subsection 4.1. 10. Submitted: 11/12/13 Effective: 1/1/14

Approved: 2/3/14

State Plan Amendment #123 (13-0123) ACA Non financial elig. Form CS17 superseded section 4.1.5. CS18 superseded section 4.1.0, 4.1-LR; 4.1.1-LR. CS19 supersedes section 4.1.9. CS21 supersedes section 8.7. CS27 supersedes section 4.1.8 and CS28 supersedes section 4.4.3. Submitted: 11/12/13 Effective: 1/1/14

Approved: 2/10/14

State Plan Amendment # 124 (13-0124) ACA Chip to XXI Medicaid. Form CS3 supersedes section 4.0. Submitted: 11/12/13 Effective: 1/1/14

Approved: 2/3/14

State Plan Amendment # 126 (15-0126) Single streamline application Form CS24 supersedes section 4.3 & 4.4. Submitted: 8/21/15 Effective: 12/15/15

Approved: 8/18/16

State Plan Amendment # 127 (15-0127) FFM assessment designation. Form CS24 Submitted: 9/17/15 Effective: 11/1/15

Approved: 12/2/15

State Plan Amendment # 128 MHPAEA provisions Submitted: 6/29/18 Effective: 10/1/17

Approved: 9/12/19

13 State Plan Amendment # 129 (18-0129) Hospital Presumptive Eligibility. Form CS28 Submitted: 7/18/18 Effective: 2/1/18

Approved:8/23/18

State Plan Amendment # 130 (OR-19-0130) CHIP MCO provisions Submitted: 6/13/19 Effective: 7/1/18

Approved: 7/11/19

14 Superseding Pages of MAGI CHIP State Plan Material State: Oregon Transmittal Number SPA Group PDF # Description Superseded Plan Section(s) OR-13-0120

Effective/Implementation Date: January 1, 2014 MAGI Eligibility & Methods CS7

CS15

CS9

CS13

Eligibility – Targeted Low Income Children

MAGI-Based Income Methodologies

Conception to birth

Deemed newborn Supersedes the current sections Geographic Area 4.1.1; Age 4.1.2; and Income 4.1.3

Incorporate within a separate subsection under section 4.3

Incorporate under new section 4.3.5

Incorporate under section 4.3

OR-13-0121

Effective/Implementation Date: October 1, 2013 Eligibility Processing CS24 Eligibility Process Supersedes the current sections 4.3 and 4.4 OR-13-0122

Effective/Implementation Date: January 1, 2014 Establish 2101(f) Group CS14 Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards Incorporate within a separate subsection under section 4.1 OR-13-0123

Effective/Implementation Date: January 1, 2014 Non-Financial Eligibility CS17

CS18

CS19

CS20

CS27

CS28 Non-Financial Eligibility – Residency

Non-Financial – Citizenship

Non-Financial – Social Security Number

Substitution of Coverage

Continuous Eligibility

Presumptive eligibility- Supersedes the current section 4.1.5

Supersedes the current sections 4.1.0; 4.1.1-LR; 4.1.1-LR

Supersedes the current section 4.1.9.1

Supersedes the current section 4.4.4

Supersedes the current section 4.1.9.2

15 Transmittal Number SPA Group PDF # Description Superseded Plan Section(s) hospitals Incorporated under new subsection 4.3.2.1 OR-13-0124

Effective/Implementation Date: January 1, 2014 XXI Medicaid Expansion CS3 Eligibility for Medicaid Expansion Program Supersedes the current Medicaid expansion section 4.0

1.4- TC Tribal Consultation (Section 2107(e)(1)(C)) Describe the consultation process that occurred specifically for the development and submission of this State Plan Amendment, when it occurred and who was involved. The State uses the consultation process as outlined in section 2.3 of this State plan. Specific to this Amendment, The OHA presented information to the ‘770’ Tribal meeting on 8/23/17. Tribal entities are given an opportunity to ask questions or to comment prior to the SPA submission as outlined in the approved Tribal consultation policy.

TN No: 10-21 Approval Date 3/21/11 Effective Date 10/1/10

Section 2. General Background and Description of Approach to Children’s Health Insurance Coverage and Coordination

Guidance: The demographic information requested in 2.1. can be used for State planning and will be used strictly for informational purposes. THESE NUMBERS WILL NOT BE USED AS A BASIS FOR THE ALLOTMENT.

Factors that the State may consider in the provision of this information are age breakouts, income brackets, definitions of insurability, and geographic location, as well as race and ethnicity. The State should describe its information sources and the assumptions it uses for the development of its description. • Population • Number of uninsured • Race demographics • Age Demographics • Info per region/Geographic information

2.1. Describe the extent to which, and manner in which, children in the State (including targeted low-income children and other groups of children specified) identified , by income level and other relevant factors, such as race, ethnicity and geographic location, currently have creditable health coverage (as defined in 42 CFR 457.10). To the extent

16 feasible, distinguish between creditable coverage under public health insurance programs and public-private partnerships (See Section 10 for annual report requirements). (Section 2102(a)(1)); (42 CFR 457.80(a)) Prior to implementation of CHIP in 1998, approximately 870,000 children in the state of Oregon were under the age of 19. About 92 percent of them, 800,000, had health insurance coverage of some form. Children of Hispanic or racial minority origin are more likely than their Caucasian counterparts to be uninsured. Fourteen percent of Hispanic children and 9 percent of other minority children are uninsured, compared with only 7 percent of Caucasian children. Most uninsured children live in households earning less than $25,000 per year, while median household income for all children in the state is more than $40,000 per year.

The economic conditions of the state and nation reflect an increase in the number of uninsured. The 2006 Oregon Population Survey (OPS) shows 12.6% of children under age 19 lacked health insurance coverage last year compared to 13% in 2004 and 10.6% in 2002. The table below compares number of uninsured children by Federal Poverty Level (FPL).

<100% 100-135% 135-150% 150-185% 186-200% >200% Age 0-4 Total 35,817 13,567 9,226 15,195 11,668 148,695 Age 0-4 insured 32,021 12,129 8,248 13,584 10,431 132,934 Age 0-4 uninsured 3,797 1,438 978 1,611 1,237 15,762 Age 5-9 Total 37,076 14,044 9,550 15,729 12,078 153,923 Age 5-9 insured 33,146 12,555 8,538 14,062 10,798 137,608 Age 5-9 uninsured 3,930 1,489 1,012 1,667 1,280 16,316 Age 10-14 Total 38,818 14,704 9,999 16,468 12,645 161,155 Age 10-14 insured 34,704 13,145 8,939 14,723 11,305 144,073 Age 10-14 Uninsured 4,115 1,559 1,060 1,746 1,340 17,082 Age 15-17 Total 23,556 8,923 6,067 9,993 7,673 97,792 Age 15-17 insured 21,059 7,977 5,424 8,934 6,860 87,426 Age 15-17 2,497 946 643 1,059 813 10,366

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<100% 100-135% 135-150% 150-185% 186-200% >200% Uninsured Sources: Population Research Center, Portland State University data for July 2008, Bureau of Labor Statistics/ U.S. Census; Current Population Survey (CPS)

The primary source of health coverage for most children is an employer-based policy, most often sponsored by a parent’s employer. In 1998 Employer-based coverage accounted for 82 percent of all children’s health insurance coverage in the state, while public sources made up 13 percent and the remaining 5 percent was from other sources. In 2007 Employer-based coverage decreased as the unemployment rate increased.

During Oregon’s 2009 Legislative Session, HB 2116 created the Healthy Kids initiative. Healthy Kids provides coverage for uninsured children through age 18 in the State. The objective of Healthy Kids is to provide options for children at all income levels, remove barriers to accessing health care coverage and build on existing programs already available to Oregon families. HB 2116 increases the FPL from 185 percent of FPL up to and including 300 percent of FPL for children.

Guidance: Section 2.2 allows states to request to use the funds available under the 10 percent limit on administrative expenditures in order to fund services not otherwise allowable. The health services initiatives must meet the requirements of 42 CFR 457.10.

2.2. Health Services Initiatives- Describe if the State will use the health services initiative option as allowed at 42 CFR 457.10. If so, describe what services or programs the State is proposing to cover with administrative funds, including the cost of each program, and how it is currently funded (if applicable), also update the budget accordingly. (Section 2105(a)(1)(D)(ii)); (42 CFR 457.10) Oregon will use CHIP funds, within the 10 percent federal administrative expenditures cap allowed for states, to support the Oregon Poison Center (OPC). The OPC provides emergency telephone treatment advice, referral assistance, and information to manage exposures to poisonous and hazardous substances. The OPC answers poisoning emergency calls from the general public as well as health care providers needing assistance 24 hours a day, 365 days each year at no charge. At all times, Specialists in Poison Information, Certified Specialists in Poison Information, and toxicologists are available to manage cases. The service is provided via a toll- free telephone number to all communities throughout Oregon, including under- served, low income, and indigent populations. Services are available by use of an interpreter in over 150 languages and via telecommunications devices for the deaf and hearing impaired (TTY).

The OPC provides public education programs directed towards pediatric accidental poisoning as well as targeted “at-risk” populations. Educational materials and teaching curricula are distributed throughout the state, free of charge. Materials

18 are also available in Spanish, Vietnamese and Russian. The OPC participates in a variety of community injury prevention including health fairs.

The OPC receives approximately 46,000 calls from Oregonians annually involving individuals exposed to poisons or hazardous substances. Sixty-four percent of all poisoning exposure calls received involve children under age 19. For CHIP eligible children, over 38 percent of the total calls relate to poisoning exposures of children in families whose annual household incomes is $44,700 or less (200% FPL for a family of 4 in 2011). In addition to calls regarding exposures, the OPC receives over 7,800 calls each year from Oregonians requesting information about poison prevention, effective use of chemicals, drug identification, substance abuse and other medical questions. These calls are considered preventive.

OPC intervention resulted in over 92 percent of the exposure calls (in children under age 19) being handled in the home so the children did not have to use an emergency department or need a 911 call and response.

The Authority has no special funding arrangement with the providers for these services and they retain 100% of the approved reimbursement from the state. Providers do not return any portion of the payments to the state.

2.3-TC Tribal Consultation Requirements- (Sections 1902(a)(73) and 2107(e)(1)(C)); (ARRA #2, CHIPRA #3, issued May 28, 2009) Section 1902(a)(73) of the Social Security Act (the Act) requires a State in which one or more Indian Health Programs or Urban Indian Organizations furnish health care services to establish a process for the State Medicaid agency to seek advice on a regular, ongoing basis from designees of Indian health programs, whether operated by the Indian Health Service (IHS), Tribes or Tribal organizations under the Indian Self-Determination and Education Assistance Act (ISDEAA), or Urban Indian Organizations under the Indian Health Care Improvement Act (IHCIA). Section 2107(e)(1)(C) of the Act was also amended to apply these requirements to the Children’s Health Insurance Program (CHIP). Consultation is required concerning Medicaid and CHIP matters having a direct impact on Indian health programs and Urban Indian organizations.

Describe the process the State uses to seek advice on a regular, ongoing basis from federally-recognized tribes, Indian Health Programs and Urban Indian Organizations on matters related to Medicaid and CHIP programs and for consultation on State Plan Amendments, waiver proposals, waiver extensions, waiver amendments, waiver renewals and proposals for demonstration projects prior to submission to CMS. Include information about the frequency, inclusiveness and process for seeking such advice. The Oregon Health Authority (OHA) has regular quarterly meetings with the nine

19 federally recognized Tribes, Urban Indian Programs and Indian Health Service (IHS) representatives. The agenda’s are mainly driven by the Indian communities of Oregon, Urban Indian Programs and Indian Health Service (IHS) representatives and are constructed by requesting topic’s to be discussed at the meeting. These meetings are referred to in Oregon as Senate Bill 770 in reference to the legislation authoring the meeting. The OHA may engage the tribal and urban program representatives outside of the meeting setting through correspondence in the event a policy change is needed more quickly than the next 770 meeting will support. Each Tribe and Indian Organization selects its representative to the meetings based on whom the Tribe or Indian Organization feels is best to represent their needs.

The OHA discusses proposed State Plan Amendments, waiver amendments, demonstration project proposals. Policies or rule-making that may have a direct impact on American Indians, Tribal entities and urban Indian programs or IHS in the SB 770 quarterly meetings. Impacts that are considered to have direct effects on Native Americans, Urban Indian programs or IHS are changes that would impact eligibility determinations, changes that reduce payment rates or changes in payment methodologies, reductions in covered services, changes in provider qualifications/requirements, and proposals for demonstrations or waivers.

Process: Thirty (30) days prior to a State Plan submission to the Centers for Medicare and Medicaid Services (CMS), the OHA distributes documents describing a proposed State Plan Amendments (SPA). This is normally discussed in a scheduled quarterly SB 770 meeting. Approximately ten (10) days prior to the quarterly 770 meeting the Division distributes the agenda and documents describing a proposed SPA. This is distributed through the Tribal Liaison to the nine federally recognized Tribes, Tribal Urban Indian programs and Indian Health Service (IHS) representatives. The types of entities on the distribution list includes, but is not limited to:

a. Oregon Tribal Governments (i.e. Tribal Executive Council, Tribal Business Council, etc.) b. Tribal Chairman or Chief or their designated representative(s) c. Tribal Health Clinic Executive Directors of Oregon’s 638/FQHC providers d. IHS representatives e. Tribal Organizations established to represent IHS and Tribal health programs and such as the Northwest Portland Indian Health Board f. Urban Indian program(s) Executive Director(s) or designee(s)

In instances where a SPA would need to be submitted prior to a regularly scheduled ‘770’ meeting the OHA would utilize electronic mail or schedule conference calls.

20

The OHA may also utilize an expedited process in the event a deadline is outside the control of the agency, or in severely time limited situations. The expedited process includes at a minimum, 10 days in advance of the change the agency provides written notification with the proposed change; anticipated impact; method for providing comments/questions; timeframe for feedback; and an opportunity for a face-to-face meeting or conference call if requested.

Tribal, Urban Indian program and IHS designees are invited to attend all Divisions’ Rule Advisory Committee meetings to provide additional input on rule concepts and language.

Section 3. Methods of Delivery and Utilization Controls

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

Guidance: In Section 3.1, describe all delivery methods the State will use to provide services to enrollees, including: (1) contracts with managed care organizations (MCO), prepaid inpatient health plans (PIHP), prepaid ambulatory health plans (PAHP), primary care case management entities (PCCM entities), and primary care case managers (PCCM); (2) contracts with indemnity health insurance plans; (3) fee-for-service (FFS) paid by the State to health care providers; and (4) any other arrangements for health care delivery. The State should describe any variations based upon geography and by population (including the conception to birth population). States must submit the managed care contract(s) to CMS’ Regional Office for review.

3.1. Delivery Systems (Section 2102(a)(4)) (42 CFR 457.490; Part 457, Subpart L)

3.1.1 Choice of Delivery System 3.1.1.1 Does the State use a managed care delivery system for its CHIP populations? Managed care entities include MCOs, PIHPs, PAHPs, PCCM entities and PCCMs as defined in 42 CFR 457.10. Please check the box and answer the questions below that apply to your State. No, the State does not use a managed care delivery system for any CHIP populations. Yes, the State uses a managed care delivery system for all CHIP populations. Yes, the State uses a managed care delivery system; however, only some of the CHIP population is included in the managed care

21 delivery system and some of the CHIP population is included in a fee- for-service system. If the State uses a managed care delivery system for only some of its CHIP populations and a fee-for-service system for some of its CHIP populations, please describe which populations are, and which are not, included in the State’s managed care delivery system for CHIP. States will be asked to specify which managed care entities are used by the State in its managed care delivery system below in Section 3.1.2. Approximately 85% of the CHIP eligible Targeted Low Income Children 0-18 years old with a FPL at or below 300%, are enrolled in a MCE known as Coordinated Care Organizations (CCO). The rest are in FFS for a variety of reasons such as; those eligible under the ‘Conception to Birth’ or ‘unborn’ population are never enrolled in a CCO; American Indians and Alaska natives must ‘opt’ into an MCO otherwise they remain FFS and Continuity of Care exemptions. Guidance: Utilization control systems are those administrative mechanisms that are designed to ensure that enrollees receiving health care services under the State plan receive only appropriate and medically necessary health care consistent with the benefit package. Examples of utilization control systems include, but are not limited to: requirements for referrals to specialty care; requirements that clinicians use clinical practice guidelines; or demand management systems (e.g., use of an 800 number for after-hours and urgent care). In addition, the State should describe its plans for review, coordination, and implementation of utilization controls, addressing both procedures and State developed standards for review, in order to assure that necessary care is delivered in a cost-effective and efficient manner. (42 CFR 457.490(b)) If the State does not use a managed care delivery system for any or some of its CHIP populations, describe the methods of delivery of the child health assistance using Title XXI funds to targeted low-income children. Include a description of: • The methods for assuring delivery of the insurance products and delivery of health care services covered by such products to the enrollees, including any variations. (Section 2102(a)(4); 42 CFR 457.490(a)) • The utilization control systems designed to ensure that enrollees receiving health care services under the State plan receive only appropriate and medically necessary health care consistent with the benefit package described in the approved State plan. (Section

22 2102(a)(4); 42 CFR 457.490(b)) Oregon’s CHIP program coverage is called the OHP which is the same coverage under its Medicaid State Plan and 1115 Waiver demonstration. The program utilizes the Health Evidence Review Committee’s prioritized list of health services as one of its main tools for utilization control. This prioritized list is authorized under Oregon’s’ 1115 demonstration waiver. Other methods are the use of Prior authorized services through medical necessity review.

