on,

DEPARTMENT OF HEALTH & HUMAN SERVICES

Centers for Medicare & Medicaid Services Cfi77. Ay JFK Federal Building, Government Center

Room 2275 CENTERS for MEDICARE & MEDICAID SERVICES

Boston, Massachusetts 02203

Division of Medicaid & Children's Health Operations / Boston Regional Office

October 30, 2009

Gary D. Alexander, Secretary

Executive Office

of Health and Human Services Hazard Bldg., 2" Floor

74 West Road

Cranston, Rhode Island 02920

Dear Mr. Alexander: °

Enclosed is a copy of approved State plan amendment (SPA) No. 09-006. This SPA is effective July 1, 2009, as requested.

SPA No. 09-006 transmitted a proposed amendment to your approved Title XIX State plan to elect the option in §214 of the Children’s Health Insurance Program Reauthorization Act of 2009, Public Law No. 111-3. This option allows State to provide full Medicaid coverage to otherwise eligible alien children or pregnant women lawfully residing in the United States.

You elected to only cover otherwise eligible alien children lawfully residing in the United States.

Should you have any questions or concerns, please contact Allen Bryan or Lynn DelVecchio. They can be reached at (617) 565-1246 or (617) 565-1201, respectively.

Sincerely,

v

Richard R. McGreal bw Associate Regional Administrator

Enclosure

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED

HEALTH CARE FINANCING ADMINISTRATION OMB NO. 0938-0193 TRANSMITTAL AND NOTICE OF APPROVAL OF | !. TRANSMITTAL NUMBER: 2. STATE STATE PLAN MATERIAL 09-006 Rhode Island

3. PROGRAM IDENTIFICATION: TITLE XIX OF THE

FOR: HEALTH CARE FINANCING ADMINISTRATION SOCIAL SECURITY ACT (MEDICAID)

TO: REGIONAL ADMINISTRATOR 4. PROPOSED EFFECTIVE DATE HEALTH CARE FINANCING ADMINISTRATION July 1, 2009 DEPARTMENT OF HEALTH AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL (Check One):

(1 NEW STATE PLAN XAMENDMENT TO BE CONSIDERED AS NEW PLAN XAMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate Transmittal for each amendment) 6. FEDERAL STATUTE/REGULATION CITATION: 7, FEDERAL BUDGET IMPACT: Section 1903(v){a)(4) of the Social Security Act a.FFY 2009 $ 0.00 b.FFY 2010 $0.00 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: | 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION ATTACHMENT 2.6-A, Page 2 OR ATTACHMENT (If Applicable): ATTACHMENT 2.6-A, Page 2a ATTACHMENT 2.6-A, Page 2

10. SUBJECT OF AMENDMENT: CHIPRA option to provide full Medicaid coverage to otherwise eligible aliens lawfully residing in the United States

11. GOVERNOR’S REVIEW (Check One): . (] GOVERNOR’S OFFICE REPORTED NO COMMENT X OTHER, AS SPECIFIED: (see attached letter) [.] COMMENTS OF GOVERNOR’S OFFICE ENCLOSED [NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL

12. SIGNATURWOR-STATE AGENCY OFFICIAL: 16, RETURN TO:

Deborah J.Florio

Administrator

Center for Child and Family Health R.I. Department of Human Services Hazard Bldg #74 1st Floor

74 West Road

Cranston,RI 02920

13. TYPED N6ME: Gary D. Alexander

14, TITLE: Secretary

15. DATE SUBMITTED: August 3, 2009

FOR REGIONAL OFFICE USE ONLY

17. DATE RECEIVED: 18, DATE APPROVED: August 3, 2009 October 30, 2009 PLAN APPROVED — ONE COPY ATTACHED 19. EFFECTIVE RE OF APPROVED MATERIAL: 0. SIGNATURE OF REGIONAL QFFICIA CN NO = - uly i; 21. TYPED NAME: vocreal 22. TITLE: Associate Regidpal Administrator

Division of Medicaid and Children's Hith Ops.

23. REMARKS:

FORM HCFA-179 (07-92)

Revision: HCFA-PM-91-4

August 1991

State:

(BPD) ATTACHMENT 2.6-A Page 2 OMB No.: 0938-

RHODE ISLAND

Citation

Condition or Requirement

1905 (p) of the Act

1905 (s) of the Act

42 CFR 435.406

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

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

For financially eligible qualified disabled and working individuals covered under section 1902 (a) (10) (E) (ii) of the Act, meets the non-financial criteria of section 1905 (s). .

Is residing in the United States and--

a.

b.

Is a citizen or national of the United States;

Is a qualified alien (QA) as defined in section 431 of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA) as amended, and the QA’s eligibility is required by section 402(b) of PRWORA as amended, and is not prohibited by section 403 of PRWORA as amended;

Is a qualified alien subject to the 5-year bar as described in section 403 of PRWORA, so that eligibility is limited to treatment of an emergency medical condition as defined in section 401 of PRWORA;

TN No._09-006

Supersedes

TN No. 92-02

Approval Date LO[30/09 Effective Date 7/1/09

Revision: CMS-PM- ATTACHMENT 2.6-A Page 2a OMB No.:

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: _ RHODE ISLAND

ELIGIBILITY CONDITIONS AND REQUIREMENTS

Citation(s) Condition or Requirement

42 CFR 435.406 d. Is a non-qualified alien, so that eligibility is limited to treatment of an emergency medical condition as defined in section 401 of PRWORA;

e. Is a qualified alien (QA) whose eligibility is authorized under section 402(b) of PRWORA as amended, and is not prohibited by section 403 of PRWORA as amended.

__X__ State covers all authorized QAs. State does not cover authorized QAs.

f. State elects Children’s Health Insurance Program Reauthorization Act (CHIPRA) option in section 214 to provide full Medicaid coverage to otherwise eligible alien children or pregnant women lawfully residing in the United States. Eligible aliens consist of qualified aliens subject to the 5-year bar, aliens described in 8 CFR 103.12(a)(4), legal non-immigrants from the Compact of Free Association States who are considered permanent non- immigrants, and also includes non-immigrants under section 101(a)(15) of the Immigration and Nationality Act subsections (K), (N). (R), (S), (T), (U), and (V):

____ Elected for pregnant women. X__ Elected for children.

TN No. __ 09-006 Approval Date VILA a Effective Date __ 7/1/09

Supersedes TN No. __ NEW

DEPARTMENT OF HEALTH & HUMAN SERVICES CIES. Ay Centers for Medicare & Medicaid Services

JFK Federal Building, Government Center

Room 2275 CENTERS lor MEDICARE & MEDICAID SERVICES

Boston, Massachusetts 02203

Division of Medicaid and Children's Health Operations / Boston Regional Office

August 1, 2011

Steven M. Costantino, Secretary Office of Health & Human Services 57 Howard Avenue

Louis Pasteur Building

Cranston, RI 02920

Dear Secretary Costantino:

We are pleased to enclose a copy of approved State plan amendment (SPA) No. 11-003. This SPA is effective April 1, 2011 as requested. °

SPA 11-003 transmitted a proposed amendment to your Department’s approved Title XIX State plan concerning an eligibility determination system that provides for data matching through the Public Assistance Reporting Information System (PARIS) project or any successor system. Section 1903(r) of the Social Security Act as amended by §3 of the Qualifying Individual Program Supplemental Funding Act of 2008. Public Law 110-379, requires that States have eligibility determination systems that provide for data matching through the PARIS project or any successor system. PARIS is a system for matching data from certain public assistance programs, including State Medicaid programs, with selected Federal and State data for purposes of facilitating appropriate enrollment and retention in public programs. This provision took effect on October 1, 2009.

If there are questions, please contact Robert Cruz. He can be reached at (617) 565-1257. Sincerely, /s/

Richard R. McGreal

Associate Regional Administrator Enclosure

ce: Sandra Powell, Director, Department of Human Services Elena Nicolella, Medicaid Director Kimberly Merolla-Brito, Chief Policy and Systems Specialist

DEPARTMENT OF HEALTH AND HUMAN SERVICES HEALTH CARE FINANCING ADMINISTRATION

FORM APPROVED OMB NO. 0938-0193.

TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL

FOR: HEALTH CARE FINANCING ADMINISTRATION

2. STATE RI

1. TRANSMITTAL NUMBER: 11-003

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

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

4. PROPOSED EFFECTIVE DATE April 1, 2011

3. TYPE OF PLAN MATERIAL (Check One):

[J AMENDMENT TO BE

NEW STATE PLAN

CONSIDERED AS NEW PLAN XX(] AMENDMENT

ONE) NNT TOE OO Cae ema {nr cachanendmen)

COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN 6. FEDERAL STATUTE/REGULATION CITATION:

AMENDMENT (Separate Transmitial for each amendment)

7, FEDERAL BUDGET IMPACT:

435.940 through 435.960 52 FR 5967 Though PARIS is intended to be a cost saving program, Rhode

Qualifying Individual (QI) Program Supplemental Funding Act of 2008 Island has been participating since 2008 so no additional impact is anticipated.

3. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: | 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION

79 Revision: HCFA-PM-87-14 (BERC) OMB no0:0938-0193 OR ATTACHMENT (ff Applicable):

’| 79 Revision: HCFA-PM-87-14 (BERC) OMB no:0938-0193

10. SUBJECT OF AMENDMENT: 4.32 Income and Eligibility Verification System; P

ublic Assistance Reporting Information System (PARIS)

11. GOVERNOR'S REVIEW (Check One):

[GOVERNOR'S OFFICE REPORTED NO COMMENT xx([] OTHER, AS SPECIFIED: [21 COMMENTS OF GOVERNOR’S OFFICE ENCLOSED (See Attached Letter) [INO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL 12. SIGNATURE OF STATE AGENCY OFFICIAL: ] 16. RETURN TO: . Kimberly Merolla-Brito 5 ci 7 Chief Policy and Systems Specialist 13. TYPED NAME: Elena Nicolella RID ent of Services

14. TITLE: Director, Medicaid

Office of Policy Analysis, Research and Development Louis Pasteur Building

15. DATE SUBMITTED: May 17, 2011

57 Howard Avenue, Fl # Cranston, RI 0292 Phone 401 462-623 Fax 401 462-616 erollabri i.gov

o

TT-DATE RECEIVED: May 17, 2011

- FOR REGIONAL OFFICE USE ONLY

18DATE APPROVED: ‘August 1, 2011

“PLAN APPROVED — ONE COPY ATTACHED.

7

| 19, BEFECTIVE DATE OF APPROVED MATERIAL: April 1, 2011

20. SIGNATURE OF REGIONAL OFFI a 1

: 21. TYPED NAME: Richard MeGreal 7

‘Associate Regonat Administrator, Division of Méeiicaid and

22. TITLE: - "Children's Health Operations, Boston Regional Office

23. REMARKS: The State agreed to the following changes: Form CMS-179

Box 1: Changed the SPA transmittal number to 11-003 Box 4: Changed date from April 1, 2010 to April 1, 2011 Box 6: Added “Qualifying Individual (QI) Program Supplemen

Peper

additional impact is anticipated.” 5.

Plan page 6. Changed the effective date to 4/1/2011 FORM HCFA-179 (07-92)

Box 7: Added the following statement: “Though PARIS is intended to be a

Act of 2008” cost saving program, Rhode Island has been participating since 2008 so no

tal Funding

Box 10: Added “Public Assistance Reporting Information System (PARIS)”

719

Revision: HCFA-PM-87-14 (BERC) OMB No: 0938-0193 October 1987 State/Territory: Rhode Island Citation 4.31 Disclosure of Information by Providers and Fiscal Agents 455.103 The Medicaid agency has established procedures for the 44 FR 41644 disclosure of information by providers and fiscal agents as 1902 (a) (38) specified in 42 CFR 455.104 through 455.106 and Of the Act sections 1128(b) (9) and 1902 (a) (38) of the Act. P.L. 100-93 (sec. 8 (f)) 435.940 4.32 Income and Eligibility Verification System through 435.960 52 FR 5967 (a) The Medicaid agency has established a system for

Income and eligibility verification in accordance with the requirements of 42 CFR 435.940 through 435.960.

(b) ATTACHMENT 4.32-A describes, in accordance with 42 CFR 435.948 (a) (6), the information that will be requested in order to verify eligibility or the correct payment amount and the agencies and the State(s) from which that information will be requested.

The State has an eligibility determination system that provides for data matching through the Public Assistance Reporting Information System (PARIS), or any successor system, including matching with medical assistance programs operated by other States. The information that is requested will be exchanged with States and other entities legally entitled to verify title XIX applications and individuals eligible for covered title XIX services consistent with applicable PARIS agreements.

(c) ATTACHMENT 4.32-B describes, in accordance with 42 CFR 435.953, the targeting methodology used in match information received through the income and Eligibility Verification System.

TN No.1 1-003 Supersedes Approval Date TN No.90-03

8/1/2011 Effective Date 4/1/2011

HCFA ID: 1010P/0012P

SUPPLEMENT 17 TO ATTACHMENT 2.6-A Page 1

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State: Rhode Island

DISQUALIFICATION FOR LONG-TERM CARE ASSISTANCE FOR INDIVIDUALS WITH SUBSTANTIAL HOME EQUITY

1917(f) The State agency denies reimbursement for nursing facility services and other long-term care services covered under the State plan for an individual who does not have a spouse, child under 21 or adult disabled child residing in the individual’s home, when the individual’s equity interest in the home exceeds the following amount:

XX_ $536,000 (increased by the annual percentage increase in the urban component of the consumer price index beginning with 2011, rounded to the nearest $1,000).

An amount that exceeds $500,000 but does not exceed $750,000 (increased by the annual percentage increase in the urban component of

the consumer price index beginning with 2011, rounded to the nearest $1,000).

The amount chosen by the State is This higher standard applies statewide.

This higher standard does not apply statewide. It only applies in the following areas of the State:

This higher standard applies to all eligibility groups.

This higher standard only applies to the following eligibility groups:

The State has a process under which this limitation will be waived in cases of undue hardship.

TN No. 13-003

Supersedes Approval Date__ 4/29/13 Effective Date_01/01/2013 TN No. 12-003

SUPPLEMENT 17 TO ATTACHMENT 2.6-A Page 1

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State: Rhode Island

DISQUALIFICATION FOR LONG-TERM CARE ASSISTANCE FOR INDIVIDUALS WITH SUBSTANTIAL HOME EQUITY

1917(f) The State agency denies reimbursement for nursing facility services and other long-term care services covered under the State plan for an individual who does not have a spouse, child under 21 or adult disabled child residing in the individual’s home, when the individual’s equity interest in the home exceeds the following amount:

XX_ $536,000 (increased by the annual percentage increase in the urban component of the consumer price index beginning with 2011, rounded to the nearest $1,000).

An amount that exceeds $500,000 but does not exceed $750,000 (increased by the annual percentage increase in the urban component of

the consumer price index beginning with 2011, rounded to the nearest $1,000).

The amount chosen by the State is This higher standard applies statewide.

This higher standard does not apply statewide. It only applies in the following areas of the State:

This higher standard applies to all eligibility groups.

This higher standard only applies to the following eligibility groups:

The State has a process under which this limitation will be waived in cases of undue hardship.

TN No. 13-003

Supersedes Approval Date__ 4/29/13 Effective Date_01/01/2013 TN No. 12-003

/s/

_____________________________________________________________________________

Table of Contents State/Territory Name: Rhode Island State Plan Amendment (SPA) #:13-0018 This file contains the following documents in the order listed: 1) Approval Letter 2) Summary Form (with 179-like data) 3) Superseding Pages Notice 4) Approved SPA Pages 5) Additional Attachments

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services JFK Federal Building, Government Center Room 2275 Boston, Massachusetts 02203

Division of Medicaid and Children’s Health Operations / Boston Regional Office

January 10, 2014

Steven M. Costantino, Secretary Executive Office of Health and Human Services State of Rhode Island and Providence Plantations 57 Howard Avenue, LP Building Cranston, RI 02920

Dear Secretary Costantino:

We are pleased to enclose a copy of approved Rhode Island State Plan Amendment (SPA) No.13- 0018MM1, submitted December 12, 2013. Effective, January 1, 2014, this SPA grants MAGI-Based Eligibility Group-Medicaid coverage as described in the following forms:

S14, S25, S28, S30, S33, S50, S51, S53, S54, S55, S57, S59

These documents in their final form were uploaded by the State into the MMDL system along with two supporting documents, consisting of a MAGI approval letter and a MAGI threshold Excel document. These documents in their totality are hereby incorporated into the RI Medicaid State Plan.

If you have any questions regarding this matter you may contact Lynn DelVecchio (617) 565-1201 or by e-mail at Lynn.DelVecchio@cms.hhs.gov

Sincerely,

/s/

Richard R. McGreal Associate Regional Administrator

logged in as LYNNDELVECCHIO(CMS RO Staff) read only mode application rev c01 Medicaid State Plan Eligibility RI.0579.R00.00 - Jan 01, 2014 Home Logout Finder Save Validate Print Help Control Panel General Information File Management Tribal Input Summary (CMS179) State/Territory name: Rhode Island Medicaid State Plan Eligibility: Summary Page (CMS 179) Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. 13-018 Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation 42 CFR 435.110, 435.116, 435.118, 435.119, 435.150, 435.214, 435.218, 435.220, 435.222, 435 Federal Budget Impact Federal Fiscal Year Amount First Year 2014 $ 21051354.00 Second Year 2015 $ 29257091.00 Subject of Amendment Character Count:29 out of 2000 MAGI-Based Eligibility Groups Governor's Office Review Governor's office reported no comment Comments of Governor's office received Describe: No reply received within 45 days of submittal Other, as specified Describe: Character Count:324 out of 2000 Page 1 of 2 MacPro Reporting System: Summary Page (CMS 179) 01/28/2014 http://157.199.113.99/MMDL/faces/protected/mac/c01/pages/mac_00.jsp

Submitted By: Jodi DiBernardo Last Revision Date: Jan 7, 2014 Submit Date: Dec 12, 2013 This amendment has not been reviewed specifically with the Governor’s Office. Under the Rhode Island Medicaid State Plan, the Governor has elected not to review the details of state plan materials. However, in accordance with Rhode Island law and practice, the Governor is kept apprised of j h i th t t l Signature of State Agency Official FAQs | Form Support | Contact | Medicaid.gov | CMS.gov Page 2 of 2 MacPro Reporting System: Summary Page (CMS 179) 01/28/2014 http://157.199.113.99/MMDL/faces/protected/mac/c01/pages/mac_00.jsp

