Page 4

Effective Date:

Approval Date:

Updated and amended effective August 24, 2001

4

SECOND AMENDMENT

This amendment expanded income eligibility by allowing a work expense deduction and day-care expenses to be subtracted from gross earnings.

Effective Date: September 1, 1999

Implementation Date: September 1, 1999

Approval for this amendment was received on March 7, 2000

THIRD AMENDMENT

This amendment expanded the benefit package to include outpatient mental health services, disposable medical supplies, inpatient and outpatient substance abuse services, and rehabilitation services.

Effective Date: September 1, 1999

Implementation Date: September 1, 1999

Approval for this amendment was received on March 7, 2000

FOURTH AMENDMENT

This amendment expanded the benefit package to include maternity care.

Effective Date: September 1, 2000

Implementation Date: September 1, 2000

Approval for this amendment was received on December 18, 2000

FIFTH AMENDMENT

This amendment describes the review process for eligibility and enrollment matters in conformance with 42 CFR 457.1120.

Effective Date: August 24, 2001

Implementation Date: August 24, 2001

Approval for this amendment was received on September 19, 2002

SIXTH AMENDMENT