Guidance: Only States that use a managed care delivery system for all or some CHIP populations need to answer the remaining questions under Section 3 (starting with 3.1.1.2). If the State uses a managed care delivery system for only some of its CHIP population, the State’s responses to the following questions will only apply to those populations. 3.1.1.2 Do any of your CHIP populations that receive services through a managed care delivery system receive any services outside of a managed care delivery system? No Yes

If yes, please describe which services are carved out of your managed care delivery system and how the State provides these services to an enrollee, such as through fee-for-service. Examples of carved out services may include transportation and dental, among others. Services that are carved out of MCE coverage and provided under the state’s FFS program are Standard Therapeutic classification 7 and 11 prescription drugs; Long Term care Services and Supports and Targeted Case Management. Family Planning services are considered open access, meaning the person is enrolled in an MCE however, they can go to the provider of their choice even if the provider is not in the MCOs network. If the provider is out of network the claim is paid FFS. 3.1.2 Use of a Managed Care Delivery System for All or Some of the State’s CHIP Populations 3.1.2.1 Check each of the types of entities below that the State will contract with under its managed care delivery system, and select and/or explain the method(s) of payment that the State will use: Managed care organization (MCO) (42 CFR 457.10) Capitation payment PMPM by category

23

Describe population served: CHIP eligible Targeted Low Income Children 0-18 years old, at or below 300% of FPL

Prepaid inpatient health plan (PIHP) (42 CFR 457.10) Capitation payment Other (please explain)

Describe population served: CHIP eligible Targeted Low Income Children 0-18 year old up to 300% of FPL

Guidance: If the State uses prepaid ambulatory health plan(s) (PAHP) to exclusively provide non-emergency medical transportation (a NEMT PAHP), the State should not check the following box for that plan. Instead, complete section 3.1.3 for the NEMT PAHP. Prepaid ambulatory health plan (PAHP) (42 CFR 457.10) Capitation payment PMPM by category Other (please explain)

Describe population served: CHIP eligible Targeted Low Income Children 0-18 years old, at or below 300% of FPL

Primary care case manager (PCCM) (individual practitioners) (42 CFR 457.10) Case management fee Other (please explain)

Primary care case management entity (PCCM Entity) (42 CFR 457.10) Case management fee Shared savings, incentive payments, and/or other financial rewards for improved quality outcomes (see 42 CFR 457.1240(f)) Other (please explain)

If PCCM entity is selected, please indicate which of the following function(s) the entity will provide (as described in 42 CFR 457.10), in addition to PCCM services: Provision of intensive telephonic case management Provision of face-to-face case management Operation of a nurse triage advice line Development of enrollee care plans Execution of contracts with fee-for-service (FFS) providers in the FFS program

24 Oversight responsibilities for the activities of FFS providers in the FFS program Provision of payments to FFS providers on behalf of the State Provision of enrollee outreach and education activities Operation of a customer service call center Review of provider claims, utilization and/or practice patterns to conduct provider profiling and/or practice improvement Implementation of quality improvement activities including administering enrollee satisfaction surveys or collecting data necessary for performance measurement of providers Coordination with behavioral health systems/providers Other (please describe)

3.1.2.2

The State assures that if its contract with an MCO, PAHP, or PIHP allows the entity to use a physician incentive plan, the contract stipulates that the entity must comply with the requirements set forth in 42 CFR 422.208 and 422.210. (42 CFR 457.1201(h), cross-referencing to 42 CFR 438.3(i)) 3.1.3 Nonemergency Medical Transportation PAHPs Guidance: Only complete Section 3.1.3 if the State uses a PAHP to exclusively provide non- emergency medical transportation (a NEMT PAHP). If a NEMT PAHP is the only managed care entity for CHIP in the State, please continue to Section 4 after checking the assurance below. If the State uses a PAHP that does not exclusively provide NEMT and/or uses other managed care entities beyond a NEMT PAHP, the State will need to complete the remaining sections within Section 3.

The State assures that it complies with all requirements applicable to NEMT PAHPs, and through its contracts with such entities, requires NEMT PAHPs to comply with all applicable requirements, including the following (from 42 CFR 457.1206(b)): • All contract provisions in 42 CFR 457.1201 except those set forth in 42 CFR 457.1201(h) (related to physician incentive plans) and 42 CFR 457.1201(l) (related to mental health parity). • The information requirements in 42 CFR 457.1207 (see Section 3.5 below for more details). • The provision against provider discrimination in 42 CFR 457.1208. • The State responsibility provisions in 42 CFR 457.1212 (about disenrollment), 42 CFR 457.1214 (about conflict of interest safeguards), and 42 CFR 438.62(a), as cross-referenced in 42 CFR 457.1216 (about continued services to enrollees). • The provisions on enrollee rights and protections in 42 CFR 457.1220, 457.1222, 457.1224, and 457.1226.

25 • The PAHP standards in 42 CFR 438.206(b)(1), as cross-referenced by 42 CFR 457.1230(a) (about availability of services), 42 CFR 457.1230(d) (about coverage and authorization of services), and 42 CFR 457.1233(a), (b) and (d) (about structure and operation standards). • An enrollee's right to a State review under subpart K of 42 CFR 457. • Prohibitions against affiliations with individuals debarred or excluded by Federal agencies in 42 CFR 438.610, as cross referenced by 42 CFR 457.1285. • Requirements relating to contracts involving Indians, Indian Health Care Providers, and Indian managed care entities in 42 CFR 457.1209.

3.2. General Managed Care Contract Provisions

3.2.1

The State assures that it provides for free and open competition, to the maximum extent practical, in the bidding of all procurement contracts for coverage or other services, including external quality review organizations, in accordance with the procurement requirements of 45 CFR part 75, as applicable. (42 CFR 457.940(b); 42 CFR 457.1250(a), cross referencing to 42 CFR 438.356(e)) 3.2.2

The State assures that it will include provisions in all managed care contracts that define a sound and complete procurement contract, as required by 45 CFR part 75, as applicable. (42 CFR 457.940(c)) 3.2.3

The State assures that each MCO, PIHP, PAHP, PCCM, and PCCM entity complies with any applicable Federal and State laws that pertain to enrollee rights, and ensures that its employees and contract providers observe and protect those rights (42 CFR 457.1220, cross-referencing to 42 CFR 438.100). These Federal and State laws include: Title VI of the Civil Rights Act of 1964 (45 CFR part 80), Age Discrimination Act of 1975 (45 CFR part 91), Rehabilitation Act of 1973, Title IX of the Education Amendments of 1972, Titles II and III of the Americans with Disabilities Act, and section 1557 of the Patient Protection and Affordable Care Act. 3.2.4

The State assures that it operates a Web site that provides the MCO, PIHP, PAHP, and PCCM entity contracts. (42 CFR 457.1207, cross-referencing to 42 CFR 438.10(c)(3)) 3.3 Rate Development Standards and Medical Loss Ratio 3.3.1 The State assures that its payment rates are: Based on public or private payment rates for comparable services for comparable populations; and

26 Consistent with actuarially sound principles as defined in 42 CFR 457.10. (42 CFR 457.1203(a))

Guidance: States that checked both boxes under 3.3.1 above do not need to make the next assurance. If the state is unable to check both boxes under 3.1.1 above, the state must check the next assurance. If the State is unable to meet the requirements under 42 CFR 457.1203(a), the State attests that it must establish higher rates because such rates are necessary to ensure sufficient provider participation or provider access or to enroll providers who demonstrate exceptional efficiency or quality in the provision of services. (42 CFR 457.1203(b)) 3.3.2

The State assures that its rates are designed to reasonably achieve a medical loss ratio standard equal to at least 85 percent for the rate year and provide for reasonable administrative costs. (42 CFR 457.1203(c)) 3.3.3

The State assures that it will provide to CMS, if requested by CMS, a description of the manner in which rates were developed in accordance with the requirements of 42 CFR 457.1203(a) through (c). (42 CFR 457.1203(d)) 3.3.4

The State assures that it annually submits to CMS a summary description of the reports pertaining to the medical loss ratio received from the MCOs, PIHPs, and PAHPs. (42 CFR 457.1203(e), cross referencing to 42 CFR 438.74(a)) 3.3.5 Does the State require an MCO, PIHP, or PAHP to pay remittances through the contract for not meeting the minimum MLR required by the State? (42 CFR 457.1203(e), cross referencing to 42 CFR 438.74(b)(1)) No, the State does not require any MCO, PIHP, or PAHP to pay remittances. Yes, the State requires all MCOs, PIHPs, and PAHPs to pay remittances. Yes, the State requires some, but not all, MCOs, PIHPs, and PAHPs to pay remittances.

If the State requests some, but not all, MCOs, PIHPs, and PAHPs to pay remittances through the contract for not meeting the minimum MLR required by the State, please describe which types of managed care entities are and are not required to pay remittances. For example, if a state requires a medical MCO to pay a remittances but not a dental PAHP, please include this information. The State only requires CCOs to meet the 85% MLR. DCOs and MHO are not required to meet the 85% MLR. If the answer to the assurance above is yes for any or all managed care entities, please answer the next assurance:

27 The State assures that it if a remittance is owed by an MCO, PIHP, or PAHP to the State, the State: • Reimburses CMS for an amount equal to the Federal share of the remittance, taking into account applicable differences in the Federal matching rate; and • Submits a separate report describing the methodology used to determine the State and Federal share of the remittance with the annual report provided to CMS that summarizes the reports received from the MCOs, PIHPs, and PAHPs. (42 CFR 457.1203(e), cross referencing to 42 CFR 438.74(b))

3.3.6

The State assures that each MCO, PIHP, and PAHP calculates and reports the medical loss ratio in accordance with 42 CFR 438.8. (42 CFR 457.1203(f)) 3.4 Enrollment

The State assures that its contracts with MCOs, PIHPs, PAHPs, PCCMs, and PCCM entities provide that the MCO, PIHP, PAHP, PCCM or PCCM entity: • Accepts individuals eligible for enrollment in the order in which they apply without restriction (unless authorized by CMS), up to the limits set under the contract (42 CFR 457.1201(d), cross-referencing to 42 CFR 438.3(d)(1)); • Will not, on the basis of health status or need for health care services, discriminate against individuals eligible to enroll (42 CFR 457.1201(d), cross-referencing to 42 CFR 438.3(d)(3)); and • Will not discriminate against individuals eligible to enroll on the basis of race, color, national origin, sex, sexual orientation, gender identity, or disability and will not use any policy or practice that has the effect of discriminating on the basis of race, color, national origin, sex, sexual orientation, gender identity or disability. (42 CFR 457.1201(d), cross-referencing to 438.3(d)(4))

3.4.1 Enrollment Process 3.4.1.1

The State assures that it provides informational notices to potential enrollees in an MCO, PIHP, PAHP, PCCM, or PCCM entity that includes the available managed care entities, explains how to select an entity, explains the implications of making or not making an active choice of an entity, explains the length of the enrollment period as well as the disenrollment policies, and complies with the information requirements in 42 CFR 457.1207 and accessibility standards established under 42 CFR 457.340. (42 CFR 457.1210(c))

28 3.4.1.2

The State assures that its enrollment system gives beneficiaries already enrolled in an MCO, PIHP, PAHP, PCCM, or PCCM entity priority to continue that enrollment if the MCO, PIHP, PAHP, PCCM, or PCCM entity does not have the capacity to accept all those seeking enrollment under the program. (42 CFR 457.1210(b)) 3.4.1.3 Does the State use a default enrollment process to assign beneficiaries to an MCO, PIHP, PAHP, PCCM, or PCCM entity? (42 CFR 457.1210(a)) Yes No

If the State uses a default enrollment process, please make the following assurances: The State assigns beneficiaries only to qualified MCOs, PIHPs, PAHPs, PCCMs, and PCCM entities that are not subject to the intermediate sanction of having suspension of all new enrollment (including default enrollment) under 42 CFR 438.702 and have capacity to enroll beneficiaries. (42 CFR 457.1210(a)(1)(i)) The State maximizes continuation of existing provider-beneficiary relationships under 42 CFR 457.1210(a)(1)(ii) or if that is not possible, distributes the beneficiaries equitably and does not arbitrarily exclude any MCO, PIHP, PAHP, PCCM or PCCM entity from being considered. (42 CFR 457.1210(a)(1)(ii), 42 CFR 457.1210(a)(1)(iii))

3.4.2 Disenrollment 3.4.2.1

The State assures that the State will notify enrollees of their right to disenroll consistent with the requirements of 42 CFR 438.56 at least annually. (42 CFR 457.1207, cross-referencing to 42 CFR 438.10(f)(2)) 3.4.2.2

The State assures that the effective date of an approved disenrollment, regardless of the procedure followed to request the disenrollment, will be no later than the first day of the second month following the month in which the enrollee requests disenrollment or the MCO, PIHP, PAHP, PCCM or PCCM entity refers the request to the State. (42 CFR 457.1212, cross-referencing to 438.56(e)(1)) 3.4.2.3

If a beneficiary disenrolls from an MCO, PIHP, PAHP, PCCM, or PCCM entity, the State assures that the beneficiary is provided the option to enroll in another plan or receive benefits from an alternative delivery system. (Section 2103(f)(3) of the Social Security Act, incorporating section

29 1932(a)(4); 42 CFR 457.1212, cross referencing to 42 CFR 438.56; State Health Official Letter #09-008) 3.4.2.4 MCO, PIHP, PAHP, PCCM and PCCM Entity Requests for Disenrollment. The State assures that contracts with MCOs, PIHPs, PAHPs, PCCMs and PCCM entities describe the reasons for which an MCO, PIHP, PAHP, PCCM and PCCM entity may request disenrollment of an enrollee, if any. (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(b)) Guidance: Reasons for disenrollment by the MCO, PIHP, PAHP, PCCM, and PCCM entity must be specified in the contract with the State. Reasons for disenrollment may not include an adverse change in the enrollee's health status, or because of the enrollee's utilization of medical services, diminished mental capacity, or uncooperative or disruptive behavior resulting from his or her special needs (except when his or her continued enrollment in the MCO, PIHP, PAHP, PCCM or PCCM entity seriously impairs the entity's ability to furnish services to either this particular enrollee or other enrollees). (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(b)(2)) 3.4.2.5 Enrollee Requests for Disenrollment. Guidance: The State may also choose to limit disenrollment from the MCO, PIHP, PAHP, PCCM, or PCCM entity, except for either: 1) for cause, at any time; or 2) without cause during the latter of the 90 days after the beneficiary’s initial enrollment or the State sends the beneficiary notice of that enrollment, at least once every 12 months, upon reenrollment if the temporary loss of CHIP eligibility caused the beneficiary to miss the annual disenrollment opportunity, or when the State imposes the intermediate sanction specified in 42 CFR 438.702(a)(4). (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(c)) Does the State limit disenrollment from an MCO, PIHP, PAHP, PCCM and PCCM entity by an enrollee? (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(c)) Yes No

If the State limits disenrollment by the enrollee from an MCO, PIHP, PAHP, PCCM and PCCM entity, please make the following assurances (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(c)):

30 The State assures that enrollees and their representatives are given written notice of disenrollment rights at least 60 days before the start of each enrollment period. (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(f)(1)) The State assures that beneficiary requests to disenroll for cause will be permitted at any time by the MCO, PIHP, PAHP, PCCM or PCCM entity. (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(c)(1) and (d)(2)) The State assures that beneficiary requests for disenrollment without cause will be permitted by the MCO, PIHP, PAHP, PCCM or PCCM entity at the following times: Oregon’s 1115 waiver:21-W-00013/10 and 11-W- 00160/10 permits us to utilize 30 day. STC #7 To enable managed care entities to permit enrollees eligible through Medicaid or the CHIP state plan, a period of only 30 days after enrollment to disenroll without cause, instead of 90 days, except beneficiaries newly entering a managed delivery system. All beneficiaries newly entering a managed delivery system receive 90 days to disenroll. Beneficiaries newly entering a managed delivery system are individuals who have never had Coordinated Care Organization -enrollable Oregon Health Plan eligibility. (Applies to all Medicaid state plan populations listed in Attachment D.)