1

SUPERSEDING PAGES OF STATE PLAN MATERIAL

TRANSMITTAL NUMBER:

13-018

STATE:

Rhode Island

Pages or sections of pages being superseded by S25, S28, S30, S51,S53, S54, S55, S57, and S14 and related pages or sections of pages being deleted as obsolete

State Plan Section

Complete Pages Removed

Partial Pages Removed Attachment 2.2-A

Page 1 Page 3 Page 3a Page 4 Page 4a Page 14 Page 14a Page 23 Page 23c

Page 2, A.2.b Page 2, A.2.c Page 2a, A.3 Page 5, A.10 Page 9c, B.1 for “Caretaker relatives” and “Pregnant women” Page 12, B.6 Page 20, B.14 Page 25, C.4

Attachment 2.6-A

Page 3b Page 11a Page 19 Page 19a Page 21

Page 1, A.2.a(i) and (iii) Page 6 related to AFDC recipients, pregnant women, infants, and children Page 7, 1.a(1) and (2) Page 12, C.1.e(2) Page 18, C.5.e Page 25, C.11.a(3) Supplement 1 to Attachment 2.6-A Pages 1- 3

Supplement 2 to Attachment 2.6-A

Pages 1-5

Supplement 5a to Attachment 2.6-A Page 1

Supplement 8b to Attachment 2.6-A Page 4

Supplement 12 to Attachment 2.6-A Pages 3 – 5

Page 1 of 5 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 AFDC Income Standards S14 Enter the AFDC Standards below. All states must enter: MAGI-equivalent AFDC Payment Standard in Effect As of May 1, 1988 and AFDC Payment Standard in Effect As of July 16, 1996 Entry of other standards is optional. MAGI-equivalent AFDC Payment Standard in Effect As of May 1, 1988 Income Standard Entry - Dollar Amount - Automatic Increase Option S13a The standard is as follows: Statewide standard Standard varies by region Standard varies by living arrangement Standard varies in some other way Enter the statewide standard Household size Standard ($) + 1 400 x + 2 547 x + 3 677 x + 4 782 x + 5 885 x + 6 1,000 x + 7 1,107 x + 8 1,222 x + 9 1,321 x + 10 1,436 x Additional incremental amount Yes No Increment amount $ 111 The dollar amounts increase automatically each year Yes No TN: RI 13-0018 Approved: 01/10/2014 S14-1 Effective: 01/01/2014

Page 2 of 5 Medicaid Eligibility AFDC Payment Standard in Effect As of July 16, 1996 Income Standard Entry - Dollar Amount - Automatic Increase Option S13a The standard is as follows: Statewide standard Standard varies by region Standard varies by living arrangement Standard varies in some other way Enter the statewide standard Household size Standard ($) + 1 327 x + 2 449 x + 3 554 x + 4 634 x + 5 714 x + 6 794 x + 7 874 x + 8 954 x + 9 1,034 x + 10 1,114 x Additional incremental amount Yes No Increment amount $ 80 The dollar amounts increase automatically each year Yes No MAGI-equivalent AFDC Payment Standard in Effect As of July 16, 1996 Income Standard Entry - Dollar Amount - Automatic Increase Option S13a The standard is as follows: Statewide standard Standard varies by region TN: RI 13-0018 Approved: 01/10/2014 S14-2 Effective: 01/01/2014

Page 3 of 5 Medicaid Eligibility Standard varies by living arrangement Standard varies in some other way Enter the statewide standard Household size Standard ($) + 1 407 x + 2 556 x + 3 689 x + 4 796 x + 5 904 x + 6 1,012 x + 7 1,119 x + 8 1,227 x + 9 1,334 x + 10 1,442 x Additional incremental amount Yes No Increment amount $ 108 The dollar amounts increase automatically each year Yes No AFDC Need Standard in Effect As of July 16, 1996 Income Standard Entry - Dollar Amount - Automatic Increase Option S13a The standard is as follows: Statewide standard Standard varies by region Standard varies by living arrangement Standard varies in some other way The dollar amounts increase automatically each year Yes No TN: RI 13-0018 Approved: 01/10/2014 S14-3 Effective: 01/01/2014

Page 4 of 5 Medicaid Eligibility AFDC Payment Standard in Effect As of July 16, 1996, increased by no more than the percentage increase in the Consumer Price Index for urban consumers (CPI-U) since such date. Income Standard Entry - Dollar Amount - Automatic Increase Option S13a The standard is as follows: Statewide standard Standard varies by region Standard varies by living arrangement Standard varies in some other way The dollar amounts increase automatically each year Yes No MAGI-equivalent AFDC Payment Standard in Effect As of July 16, 1996, increased by no more than the percentage increase in the Consumer Price Index for urban consumers (CPI-U) since such date Income Standard Entry - Dollar Amount - Automatic Increase Option S13a The standard is as follows: Statewide standard Standard varies by region Standard varies by living arrangement Standard varies in some other way The dollar amounts increase automatically each year Yes No TANF payment standard Income Standard Entry - Dollar Amount - Automatic Increase Option S13a The standard is as follows: Statewide standard Standard varies by region Standard varies by living arrangement Standard varies in some other way TN: RI 13-0018 Approved: 01/10/2014 S14-4 Effective: 01/01/2014

Page 5 of 5 Medicaid Eligibility The dollar amounts increase automatically each year Yes No MAGI-equivalent TANF payment standard Income Standard Entry - Dollar Amount - Automatic Increase Option S13a The standard is as follows: Statewide standard Standard varies by region Standard varies by living arrangement Standard varies in some other way The dollar amounts increase automatically each year Yes No PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938‐1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4‐26‐05, Baltimore, Maryland 21244‐1850. TN: RI 13-0018 Approved: 01/10/2014 S14-5 Effective: 01/01/2014

Page 1 of 3 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups - Mandatory Coverage Parents and Other Caretaker Relatives S25 42 CFR 435.110 1902(a)(10)(A)(i)(I) 1931(b) and (d) Parents and Other Caretaker Relatives - Parents and other caretaker relatives of dependent children with household income at or below a standard established by the state. ■ The state attests that it operates this eligibility group in accordance with the following provisions: ✔ Individuals qualifying under this eligibility group must meet the following criteria: ■ Are parents or other caretaker relatives (defined at 42 CFR 435.4), including pregnant women, of dependent children (defined at 42 CFR 435.4) under age 18. Spouses of parents and other caretaker relatives are also included. ■ The state elects the following options: This eligibility group includes individuals who are parents or other caretakers of children who are 18 years old, provided the children are full-time students in a secondary school or the equivalent level of vocational or technical training. Options relating to the definition of caretaker relative (select any that apply): The definition of caretaker relative includes the domestic partner of the parent or other caretaker relative, even after the partnership is terminated. Definition of domestic partner: The definition of caretaker relative includes other relatives of the child based on blood (including those of half-blood), adoption or marriage. Description of other relatives: The definition of caretaker relative includes any adult with whom the child is living and who assumes primary responsibility for the dependent child's care. Options relating to the definition of dependent child (select the one that applies): The state elects to eliminate the requirement that a dependent child must be deprived of parental support or care by reason of the death, physical or mental incapacity, or absence from the home or unemployment of at least one parent. The child must be deprived of parental support or care, but a less restrictive standard is used to measure unemployment of the parent (select the one that applies): TN: RI 13-0018 Approved: 01/10/2014 S25-1 Effective: 01/01/2014

Page 2 of 3 Medicaid Eligibility Have household income at or below the standard established by the state. ■ MAGI-based income methodologies are used in calculating household income. Please refer as necessary to S10 MAGI- Based Income Methodologies, completed by the state. ■ Income standard used for this group ■ Minimum income standard ■ The minimum income standard used for this group is the state's AFDC payment standard in effect as of May 1, 1988, converted to MAGI-equivalent amounts by household size. The standard is described in S14 AFDC Income Standards. The state certifies that it has submitted and received approval for its converted May 1, 1988 AFDC payment standard. ✔ An attachment is submitted. Maximum income standard ■ The state certifies that it has submitted and received approval for its converted income standard(s) for parents and other caretaker relatives to MAGI-equivalent standards and the determination of the maximum income standard to be used for parents and other caretaker relatives under this eligibility group. ✔ An attachment is submitted. The state's maximum income standard for this eligibility group is: The state's effective income level for section 1931 families under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size. The state's effective income level for section 1931 families under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL or amounts by household size. The state's effective income level for any population of parents/caretaker relatives under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size. The state's effective income level for any population of parents/caretaker relatives under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL or amounts by household size. Enter the amount of the maximum income standard: TN: RI 13-0018 Approved: 01/10/2014 S25-2 Effective: 01/01/2014

