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Approval Period: October 1, 2022 – September 30, 2027 Amended November 14, 2024 7

demonstration enrollees for all MEGs identified as WOW Per Capita in the Master MEG Chart table above, and as also indicated in the MEG Detail for Expenditure and Member Month Reporting table below, with the exception of the Continuous Eligibility (CE) MEGs. The term “eligible member months” refers to the number of months in which persons enrolled in the demonstration are eligible to receive services. For example, a person who is eligible for three months contributes three eligible member months to the total. Two individuals who are eligible for two months each contribute two eligible member months per person, for a total of four eligible member months. The state must submit a statement accompanying the annual report certifying the accuracy of this information. For the Children CE MEGs, this percentage will be 0.11 percent. For Formerly Incarcerated CE MEGs, this percentage will be 2.6 percent. For example, the actual member months and expenditures for formerly incarcerated individuals in the corresponding MEGs will be reduced by 2.6 percent and the equivalent member months and expenditures will be reported on the CE - Formerly Incarcerated MEG so that the total calculated member months and expenditures between the two MEGs are equal to the actual member months and expenditures for the group. b. Budget Neutrality Specifications Manual. The state will create and maintain a Budget Neutrality Specifications Manual that describes in detail how the state will compile data on actual or calculated expenditures related to budget neutrality, including methods used to extract and compile data from the state’s Medicaid Management Information System, eligibility system, and accounting systems for reporting on the CMS-64, consistent with the terms of the demonstration. The Budget Neutrality Specifications Manual will also describe how the state compiles counts of Medicaid member months. The Budget Neutrality Specifications Manual must be made available to CMS on request. Table 3: MEG Detail for Expenditure and Member Month Reporting MEG (Waiver Name) Detailed Description CMS-64.9 or 64.10 Line(s) to Use How Expend. Are Assigned to DY MAP or ADM Report Member Months (Y/N) MEG Start Date MEG End Date CE – Children Age 0 to 6 TANF/MAGI Children who are eligible via CE, equaling 0.11% of total Medicaid expenditures for Children 0- 6 Follow 64.9 Base Category of Service Definition Date of service MAP Y 0.11% of total member months for children aged 0-6 11/14/2024 9/30/2027 CE – Children Age 0 to 6 SSI/HH and Other Disabled Children who are eligible via CE, equaling 0.11% of total Medicaid expenditures Follow 64.9 Base Category of Service Definition Date of service MAP Y 0.11% of total member months for children aged 0-6 11/14/2024 9/30/2027