• During the 90 days following the date of the beneficiary's initial enrollment into the MCO, PIHP, PAHP, PCCM, or PCCM entity, or during the 90 days following the date the State sends the beneficiary notice of that enrollment, whichever is later; • At least once every 12 months thereafter; • If the State plan provides for automatic reenrollment for an individual who loses CHIP eligibility for a period of 2 months or less and the temporary loss of CHIP eligibility has caused the beneficiary to miss the annual disenrollment opportunity; and • When the State imposes the intermediate sanction on the MCO, PIHP, PAHP, PCCM or PCCM entity specified in 42 CFR 438.702(a)(4). (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(c)(2)) 3.4.2.6

The State assures that the State ensures timely access to a State review for any enrollee dissatisfied with a State agency determination that there is not good cause for disenrollment. (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(f)(2)) 3.5 Information Requirements for Enrollees and Potential Enrollees 3.5.1

The State assures that it provides, or ensures its contracted MCOs, PAHPs, PIHPs, PCCMs and PCCM entities provide, all enrollment notices, informational materials, and instructional materials related to enrollees and potential enrollees in

31 accordance with the terms of 42 CFR 457.1207, cross-referencing to 42 CFR 438.10. 3.5.2

The State assures that all required information provided to enrollees and potential enrollees are in a manner and format that may be easily understood and is readily accessible by such enrollees and potential enrollees. (42 CFR 457.1207, cross- referencing to 42 CFR 438.10(c)(1)) 3.5.3

The State assures that it operates a Web site that provides the content specified in 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(g)-(i) either directly or by linking to individual MCO, PIHP, PAHP and PCCM entity Web sites. 3.5.4

The State assures that it has developed and requires each MCO, PIHP, PAHP and PCCM entity to use: • Definitions for the terms specified under 42 CFR 438.10(c)(4)(i), and • Model enrollee handbooks, and model enrollee notices. (42 CFR 457.1207, cross-referencing to 42 CFR 438.10(c)(4))

3.5.5

If the State, MCOs, PIHPs, PAHPs, PCCMs or PCCM entities provide the information required under 42 CFR 457.1207 electronically, check this box to confirm that the State assures that it meets the requirements under 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(c)(6) for providing the material in an accessible manner. Including that: • The format is readily accessible; • The information is placed in a location on the State, MCO's, PIHP's, PAHP's, or PCCM's, or PCCM entity's Web site that is prominent and readily accessible; • The information is provided in an electronic form which can be electronically retained and printed; • The information is consistent with the content and language requirements in 42 CFR 438.10; and • The enrollee is informed that the information is available in paper form without charge upon request and is provided the information upon request within 5 business days. 3.5.6

The State assures that it meets the language and format requirements set forth in 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(d), including but not limited to: • Establishing a methodology that identifies the prevalent non-English languages spoken by enrollees and potential enrollees throughout the State, and in each MCO, PIHP, PAHP, or PCCM entity service area; • Making oral interpretation available in all languages and written translation available in each prevalent non-English language;

32 • Requiring each MCO, PIHP, PAHP, and PCCM entity to make its written materials that are critical to obtaining services available in the prevalent non- English languages in its particular service area; • Making interpretation services available to each potential enrollee and requiring each MCO, PIHP, PAHP, and PCCM entity to make those services available free of charge to each enrollee; and • Notifying potential enrollees, and requiring each MCO, PIHP, PAHP, and PCCM entity to notify its enrollees: o That oral interpretation is available for any language and written translation is available in prevalent languages; o That auxiliary aids and services are available upon request and at no cost for enrollees with disabilities; and o How to access the services in 42 CFR 457.1207, cross-referencing 42 CFR 438.10(d)(5)(i) and (ii).

3.5.7

The State assures that the State or its contracted representative provides the information specified in 42 CFR 457.1207, cross-referencing to 438.10(e)(2), and includes the information either in paper or electronic format, to all potential enrollees at the time the potential enrollee becomes eligible to enroll in a voluntary managed care program or is first required to enroll in a mandatory managed care program and within a timeframe that enables the potential enrollee to use the information to choose among the available MCOs, PIHPs, PAHPs, PCCMs and PCCM entities: • Information about the potential enrollee's right to disenroll consistent with the requirements of 42 CFR 438.56 and which explains clearly the process for exercising this disenrollment right, as well as the alternatives available to the potential enrollee based on their specific circumstance; • The basic features of managed care; • Which populations are excluded from enrollment in managed care, subject to mandatory enrollment, or free to enroll voluntarily in the program; • The service area covered by each MCO, PIHP, PAHP, PCCM, or PCCM entity; • Covered benefits including: o Which benefits are provided by the MCO, PIHP, or PAHP; and which, if any, benefits are provided directly by the State; and o For a counseling or referral service that the MCO, PIHP, or PAHP does not cover because of moral or religious objections, where and how to obtain the service; • The provider directory and formulary information required in 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(h) and (i); • Any cost-sharing for the enrollee that will be imposed by the MCO, PIHP, PAHP, PCCM, or PCCM entity consistent with those set forth in the State

33 plan; • The requirements for each MCO, PIHP or PAHP to provide adequate access to covered services, including the network adequacy standards established in 42 CFR 457.1218, cross-referencing 42 CFR 438.68; • The MCO, PIHP, PAHP, PCCM and PCCM entity's responsibilities for coordination of enrollee care; and • To the extent available, quality and performance indicators for each MCO, PIHP, PAHP and PCCM entity, including enrollee satisfaction. 3.5.8

The State assures that it will provide the information specified in 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(f) to all enrollees of MCOs, PIHPs, PAHPs and PCCM entities, including that the State must notify all enrollees of their right to disenroll consistent with the requirements of 42 CFR 438.56 at least annually. 3.5.9

The State assures that each MCO, PIHP, PAHP and PCCM entity will provide the information specified in 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(f) to all enrollees of MCOs, PIHPs, PAHPs and PCCM entities, including that: • The MCO, PIHP, PAHP and, when appropriate, the PCCM entity, must make a good faith effort to give written notice of termination of a contracted provider within the timeframe specified in 42 CFR 438.10(f), and • The MCO, PIHP, PAHP and, when appropriate, the PCCM entity must make available, upon request, any physician incentive plans in place as set forth in 42 CFR 438.3(i).

3.5.10

The State assures that each MCO, PIHP, PAHP and PCCM entity will provide enrollees of that MCO, PIHP, PAHP or PCCM entity an enrollee handbook that meets the requirements as applicable to the MCO, PIHP, PAHP and PCCM entity, specified in 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(g)(1)-(2), within a reasonable time after receiving notice of the beneficiary's enrollment, by a method consistent with 42 CFR 438.10(g)(3), and including the following items: • Information that enables the enrollee to understand how to effectively use the managed care program, which, at a minimum, must include: o Benefits provided by the MCO, PIHP, PAHP or PCCM entity; o How and where to access any benefits provided by the State, including any cost sharing, and how transportation is provided; and o In the case of a counseling or referral service that the MCO, PIHP, PAHP, or PCCM entity does not cover because of moral or religious objections, the MCO, PIHP, PAHP, or PCCM entity must inform enrollees that the service is not covered by the MCO, PIHP, PAHP, or PCCM entity and how they can obtain information from the State about how to access these services;

34 • The amount, duration, and scope of benefits available under the contract in sufficient detail to ensure that enrollees understand the benefits to which they are entitled; • Procedures for obtaining benefits, including any requirements for service authorizations and/or referrals for specialty care and for other benefits not furnished by the enrollee's primary care provider; • The extent to which, and how, after-hours and emergency coverage are provided, including: o What constitutes an emergency medical condition and emergency services; o The fact that prior authorization is not required for emergency services; and o The fact that, subject to the provisions of this section, the enrollee has a right to use any hospital or other setting for emergency care; • Any restrictions on the enrollee's freedom of choice among network providers; • The extent to which, and how, enrollees may obtain benefits, including family planning services and supplies from out-of-network providers; • Cost sharing, if any is imposed under the State plan; • Enrollee rights and responsibilities, including the elements specified in 42 CFR §438.100; • The process of selecting and changing the enrollee's primary care provider; • Grievance, appeal, and review procedures and timeframes, consistent with 42 CFR 457.1260, in a State-developed or State-approved description, including: o The right to file grievances and appeals; o The requirements and timeframes for filing a grievance or appeal; o The availability of assistance in the filing process; and o The right to request a State review after the MCO, PIHP or PAHP has made a determination on an enrollee's appeal which is adverse to the enrollee; • How to access auxiliary aids and services, including additional information in alternative formats or languages; • The toll-free telephone number for member services, medical management, and any other unit providing services directly to enrollees; and • Information on how to report suspected fraud or abuse. 3.5.11

The State assures that each MCO, PIHP, PAHP and PCCM entity will give each enrollee notice of any change that the State defines as significant in the information specified in the enrollee handbook at least 30 days before the

35 intended effective date of the change. (42 CFR 457.1207, cross-referencing to 42 CFR 438.10(g)(4)) 3.5.12

The State assures that each MCO, PIHP, PAHP and when appropriate, PCCM entity, will make available a provider directory for the MCO’s, PIHP’s, PAHP’s or PCCM entity’s network providers, including for physicians (including specialists), hospitals, pharmacies, and behavioral health providers, that includes information as specified in 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(h)(1)-(2) and (4). 3.5.13

The State assures that each MCO, PIHP, PAHP and when appropriate, PCCM entity, will update any information included in a paper provider directory at least monthly and in an electronic provider directories as specified in 42 CFR 438.10(h)(3). (42 CFR 457.1207, cross-referencing to 42 CFR 438.10(h)(3)) 3.5.14

The State assures that each MCO, PIHP, PAHP and when appropriate, PCCM entity, will make available the MCO’s, PIHP’s, PAHP’s, or PCCM entity’s formulary that meets the requirements specified in 42 CFR 457.1207, cross- referencing to 42 CFR 438.10(i), including: • Which medications are covered (both generic and name brand); and • What tier each medication is on. 3.5.15

The State assures that each MCO, PIHP, PAHP, PCCM and PCCM entity follows the requirements for marketing activities under 42 CFR 457.1224, cross- referencing to 42 CFR 438.104 (except 42 CFR 438.104(c)). Guidance: Requirements for marketing activities include, but are not limited to, that the MCO, PIHP, PAHP, PCCM, or PCCM entity does not distribute any marketing materials without first obtaining State approval; distributes the materials to its entire service areas as indicated in the contract; does not seek to influence enrollment in conjunction with the sale or offering of any private insurance; and does not, directly or indirectly, engage in door-to-door, telephone, email, texting, or other cold-call marketing activities. (42 CFR 104(b)) Guidance: Only States with MCOs, PIHPs, or PAHPs need to answer the remaining assurances in Section 3.5 (3.5.16 through 3.5.18). 3.5.16

The State assures that each MCO, PIHP and PAHP protects communications between providers and enrollees under 42 CFR 457.1222, cross-referencing to 42 CFR 438.102. 3.5.17

The State assures that MCOs, PIHPs, and PAHPs have arrangements and procedures that prohibit the MCO, PIHP, and PAHP from conducting any unsolicited personal contact with a potential enrollee by an employee or agent of

36 the MCO, PAHP, or PIHP for the purpose of influencing the individual to enroll with the entity. (42 CFR 457.1280(b)(2)) Guidance: States should also complete Section 3.9, which includes additional provisions about the notice procedures for grievances and appeals. 3.5.18

The State assures that each contracted MCO, PIHP, and PAHP comply with the notice requirements specified for grievances and appeals in accordance with the terms of 42 CFR 438, Subpart F, except that the terms of 42 CFR 438.420 do not apply and that references to reviews should be read to refer to reviews as described in 42 CFR 457, Subpart K. (42 CFR 457.1260) 3.6 Benefits and Services Guidance: The State should also complete Section 3.10 (Program Integrity). 3.6.1

The State assures that MCO, PIHP, PAHP, PCCM entity, and PCCM contracts involving Indians, Indian health care providers, and Indian managed care entities comply with the requirements of 42 CFR 438.14. (42 CFR 457.1209) 3.6.2

The State assures that all services covered under the State plan are available and accessible to enrollees. (42 CFR 457.1230(a), cross-referencing to 42 CFR 438.206) 3.6.3

The State assures that it: • Publishes the State’s network adequacy standards developed in accordance with 42 CFR 457.1218, cross-referencing 42 CFR 438.68(b)(1) on the Web site required by 42 CFR 438.10; • Makes available, upon request, the State’s network adequacy standards at no cost to enrollees with disabilities in alternate formats or through the provision of auxiliary aids and services. (42 CFR 457.1218, cross- referencing 42 CFR 438.68(e)) Guidance: Only States with MCOs, PIHPs, or PAHPs need to complete the remaining assurances in Section 3.6 (3.6.4 through 3.6.20. 3.6.4

The State assures that each MCO, PAHP and PIHP meet the State’s network adequacy standards. (42 CFR 457.1218, cross-referencing 42 CFR 438.68; 42 CFR 457.1230(a), cross-referencing to 42 CFR 438.206) 3.6.5

The State assures that each MCO, PIHP, and PAHP includes within its network of credentialed providers: • A sufficient number of providers to provide adequate access to all services covered under the contract for all enrollees, including those

37 with limited English proficiency or physical or mental disabilities; • Women’s health specialists to provide direct access to covered care necessary to provide women’s routine and preventative health care services for female enrollees; and • Family planning providers to ensure timely access to covered services. (42 CFR 457.1230(a), cross-referencing to 42 CFR 438.206(b) 3.6.6

The State assures that each contract under 42 CFR 457.1201 permits an enrollee to choose his or her network provider. (42 CFR 457.1201(j), cross-referencing 42 CFR 438.3(l)) 3.6.7

The State assures that each MCO, PIHP, and PAHP provides for a second opinion from a network provider, or arranges for the enrollee to obtain one outside the network, at no cost. (42 CFR 457.1230(a), cross-referencing to 42 CFR 438.206(b)(3)) 3.6.8

The State assures that each MCO, PIHP, and PAHP ensures that providers, in furnishing services to enrollees, provide timely access to care and services, including by: • Requiring the contract to adequately and timely cover out-of-network services if the provider network is unable to provide necessary services covered under the contract to a particular enrollee and at a cost to the enrollee that is no greater than if the services were furnished within the network; • Requiring the MCO, PIHP and PAHP meet and its network providers to meet State standards for timely access to care and services, taking into account the urgency of the need for services; • Ensuring that the hours of operation for a network provider are no less than the hours of operation offered to commercial enrollees or comparable to Medicaid or CHIP Fee-For-Service, if the provider serves only Medicaid or CHIP enrollees; • Ensuring that the MCO, PIHP and PAHP makes available services include in the contract on a 24 hours a day, 7 days a week basis when medically necessary; • Establishing mechanisms to ensure compliance by network providers; • Monitoring network providers regularly to determine compliance; • Taking corrective action if there is a failure to comply by a network provider. (42 CFR 457.1230(a), cross-referencing to 42 CFR 438.206(b)(4) and (5) and (c)) 3.6.9

The State assures that each MCO, PIHP, and PAHP has the capacity to serve the expected enrollment in its service area in accordance with the State's standards for access to care. (42 CFR 457.1230(b), cross-referencing to 42 CFR 438.207)

38 3.6.10

The State assures that each MCO, PIHP, and PAHP will be required to submit documentation to the State, at the time of entering into a contract with the State, on an annual basis, and at any time there has been a significant change to the MCO, PIHP, or PAHP’s operations that would affect the adequacy of capacity and services, to demonstrate that each MCO, PIHP, and PAHP for the anticipated number of enrollees for the service area: • Offers an appropriate range of preventative, primary care and specialty services; and • Maintains a provider network that is sufficient in number, mix, and geographic distribution. (42 CFR 457.1230, cross-referencing to 42 CFR 438.207(b)) 3.6.11

Except that 42 CFR 438.210(a)(5) does not apply to CHIP, the State assures that its contracts with each MCO, PIHP, or PAHP comply with the coverage of services requirements under 42 CFR 438.210, including: • Identifying, defining, and specifying the amount, duration, and scope of each service that the MCO, PIHP, or PAHP is required to offer; and • Permitting an MCO, PIHP, or PAHP to place appropriate limits on a service. (42 CFR 457.1230(d), cross referencing to 42 CFR 438.210(a) except that 438.210(a)(5) does not apply to CHIP contracts) 3.6.12