Page 3 of 3 Medicaid Eligibility A percentage of the federal poverty level: The state's AFDC payment standard in effect as of July 16, 1996, converted to a MAGI-equivalent standard. The standard is described in S14 AFDC Income Standards. The state's AFDC payment standard in effect as of July 16, 1996, increased by no more than the percentage increase in the Consumer Price Index for urban consumers (CPI-U) since such date, converted to a MAGI- equivalent standard. The standard is described in S14 AFDC Income Standards. The state's TANF payment standard, converted to a MAGI-equivalent standard. The standard is described in S14 AFDC Income Standards. Other dollar amount % 116 Income standard chosen: ■ Indicate the state's income standard used for this eligibility group: The minimum income standard The maximum income standard The state's AFDC payment standard in effect as of July 16, 1996, increased by no more than the percentage increase in the Consumer Price Index for urban consumers (CPI-U) since such date. The standard is described in S14 AFDC Income Standards. Another income standard in-between the minimum and maximum standards allowed There is no resource test for this eligibility group. ■ Presumptive Eligibility ■ The state covers individuals under this group when determined presumptively eligible by a qualified entity. The state assures it also covers individuals under the Pregnant Women (42 CFR 435.116) and/or Infants and Children under Age 19 (42 CFR 435.118) eligibility groups when determined presumptively eligible. Yes No PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN: RI 13-0018 Approved: 01/10/2014 S25-3 Effective: 01/01/2014

Page 1 of 2 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups - Mandatory Coverage Pregnant Women S28 42 CFR 435.116 1902(a)(10)(A)(i)(III) and (IV) 1902(a)(10)(A)(ii)(I), (IV) and (IX) 1931(b) and (d) 1920 Pregnant Women - Women who are pregnant or post-partum, with household income at or below a standard established by the state. ■ The state attests that it operates this eligibility group in accordance with the following provisions: ✔ Individuals qualifying under this eligibility group must be pregnant or post-partum, as defined in 42 CFR 435.4. ■ Pregnant women in the last trimester of their pregnancy without dependent children are eligible for full benefits under this group in accordance with section 1931 of the Act, if they meet the income standard for state plan Parents and Other Caretaker Relatives at 42 CFR 435.110. Yes No MAGI-based income methodologies are used in calculating household income. Please refer as necessary to S10 MAGI-Based Income Methodologies, completed by the state. ■ Income standard used for this group ■ Minimum income standard (Once entered and approved by CMS, the minimum income standard cannot be changed.) ■ The state had an income standard higher than 133% FPL established as of December 19, 1989 for determining eligibility for pregnant women, or as of July 1, 1989, had authorizing legislation to do so. Yes No Enter the amount of the minimum income standard (no higher than 185% FPL): 185 % FPL Maximum income standard ■ The state certifies that it has submitted and received approval for its converted income standard(s) for pregnant women to MAGI-equivalent standards and the determination of the maximum income standard to be used for pregnant women under this eligibility group. ✔ An attachment is submitted. The state's maximum income standard for this eligibility group is: The state's highest effective income level for coverage of pregnant women under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified pregnant women), 1902(a)(10)(A)(i)(IV) (mandatory poverty level- related pregnant women), 1902(a)(10)(A)(ii)(IX) (optional poverty level-related pregnant women), 1902(a)(10) (A)(ii)(I) (pregnant women who meet AFDC financial eligibility criteria) and 1902(a)(10)(A)(ii)(IV) (institutionalized pregnant women) in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. TN: RI 13-0018 Approved: 01/10/2014 S28-1 Effective: 01/01/2014

Page 2 of 2 Medicaid Eligibility The state's highest effective income level for coverage of pregnant women under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified pregnant women), 1902(a)(10)(A)(i)(IV) (mandatory poverty level- related pregnant women), 1902(a)(10)(A)(ii)(IX) (optional poverty level-related pregnant women), 1902(a)(10) (A)(ii)(I) (pregnant women who meet AFDC financial eligibility criteria) and 1902(a)(10)(A)(ii)(IV) (institutionalized pregnant women) in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. The state's effective income level for any population of pregnant women under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. The state's effective income level for any population of pregnant women under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. 185% FPL The amount of the maximum income standard is: 190 % FPL Income standard chosen ■ Indicate the state's income standard used for this eligibility group: The minimum income standard The maximum income standard Another income standard in-between the minimum and maximum standards allowed. There is no resource test for this eligibility group. ■ Benefits for individuals in this eligibility group consist of the following: ■ All pregnant women eligible under this group receive full Medicaid coverage under this state plan. Pregnant women whose income exceeds the income limit specified below for full coverage of pregnant women receive only pregnancy-related services. Presumptive Eligibility ■ The state covers ambulatory prenatal care for individuals under this group when determined presumptively eligible by a qualified entity. Yes No PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938‐1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4‐26‐05, Baltimore, Maryland 21244‐1850. TN: RI 13-0018 Approved: 01/10/2014 S28-2 Effective: 01/01/2014

Page 1 of 5 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups - Mandatory Coverage Infants and Children under Age 19 S30 42 CFR 435.118 1902(a)(10)(A)(i)(III), (IV), (VI) and (VII) 1902(a)(10)(A)(ii)(IV) and (IX) 1931(b) and (d) Infants and Children under Age 19 - Infants and children under age 19 with household income at or below standards established by the state based on age group. ■ The state attests that it operates this eligibility group in accordance with the following provisions: ✔ Children qualifying under this eligibility group must meet the following criteria: ■ Are under age 19 ■ Have household income at or below the standard established by the state. ■ MAGI-based income methodologies are used in calculating household income. Please refer as necessary to S10 MAGI- Based Income Methodologies, completed by the state. ■ Income standard used for infants under age one ■ Minimum income standard ■ The state had an income standard higher than 133% FPL established as of December 19, 1989 for determining eligibility for infants under age one, or as of July 1, 1989, had authorizing legislation to do so. Yes No Enter the amount of the minimum income standard (no higher than 185% FPL): 185 % FPL Maximum income standard ■ The state certifies that it has submitted and received approval for its converted income standard(s) for infants under age one to MAGI-equivalent standards and the determination of the maximum income standard to be used for infants under age one. ✔ An attachment is submitted. The state's maximum income standard for this age group is: The state's highest effective income level for coverage of infants under age one under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(IV) (mandatory poverty level-related infants), 1902(a)(10)(A)(ii)(IX) (optional poverty level-related infants) and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI- equivalent percent of FPL. TN: RI 13-0018 Approved: 01/10/2014 S30-1 Effective: 01/01/2014

Page 2 of 5 Medicaid Eligibility The state's highest effective income level for coverage of infants under age one under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(IV) (mandatory poverty level-related infants), 1902(a)(10)(A)(ii)(IX) (optional poverty level-related infants) and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. The state's effective income level for any population of infants under age one under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. The state's effective income level for any population of infants under age one under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. 185% FPL Enter the amount of the maximum income standard: 190 % FPL Income standard chosen ■ The state's income standard used for infants under age one is: The maximum income standard If not chosen as the maximum income standard, the state's highest effective income level for coverage of infants under age one under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10) (A)(i)(IV) (mandatory poverty level-related infants), 1902(a)(10)(A)(ii)(IX) (optional poverty level-related infants) and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's highest effective income level for coverage of infants under age one under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10) (A)(i)(IV) (mandatory poverty level-related infants), 1902(a)(10)(A)(ii)(IX) (optional poverty level-related infants) and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's effective income level for any population of infants under age one under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's effective income level for any population of infants under age one under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. Another income standard in-between the minimum and maximum standards allowed, provided it is higher than the effective income standard for this age group in the state plan as of March 23, 2010. Income standard for children age one through age five, inclusive ■ Minimum income standard ■ TN: RI 13-0018 Approved: 01/10/2014 S30-2 Effective: 01/01/2014

Page 3 of 5 Medicaid Eligibility The minimum income standard used for this age group is 133% FPL. Maximum income standard ■ The state certifies that it has submitted and received approval for its converted income standard(s) for children age one through five to MAGI-equivalent standards and the determination of the maximum income standard to be used for children age one through five. ✔ An attachment is submitted. The state's maximum income standard for children age one through five is: The state's highest effective income level for coverage of children age one through five under sections 1931 (low- income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(VI) (mandatory poverty level- related children age one through five), and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. The state's highest effective income level for coverage of children age one through five under sections 1931 (low- income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(VI) (mandatory poverty level- related children age one through five), and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. The state's effective income level for any population of children age one through five under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. The state's effective income level for any population of children age one through five under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. Enter the amount of the maximum income standard: 142 % FPL Income standard chosen ■ The state's income standard used for children age one through five is: The maximum income standard If not chosen as the maximum income standard, the state's highest effective income level for coverage of children age one through five under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(VI) (mandatory poverty level-related children age one through five), and 1902(a)(10)(A)(ii) (IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's highest effective income level for coverage of children age one through five under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(VI) (mandatory poverty level-related children age one through five), and 1902(a)(10)(A)(ii) (IV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. TN: RI 13-0018 Approved: 01/10/2014 S30-3 Effective: 01/01/2014

Page 4 of 5 Medicaid Eligibility If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's effective income level for any population of children age one through five under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI- equivalent percent of FPL. If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's effective income level for any population of children age one through five under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI- equivalent percent of FPL. Another income standard in-between the minimum and maximum standards allowed, provided it is higher than the effective income standard for this age group in the state plan as of March 23, 2010. Income standard for children age six through age eighteen, inclusive ■ Minimum income standard ■ The minimum income standard used for this age group is 133% FPL. Maximum income standard ■ The state certifies that it has submitted and received approval for its converted income standard(s) for children age six through eighteen to MAGI-equivalent standards and the determination of the maximum income standard to be used for children age six through age eighteen. ✔ An attachment is submitted. The state's maximum income standard for children age six through eighteen is: The state's highest effective income level for coverage of children age six through eighteen under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(VII) (mandatory poverty level-related children age six through eighteen) and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. The state's highest effective income level for coverage of children age six through eighteen under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(VII) (mandatory poverty level-related children age six through eighteen) and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. The state's effective income level for any population of children age six through eighteen under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. The state's effective income level for any population of children age six through eighteen under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. 133% FPL Income standard chosen ■ The state's income standard used for children age six through eighteen is: TN: RI 13-0018 Approved: 01/10/2014 S30-4 Effective: 01/01/2014