Except that 438.210(b)(2)(iii) does not apply to CHIP, the State assures that its contracts with each MCO, PIHP, or PAHP comply with the authorization of services requirements under 42 CFR 438.210, including that: • The MCO, PIHP, or PAHP and its subcontractors have in place and follow written policies and procedures; • The MCO, PIHP, or PAHP have in place mechanisms to ensure consistent application of review criteria and consult with the requesting provider when appropriate; and • Any decision to deny a service authorization request or to authorize a service in an amount, duration, or scope that is less than requested be made by an individual with appropriate expertise in addressing the enrollee’s medical, or behavioral health needs. (42 CFR 457.1230(d), cross referencing to 42 CFR 438.210(b), except that 438.210(b)(2)(iii) does not apply to CHIP contracts) 3.6.13

The State assures that its contracts with each MCO, PIHP, or PAHP require each MCO, PIHP, or PAHP to notify the requesting provider and given written notice to the enrollee of any adverse benefit determination to deny a service authorization request, or to authorize a service in an amount, duration, or scope that is less than requested. (42 CFR 457.1230(d), cross-referencing to 42 CFR 438.210(c))

39 3.6.14

The State assures that its contracts with each MCO, PIHP, or PAHP provide that compensation to individuals or entities that conduct utilization management activities is not structured so as to provide incentives for the individual or entity to deny, limit, or discontinue medically necessary services to any enrollee. (42 CFR 457.1230(d), cross-referencing to 42 CFR 438.210(e)) 3.6.15

The State assures that it has a transition of care policy that meets the requirements of 438.62(b)(1) and requires that each contracted MCO, PIHP, and PAHP implements the policy. (42 CFR 457.1216, cross-referencing to 42 CFR 438.62) 3.6.16

The State assures that each MCO, PIHP, and PAHP has implemented procedures to deliver care to and coordinate services for all enrollees in accordance with 42 CFR 457.1230(c), cross-referencing to 42 CFR 438.208, including: • Ensure that each enrollee has an ongoing source of care appropriate to his or her needs; • Ensure that each enrollee has a person or entity formally designated as primarily responsible for coordinating the services accessed by the enrollee; • Provide the enrollee with information on how to contract their designated person or entity responsible for the enrollee’s coordination of services; • Coordinate the services the MCO, PIHP, or PAHP furnishes to the enrollee between settings of care; with services from any other MCO, PIHP, or PAHP; with fee-for-service services; and with the services the enrollee receives from community and social support providers; • Make a best effort to conduct an initial screening of each enrollees needs within 90 days of the effective date of enrollment for all new enrollees; • Share with the State or other MCOs, PIHPs, or PAHPs serving the enrollee the results of any identification and assessment of the enrollee’s needs; • Ensure that each provider furnishing services to enrollees maintains and shares, as appropriate, an enrollee health record in accordance with professional standards; and • Ensure that each enrollee’s privacy is protected in the process of coordinating care is protected with the requirements of 45 CFR parts 160 and 164 subparts A and E. (42 CFR 457.1230(c), cross-referencing to 42 CFR 438.208(b)) Guidance: For assurances 3.6.17 through 3.6.20, applicability to PIHPs and PAHPs is based a determination by the State in relation to the scope of the entity’s services and on the way the State has organized its delivery of managed care services, whether a particular PIHP or PAHP is required to implement the mechanisms for

40 identifying, assessing, and producing a treatment plan for an individual with special health care needs. (42 CFR 457.1230(c), cross-referencing to 42 CFR 438.208(a)(2)) 3.6.17

The State assures that it has implemented mechanisms for identifying to MCOs, PIHPs, and PAHPs enrollees with special health care needs who are eligible for assessment and treatment services under 42 CFR 457.1230(c), cross-referencing to 42 CFR 438.208(c) and included the mechanism in the State’s quality strategy. 3.6.18

The State assures that each applicable MCO, PIHP, and PAHP implements the mechanisms to comprehensively assess each enrollee identified by the state as having special health care needs. (42 CFR 457.1230(c), cross-referencing to 42 CFR 438.208(c)(2)) 3.6.19

The State assures that each MCO, PIHP, and PAHP will produce a treatment or service plan that meets the following requirements for enrollees identified with special health care needs: • Is in accordance with applicable State quality assurance and utilization review standards; • Reviewed and revised upon reassessment of functional need, at least every 12 months, or when the enrollee’s circumstances or needs change significantly. (42 CFR 457.1230(c), cross-referencing to 42 CFR 438.208(c)(3)) 3.6.20

The State assures that each MCO, PIHP, and PAHP must have a mechanism in place to allow enrollees to directly access a specialist as appropriate for the enrollee's condition and identified needs for enrollees identified with special health care needs who need a course of treatment or regular care monitoring. (42 CFR 457.1230(c), cross-referencing to 42 CFR 438.208(c)(4)) 3.7 Operations 3.7.1

The State assures that it has established a uniform credentialing and recredentialing policy that addresses acute, primary, behavioral, and substance use disorders providers and requires each MCO, PIHP and PAHP to follow those policies. (42 CFR 457.1233(a), cross-referencing 42 CFR 438.214(b)(1)) Guidance: Only States with MCOs, PIHPs, or PAHPs need to answer the remaining assurances in Section 3.7 (3.7.2 through 3.7.9). 3.7.2 The State assures each contracted MCO, PIHP and PAHP will comply with the provider selection requirements in 42 CFR 457.1208 and 457.1233(a), cross- referencing 42 CFR 438.12 and 438.214, including that:

41 Each MCO, PIHP, or PAHP implements written policies and procedures for selection and retention of network providers (42 CFR 457.1233(a), cross- referencing 42 CFR 438.214(a)); MCO, PIHP, and PAHP network provider selection policies and procedures do not discriminate against particular providers that serve high-risk populations or specialize in conditions that require costly treatment (42 CFR 457.1233(a), cross-referencing 42 CFR 438.214(c)); MCOs, PIHPs, and PAHPs do not discriminate in the participation, reimbursement, or indemnification of any provider who is acting within the scope of his or her license or certification, solely on the basis of that license or certification (42 CFR 457.1208, cross referencing 42 CFR 438.12(a)); If an MCO, PIHP, or PAHP declines to include individual or groups of providers in the MCO, PIHP, or PAHP’s provider network, the MCO, PIHP, and PAHP gives the affected providers written notice of the reason for the decision (42 CFR 457.1208, cross referencing 42 CFR 438.12(a)); and MCOs, PIHPs, and PAHPs do not employ or contract with providers excluded from participation in Federal health care programs under either section 1128 or section 1128A of the Act. (42 CFR 457.1233(a), cross- referencing 42 CFR 438.214(d)).

3.7.3 The State assures that each contracted MCO, PIHP, and PAHP complies with the subcontractual relationships and delegation requirements in 42 CFR 457.1233(b), cross-referencing 42 CFR 438.230, including that: The MCO, PIHP, or PAHP maintains ultimate responsibility for adhering to and otherwise fully complying with all terms and conditions of its contract with the State; All contracts or written arrangements between the MCO, PIHP, or PAHP and any subcontractor specify that all delegated activities or obligations, and related reporting responsibilities, are specified in the contract or written agreement, the subcontractor agrees to perform the delegated activities and reporting responsibilities specified in compliance with the MCO's, PIHP's, or PAHP's contract obligations, and the contract or written arrangement must either provide for revocation of the delegation of activities or obligations, or specify other remedies in instances where the State or the MCO, PIHP, or PAHP determine that the subcontractor has not performed satisfactorily; All contracts or written arrangements between the MCO, PIHP, or PAHP and any subcontractor must specify that the subcontractor agrees to comply with all applicable CHIP laws, regulations, including applicable subregulatory guidance and contract provisions; and The subcontractor agrees to the audit provisions in 438.230(c)(3).

42 3.7.4

The State assures that each contracted MCO and, when applicable, each PIHP and PAHP, adopts and disseminates practice guidelines that are based on valid and reliable clinical evidence or a consensus of providers in the particular field; consider the needs of the MCO's, PIHP's, or PAHP's enrollees; are adopted in consultation with network providers; and are reviewed and updated periodically as appropriate. (42 CFR 457.1233(c), cross referencing 42 CFR 438.236(b) and (c)) 3.7.5

The State assures that each contracted MCO and, when applicable, each PIHP and PAHP makes decisions for utilization management, enrollee education, coverage of services, and other areas to which the guidelines apply are consistent with the practice guidelines. (42 CFR 457.1233(c), cross referencing 42 CFR 438.236(d)) 3.7.6

The State assures that each contracted MCO, PIHP, and PAHP maintains a health information system that collects, analyzes, integrates, and reports data consistent with 42 CFR 438.242. The systems must provide information on areas including, but not limited to, utilization, claims, grievances and appeals, and disenrollments for other than loss of CHIP eligibility. (42 CFR 457.1233(d), cross referencing 42 CFR 438.242) 3.7.7

The State assures that it reviews and validates the encounter data collected, maintained, and submitted to the State by the MCO, PIHP, or PAHP to ensure it is a complete and accurate representation of the services provided to the enrollees under the contract between the State and the MCO, PIHP, or PAHP and meets the requirements 42 CFR 438.242 of this section. (42 CFR 457.1233(d), cross referencing 42 CFR 438.242) 3.7.8

The State assures that it will submit to CMS all encounter data collected, maintained, submitted to the State by the MCO, PIHP, and PAHP once the State has reviewed and validated the data based on the requirements of 42 CFR 438.242. (CMS State Medicaid Director Letter #13-004) 3.7.9

The State assures that each contracted MCO, PIHP and PAHP complies with the privacy protections under 42 CFR 457.1110. (42 CFR 457.1233(e)) 3.8 Beneficiary Protections 3.8.1

The State assures that each MCO, PIHP, PAHP, PCCM and PCCM entity has written policies regarding the enrollee rights specified in 42 CFR 438.100. (42 CFR 457.1220, cross-referencing to 42 CFR 438.100(a)(1)) 3.8.2

The State assures that its contracts with an MCO, PIHP, PAHP, PCCM, or PCCM entity include a guarantee that the MCO, PIHP, PAHP, PCCM, or PCCM entity

43 will not avoid costs for services covered in its contract by referring enrollees to publicly supported health care resources. (42 CFR 457.1201(p)) 3.8.3

The State assures that MCOs, PIHPs, and PAHPs do not hold the enrollee liable for the following: • The MCO’s, PIHP’s or PAHP’s debts, in the event of the entity’s solvency. (42 CFR 457.1226, cross-referencing to 42 CFR 438.106(a)) • Covered services provided to the enrollee for which the State does not pay the MCO, PIHP or PAHP or for which the State, MCO, PIHP, or PAHP does not pay the individual or the health care provider that furnished the services under a contractual, referral or other arrangement. (42 CFR 457.1226, cross- referencing to 42 CFR 438.106(b)) • Payments for covered services furnished under a contract, referral or other arrangement that are in excess of the amount the enrollee would owe if the MCO, PIHP or PAHP covered the services directly. (42 CFR 457.1226, cross- referencing to 42 CFR 438.106(c)) 3.9 Grievances and Appeals Guidance: Only States with MCOs, PIHPs, or PAHPs need to complete Section 3.9. States with PCCMs and/or PCCM entities should be adhering to the State’s review process for benefits. 3.9.1

The State assures that each MCO, PIHP, and PAHP has a grievance and appeal system in place that allows enrollees to file a grievance and request an appeal. (42 CFR 457.1260, cross-referencing to 42 CFR 438.402(a) and 438.402(c)) 3.9.2

The State assures that each MCO, PIHP, and PAHP has only one level of appeal for enrollees. (42 CFR 457.1260, cross-referencing to 42 CFR 438.402(b)) 3.9.3

The State assures that an enrollee may request a State review after receiving notice that the adverse benefit determination is upheld, or after an MCO, PIHP, or PAHP fails to adhere to the notice and timing requirements in 42 CFR 438.408. (42 CFR 457.1260, cross-referencing to 438.402(c)) 3.9.4. Does the state offer and arrange for an external medical review? Yes No

Guidance: Only states that answered yes to assurance 3.9.4 need to complete the next assurance (3.9.5). 3.9.5

The State assures that the external medical review is:

44 • At the enrollee's option and not required before or used as a deterrent to proceeding to the State review; • Independent of both the State and MCO, PIHP, or PAHP; • Offered without any cost to the enrollee; and • Not extending any of the timeframes specified in 42 CFR 438.408. (42 CFR 457.1260, cross-referencing to 42 CFR 438.402(a) and 438.402(c)(1)(i)) 3.9.6

The State assures that an enrollee may file a grievance with the MCO, PIHP, or PAHP at any time. (42 CFR 457.1260, cross-referencing to 42 CFR 438.402(a) and 438.402(c)(2)(i)) 3.9.7

The State assures that an enrollee has 60 calendar days from the date on an adverse benefit determination notice to file a request for an appeal to the MCO, PIHP, or PAHP. (42 CFR 457.1260, cross-referencing to 42 CFR 438.402(a) and 438.402(c)(2)(ii)) 3.9.8

The State assures that an enrollee may file a grievance and request an appeal either orally or in writing. (42 CFR 457.1260, cross-referencing to 42 CFR 438.402(a) and 438.402(c)(3)(i)) 3.9.9

The State assures that each MCO, PIHP, and PAHP gives enrollees timely and adequate notice of an adverse benefit determination in writing consistent with the requirements below in Section 3.9.10 and in 42 CFR 438.10. 3.9.10

The State assures that the notice of an adverse benefit determination explains: • The adverse benefit determination. • The reasons for the adverse benefit determination, including the right of the enrollee to be provided upon request and free of charge, reasonable access to and copies of all documents, records, and other information relevant to the enrollee's adverse benefit determination. Such information includes medical necessity criteria, and any processes, strategies, or evidentiary standards used in setting coverage limits. • The enrollee's right to request an appeal of the MCO's, PIHP's, or PAHP's adverse benefit determination, including information on exhausting the MCO's, PIHP's, or PAHP's one level of appeal and the right to request a State review. • The procedures for exercising the rights specified above under this assurance. • The circumstances under which an appeal process can be expedited and how to request it. (42 CFR 457.1260, cross-referencing to 42 CFR 438.404(b)) 3.9.11

The State assures that the notice of an adverse benefit determination is provided in a timely manner in accordance with 42 CFR 457.1260. (42 CFR 457.1260, cross-referencing to 42 CFR 438.404(c))

45 3.9.12

The State assures that MCOs, PIHPs, and PAHPs give enrollees reasonable assistance in completing forms and taking other procedural steps related to a grievance or appeal. This includes, but is not limited to, auxiliary aids and services upon request, such as providing interpreter services and toll-free numbers that have adequate TTY/TTD and interpreter capability. (42 CFR 457.1260, cross-referencing to 42 CFR 438.406(a)) 3.9.13 The state makes the following assurances related to MCO, PIHP, and PAHP processes for handling enrollee grievances and appeals: Individuals who make decisions on grievances and appeals were neither involved in any previous level of review or decision-making nor a subordinate of any such individual. Individuals who make decisions on grievances and appeals, if deciding any of the following, are individuals who have the appropriate clinical expertise in treating the enrollee's condition or disease: • An appeal of a denial that is based on lack of medical necessity. • A grievance regarding denial of expedited resolution of an appeal. • A grievance or appeal that involves clinical issues. All comments, documents, records, and other information submitted by the enrollee or their representative will be taken into account, without regard to whether such information was submitted or considered in the initial adverse benefit determination. Enrollees have a reasonable opportunity, in person and in writing, to present evidence and testimony and make legal and factual arguments. Enrollees are provided the enrollee's case file, including medical records, other documents and records, and any new or additional evidence considered, relied upon, or generated by the MCO, PIHP or PAHP (or at the direction of the MCO, PIHP or PAHP) in connection with the appeal of the adverse benefit determination. This information must be provided free of charge and sufficiently in advance of the resolution timeframe for appeals. The enrollee and his or her representative or the legal representative of a deceased enrollee's estate are included as parties to the appeal. (42 CFR 457.1260, cross-referencing to 42 CFR 438.406(b)) 3.9.14

The State assures that standard grievances are resolved (including notice to the affected parties) within 90 calendar days from the day the MCO, PIHP, or PAHP receives the grievance. (42 CFR 457.1260, cross-referencing to 42 CFR 438.408(b)) 3.9.15

The State assures that standard appeals are resolved (including notice to the affected parties) within 30 calendar days from the day the MCO, PIHP, or PAHP receives the appeal. The MCO, PIHP, or PAHP may extend the timeframe by up

46 to 14 calendar days if the enrollee requests the extension or the MCO, PIHP, or PAHP shows that there is need for additional information and that the delay is in the enrollee's interest. (42 CFR 457.1260, cross-referencing to 42 CFR 42 CFR 438.408(b) and (c)) 3.9.16

The State assures that each MCO, PIHP, and PAHP establishes and maintains an expedited review process for appeals that is no longer than 72 hours after the MCO, PIHP, or PAHP receives the appeal. The expedited review process applies when the MCO, PIHP, or PAHP determines (for a request from the enrollee) or the provider indicates (in making the request on the enrollee's behalf or supporting the enrollee's request) that taking the time for a standard resolution could seriously jeopardize the enrollee's life, physical or mental health, or ability to attain, maintain, or regain maximum function. (42 CFR 457.1260, cross- referencing to 42 CFR 438.408(b) and (c), and 42 CFR 438.410(a)) 3.9.17

The State assures that if an MCO, PIHP, or PAHP denies a request for expedited resolution of an appeal, it transfers the appeal within the timeframe for standard resolution in accordance with 42 CFR 438.408(b)(2). (42 CFR 457.1260, cross- referencing to 42 CFR 438.410(c)(1)) 3.9.18

The State assures that if the MCO, PIHP, or PAHP extends the timeframes for an appeal not at the request of the enrollee or it denies a request for an expedited resolution of an appeal, it completes all of the following: • Make reasonable efforts to give the enrollee prompt oral notice of the delay. • Within 2 calendar days give the enrollee written notice of the reason for the decision to extend the timeframe and inform the enrollee of the right to file a grievance if he or she disagrees with that decision. • Resolve the appeal as expeditiously as the enrollee's health condition requires and no later than the date the extension expires. (42 CFR 457.1260, cross- referencing to 42 CFR 438.408(c) and 42 CFR 438.410(c)) 3.9.19

The State assures that if an MCO, PIHP, or PAHP fails to adhere to the notice and timing requirements in this section, the enrollee is deemed to have exhausted the MCO's, PIHP's, or PAHP's appeals process and the enrollee may initiate a State review. (42 CFR 457.1260, cross-referencing to 42 CFR 438.408(c)(3)) 3.9.20

The State assures that has established a method that an MCO, PIHP, and PAHP will use to notify an enrollee of the resolution of a grievance and ensure that such methods meet, at a minimum, the standards described at 42 CFR 438.10. (42 CFR 457.1260, cross referencing to 42 CFR 457.408(d)(1)) 3.9.21

For all appeals, the State assures that each contracted MCO, PIHP, and PAHP provides written notice of resolution in a format and language that, at a minimum,

47 meet the standards described at 42 CFR 438.10. The notice of resolution includes at least the following items: • The results of the resolution process and the date it was completed; and • For appeals not resolved wholly in favor of the enrollees: o The right to request a State review, and how to do so. o The right to request and receive benefits while the hearing is pending, and how to make the request. o That the enrollee may, consistent with State policy, be held liable for the cost of those benefits if the hearing decision upholds the MCO's, PIHP's, or PAHP's adverse benefit determination. (42 CFR 457.1260, cross referencing to 42 CFR 457.408(d)(2)(i) and (e))

3.9.22

For notice of an expedited resolution, the State assures that each contracted MCO, PIHP, or PAHP makes reasonable efforts to provide oral notice, in addition to the written notice of resolution. (42 CFR 457.1260, cross referencing to 42 CFR 457.408(d)(2)(ii)) 3.9.23

The State assures that if it offers an external medical review: • The review is at the enrollee's option and is not required before or used as a deterrent to proceeding to the State review; • The review is independent of both the State and MCO, PIHP, or PAHP; and • The review is offered without any cost to the enrollee. (42 CFR 457.1260, cross-referencing to 42 CFR 438.408(f)) 3.9.24

The State assures that MCOs, PIHPs, and PAHPs do not take punitive action against providers who request an expedited resolution or support an enrollee's appeal. (42 CFR 457.1260, cross-referencing to 42 CFR 438.410(b)) 3.9.25

The State assures that MCOs, PIHPs, or PAHPs must provide information specified in 42 CFR 438.10(g)(2)(xi) about the grievance and appeal system to all providers and subcontractors at the time they enter into a contract. This includes: • The right to file grievances and appeals; • The requirements and timeframes for filing a grievance or appeal; • The availability of assistance in the filing process; • The right to request a State review after the MCO, PIHP or PAHP has made a determination on an enrollee's appeal which is adverse to the enrollee; and • The fact that, when requested by the enrollee, benefits that the MCO, PIHP, or PAHP seeks to reduce or terminate will continue if the enrollee files an appeal or a request for State review within the timeframes specified for filing, and that the enrollee may, consistent with State policy, be required to pay the cost of services furnished while the appeal or State review is pending if the final decision is adverse to the enrollee. (42 CFR 457.1260, cross-referencing to 42 CFR 438.414)

48 3.9.26

The State assures that it requires MCOs, PIHPs, and PAHPs to maintain records of grievances and appeals and reviews the information as part of its ongoing monitoring procedures, as well as for updates and revisions to the State quality strategy. The record must be accurately maintained in a manner accessible to the state and available upon request to CMS. (42 CFR 457.1260, cross-referencing to 42 CFR 438.416) 3.9.27

The State assures that if the MCO, PIHP, or PAHP, or the State review officer reverses a decision to deny, limit, or delay services that were not furnished while the appeal was pending, the MCO, PIHP, or PAHP must authorize or provide the disputed services promptly and as expeditiously as the enrollee's health condition requires but no later than 72 hours from the date it receives notice reversing the determination. (42 CFR 457.1260, cross-referencing to 42 CFR 438.424(a))

3.10 Program Integrity Guidance: The State should complete Section 11 (Program Integrity) in addition to Section 3.10. Guidance: Only States with MCOs, PIHPs, or PAHPs need to answer the first seven assurances (3.10.1 through 3.10.7). 3.10.1 The State assures that any entity seeking to contract as an MCO, PIHP, or PAHP under a separate child health program has administrative and management arrangements or procedures designed to safeguard against fraud and abuse, including:

Enforcing MCO, PIHP, and PAHP compliance with all applicable Federal and State statutes, regulations, and standards;

Prohibiting MCOs, PIHPs, or PAHPs from conducting any unsolicited personal contact with a potential enrollee by an employee or agent of the MCO, PAHP, or PIHP for the purpose of influencing the individual to enroll with the entity; and

Including a mechanism for MCOs, PIHPs, and PAHPs to report to the State, to CMS, or to the Office of Inspector General (OIG) as appropriate, information on violations of law by subcontractors, providers, or enrollees of an MCO, PIHP, or PAHP and other individuals. (42 CFR 457.1280)

3.10.2

The State assures that it has in effect safeguards against conflict of interest on the part of State and local officers and employees and agents of the State who have responsibilities relating to the MCO, PIHP, or PAHP contracts or enrollment processes described in 42 CFR 457.1210(a). (42 CFR 457.1214, cross referencing 42 CFR 438.58)

49 3.10.3

The State assures that it periodically, but no less frequently than once every 3 years, conducts, or contracts for the conduct of, an independent audit of the accuracy, truthfulness, and completeness of the encounter and financial data submitted by, or on behalf of, each MCO, PIHP or PAHP. (42 CFR 457.1285, cross referencing 42 CFR 438.602(e)) 3.10.4

The State assures that it requires MCOs, PIHPs, PAHP, and or subcontractors (only to the extent that the subcontractor is delegated responsibility by the MCO, PIHP, or PAHP for coverage of services and payment of claims) implement and maintain arrangements or procedures that are designed to detect and prevent fraud, waste, and abuse. The arrangements or procedures must include the following: • A compliance program that include all of the elements described in 42 CFR 438.608(a)(1); • Provision for prompt reporting of all overpayments identified or recovered, specifying the overpayments due to potential fraud, to the State; • Provision for prompt notification to the State when it receives information about changes in an enrollee's circumstances that may affect the enrollee's eligibility; • Provision for notification to the State when it receives information about a change in a network provider's circumstances that may affect the network provider's eligibility to participate in the managed care program, including the termination of the provider agreement with the MCO, PIHP or PAHP; • Provision for a method to verify, by sampling or other methods, whether services that have been represented to have been delivered by network providers were received by enrollees and the application of such verification processes on a regular basis; • In the case of MCOs, PIHPs, or PAHPs that make or receive annual payments under the contract of at least $5,000,000, provision for written policies for all employees of the entity, and of any contractor or agent, that provide detailed information about the False Claims Act and other Federal and State laws described in section 1902(a)(68) of the Act, including information about rights of employees to be protected as whistleblowers; • Provision for the prompt referral of any potential fraud, waste, or abuse that the MCO, PIHP, or PAHP identifies to the State Medicaid/CHIP program integrity unit or any potential fraud directly to the State Medicaid Fraud Control Unit; and • Provision for the MCO's, PIHP's, or PAHP's suspension of payments to a network provider for which the State determines there is a credible allegation of fraud in accordance with 42 CFR 455.23. (42 CFR 457.1285, cross referencing 42 CFR 438.608(a))

50 3.10.5

The State assures that each MCO, PIHP, or PAHP requires and has a mechanism for a network provider to report to the MCO, PIHP or PAHP when it has received an overpayment, to return the overpayment to the MCO, PIHP or PAHP within 60 calendar days after the date on which the overpayment was identified, and to notify the MCO, PIHP or PAHP in writing of the reason for the overpayment. (42 CFR 457.1285, cross referencing 42 CFR 438.608(d)(2)) 3.10.6

The State assures that each MCO, PIHP, or PAHP reports annually to the State on their recoveries of overpayments. (42 CFR 457.1285, cross referencing 42 CFR 438.608(d)(3)) 3.10.7

The State assures that it screens and enrolls, and periodically revalidates, all network providers of MCOs, PIHPs, and PAHPs, in accordance with the requirements of part 455, subparts B and E. This requirement also extends to PCCMs and PCCM entities to the extent that the primary care case manager is not otherwise enrolled with the State to provide services to fee-for-service beneficiaries. (42 CFR 457.1285, cross referencing 42 CFR 438.602(b)(1) and 438.608(b)) 3.10.8

The State assures that it reviews the ownership and control disclosures submitted by the MCO, PIHP, PAHP, PCCM or PCCM entity, and any subcontractors. (42 CFR 457.1285, cross referencing 42 CFR 438.602(c)) 3.10.9

The State assures that it confirms the identity and determines the exclusion status of the MCO, PIHP, PAHP, PCCM or PCCM entity, any subcontractor, as well as any person with an ownership or control interest, or who is an agent or managing employee of the MCO, PIHP, PAHP, PCCM or PCCM entity through routine checks of Federal databases. If the State finds a party that is excluded, the State promptly notifies the MCO, PIHP, PAHP, PCCM, or PCCM entity and takes action consistent with 42 CFR 438.610(c). (42 CFR 457.1285, cross referencing 42 CFR 438.602(d)) 3.10.10

The State assures that it receives and investigates information from whistleblowers relating to the integrity of the MCO, PIHP, PAHP, PCCM, or PCCM entity, subcontractors, or network providers receiving Federal funds under this part. (42 CFR 457.1285, cross referencing 42 CFR 438.602(f)) 3.10.11

The State assures that MCOs, PIHPs, PAHPs, PCCMs, or PCCM entities with which the State contracts are not located outside of the United States and that no claims paid by an MCO, PIHP, or PAHP to a network provider, out-of-network provider, subcontractor or financial institution located outside of the U.S. are considered in the development of actuarially sound capitation rates. (42 CFR 457.1285, cross referencing to 42 CFR 438.602(i); Section 1902(a)(80) of the Social Security Act)

51 3.10.12 The State assures that MCOs, PIHPs, PAHPs, PCCMs, and PCCM entities submit to the State the following data, documentation, and information:

Encounter data in the form and manner described in 42 CFR 438.818.

Data on the basis of which the State determines the compliance of the MCO, PIHP, or PAHP with the medical loss ratio requirement described in 42 CFR 438.8.

Data on the basis of which the State determines that the MCO, PIHP or PAHP has made adequate provision against the risk of insolvency as required under 42 CFR 438.116.

Documentation described in 42 CFR 438.207(b) on which the State bases its certification that the MCO, PIHP or PAHP has complied with the State's requirements for availability and accessibility of services, including the adequacy of the provider network, as set forth in 42 CFR 438.206.

Information on ownership and control described in 42 CFR 455.104 of this chapter from MCOs, PIHPs, PAHPs, PCCMs, PCCM entities, and subcontractors as governed by 42 CFR 438.230.

The annual report of overpayment recoveries as required in 42 CFR 438.608(d)(3). (42 CFR 457.1285, cross referencing 42 CFR 438.604(a))

3.10.13 The State assures that:

It requires that the data, documentation, or information submitted in accordance with 42 CFR 457.1285, cross referencing 42 CFR 438.604(a), is certified in a manner that the MCO's, PIHP's, PAHP's, PCCM's, or PCCM entity's Chief Executive Officer or Chief Financial Officer is ultimately responsible for the certification. (42 CFR 457.1285, cross referencing 42 CFR 438.606(a))

It requires that the certification includes an attestation that, based on best information, knowledge, and belief, the data, documentation, and information specified in 42 CFR 438.604 are accurate, complete, and truthful. (42 CFR 457.1285, cross referencing 42 CFR 438.606(b)); and

It requires the MCO, PIHP, PAHP, PCCM, or PCCM entity to submit the certification concurrently with the submission of the data, documentation, or information required in 42 CFR 438.604(a) and (b). (42 CFR 457.1285, cross referencing 42 CFR 438.604(c))

3.10.14

The State assures that each MCO, PIHP, PAHP, PCCM, PCCM entity, and any subcontractors provides: written disclosure of any prohibited affiliation under 42 CFR 438.610, written disclosure of and information on ownership and control required under 42 CFR 455.104, and reports to the State within 60 calendar days when it has identified the capitation payments or other payments in excess of amounts specified in the contract. (42 CFR 457.1285, cross referencing 42 CFR 438.608(c))

52 3.10.15

The State assures that services are provided in an effective and efficient manner. (Section 2101(a)) 3.10.16

The State assures that it operates a Web site that provides: • The documentation on which the State bases its certification that the MCO, PIHP or PAHP has complied with the State's requirements for availability and accessibility of services; • Information on ownership and control of MCOs, PIHPs, PAHPs, PCCMs, PCCM entities, and subcontractors; and • The result of any audits conducted under 42 CFR 438.602(e). (42 CFR 457.1285, cross-referencing to 42 CFR 438.602(g)).

3.11 Sanctions Guidance: Only States with MCOs need to answer the next three assurances (3.11.1 through 3.11.3).

Intermediate sanctions are defined at 42 CFR 438.702(a)(4) as: (1) Civil money penalties; (2) Appointment of temporary management (for an MCO); (3) Granting enrollees the right to terminate enrollment without cause; (4) Suspension of all new enrollment; and (5) Suspension of payment for beneficiaries.