Page 5 of 5 Medicaid Eligibility The maximum income standard If not chosen as the maximum income standard, the state's highest effective income level for coverage of children age six through eighteen under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(VII) (mandatory poverty level-related children age six through eighteen) and 1902(a)(10)(A) (ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's highest effective income level for coverage of children age six through eighteen under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(VII) (mandatory poverty level-related children age six through eighteen) and 1902(a)(10)(A) (ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's effective income level for any population of children age six through eighteen under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI- equivalent percent of FPL. If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's effective income level for any population of children age six through eighteen under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI- equivalent percent of FPL. Another income standard in-between the minimum and maximum standards allowed, provided it is higher than the effective income standard for this age group in the state plan as of March 23, 2010. There is no resource test for this eligibility group. ■ Presumptive Eligibility ■ The state covers children when determined presumptively eligible by a qualified entity. Yes No PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938‐1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4‐26‐05, Baltimore, Maryland 21244‐1850. TN: RI 13-0018 Approved: 01/10/2014 S30-5 Effective: 01/01/2014

Page 1 of 5 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups - Mandatory Coverage Infants and Children under Age 19 S30 42 CFR 435.118 1902(a)(10)(A)(i)(III), (IV), (VI) and (VII) 1902(a)(10)(A)(ii)(IV) and (IX) 1931(b) and (d) Infants and Children under Age 19 - Infants and children under age 19 with household income at or below standards established by the state based on age group. ■ The state attests that it operates this eligibility group in accordance with the following provisions: ✔ Children qualifying under this eligibility group must meet the following criteria: ■ Are under age 19 ■ Have household income at or below the standard established by the state. ■ MAGI-based income methodologies are used in calculating household income. Please refer as necessary to S10 MAGI- Based Income Methodologies, completed by the state. ■ Income standard used for infants under age one ■ Minimum income standard ■ The state had an income standard higher than 133% FPL established as of December 19, 1989 for determining eligibility for infants under age one, or as of July 1, 1989, had authorizing legislation to do so. Yes No Enter the amount of the minimum income standard (no higher than 185% FPL): 185 % FPL Maximum income standard ■ The state certifies that it has submitted and received approval for its converted income standard(s) for infants under age one to MAGI-equivalent standards and the determination of the maximum income standard to be used for infants under age one. ✔ An attachment is submitted. The state's maximum income standard for this age group is: The state's highest effective income level for coverage of infants under age one under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(IV) (mandatory poverty level-related infants), 1902(a)(10)(A)(ii)(IX) (optional poverty level-related infants) and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI- equivalent percent of FPL. TN: RI 13-0018 Approved: 01/10/2014 S30-1 Effective: 01/01/2014

Page 2 of 5 Medicaid Eligibility The state's highest effective income level for coverage of infants under age one under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(IV) (mandatory poverty level-related infants), 1902(a)(10)(A)(ii)(IX) (optional poverty level-related infants) and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. The state's effective income level for any population of infants under age one under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. The state's effective income level for any population of infants under age one under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. 185% FPL Enter the amount of the maximum income standard: 190 % FPL Income standard chosen ■ The state's income standard used for infants under age one is: The maximum income standard If not chosen as the maximum income standard, the state's highest effective income level for coverage of infants under age one under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10) (A)(i)(IV) (mandatory poverty level-related infants), 1902(a)(10)(A)(ii)(IX) (optional poverty level-related infants) and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's highest effective income level for coverage of infants under age one under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10) (A)(i)(IV) (mandatory poverty level-related infants), 1902(a)(10)(A)(ii)(IX) (optional poverty level-related infants) and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's effective income level for any population of infants under age one under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's effective income level for any population of infants under age one under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. Another income standard in-between the minimum and maximum standards allowed, provided it is higher than the effective income standard for this age group in the state plan as of March 23, 2010. Income standard for children age one through age five, inclusive ■ Minimum income standard ■ TN: RI 13-0018 Approved: 01/10/2014 S30-2 Effective: 01/01/2014

Page 3 of 5 Medicaid Eligibility The minimum income standard used for this age group is 133% FPL. Maximum income standard ■ The state certifies that it has submitted and received approval for its converted income standard(s) for children age one through five to MAGI-equivalent standards and the determination of the maximum income standard to be used for children age one through five. ✔ An attachment is submitted. The state's maximum income standard for children age one through five is: The state's highest effective income level for coverage of children age one through five under sections 1931 (low- income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(VI) (mandatory poverty level- related children age one through five), and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. The state's highest effective income level for coverage of children age one through five under sections 1931 (low- income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(VI) (mandatory poverty level- related children age one through five), and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. The state's effective income level for any population of children age one through five under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. The state's effective income level for any population of children age one through five under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. Enter the amount of the maximum income standard: 142 % FPL Income standard chosen ■ The state's income standard used for children age one through five is: The maximum income standard If not chosen as the maximum income standard, the state's highest effective income level for coverage of children age one through five under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(VI) (mandatory poverty level-related children age one through five), and 1902(a)(10)(A)(ii) (IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's highest effective income level for coverage of children age one through five under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(VI) (mandatory poverty level-related children age one through five), and 1902(a)(10)(A)(ii) (IV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. TN: RI 13-0018 Approved: 01/10/2014 S30-3 Effective: 01/01/2014

Page 4 of 5 Medicaid Eligibility If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's effective income level for any population of children age one through five under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI- equivalent percent of FPL. If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's effective income level for any population of children age one through five under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI- equivalent percent of FPL. Another income standard in-between the minimum and maximum standards allowed, provided it is higher than the effective income standard for this age group in the state plan as of March 23, 2010. Income standard for children age six through age eighteen, inclusive ■ Minimum income standard ■ The minimum income standard used for this age group is 133% FPL. Maximum income standard ■ The state certifies that it has submitted and received approval for its converted income standard(s) for children age six through eighteen to MAGI-equivalent standards and the determination of the maximum income standard to be used for children age six through age eighteen. ✔ An attachment is submitted. The state's maximum income standard for children age six through eighteen is: The state's highest effective income level for coverage of children age six through eighteen under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(VII) (mandatory poverty level-related children age six through eighteen) and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. The state's highest effective income level for coverage of children age six through eighteen under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(VII) (mandatory poverty level-related children age six through eighteen) and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. The state's effective income level for any population of children age six through eighteen under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. The state's effective income level for any population of children age six through eighteen under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. 133% FPL Income standard chosen ■ The state's income standard used for children age six through eighteen is: TN: RI 13-0018 Approved: 01/10/2014 S30-4 Effective: 01/01/2014

Page 5 of 5 Medicaid Eligibility The maximum income standard If not chosen as the maximum income standard, the state's highest effective income level for coverage of children age six through eighteen under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(VII) (mandatory poverty level-related children age six through eighteen) and 1902(a)(10)(A) (ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's highest effective income level for coverage of children age six through eighteen under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(VII) (mandatory poverty level-related children age six through eighteen) and 1902(a)(10)(A) (ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's effective income level for any population of children age six through eighteen under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI- equivalent percent of FPL. If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's effective income level for any population of children age six through eighteen under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI- equivalent percent of FPL. Another income standard in-between the minimum and maximum standards allowed, provided it is higher than the effective income standard for this age group in the state plan as of March 23, 2010. There is no resource test for this eligibility group. ■ Presumptive Eligibility ■ The state covers children when determined presumptively eligible by a qualified entity. Yes No PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938‐1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4‐26‐05, Baltimore, Maryland 21244‐1850. TN: RI 13-0018 Approved: 01/10/2014 S30-5 Effective: 01/01/2014

Page 1 of 1 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups - Mandatory Coverage Former Foster Care Children S33 42 CFR 435.150 1902(a)(10)(A)(i)(IX) Former Foster Care Children - Individuals under the age of 26, not otherwise mandatorily eligible, who were on Medicaid and in foster care when they turned age 18 or aged out of foster care. ■ The state attests that it operates this eligibility group under the following provisions: ✔ Individuals qualifying under this eligibility group must meet the following criteria: ■ Are under age 26. ■ Are not otherwise eligible for and enrolled for mandatory coverage under the state plan, except that eligibility under this group takes precedence over eligibility under the Adult Group. ■ Were in foster care under the responsibility of the state or Tribe and were enrolled in Medicaid under the state's state plan or 1115 demonstration when they turned 18 or at the time of aging out of that state's or Tribe's foster care program. ■ The state elects to cover children who were in foster care and on Medicaid in any state at the time they turned 18 or aged out of the foster care system. Yes No The state covers individuals under this group when determined presumptively eligible by a qualified entity. The state assures it also covers individuals under the Pregnant Women (42 CFR 435.116) and/or Infants and Children under Age 19 (42 CFR 435.118) eligibility groups when determined presumptively eligible. Yes No PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938‐1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4‐26‐05, Baltimore, Maryland 21244‐1850. TN: RI 13-0018 Approved: 01/10/2014 S33-1 Effective: 01/01/2014