3.11.1

The State assures that it has established intermediate sanctions that it may impose if it makes the determination that an MCO has acted or failed to act in a manner specified in 438.700(b)-(d). (42 CFR 457.1270, cross referencing 42 CFR 438.700) 3.11.2

The State assures that it will impose temporary management if it finds that an MCO has repeatedly failed to meet substantive requirements of part 457 subpart L. (42 CFR 457.1270, cross referencing 42 CFR 438.706(b)) 3.11.3

The State assures that if it imposes temporary management on an MCO, the State allows enrollees the right to terminate enrollment without cause and notifies the affected enrollees of their right to terminate enrollment. (42 CFR 457.1270, cross referencing 42 CFR 438.706(b)) Guidance: Only states with PCCMs, or PCCM entities need to answer the next assurance (3.11.4). 3.11.4 Does the State establish intermediate sanctions for PCCMs or PCCM entities? Yes No

53 Guidance: Only states with MCOs and states that answered yes to assurance 3.11.4 need to complete the next three assurances (3.11.5 through 3.11.7). 3.11.5

The State assures that before it imposes intermediate sanctions, it gives the affected entity timely written notice. (42 CFR 457.1270, cross referencing 42 CFR 438.710(a)) 3.11.6

The State assures that if it intends to terminate an MCO, PCCM, or PCCM entity, it provides a pre-termination hearing and written notice of the decision as specified in 42 CFR 438.710(b). If the decision to terminate is affirmed, the State assures that it gives enrollees of the MCO, PCCM or PCCM entity notice of the termination and information, consistent with 42 CFR 438.10, on their options for receiving CHIP services following the effective date of termination. (42 CFR 457.1270, cross referencing 42 CFR 438.710(b)) 3.11.7

The State assures that it will give CMS written notice that complies with 42 CFR 438.724 whenever it imposes or lifts a sanction for one of the violations listed in 42 CFR 438.700. (42 CFR 457.1270, cross referencing 42 CFR 438.724) 3.12 Quality Measurement and Improvement; External Quality Review Guidance: The State should complete Sections 7 (Quality and Appropriateness of Care) and 9 (Strategic Objectives and Performance Goals and Plan Administration) in addition to Section 3.12. Guidance: States with MCO(s), PIHP(s), PAHP(s), or certain PCCM entity/ies (PCCM entities whose contract with the State provides for shared savings, incentive payments or other financial reward for improved quality outcomes - see 42 CFR 457.1240(f)) - should complete the applicable sub-sections for each entity type in this section, regarding 42 CFR 457.1240 and 1250. 3.12.1 Quality Strategy Guidance: All states with MCOs, PIHPs, PAHPs, PCCMs, or PCCM entities need to complete section 3.12.1. 3.12.1.1

The State assures that it will draft and implement a written quality strategy for assessing and improving the quality of health care and services furnished CHIP enrollees as described in 42 CFR 438.340(a). The quality strategy must include the following items: • The State-defined network adequacy and availability of services standards for MCOs, PIHPs, and PAHPs required by 42 CFR 438.68 and 438.206 and examples of evidence-based clinical practice guidelines the State requires in accordance with 42 CFR 438.236;

54 • A description of: o The quality metrics and performance targets to be used in measuring the performance and improvement of each MCO, PIHP, and PAHP with which the State contracts, including but not limited to, the performance measures reported in accordance with 42 CFR 438.330(c); and o The performance improvement projects to be implemented in accordance with 42 CFR 438.330(d), including a description of any interventions the State proposes to improve access, quality, or timeliness of care for beneficiaries enrolled in an MCO, PIHP, or PAHP; • Arrangements for annual, external independent reviews, in accordance with 42 CFR 438.350, of the quality outcomes and timeliness of, and access to, the services covered under each contract; • A description of the State's transition of care policy required under 42 CFR 438.62(b)(3); • The State's plan to identify, evaluate, and reduce, to the extent practicable, health disparities based on age, race, ethnicity, sex, and primary language; • For MCOs, appropriate use of intermediate sanctions that, at a minimum, meet the requirements of subpart I of 42 CFR Part 438; • A description of how the State will assess the performance and quality outcomes achieved by each PCCM entity; • The mechanisms implemented by the State to comply with 42 CFR 438.208(c)(1) (relating to the identification of persons with special health care needs); • Identification of the external quality review (EQR)-related activities for which the State has exercised the option under 42 CFR 438.360 (relating to nonduplication of EQR-related activities), and explain the rationale for the State's determination that the private accreditation activity is comparable to such EQR-related activities; • Identification of which quality measures and performance outcomes the State will publish at least annually on the Web site required under 42 CFR 438.10(c)(3); and • The State's definition of a “significant change” for the purposes of updating the quality strategy under 42 CFR 438.340(c)(3)(ii). (42 CFR 457.1240(e), cross referencing to 42 CFR 438.340(b)) 3.12.1.2

The State assures that the goals and objectives for continuous quality improvement in the quality strategy are measurable and take into consideration the health status of all populations in the State served by the

55 MCO, PIHP, and PAHP. (42 CFR 457.1240(e), cross referencing to 42 CFR 438.340(b)(2)) 3.12.1.3

The State assures that for purposes of the quality strategy, the State provides the demographic information for each CHIP enrollee to the MCO, PIHP or PAHP at the time of enrollment. (42 CFR 457.1240(e), cross referencing to 42 CFR 438.340(b)(6)) 3.12.1.4

The State assures that it will review and update the quality strategy as needed, but no less than once every 3 years. (42 CFR 457.1240(e), cross referencing to 42 CFR 438.340(c)(2)) 3.12.1.5

The State assures that its review and updates to the quality strategy will include an evaluation of the effectiveness of the quality strategy conducted within the previous 3 years and the recommendations provided pursuant to 42 CFR 438.364(a)(4). (42 CFR 457.1240(e), cross referencing to 42 CFR 438.340(c)(2)(i) and (iii). 3.12.1.6

The State assures that it will submit to CMS: • A copy of the initial quality strategy for CMS comment and feedback prior to adopting it in final; and • A copy of the revised strategy whenever significant changes are made to the document, or whenever significant changes occur within the State's CHIP program, including after the review and update required every 3 years. (42 CFR 457.1240(e), cross referencing to 42 CFR 438.340(c)(3)) 3.12.1.7

Before submitting the strategy to CMS for review, the State assures that when it drafts or revises the State’s quality strategy it will: • Make the strategy available for public comment; and • If the State enrolls Indians in the MCO, PIHP, or PAHP, consult with Tribes in accordance with the State's Tribal consultation policy. (42 CFR 457.1240(e), cross referencing to 42 CFR 438.340(c)(1)) 3.12.1.8

The State assures that it makes the results of the review of the quality strategy (including the effectiveness evaluation) and the final quality strategy available on the Web site required under 42 CFR 438.10(c)(3). (42 CFR 457.1240(e), cross referencing to 42 CFR 438.340(c)(2)(ii) and (d)) 3.12.2 Quality Assessment and Performance Improvement Program 3.12.2.1 Quality Assessment and Performance Improvement Program: Measures and Projects

56 Guidance: Only states with MCOs, PIHPs, or PAHPs need to complete the next two assurances (3.12.2.1.1 and 3.12.2.1.2). 3.12.2.1.1 The State assures that it requires that each MCO, PIHP, and PAHP establish and implement an ongoing comprehensive quality assessment and performance improvement program for the services it furnishes to its enrollees as provided in 42 CFR 438.330, except that the terms of 42 CFR 438.330(d)(4) (related to dual eligibles) do not apply. The elements of the assessment and program include at least: • Standard performance measures specified by the State; • Any measures and programs required by CMS (42 CFR 438.330(a)(2); • Performance improvement projects that focus on clinical and non-clinical areas, as specified in 42 CFR 438.330(d); • Collection and submission of performance measurement data in accordance with 42 CFR 438.330(c); • Mechanisms to detect both underutilization and overutilization of services; and • Mechanisms to assess the quality and appropriateness of care furnished to enrollees with special health care needs, as defined by the State in the quality strategy under 42 CFR 457.1240(e) and Section 3.12.1 of this template). (42 CFR 457.1240(b), cross referencing to 42 CFR 438.330(b) and (c)(1))

Guidance: A State may request an exemption from including the performance measures or performance improvement programs established by CMS under 42 CFR 438.330(a)(2), by submitting a written request to CMS explaining the basis for such request. 3.12.2.1.2 The State assures that each MCO, PIHP, and PAHP’s performance improvement projects are designed to achieve significant improvement, sustained over time, in health outcomes and enrollee satisfaction. The performance improvement projects include at least the following elements: • Measurement of performance using objective quality indicators; • Implementation of interventions to achieve improvement in the access to and quality of care; • Evaluation of the effectiveness of the interventions based on the performance measures specified in 42 CFR 438.330(d)(2)(i); and

57 • Planning and initiation of activities for increasing or sustaining improvement. (42 CFR 457.1240(b), cross referencing to 42 CFR 438.330(d)(2)) Guidance: Only states with a PCCM entity whose contract with the State provides for shared savings, incentive payments or other financial reward for improved quality outcomes need to, complete the next assurance (3.12.2.1.3).

3.12.2.1.3 The State assures that it requires that each PCCM entity establishes and implements an ongoing comprehensive quality assessment and performance improvement program for the services it furnishes to its enrollees as provided in 42 CFR 438.330, except that the terms of 42 CFR 438.330(d)(4) (related to dual eligibles) do not apply. The assessment and program must include: • Standard performance measures specified by the State; • Mechanisms to detect both underutilization and overutilization of services; and • Collection and submission of performance measurement data in accordance with 42 CFR 438.330(c). (42 CFR 457.1240(a) and (b), cross referencing to 42 CFR 438.330(b)(3) and (c)) 3.12.2.2 Quality Assessment and Performance Improvement Program: Reporting and Effectiveness Guidance: Only states with MCOs, PIHPs, or PAHPs need to complete Section 3.12.2.2. 3.12.2.2.1 The State assures that each MCO, PIHP, and PAHP reports on the status and results of each performance improvement project conducted by the MCO, PIHP, and PAHP to the State as required by the State, but not less than once per year. (42 CFR 457.1240(b), cross referencing to 42 CFR 438.330(d)(3)) 3.12.2.2.2 The State assures that it annually requires each MCO, PIHP, and PAHP to:

1) Measure and report to the State on its performance using the standard measures required by the State;

2) Submit to the State data specified by the State to calculate the MCO's, PIHP's, or PAHP's performance using the standard measures identified by the State; or

3) Perform a combination of options (1) and (2) of this assurance. (42 CFR 457.1240(b), cross referencing to 42 CFR 438.330(c)(2))

58 3.12.2.2.3 The State assures that the State reviews, at least annually, the impact and effectiveness of the quality assessment and performance improvement program of each MCO, PIHP, PAHP and PCCM entity. The State’s review must include: • The MCO's, PIHP's, PAHP's, and PCCM entity's performance on the measures on which it is required to report; and • The outcomes and trended results of each MCO's, PIHP's, and PAHP's performance improvement projects. (42 CFR 457.1240(b), cross referencing to 42 CFR 438.330(e)(1)) 3.12.3 Accreditation Guidance: Only states with MCOs, PIHPs, or PAHPs need to complete Section 3.12.3. 3.12.3.1

The State assures that it requires each MCO, PIHP, and PAHP to inform the state whether it has been accredited by a private independent accrediting entity, and, if the MCO, PIHP, or PAHP has received accreditation by a private independent accrediting agency, that the MCO, PIHP, and PAHP authorizes the private independent accrediting entity to provide the State a copy of its recent accreditation review that includes the MCO, PIHP, and PAHP’s accreditation status, survey type, and level (as applicable); accreditation results, including recommended actions or improvements, corrective action plans, and summaries of findings; and expiration date of the accreditation. (42 CFR 457.1240(c), cross referencing to 42 CFR 438.332(a) and (b)). 3.12.3.2

The State assures that it will make the accreditation status for each contracted MCO, PIHP, and PAHP available on the Web site required under 42 CFR 438.10(c)(3), including whether each MCO, PIHP, and PAHP has been accredited and, if applicable, the name of the accrediting entity, accreditation program, and accreditation level; and update this information at least annually. (42 CFR 457.1240(c), cross referencing to 42 CFR 438.332(c)) 3.12.4 Quality Rating Guidance: Only states with MCOs, PIHPs, or PAHPs need to complete Section 3.12.4.

The State assures that it will implement and operate a quality rating system that issues an annual quality rating for each MCO, PIHP, and PAHP, which the State will prominently display on the Web site required under 42 CFR 438.10(c)(3), in accordance with the requirements set forth in 42 CFR 438.334. (42 CFR 457.1240(d))

59 Guidance: States will be required to comply with this assurance within 3 years after CMS, in consultation with States and other Stakeholders and after providing public notice and opportunity for comment, has identified performance measures and a methodology for a Medicaid and CHIP managed care quality rating system in the Federal Register. 3.12.5 Quality Review Guidance: All states with MCOs, PIHPs, PAHPs, PCCMs or PCCM entities need to complete Sections 3.12.5 and 3.12.5.1.

The State assures that each contract with a MCO, PIHP, PAHP, or PCCM entity requires that a qualified EQRO performs an annual external quality review (EQR) for each contracting MCO, PIHP, PAHP or PCCM entity, except as provided in 42 CFR 438.362. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.350(a)) 3.12.5.1 External Quality Review Organization 3.12.5.1.1 The State assures that it contracts with at least one external quality review organization (EQRO) to conduct either EQR alone or EQR and other EQR-related activities. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.356(a)) 3.12.5.1.2 The State assures that any EQRO used by the State to comply with 42 CFR 457.1250 must meet the competence and independence requirements of 42 CFR 438.354 and, if the EQRO uses subcontractors, that the EQRO is accountable for and oversees all subcontractor functions. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.354 and 42 CFR 438.356(b) through (d)) 3.12.5.2 External Quality Review-Related Activities Guidance: Only states with MCOs, PIHPs, or PAHPs need to complete the next three assurances (3.12.5.2.1 through 3.12.5.2.3). Under 42 CFR 457.1250(a), the State, or its agent or EQRO, must conduct the EQR-related activity under 42 CFR 438.358(b)(1)(iv) regarding validation of the MCO, PIHP, or PAHP’s network adequacy during the preceding 12 months; however, the State may permit its contracted MCO, PIHP, and PAHPs to use information from a private accreditation review in lieu of any or all the EQR-related activities under 42 CFR 438.358(b)(1)(i) through (iii) (relating to the validation of performance improvement projects, validation of performance measures, and compliance review).

60 3.12.5.2.1 The State assures that the mandatory EQR-related activities described in 42 CFR 438.358(b)(1)(i) through (iv) (relating to the validation of performance improvement projects, validation of performance measures, compliance review, and validation of network adequacy) will be conducted on all MCOs, PIHPs, or PAHPs. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.358(b)(1))

3.12.5.2.2 The State assures that if it elects to use nonduplication for any or all of the three mandatory EQR-related activities described at 42 CFR 438.358(b)(1)(i) – (iii), the State will document the use of nonduplication in the State’s quality strategy. (42 CFR 457.1250(a), cross referencing 438.360, 438.358(b)(1)(i) through (b)(1)(iii), and 438.340) 3.12.5.2.3 The State assures that if the State elects to use nonduplication for any or all of the three mandatory EQR-related activities described at 42 CFR 438.358(b)(1)(i) – (iii), the State will ensure that all information from a Medicare or private accreditation review for an MCO, PIHP, or PAHP will be furnished to the EQRO for analysis and inclusion in the EQR technical report described in 42 CFR 438.364. ((42 CFR 457.1250(a), cross referencing to 42 CFR 438.360(b)) Guidance: Only states with PCCM entities need to complete the next assurance (3.12.5.2.4). 3.12.5.2.4 The State assures that the mandatory EQR-related activities described in 42 CFR 438.358(b)(2) (cross-referencing 42 CFR 438.358(b)(1)(ii) and (b)(1)(iii)) will be conducted on all PCCM entities, which include: • Validation of PCCM entity performance measures required in accordance with 42 CFR 438.330(b)(2) or PCCM entity performance measures calculated by the State during the preceding 12 months; and • A review, conducted within the previous 3-year period, to determine the PCCM entity’s compliance with the standards set forth in subpart D of 42 CFR part 438 and the quality assessment and performance improvement requirements described in 42 CFR 438.330. (42 CFR 457.1250(a), cross referencing to 438.358(b)(2))

61 3.12.5.3 External Quality Review Report Guidance: All states with MCOs, PIHPs, PAHPs, PCCMs or PCCM entities need to complete Sections 3.12.5.3. 3.12.5.3.1 The State assures that data obtained from the mandatory and optional, if applicable, EQR-related activities in 42 CFR 438.358 is used for the annual EQR to comply with 42 CFR 438.350 and must include, at a minimum, the elements in §438.364(a)(2)(i) through (iv). (42 CFR 457.1250(a), cross referencing to 42 CFR 438.358(a)(2))

3.12.5.3.2 The State assures that only a qualified EQRO will produce the EQR technical report (42 CFR 438.364(c)(1)).

3.12.5.3.3 The State assures that in order for the qualified EQRO to perform an annual EQR for each contracting MCO, PIHP, PAHP or PCCM entity under 42 CFR 438.350(a) that the following conditions are met: • The EQRO has sufficient information to use in performing the review; • The information used to carry out the review must be obtained from the EQR-related activities described in 42 CFR 438.358 and, if applicable, from a private accreditation review as described in 42 CFR 438.360; • For each EQR-related activity (mandatory or optional), the information gathered for use in the EQR must include the elements described in 42 CFR 438.364(a)(2)(i) through (iv); and • The information provided to the EQRO in accordance with 42 CFR 438.350(b) is obtained through methods consistent with the protocols established by the Secretary in accordance with 42 CFR 438.352. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.350(b) through (e)) 3.12.5.3.4 The State assures that the results of the reviews performed by a qualified EQRO of each contracting MCO, PIHP, PAHP, and PCCM entity are made available as specified in 42 CFR 438.364 in an annual detailed technical report that summarizes findings on access and quality of care. The report includes at least the following items: • A description of the manner in which the data from all activities conducted in accordance with 42 CFR 438.358 were

62 aggregated and analyzed, and conclusions were drawn as to the quality, timeliness, and access to the care furnished by the MCO, PIHP, PAHP, or PCCM entity (described in 42 CFR 438.310(c)(2)); • For each EQR-related activity (mandatory or optional) conducted in accordance with 42 CFR 438.358: o Objectives; o Technical methods of data collection and analysis; o Description of data obtained, including validated performance measurement data for each activity conducted in accordance with 42 CFR 438.358(b)(1)(i) and (ii); and o Conclusions drawn from the data; • An assessment of each MCO's, PIHP's, PAHP's, or PCCM entity's strengths and weaknesses for the quality, timeliness, and access to health care services furnished to CHIP beneficiaries; • Recommendations for improving the quality of health care services furnished by each MCO, PIHP, PAHP, or PCCM entity, including how the State can target goals and objectives in the quality strategy, under 42 CFR 438.340, to better support improvement in the quality, timeliness, and access to health care services furnished to CHIP beneficiaries; • Methodologically appropriate, comparative information about all MCOs, PIHPs, PAHPs, and PCCM entities, consistent with guidance included in the EQR protocols issued in accordance with 42 CFR 438.352(e); and • An assessment of the degree to which each MCO, PIHP, PAHP, or PCCM entity has addressed effectively the recommendations for quality improvement made by the EQRO during the previous year's EQR. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.350(f) and 438.364(a)) 3.12.5.3.5 The State assures that it does not substantively revise the content of the final EQR technical report without evidence of error or omission. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.364(b)) 3.12.5.3.6 The State assures that it finalizes the annual EQR technical report by April 30th of each year. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.364(c)(1)) 3.12.5.3.7 The State assures that it posts the most recent copy of the annual EQR technical report on the Web site required under 42 CFR

63 438.10(c)(3) by April 30th of each year. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.364(c)(2)(i)) 3.12.5.3.8 The State assures that it provides printed or electronic copies of the information specified in 42 CFR 438.364(a) for the annual EQR technical report, upon request, to interested parties such as participating health care providers, enrollees and potential enrollees of the MCO, PIHP, PAHP, or PCCM, beneficiary advocacy groups, and members of the general public. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.364(c)(2)(ii)) 3.12.5.3.9 The State assures that it makes the information specified in 42 CFR 438.364(a) for the annual EQR technical report available in alternative formats for persons with disabilities, when requested. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.364(c)(3)) 3.12.5.3.10 The State assures that information released under 42 CFR 438.364 for the annual EQR technical report does not disclose the identity or other protected health information of any patient. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.364(d))

3.2. Describe the utilization controls under the child health assistance provided under the plan for targeted low-income children. Describe the systems designed to ensure that enrollees receiving health care services under the State plan receive only appropriate and medically necessary health care consistent with the benefit package described in the approved State plan. (Section 2102)(a)(4) (42CFR 457.490(b)) Oregon Administrative rules for quality assurance and quality improvement review process require DMAP contracted coordinated care organizations to have an internal utilization review infrastructure and to specifically monitor utilization of preventive care, the operation and outcome of referral procedures, and persistent or significant DMAP member complaints. DMAP staff annually reviews health plan compliance with utilization and quality assurance requirements to ensure appropriate utilization of health care services. The quality improvement process ensures services provided are appropriate and medically necessary, and approved by the state. The following are examples of administrative mechanisms required of the managed care plans in the Oregon Health Plan Medicaid Demonstration Project, which are also required under CHIP to ensure CHIP children receive appropriate and medically necessary health care.

• Plans must provide 24-hour-a-day, 7 day-a-week appropriate urgent, emergent, and triage services. Plans are required to have written policies and procedures that they communicate to providers, and plans are required to review their policies and procedures annually.

64 • Plans must ensure and monitor the availability of an after-hours call-in system to triage urgent and emergent call from clients. • Plans must assure access to services according to the following time standards: • Immediately for emergency medical services. Within 24 hours for emergency dental, mental health, or chemical dependency services. • Within 48 hours for urgent medical, mental health, or chemical dependency services. Within one to two weeks for urgent dental services. • Within four weeks, or within the community standard, for well care for preventive or non emergent medical services. • Within two weeks of patient request for intake assessment for mental health or chemical dependency services. • Within twelve weeks, or the community standard, for dental services.

For CHIP services provided on a FFS basis, all utilization review requirements of Title XIX and the 1115 Demonstration apply. The Quality Improvement Organization (QIO) contractor reviews inpatient hospital services. DMAP requires prior authorization for certain services according to OHP Medicaid FFS protocols and claims are subject to SURS post-payment review.

Section 4. Eligibility Standards and Methodology

Guidance: States electing to use funds provided under Title XXI only to provide expanded eligibility under the State’s Medicaid plan or combination plan should check the appropriate box and provide the ages and income level for each eligibility group. If the State is electing to take up the option to expand Medicaid eligibility as allowed under section 214 of CHIPRA regarding lawfully residing, complete section 4.1-LR as well as update the budget to reflect the additional costs if the state will claim title XXI match for these children until and if the time comes that the children are eligible for Medicaid.

4.0.

Medicaid Expansion Eligibility for Medicaid Expansion Program CS3 42 CFR 457.320(a)(2) and (3)

Income eligibility for children under the Medicaid Expansion is determined in accordance with the following income standards:

4.0.1. Ages of each eligibility group and the income standard for that group:

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

65 0 1 133 185 6 19 100 133

4.1.

Separate Program Check all standards that will apply to the State plan. (42 CFR 457.305(a) and 457.320(a))

4.1.0 Describe how the State meets the citizenship verification requirements. Include whether or not State has opted to use SSA verification option. Oregon uses a match with the SSA to verify citizenship in an overnight process. A new citizenship verification field was added to the system used by eligibility staff. The new citizenship code field uses SSA data to confirm the individual meets medical program U.S. citizenship documentation requirements. In cases where the data match does not confirm the individual is a U.S. citizen, the eligibility worker sends the applicant a notice requesting citizenship/identity documentation. Individuals who do not provide the U.S. citizenship documentation in the time frame allowed will have their medical assistance closed.

Separate Child Health Insurance Program Eligibility - Targeted Low-Income Children CS7 2102(b)(1)(B)(v) of the SSA and 42 CFR 457.310, 315 and 320

4.1.1 Geographic area served by the Plan if less than Statewide: Income standards are applied statewide, there are no exceptions by population or county.

4.1.2 Ages of each eligibility group, including unborn children and pregnant women (if applicable) and the income standard for that group:

Children: Age must be under 19

4.1.2.1-PC Age: conception through birth (SHO #02-004, issued November 12, 2002)

4.1.3 Income of each separate eligibility group (if applicable):

From Age To Age Above (% FPL) Up to & including (% FPL) 0 1 185 300 1 19 133 300

There is no special program for children with disabilities.

66

4.1.3.1-PC 0% of the FPL (and not eligible for Medicaid) through 185% of the FPL (SHO #02-004, issued November 12, 2002)

4.1.4 Resources of each separate eligibility group (including any standards relating to spend downs and disposition of resources):

No asset limit 4.1.5 Residency (so long as residency requirement is not based on length of time in state):

Separate Child Health Insurance Program Non-Financial Eligibility – Residency CS17 42 CFR 457.320

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

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

A non-institutionalized child, if capable of indicating intent and who is emancipated or married, if the child is living in the state and: 1. Intends to reside in the state, including without a fixed address, or 2. Has entered the state with a job commitment or seeking employment, whether or not currently employed.

A non-institutionalized child not described above and a child who is not a ward of the state: 1. Residing in the state, with or without a fixed address, or 2. The state of residency of the parent or caretaker, in accordance with 42 CFR.435.403(h)(1), with whom the individual resides.

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

A child who is a ward of the state regardless of where the child lives, or

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

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

A non-institutionalized pregnant woman who is living in the state and: 1. Intends to reside in the state, including without a fixed address, or if incapable of indicating intent, is living in the state, or 2. Entered with a job commitment or seeking employment, whether or not currently employed.

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

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

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

The state has in place related to the residency of children and pregnant women (if covered by the state): One or more interstate agreement(s). Yes No

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

4.1.6 Disability Status (so long as any standard relating to disability status does not restrict eligibility):

Not applicable 4.1.7 Access to or coverage under other health coverage: A child must be uninsured at the date of eligibility for the CHIP program.

4.1.8 Duration of eligibility, not to exceed 12 months:

12 months

4.1.9 Other Standards- Identify and describe other standards for or affecting eligibility, including those standards in 42 CFR 457.310 and 457.320 that are not addressed above. For instance: Although eligibility is retroactive to date of CHIP application, if the client does not include selection of a CCO in mandatory managed care areas they are auto assigned to a CCO for OHP Plus coverage. This is the same as the current rule applied to OHP Medicaid non-categorical members. The twelve-month eligibility period for Healthy KidsConnect members begins on the date of application approval. Plan enrollment will be no earlier than the first of the month following eligibility approval. Enrollment in HKC plans is the first of the month following application approval, if application approval occurs on or before the 25th of the approval month. If application approval is the 26th or after in the approval month, enrollment will be the first of the next month. The office of Private Health Partnerships (OPHP) is abolished effective 1/1/2014. Redeterminations and new applications received on or after 8/23/13 will be enrolled in OHP direct coverage. Children currently

68 enrolled in Healthy KidsConnect with incomes above 200% up to and including 300% of FPL will be converted to CHIP direct coverage on or before 1/1/14.

Guidance: States may only require the SSN of the child who is applying for coverage. If SSNs are required and the State covers unborn children, indicate that the unborn children are exempt from providing a SSN. Other standards include, but are not limited to presumptive eligibility and deemed newborns.

4.1.9.1

States should specify whether Social Security Numbers (SSN) are required. Separate Child Health Insurance Program Non-Financial Eligibility - Social Security Number CS19 42 CFR 457.340(b)

Social Security Number As a condition of eligibility, the CHIP Agency must require individuals who have a social security number or are eligible for one as determined by the Social Security Administration, to furnish their social security number, or numbers if they have more than one number. The CHIP Agency requires individuals, as a condition of eligibility, to furnish their social

security number(s), with the following exceptions: • Individuals refusing to obtain a social security number (SSN) because of well established religious objections, or • Individuals who are not eligible for an SSN, or • Individuals who are issued an SSN only for a valid non-work purpose.

The CHIP Agency assists individuals, who are required to provide their SSN, to apply for or obtain an SSN from the Social Security Administration if the individual does not have or forgot their SSN.

The CHIP Agency informs individuals required to provide their SSN: • By what statutory authority the number is solicited; and • How the state will use the SSN.

The CHIP Agency provides assurance that it will verify each SSN furnished by an applicant or beneficiary with the Social Security Administration, not deny or delay services to an otherwise eligible applicant pending issuance or verification of the individual's SSN by the Social Security Administration and that the state's utilization of the SSNs is consistent with sections 205 and 1137 of the Social Security Act and the Privacy Act of 1974.

69 The state may request non-applicant household members to voluntarily provide their SSN, if the state meets the requirements below.

The state requests non-applicant household members to voluntarily provide their SSN. Yes No

When requesting an SSN for non-applicant household members, the state assures that:

At the time such SSN is requested, the state informs the non-applicant that this

information is voluntary and provides information regarding how the SSN will be used; and

The state only uses the SSN for determination of eligibility for CHIP or other insurance affordability programs, or for a purpose directly connected with the administration of the state plan

Guidance: States should describe their continuous eligibility process and populations that can be continuously eligible.

4.1.9.2 Continuous eligibility Eligibility is for 12 continuous months, unless one of the following events occurs before the annual renewal: 1) moves out of state; 2) obtains other health insurance; 3) a child turns age 19; 4) the family requests cancellation; 5) the family applies for Medicaid and the child is determined eligible for Medicaid or 6) if the child is enrolled in a HKC plan and does not pay the premium. Families with HKC children will have a minimum 30 days to pay their portion of the premium before being disenrolled. People in HKC are billed by OPHP each month for their portion of the premium. OPHP combines the member’s portion with the subsidy and pays the insurance carrier. Individuals who fail to pay their premium will be disenrolled. Members are billed approximately 45 days in advance of the date premiums are due to the carrier. Members are provided a premium grace period of at least 30 days from the billing date. Reminder notices are mailed mid-way through this grace period. Subsidy cancellation notices outlining the program’s intent to terminate, are mailed at the end of the grace period. Terminated individuals can be reinstated on a one time exception basis. Once terminated for non

70 payment of premium members are able to re-enroll in the program..

Eligibility is redeterminded every twelve months for State Plan

children . No limit to duration of eligibility if

all conditions are met. The PC-Unborn population is eligible for CHIP benefits while in utero and redetermined at birth.

The PC-Unborn population is eligible for CHIP benefits while in utero and redetermined at birth.

4.1.10 Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards Child Health Insurance Program Eligibility - Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards CS14 Section 2101(f) of the ACA and 42 CFR 457.310(d)

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

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

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

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

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

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

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

The state will enroll children in a separate CHIP who are found to be ineligible for Medicaid based on MAGI but whose family income has not increased since the child’s last determination of Medicaid eligibility or who would have remained eligible for Medicaid (based on the 2013 Medicaid income standard) if the value of their 2013

71 disregards had been applied to the family income as determined by MAGI methodology.

Other.

Describe the benefits provided to this population:

This population will be provided the same benefits as are provided to children in the state’s Medicaid program.

4.1-PW

Pregnant Women Option (section 2112)- The State includes eligibility for one or more populations of targeted low-income pregnant women under the plan. Describe the population of pregnant women that the State proposes to cover in this section. Include all eligibility criteria, such as those described in the above categories (for instance, income and resources) that will be applied to this population. Use the same reference number system for those criteria (for example, 4.1.1-P for a geographic restriction). Please remember to update sections 8.1.1-PW, 8.1.2-PW, and 9.10 when electing this option.

Guidance: States have the option to cover groups of “lawfully residing” children and/or pregnant women. States may elect to cover (1) “lawfully residing” children described at section 2107(e)(1)(J) of the Act; (2) “lawfully residing” pregnant women described at section 2107(e)(1)(J) of the Act; or (3) both. A state electing to cover children and/or pregnant women who are considered lawfully residing in the U.S. must offer coverage to all such individuals who meet the definition of lawfully residing, and may not cover a subgroup or only certain groups. In addition, states may not cover these new groups only in CHIP, but must also extend the coverage option to Medicaid. States will need to update their budget to reflect the additional costs for coverage of these children. If a State has been covering these children with State only funds, it is helpful to indicate that so CMS understands the basis for the enrollment estimates and the projected cost of providing coverage. Please remember to update section 9.10 when electing this option.

4.1- LR

Lawfully Residing Option(Sections 2107(e)(1)(J) and 1903(v)(4)(A); (CHIPRA # 17, SHO # 10-006 issued July 1, 2010) Check if the State is electing the option under section 214 of the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA) regarding lawfully residing to provide coverage to the following otherwise eligible pregnant women and children as specified below who are lawfully residing in the United States including the following: A child or pregnant woman shall be considered lawfully present if he or she is: (1) A qualified alien as defined in section 431 of PRWORA (8 U.S.C. §1641); (2) An alien in nonimmigrant status who has not violated the terms of the status under which he or she was admitted or to which he or she has changed after admission; (3) An alien who has been paroled into the United States pursuant to section 212(d)(5) of the Immigration and Nationality Act (INA) (8 U.S.C.

72 §1182(d)(5)) for less than 1 year, except for an alien paroled for prosecution, for deferred inspection or pending removal proceedings; (4) An alien who belongs to one of the following classes: (i) Aliens currently in temporary resident status pursuant to section 210 or 245A of the INA (8 U.S.C. §§1160 or 1255a, respectively); (ii) Aliens currently under Temporary Protected Status (TPS) pursuant to section 244 of the INA (8 U.S.C. §1254a), and pending applicants for TPS who have been granted employment authorization; (iii) Aliens who have been granted employment authorization under 8 CFR 274a.12(c)(9), (10), (16), (18), (20), (22), or (24); (iv) Family Unity beneficiaries pursuant to section 301 of Pub. L. 101- 649, as amended; (v) Aliens currently under Deferred Enforced Departure (DED) pursuant to a decision made by the President; (vi) Aliens currently in deferred action status; or (vii) Aliens whose visa petition has been approved and who have a pending application for adjustment of status; (5) A pending applicant for asylum under section 208(a) of the INA (8 U.S.C. § 1158) or for withholding of removal under section 241(b)(3) of the INA (8 U.S.C. § 1231) or under the Convention Against Torture who has been granted employment authorization, and such an applicant under the age of 14 who has had an application pending for at least180 days; (6) An alien who has been granted withholding of removal under the Convention Against Torture; (7) A child who has a pending application for Special Immigrant Juvenile status as described in section 101(a)(27)(J) of the INA (8 U.S.C. §1101(a)(27)(J)); (8) An alien who is lawfully present in the Commonwealth of the Northern Mariana Islands under 48 U.S.C. § 1806(e); or (9) An alien who is lawfully present in American Samoa under the immigration laws of American Samoa.