Page 1 of 1 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups - Options for Coverage Individuals above 133% FPL S50 1902(a)(10)(A)(ii)(XX) 1902(hh) 42 CFR 435.218 Individuals above 133% FPL - The state elects to cover individuals under 65, not otherwise mandatorily or optionally eligible, with income above 133% FPL and at or below a standard established by the state and in accordance with provisions described at 42 CFR 435.218. Yes No PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN: RI 13-0018 Approved: 01/10/2014 S50-1 Effective: 01/01/2014

Page 1 of 1 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups - Options for Coverage Optional Coverage of Parents and Other Caretaker Relatives S51 42 CFR 435.220 1902(a)(10)(A)(ii)(I) Optional Coverage of Parents and Other Caretaker Relatives - The state elects to cover individuals qualifying as parents or other caretaker relatives who are not mandatorily eligible and who have income at or below a standard established by the state and in accordance with provisions described at 42 CFR 435.220. Yes No PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN: RI 13-0018 Approved: 01/10/2014 S51-1 Effective: 01/01/2014

Page 1 of 1 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups - Options for Coverage Children with Non IV-E Adoption Assistance S53 42 CFR 435.227 1902(a)(10)(A)(ii)(VIII) Children with Non IV-E Adoption Assistance - The state elects to cover children with special needs for whom there is a non IV-E adoption assistance agreement in effect with a state, who were eligible for Medicaid, or who had income at or below a standard established by the state and in accordance with provisions described at 42 CFR 435.227. Yes No The state attests that it operates this eligibility group in accordance with the following provisions: ✔ Individuals qualifying under this eligibility group must meet the following criteria: ■ The state adoption agency has determined that they cannot be placed without Medicaid coverage because of special needs for medical or rehabilitative care; ■ Are under the following age (see the Guidance for restrictions on the selection of an age): ■ Under age 21 Under age 20 Under age 19 Under age 18 MAGI-based income methodologies are used in calculating household income. Please refer as necessary to S10 MAGI- Based Income Methodologies, completed by the state. ■ The state covered this eligibility group in the Medicaid state plan as of December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013. Yes No The state also covered this eligibility group in the Medicaid state plan as of March 23, 2010. Yes No Individuals qualify under this eligibility group if they were eligible under the state's approved state plan prior to the execution of the adoption agreement. ■ The state used an income standard or disregarded all income for this eligibility group either in the Medicaid state plan as of March 23, 2010 or December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013. Yes No There is no resource test for this eligibility group. ■ PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN: RI 13-0018 Approved: 01/10/2014 S53-1 Effective: 01/01/2014

Page 1 of 1 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups - Options for Coverage Children with Non IV-E Adoption Assistance S53 42 CFR 435.227 1902(a)(10)(A)(ii)(VIII) Children with Non IV-E Adoption Assistance - The state elects to cover children with special needs for whom there is a non IV-E adoption assistance agreement in effect with a state, who were eligible for Medicaid, or who had income at or below a standard established by the state and in accordance with provisions described at 42 CFR 435.227. Yes No The state attests that it operates this eligibility group in accordance with the following provisions: ✔ Individuals qualifying under this eligibility group must meet the following criteria: ■ The state adoption agency has determined that they cannot be placed without Medicaid coverage because of special needs for medical or rehabilitative care; ■ Are under the following age (see the Guidance for restrictions on the selection of an age): ■ Under age 21 Under age 20 Under age 19 Under age 18 MAGI-based income methodologies are used in calculating household income. Please refer as necessary to S10 MAGI- Based Income Methodologies, completed by the state. ■ The state covered this eligibility group in the Medicaid state plan as of December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013. Yes No The state also covered this eligibility group in the Medicaid state plan as of March 23, 2010. Yes No Individuals qualify under this eligibility group if they were eligible under the state's approved state plan prior to the execution of the adoption agreement. ■ The state used an income standard or disregarded all income for this eligibility group either in the Medicaid state plan as of March 23, 2010 or December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013. Yes No There is no resource test for this eligibility group. ■ PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN: RI 13-0018 Approved: 01/10/2014 S53-1 Effective: 01/01/2014

Page 1 of 3 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups - Options for Coverage Optional Targeted Low Income Children S54 1902(a)(10)(A)(ii)(XIV) 42 CFR 435.229 and 435.4 1905(u)(2)(B) Optional Targeted Low Income Children - The state elects to cover uninsured children who meet the definition of optional targeted low income children at 42 CFR 435.4, who have household income at or below a standard established by the state and in accordance with provisions described at 42 CFR 435.229. Yes No The state attests that it operates this eligibility group in accordance with the following provisions: ✔ Individuals qualifying under this eligibility group must not be eligible for Medicaid under any mandatory eligibility group. ■ MAGI-based income methodologies are used in calculating household income. Please refer as necessary to S10 MAGI- Based Income Methodologies, completed by the state. ■ The state covered this eligibility group in the state plan as of December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013. Yes No The state also covered this eligibility group in the state plan as of March 23, 2010. Yes No Individuals are covered under this eligibility group, as follows: ■ All children under age 18 or 19 are covered: The reasonable classification of children covered is: Under age 19 Under age 18 Income standard used for this classification Minimum income standard ■ The minimum income standard for this classification of children must exceed the lowest income standard chosen for children in the age group selected above, under the mandatory Infants and Children under Age 19 eligibility group. Maximum income standard ■ The state certifies that it has submitted and received approval for its converted income standard(s) for this classification of children to MAGI-equivalent standards and the determination of the maximum income standard to be used for this classification of children under this eligibility group. ✔ An attachment is submitted. TN: RI 13-0018 Approved: 01/10/2014 S54-1 Effective: 01/01/2014

Page 2 of 3 Medicaid Eligibility The state's maximum income standard for this classification of children (which must exceed the minimum for the classification) is: The state's effective income level for this classification of children under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL or amounts by household size. The state's effective income level for this classification of children under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size. The state's effective income level for this classification of children under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL or amounts by household size. 200% FPL. A percentage of the FPL which may exceed the Medicaid Applicable Income Level, defined in section 2110(b)(4) of the Act, but by no more than 50 percentage points. The state's maximum income standard for this classification of children (which must exceed the minimum for the classification) is: ■ % FPL 261 Income standard chosen, which must exceed the minimum income standard ■ Individuals qualify under the following income standard: The maximum income standard. The state's effective income level for this eligibility group under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. The state's effective income level for this eligibility group under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. The state's effective income level for this eligibility group under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. 200% FPL. A percentage of the FPL which may exceed the Medicaid Applicable Income Level, defined in section 2110(b)(4) of the Act, but by no more than 50 percentage points. Another income standard in-between the minimum and maximum standards allowed. The income standard for this eligibility group is: 261 % FPL There is no resource test for this eligibility group. ■ Presumptive Eligibility ■ Presumptive eligibility for this group depends upon the selection of presumptive eligibility for the Infants and Children under Age 19 eligibility group. If presumptive eligibility is done for that group, it is done for this group under the same provisions. ■ PRA Disclosure Statement TN: RI 13-0018 Approved: 01/10/2014 S54-2 Effective: 01/01/2014

Page 3 of 3 Medicaid 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 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN: RI 13-0018 Approved: 01/10/2014 S54-3 Effective: 01/01/2014

Page 1 of 1 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups - Options for Coverage Individuals with Tuberculosis S55 1902(a)(10)(A)(ii)(XII) 1902(z) Individuals with Tuberculosis - The state elects to cover individuals infected with tuberculosis who have income at or below a standard established by the state, limited to tuberculosis-related services. Yes No PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN: RI 13-0018 Approved: 01/10/2014 S55-1 Effective: 01/01/2014

Page 1 of 2 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups - Options for Coverage Independent Foster Care Adolescents S57 42 CFR 435.226 1902(a)(10)(A)(ii)(XVII) Independent Foster Care Adolescents - The state elects to cover individuals under an age specified by the state, less than age 21, who were in state-sponsored foster care on their 18th birthday and who meet the income standard established by the state and in accordance with the provisions described at 42 CFR 435.226. Yes No The state attests that it operates this eligibility group in accordance with the following provisions: ✔ Individuals qualifying under this eligibility group must meet the following criteria: ■ Are under the following age ■ Under age 21 Under age 20 Under age 19 Were in foster care under the responsibility of a state on their 18th birthday. ■ Are not eligible and enrolled for mandatory coverage under the Medicaid state plan. ■ Have household income at or below a standard established by the state. ■ MAGI-based income methodologies are used in calculating household income. Please refer as necessary to S10 MAGI- Based Income Methodologies, completed by the state. ■ The state covered this eligibility group under its Medicaid state plan as of December 31, 2013, or under a Medicaid 1115 demonstration as of March 23, 2010 or December 31, 2013. Yes No The state also covered this eligibility group in the Medicaid state plan as of March 23, 2010. Yes No The state covers children under this eligibility group, as follows (selection may not be more restrictive than the coverage in the Medicaid state plan as of March 23, 2010 until October 1, 2019, nor more liberal than the most liberal coverage in the Medicaid state plan as of December 31, 2013, or under a Medicaid 1115 demonstration as of March 23, 2010 or December 31, 2013): ■ All children under the age selected A reasonable classification of children under the age selected: Income standard used for this eligibility group ■ Minimum income standard ■ The minimum income standard for this classification of children is the AFDC payment standard in effect as of July 16, 1996, not converted to MAGI-equivalent. This standard is described in S14 AFDC Income Standards. TN: RI 13-0018 Approved: 01/10/2014 S57-1 Effective: 01/01/2014

Page 2 of 2 Medicaid Eligibility Maximum income standard ■ No income test was used (all income was disregarded) for this eligibility group either in the Medicaid state plan as of March 23, 2010 or December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013. Yes No No income test was used (all income was disregarded) for this eligibility group under (check all that apply): ■ The Medicaid state plan as of March 23, 2010. The Medicaid state plan as of December 31, 2013. A Medicaid 1115 demonstration as of March 23, 2010. A Medicaid 1115 demonstration as of December 31, 2013. The state's maximum standard for this eligibility group is no income test (all income is disregarded). Income standard chosen ■ Individuals qualify under this eligibility group under the following income standard: This eligibility group does not use an income test (all income is disregarded). There is no resource test for this eligibility group. ■ PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN: RI 13-0018 Approved: 01/10/2014 S57-2 Effective: 01/01/2014

Page 1 of 1 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups - Options for Coverage Individuals Eligible for Family Planning Services S59 1902(a)(10)(A)(ii)(XXI) 42 CFR 435.214 Individuals Eligible for Family Planning Services - The state elects to cover individuals who are not pregnant, and have household income at or below a standard established by the state, whose coverage is limited to family planning and related services and in accordance with provisions described at 42 CFR 435.214. Yes No PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN: RI 13-0018 Approved: 01/10/2014 Effective: 01/01/2014

S59-1

TN: RI 13-0018 Approved 01/10/2014 MAGI Conv Pt 1 App Let-1 Effective: 01/01/2014

TN: RI 13-0018 Approved 01/10/2014 MAGI Conv Pt 1 App Let-2 Effective: 01/01/2014 /s/

TN: RI 13-0018 Approved 01/10/2014 MAGI Conv Pt 1 App Let-3 Effective: 01/01/2014

_____________________________________________________________________________

Table of Contents State/Territory Name: Rhode Island State Plan Amendment (SPA) #:13-0019 This file contains the following documents in the order listed: 1) Approval Letter 2) Companion Letter 3) Summary Form (with 179-like data) 4) Superseding Pages Notice 5) Approved SPA Pages 6) Additional Attachments that are part of the state plan

TN 13-019 Rhode Island Approved: 03/11/2014 Effective: 10/01/2013

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services JFK Federal Building, Government Center Room 2275 Boston, Massachusetts 02203

Division of Medicaid and Children’s Health Operations / Boston Regional Office

March 11, 2014

Steven M. Costantino, Secretary Executive Office of Health and Human Services State of Rhode Island and Providence Plantations 57 Howard Avenue, LP Building Cranston, RI 02920

Enclosed is an approved copy of Rhode Island’s state plan amendment (SPA) 13-0019-MM2, which was submitted to CMS on December 12, 2013. SPA 13-0019-MM2 incorporates the MAGI-based eligibility process requirements, including the single streamlined application, into Rhode Island’s Medicaid state plan in accordance with the Affordable Care Act. The effective date of this SPA is October 1, 2013.

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

Enclosed is a copy of the following S94 state plan pages and attachments to be incorporated within a separate section of Rhode Island’s approved state plan:

• S94, pages S94-1 and S94-2 • Attachment 1 – Statement of use with respect to the alternative single, streamlined online application • Attachment 2 – Statement of use with respect to the alternative single, streamlined paper application

In addition, enclosed is a summary of the state plan pages which are superseded by SPA 13-0019-MM2, which should also be incorporated into the state plan.

• Superseding pages of state plan material, SPA 13-0019-MM2.

CMS appreciates the significant amount of work your staff dedicated to preparing this state plan amendment. If you have any questions concerning this SPA, please contact Lynn DelVecchio at 617- 565-1201or lynn.delvecchio@cms.hhs.gov.

Sincerely,

TN 13-019 Rhode Island Approved: 03/11/2014 Effective: 10/01/2013

Sincerely,

/s/

Richard R. McGreal Associate Regional Administrator

Enclosures

Cc: Elena Nicolella, Medicaid Director

Darren J. McDonald, Ph.D., Interdepartmental Project Manager

MD-S-30-RI

TN 13-019 Rhode Island Approved: 03/11/2014 Effective: 10/01/2013

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services JFK Federal Building, Government Center Room 2275 Boston, Massachusetts 02203

Division of Medicaid and Children’s Health Operations / Boston Regional Office

March 11, 2014

Steven M. Costantino, Secretary Executive Office of Health and Human Services State of Rhode Island and Providence Plantations 57 Howard Avenue, LP Building Cranston, RI 02920

This letter is being sent as a companion to the Centers for Medicare & Medicaid Services’ (CMS) approval of state plan amendment (SPA) transmittal RI-13-0019-MM2, which was submitted to CMS on December 12, 2013. Our review of this submission included a review of the online and paper alternative single streamlined applications developed by the state.

Until December 31, 2014, the state is using interim alternative single streamlined paper and online applications. These interim applications need to be revised to reflect the following changes.

Necessary changes:

Completion Date: Paper Application

The questions about disability and foster care will only be asked of applicants.

December 31, 2014

The detailed questions regarding an absent parent (name, address, and SSN) will be removed.

December 31, 2014 Online Application The questions regarding citizenship and immigration status, as well as questions regarding disabilities and foster care, will not be asked of non-applicants.

December 31, 2014 In the question about other insurance enrollment, the state will add an option for Tricare. December 31, 2014 TN 13-019 Rhode Island Approved: 03/11/2014 Effective: 10/01/2013

Please submit the revised applications to CMS for review no later than December 1, 2014 to ensure approval by December 31, 2014. We continue to be available to provide technical assistance. If you have any questions about your application, please contact Dena Greenblum at Dena.Greenblum@cms.hhs.gov or (410) 786-8684. If you have any questions about this letter or need any additional information, please contact please contact Lynn DelVecchio of my staff at (617) 565 – 1201 or by email at Lynn.Delvecchio@cms.hhs.gov.

Sincerely,

Sincerely,

/s/

Richard R. McGreal Associate Regional Administrator

Enclosure

Cc: Elena Nicolella, Medicaid Director

Darren J. McDonald, Ph.D., Interdepartmental Project Manager

MD-S-30-RI

TN 13-019 Rhode Island Approved: 03/11/2014 Effective: 10/01/2013

Medicaid State Plan Eligibility: Summary Page (CMS 179) Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. Proposed Effective Date (mm/dd/yyyy) Federal Statute/Regulation Citation Federal Budget Impact Subject of Amendment MAGI Eligibility Process Governor's Office Review Governor's office reported no comment Comments of Governor's office received Describe: No reply received within 45 days of submittal Other, as specified Describe: This amendment has not been reviewed specifically with the Governor’s Office. Under the Rhode Island Medicaid State Plan, the Governor has elected not to review the details of state plan materials. However, in accordance with Rhode Island law and practice, the Governor is kept apprised of major changes in the state plan. Signature of State Agency Official State/Territory name: Rhode Island 13-019 10/01/2013 42 CFR 435,sub parts J and M Federal Fiscal Year Amount First Year 2014 $ 0.00 Second Year 2015 $ 0.00 Submitted By: Jodi DiBernardo Last Revision Date: Mar 11, 2014 Submit Date: Dec 12, 2013 Page 1 of 1 RI.0581.R00.00 - Oct 01, 2013 03/12/2014 http://157.199.113.99/MMDL/faces/protected/mac/c01/print/PrintSelector.jsp TN 13-019 Rhode Island Approved: 03/11/2014 Effective: 10/01/2013

Page 1 of 2 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 General Eligibility Requirements Eligibility Process S94 42 CFR 435, Subpart J and Subpart M Eligibility Process The state meets all the requirements of 42 CFR 435, Subpart J for processing applications, determining and verifying eligibility, and furnishing Medicaid. ✔ Application Processing Indicate which application the agency uses for individuals applying for coverage who may be eligible based on the applicable modified adjusted gross income standard. The single, streamlined application for all insurance affordability programs, developed by the Secretary in accordance with section 1413(b)(1)(A) of the Affordable Care Act An alternative single, streamlined application developed by the state in accordance with section 1413(b)(1)(B) of the Affordable Care Act and approved by the Secretary, which may be no more burdensome than the streamlined application developed by the Secretary. An attachment is submitted. An alternative application used to apply for multiple human service programs approved by the Secretary, provided that the agency makes readily available the single or alternative application used only for insurance affordability programs to individuals seeking assistance only through such programs. An attachment is submitted. Indicate which application the agency uses for individuals applying for coverage who may be eligible on a basis other than the applicable modified adjusted gross income standard: The single, streamlined application developed by the Secretary or one of the alternate forms developed by the state and approved by the Secretary, and supplemental forms to collect additional information needed to determine eligibility on such other basis, submitted to the Secretary. An attachment is submitted. An application designed specifically to determine eligibility on a basis other than the applicable MAGI standard which minimizes the burden on applicants, submitted to the Secretary. An attachment is submitted. The agency's procedures permit an individual, or authorized person acting on behalf of the individual, to submit an application via the internet website described in 42 CFR 435.1200(f), by telephone, via mail, and in person. The agency also accepts applications by other electronic means: Yes No TN 13-019 Rhode Island Approved: 03/11/2014 Effective: 10/01/2013