Elected for pregnant women. Elected for children under age 19

4.1.1-LR The State provides assurance that for an individual whom it enrolls in Medicaid under the CHIPRA Lawfully Residing option, it has verified, at the time of the individual’s initial eligibility determination and at the time of the eligibility redetermination that the individual continues to be lawfully residing in the United States. The State must first attempt to verify this status using information provided at the time of initial application. If the State cannot do so from the information readily available, it must require the individual to provide documentation or

73 further evidence to verify satisfactory immigration status in the same manner as it would for anyone else claiming satisfactory immigration status under section 1137(d) of the Act.

Refer to form CS18 approved 2/10/14

Separate Child Health Insurance Program Non-Financial Eligibility – Citizenship CS18 Sections 2105(c)(9) and 2107(e)(1)(J) of the SSA and 42 CFR 457.320(b)(6), (c) and (d)

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

The CHIP Agency provides eligibility under the Plan to otherwise eligible individuals: Who are citizens or nationals of the United States; or

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

Who have declared themselves to be citizens or nationals of the United States, or an individual having satisfactory immigration status, during a reasonable opportunity period pending verification of their citizenship, nationality, or satisfactory immigration status consistent with requirements of 1903(x), 1137(d), and 1902(ee) of the Act, and 42 CFR 435.406, 407, 956 and 457.380.

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

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

Yes No The agency begins to furnish benefits to otherwise eligible individuals during the reasonable opportunity period on a date earlier than the date the notice is received by the individual.

The date benefits are furnished is:

The date of application containing the declaration of citizenship or immigration status.

The date the reasonable opportunity notice is sent.

Other date, as described:

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The CHIP Agency elects the option to provide CHIP coverage to otherwise eligible children up to age 19, lawfully residing in the United States, as provided in Section 2107(e)(1)(J) of the SSA (Section 214 of CHIPRA 2009, P.L. 111-3). Yes No

Otherwise eligible children means children meeting the eligibility requirements of targeted low- income children with the exception of non-citizen status.

The CHIP Agency provides assurance that lawfully residing children are also covered under the state's Medicaid program.

The CHIP Agency elects the option to provide CHIP coverage to otherwise eligible pregnant women, lawfully residing in the United States, as provided in Section 214 of CHIPRA 2009, P.L. 111-3. The state may not select this option unless the state also elects to cover lawfully residing children. A state may not select this option unless the state also covers Targeted Low- Income Pregnant Women. Yes No

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

4.1-DS

Supplemental Dental (Section 2103(c)(5) - A child who is eligible to enroll in dental- only supplemental coverage, effective January 1, 2009. Eligibility is limited to only targeted low-income children who are otherwise eligible for CHIP but for the fact that they are enrolled in a group health plan or health insurance offered through an employer. The State’s CHIP plan income eligibility level is at least the highest income eligibility standard under its approved State child health plan (or under a waiver) as of January 1, 2009. All who meet the eligibility standards and apply for dental-only supplemental coverage shall be provided benefits. States choosing this option must report these children separately in SEDS. Please update sections 1.1-DS, 4.2-DS, and 9.10 when electing this option.

4.2. Assurances The State assures by checking the box below that it has made the following findings with respect to the eligibility standards in its plan: (Section 2102(b)(1)(B) and 42 CFR 457.320(b))

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

4.2.2. Within a defined group of covered targeted low-income children, these

standards do not cover children of higher income families without covering

children with a lower family income. This applies to pregnant women included

in the State plan as well as targeted low-income children.

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

medical condition. This applies to pregnant women as well as targeted low-

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income children.

4.2-DS Supplemental Dental - Please update sections 1.1-DS, 4.1-DS, and 9.10 when electing this option. For dental-only supplemental coverage, the State assures that it has made the following findings with standards in its plan: (Section 2102(b)(1)(B) and 42 CFR 457.320(b))

4.2.1-DS These standards do not discriminate on the basis of diagnosis.

4.2.2-DS Within a defined group of covered targeted low-income children, these

standards do not cover children of higher income families without covering

children with a lower family income.

4.2.3-DS These standards do not deny eligibility based on a child having a pre-

existing medical condition.

4.3. Methodology. Describe the methods of establishing and continuing eligibility and enrollment. The description should address the procedures for applying the eligibility standards, the organization and infrastructure responsible for making and reviewing eligibility determinations, and the process for enrollment of individuals receiving covered services, and whether the State uses the same application form for Medicaid and/or other public benefit programs. (Section 2102)(b)(2)) (42 CFR 457.350)

Separate Child Health Insurance Program General Eligibility - Eligibility Processing CS24 See 4.4 below for details in form

Guidance: The box below should be checked as related to children and pregnant women. Please note: A State providing dental-only supplemental coverage may not have a waiting list or limit eligibility in any way.

4.3.1. Limitation on Enrollment Describe the processes, if any, that a State will use for instituting enrollment caps, establishing waiting lists, and deciding which children will be given priority for enrollment. If this section does not apply to your state, check the box below. (Section 2102(b)(2)) (42 CFR 457.305(b))

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

Guidance: Note that for purposes of presumptive eligibility, States do not need to verify the

citizenship status of the child. States electing this option should indicate so in the

State plan. (42 CFR 457.355)

4.3.2. Check if the State elects to provide presumptive eligibility for children that meets the requirements of section 1920A of the Act. (Section 2107(e)(1)(L)); (42 CFR 457.355)

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4.3.2.1 Presumptive Eligibility for Children-Hospital Separate Child Health Insurance Program General Eligibility - Presumptive Eligibility for Children CS28 42 CFR 457.355 and 435.1102, 2107(e)(1)(L) and 1920A of the SSA

The CHIP Agency covers children when determined presumptively eligible by a qualified entity. Yes No

Describe the population of children to whom presumptive eligibility applies: Targeted Low-income Children (2102(b)(1)(B)(v) of the SSA and 42 CFR 457.310, 315 and 320). HPE does not apply to the 'conception to birth'/'unborn' population known in Oregon as the Citizen Alien Waived Emergent Medical (CAWEM) Plus population.

Describe the duration of the presumptive eligibility period and any limitations: The presumptive period begins on the date the determination is made or the date that the individual received a covered service as long as the qualified hospital submits the decision to the Authority within 5 calendar days of the service date. The end date of the presumptive period is the earlier of: The date the eligibility determination for regular CHIP is made, if an application for CHIP 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 CHIP is filed by that date. The period of eligibility is once every 12 months.

Describe the application process and eligibility determination factors used: The Hospital is responsible for making immediate eligibility determinations that: Are initiated using the OHA Hospital Presumptive Medical application (OHP 7260) and are based only on information provided by the applicant or his/her representative in Part 1 of the OHP 7260. No additional documentation or verification may be required at the time of the Hospital Presumptive Medical eligibility determination. Information required in order for the hospital to make the determinations are: Applicant’s full legal name; Household’s gross monthly income and family size; citizenship; state residency; and previous period of Hospital Presumptive Medical Assistance. At the time of the presumptive determination, the Hospital gives the applicant immediate written notice of whether s/he is eligible, or ineligible, for Hospital Presumptive Medical coverage.

Within 5 working days of each Hospital Presumptive Medical eligibility determination, the Hospital is responsible for submitting the a copy of the completed Approval or Denial Notice issued to the applicant along with a copy of the applicant’s completed Hospital Presumptive Medical application to OHP Customer Service.

The CHIP Agency covers children when determined presumptively eligible by a qualified entity. Separate Child Health Insurance Program

77 General Eligibility - List of Qualified Entities CS30 42 CFR 457.355 and 435.1102, 2107(e)(1)(L) and 1920A of the SSA

A qualified entity is an entity that is determined by the agency to be capable of making presumptive eligibility determinations based on an individual’s household income and other requirements, and that meets at least one of the following requirements. Select the types of entities used to determine presumptive eligibility: Furnishes health care items and services covered under the approved plan and is

eligible to receive payments under the approved plan.

Is authorized to determine a child’s eligibility to participate in a Head Start program

under the Head Start.

Is authorized to determine a child’s eligibility to receive child care services for

which financial assistance is provided under the Child Care and Development Block

Grant Act of 1990.

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

Is authorized to determine a child’s eligibility under the Medicaid state plan or for

child health assistance under the Children’s Health Insurance Program (CHIP).

Is authorized to determine a child’s eligibility under the Medicaid state plan or for

child health assistance under the Children’s Health Insurance Program (CHIP).

Is an elementary or secondary school, as defined in section 14101 of the Elementary

and Secondary Education Act of 1965 (20 U.S.C. 8801).

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

Affairs Is a state or Tribal child support enforcement agency under title IV-D of the

Act.

Is an organization that provides emergency food and shelter under a grant under the

Stewart B. McKinney Homeless Assistance Act.

Is a state or Tribal office or entity involved in enrollment in the program under

Medicaid, CHIP, or title IV-A of the Act.

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

under any program of public or assisted housing that receives Federal funds,

including the program under section 8 or any other section of the United States

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Housing Act of 1937 (42 U.S.C. 1437) or under the Native American Housing

Assistance and Self Determination Act of 1996 (25 U.S.C. 4101 et seq.)

Any other entity the state so deems, as approved by the Secretary

Name of entity Description A qualified hospital A qualified hospital is a hospital that: Participates as a provider under the CHIP, Medicaid state plan or a Medicaid 1115 Demonstration, notifies the Medicaid/CHIP 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/CHIP 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/CHIP agency.

The CHIP Agency assures that it has communicated the requirements for qualified

entities, at 1920A(b)(3) of the Act, and provided adequate training to the entities and

organizations involved. A copy of the training materials has been included.

Attachment submitted Yes No

Guidance: Describe how the State intends to implement the Express Lane option. Include information on the identified Express Lane agency or agencies, and whether the State will be using the Express Lane eligibility option for the initial eligibility determinations, redeterminations, or both.

4.3.3-EL Express Lane Eligibility Check here if the state elects the option to rely on a finding from an Express Lane agency when determining whether a child satisfies one or more components of CHIP eligibility. The state agrees to comply with the requirements of sections 2107(e)(1)(E) and 1902(e)(13) of the Act for this option. Please update sections 4.4-EL, 5.2-EL, 9.10, and 12.1 when electing this option. This authority may not apply to eligibility determinations made before February 4, 2009, or after September 30, 2013. (Section 2107(e)(1)(E))

4.3.3.1-EL Also indicate whether the Express Lane option is applied to (1) initial eligibility determination, (2) redetermination, or (3) both. ELE is applied to initial eligibility determinations only.

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4.3.3.2-EL List the public agencies approved by the State as Express Lane agencies. Express Lane agencies. The Supplemental Nutritional Assistance Program (SNAP) and selected Department of Education National School Lunch Programs (NSLP).

4.3.3.3-EL List the components/components of CHIP eligibility that are determined under the Express Lane. In this section, specify any differences in budget unit, deeming, income exclusions, income disregards, or other methodology between CHIP eligibility determinations for such children and the determination under the Express Lane option. SNAP: The state will use SNAP income findings and apply this income to the child who is applying for medical. The state will use SNAP findings on verification of SSN and state residency. The state will verify citizenship. The state allows child support income disregard of $50 per child, up to $200 for a family for medical eligibility determinations. Additionally, the state allows the federal earned income disregard of $33. These disregards do not apply to SNAP. The state considers money from an assistance program withheld to repay an overpayment as available income in determining medical eligibility. SNAP excludes this income. The state excludes the portion of a payment from the TANF program that is counted as disqualifying income in determining medical eligibility. SNAP does not exclude this income.

The state counts periodic income in the month it is received when determining eligibility for medical programs. SNAP gives clients the choice of either averaging the income over the applicable time period or to have the income counted in the month it is expected to be received.

For medical program determination, the state excludes the first $30 of lump- sum income received by each family member each quarter. The state counts the amount that exceeds $30 a quarter as countable income. SNAP excludes lump-sum income. For medical program determination, the state excludes the portion of adoption assistance that is for the special needs of a child. SNAP does not exclude the income.

Cash medical support is excluded by the state for medical program determination. SNAP counts the amount of cash medical support not used to reimburse an actual medical cost.

The state excludes the amount of charitable contributions used to assist with a client’s medical expenses for medical eligibility determinations. SNAP

80 counts charitable contributions that exceed $300 a quarter.

In determining eligibility for medical, the state excludes the earned income of children up to age 19. SNAP counts the earned income of individuals age 18’ and over.

Filing groups differ between SNAP and Medicaid/CHIP. For SNAP, filing groups may include anyone living in the same home who purchases and prepares food together. For Medicaid/CHIP, there must be specific relations (blood relationships/marriage).

The National School Lunch Program (NSLP): The state will use the NSLP income findings and apply this income to the child who is applying for medical. The state will also use the NSLP findings for eligibility group size and residency. The state will then verify SSN and citizenship. The state allows a child support income disregard of $50 per child, up to $200 for a family for medical eligibility determinations. Additionally, the state allows the federal earned income disregard of $33. These disregards do not apply to the NSLP. Cash medical support is excluded by the state for medical program determination. NSLP counts cash medical support.

The state counts periodic income in the month income in the month it is received when determining eligibility for medical programs. NSLP does not count this income. For medical program determination, the state excludes the first $30 of lump- sum income received and counts the rest. NSLP does not count lump-sum income. The state excludes the amount of charitable contributions used to assist with a client’s medical expenses for medical eligibility determinations. NSLP counts charitable contributions. In determining eligibility for medical, the state excludes the earned income of children up to age 19. NSLP counts this income. The state excludes adoption assistance, while NSLP counts this income. The state excludes the income of household members who are not related to children. NSLP counts the income of all household members. The state excludes income of relatives who are not required to be in the eligibility group. NSLP counts the income of all household members. The state counts the income of eligibility group members who are in the military and away only because they are deployed. NSLP counts only the income the service people send home.

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4.3.3.3-EL List the component/components of CHIP eligibility that are determined under the Express Lane.

4.3.3.4-EL Describe the option used to satisfy the screen and enrollment requirements before a child may be enrolled under title XXI.

See 4.4 below Guidance: States should describe the process they use to screen and enroll children required under section 2102(b)(3)(A) and (B) of the Social Security Act and 42 CFR 457.350(a) and 457.80(c). Describe the screening threshold set as a percentage of the Federal poverty level (FPL) that exceeds the highest Medicaid income threshold applicable to a child by a minimum of 30 percentage points. (NOTE: The State may set this threshold higher than 30 percentage points to account for any differences between the income calculation methodologies used by an Express Lane agency and those used by the State for its Medicaid program. The State may set one screening threshold for all children, based on the highest Medicaid income threshold, or it may set more than one screening threshold, based on its existing, age-related Medicaid eligibility thresholds.) Include the screening threshold(s) expressed as a percentage of the FPL, and provide an explanation of how this was calculated. Describe whether the State is temporarily enrolling children in CHIP, based on the income finding from an Express Lane agency, pending the completion of the screen and enroll process.

In this section, states should describe their eligibility screening process in a way that addresses the five assurances specified below. The State should consider including important definitions, the relationship with affected Federal, State and local agencies, and other applicable criteria that will describe the State’s ability to make assurances. (Sections 2102(b)(3)(A) and 2110(b)(2)(B)), (42 CFR 457.310(b)(2), 42 CFR 457.350(a)(1) and 457.80(c)(3))

4.3.4 MAGI-Based Income Methodologies

Separate Child Health Insurance Program MAGI-Based Income Methodologies CS15 2102(b)(1)(B)(v) of the SSA and 42 CFR 457.315

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

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

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

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

The pregnant woman is counted just as herself.

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

The pregnant woman is counted as herself, plus the number of children she is expected to deliver.

Financial eligibility is determined consistent with the following provisions: When determining eligibility for new applicants, financial eligibility is based on current monthly income and family size.

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

Current monthly household income and family size.

Projected annual household income for the remaining months of the current calendar year and family size. In determining current monthly or projected annual household income the state will use reasonable methods to:

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

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

Except as provided at 42 CFR 457.315 and 435.603(d)(2) through (d)(4), household income is the sum of the MAGI-based income of every individual included in the individual's household. Household income includes actually available cash support, exceeding nominal amounts, provided by the person claiming an individual described at §435.603(f)(2)(i) as a tax dependent. Yes No

The CHIP Agency certifies that it has submitted and received approval for the conversion for all separate CHIP covered group income standards to MAGI-equivalent standards. Yes No Attachment submitted.

4.3.5 Conception to birth

Separate Child Health Insurance Program Eligibility - Coverage From Conception to Birth CS9 42 CFR 457.10

Coverage From Conception to Birth - Coverage from conception to birth when the mother is not eligible for Medicaid.

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