Page 2 of 2 Medicaid Eligibility Indicate the other electronic means below: Name of Method Description + Web Portal Internet access to electronic application x The agency has procedures to take applications, assist applicants and perform initial processing of applications for the eligibility groups listed below at locations other than those used for the receipt and processing of applications for the title IV-A program, including Federally-qualified health centers and disproportionate share hospitals. ✔ Parents and Other Caretaker Relatives Pregnant Women Infants and Children under Age 19 Redetermination Processing Redeterminations of eligibility for individuals whose financial eligibility is based on the applicable modified adjusted gross income standard are performed as follows, consistent with 42 CFR 435.916: ✔ Once every 12 months ■ Without requiring information from the individual if able to do so based on reliable information contained in the individual's account or other more current information available to the agency ■ If the agency cannot determine eligibility solely on the basis of the information available to it, or otherwise needs additional information to complete the redetermination, it provides the individual with a pre-populated renewal form containing the information already available. ■ Redeterminations of eligibility for individuals whose financial eligibility is not based on the applicable modified adjusted gross income standard are performed, consistent with 42 CFR 435.916 (check all that apply): ■ Once every 12 months Once every 6 months Other, more often than once every 12 months Coordination of Eligibility and Enrollment The state meets all the requirements of 42 CFR 435, Subpart M relative to coordination of eligibility and enrollment between Medicaid, CHIP, Exchanges and other insurance affordability programs. The single state agency has entered into agreements with the Exchange and with other agencies administering insurance affordability programs. ✔ PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN 13-019 Rhode Island Approved: 03/11/2014 Effective: 10/01/2013

_____________________________________________________________________________

Table of Contents State/Territory Name: Rhode Island State Plan Amendment (SPA) #:13-0020MM3 This file contains the following documents in the order listed: 1) Approval Letter 2) Summary Form (with 179-like data) 3) Superseding Pages Notice 4) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services JFK Federal Building, Government Center Room 2275 Boston, Massachusetts 02203

Division of Medicaid and Children’s Health Operations / Boston Regional Office

February 7, 2014

Steven M. Costantino, Secretary Executive Office of Health and Human Services State of Rhode Island and Providence Plantations 57 Howard Avenue, LP Building Cranston, RI 02920

Dear Secretary Costantino:

We are pleased to enclose a copy of approved Rhode Island State Plan Amendment (SPA) No.13- 0020MM3, submitted December 12, 2013 in order to designate the income options selected by the State for 2014. Effective, January 1, 2014, this SPA is approved as described in the pdf S10and is hereby incorporated into the RI Medicaid State Plan.

If you have any questions regarding this matter you may contact Lynn DelVecchio (617) 565-1201 or by e-mail at Lynn.DelVecchio@cms.hhs.gov

Sincerely,

/s/

Richard R. McGreal Associate Regional Administrator

Enclosure

Cc: Elena Nicolella, Medicaid Director

Darren J. McDonald, Ph.D., Interdepartmental Project Manager

MD-S-30-RI

State/Territory name: Rhode Island Submitted By: Jodi DiBernardo Last Revision Date: Feb 6, 2014 Submit Date: Dec 12, 2013 Medicaid State Plan Eligibility: Summary Page (CMS 179) Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. 13-020 Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation 42 CFR 435.603; section 1902(e)(14) of the Social Security Act Federal Budget Impact Federal Fiscal Year Amount First Year 2014 $ 0.00 Second Year 2015 $ 0.00 Subject of Amendment MAGI Income Methodology Governor's Office Review Governor's office reported no comment Comments of Governor's office received Describe: No reply received within 45 days of submittal Other, as specified Describe: This amendment has not been reviewed specifically with the Governor’s Office. Under the Rhode Island Medicaid State Plan, the Governor has elected not to review the details of state plan materials. However, in accordance with Rhode Island law and practice, the Governor is kept apprised of major changes in the state plan. Signature of State Agency Official Page 1 of 2 RI.0582.R00.00 - Jan 01, 2014 02/10/2014 http://157.199.113.99/MMDL/faces/protected/mac/c01/print/PrintSelector.jsp

SUPERSEDING PAGES OF STATE PLAN MATERIAL

TRANSMITTAL NUMBER:

TN# 13-020-MM3 STATE: Rhode Island

PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:

S10 - MAGI Income Methodology

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

Notwithstanding any other provisions of the Rhode Island Medicaid State Plan, the financial eligibility methodologies described in State Plan Amendment 13-020-MM3 will apply to all MAGI-based eligibility groups covered under Rhode Island Medicaid State Plan. The MAGI financial methodologies set forth in 42 CFR § 435.603 apply to everyone except those individuals described at 42 CFR § 435.603(j) for whom MAGI-based methods do not apply. This State Plan Amendment supersedes the current financial eligibility provisions of the Medicaid State Plan only with respect to the MAGI-based eligibility groups.

Page 1 of 2 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 MAGI-Based Income Methodologies S10 1902(e)(14) 42 CFR 435.603 The state will apply Modified Adjusted Gross Income (MAGI)-based methodologies as described below, and consistent with 42 CFR 435.603. ■ In the case of determining ongoing eligibility for beneficiaries determined eligible for Medicaid 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 application of such methods results in a determination of ineligibility prior to such date. 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 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 and family size for the remaining months of the current calendar year In determining current monthly or projected annual household income, the state will use reasonable methods to: Include a prorated portion of a 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 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. In determining eligibility for Medicaid, an amount equivalent to 5 percentage points of the FPL for the applicable family size will be deducted from household income in accordance with 42 CFR 435.603(d). 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 TN# 13-0020 Rhode Island Approved: 02/07/2014 Effective Date: 01/01/2014

Page 2 of 2 Medicaid Eligibility The age used for children with respect to 42 CFR 435.603(f)(3)(iv) is: ■ Age 19 Age 19, or in the case of full-time students, age 21 PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN# 13-0020 Rhode Island Approved: 02/07/2014 Effective Date: 01/01/2014

_____________________________________________________________________________

Table of Contents State/Territory Name: Rhode Island State Plan Amendment (SPA) #:13-0022 This file contains the following documents in the order listed: 1) Approval Letter 2) Summary Form (with 179-like data) 3) Superseding Pages Notice 4) Approved SPA Pages

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

JFK Federal Building, Government Center

Room 2275

Boston, Massachusetts 02203

CMS

CENTERS FOR MEDICARE & MEDICAID SERVICES

Division of Medicaid and Children’s Health Operations / Boston Regional Office

March 11, 2014

Steven M. Costantino, Secretary

Executive Office of Health and Human Services State of Rhode Island and Providence Plantations 57 Howard Avenue, LP Building

Cranston, RI 02920

Dear Mr. Costantino:

Enclosed is an approved copy of Rhode Island’s state plan amendment (SPA) 13-022, which was submitted to CMS on December 12, 2013. SPA 13-022 incorporates standards for Non-Financial Eligibility- Citizenship and Non-Citizen Eligibility as reflected in pdf $89, into Rhode Island’s Medicaid state plan in accordance with the Affordable Care Act. The effective date of this SPA is January 1, 2014.

Enclosed is a copy of S89 state plan pages and attachments to be incorporated within a separate section of Rhode Island’s approved state plan:

In addition, enclosed is a summary of the state plan pages which are superseded by SPA 13-022. This summary should also be incorporated into the state plan.

CMS appreciates the significant amount of work your staff dedicated to preparing this state plan amendment. If you have any questions concerning this SPA, please contact Lynn Del Vecchio at 617-565-1201lor lynn.delvecchio@cms.hhs.gov.

Sincerely, /s/

Richard R. McGreal Associate Regional Administrator Enclosures

cc: Elena Nicolella, Medicaid Director Darren J. McDonald, Ph.D., Interdepartmental Project Manager

Medicaid State Plan Eligibility: Summary Page (CMS 179) Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. Proposed Effective Date (mm/dd/yyyy) Federal Statute/Regulation Citation Federal Budget Impact Subject of Amendment Non-Financial Eligibility: Citizenship and Non-Citizenship Eligibility Governor's Office Review Governor's office reported no comment Comments of Governor's office received Describe: No reply received within 45 days of submittal Other, as specified Describe: This amendment has not been reviewed specifically with the Governor’s Office. Under the Rhode Island Medicaid State Plan, the Governor has elected not to review the details of state plan materials. However, in accordance with Rhode Island law and practice, the Governor is kept apprised of major changes in the state plan. Signature of State Agency Official State/Territory name: Rhode Island 13-022 01/01/2014 42 CFR 435.4, 435.406, 435.956; Section 1902(a)(46)(B) of the Social Security Act; Sections 1903(v)(2), (3), (4) Federal Fiscal Year Amount First Year 2014 $ 1612500.00 Second Year 2015 $ 2150000.00 Submitted By: Jodi DiBernardo Last Revision Date: Feb 14, 2014 Submit Date: Dec 12, 2013 Page 1 of 1 RI.0584.R00.00 - Jan 01, 2014 03/12/2014 http://157.199.113.99/MMDL/faces/protected/mac/c01/print/PrintSelector.jsp

SUPERSEDING PAGES OF STATE PLAN MATERIAL

TRANSMITTAL NUMBER:

13-022 STATE:

Rhode Island

PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:

S89 Non-Financial Eligibility- Citizenship and Non-Citizen Eligibility PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable):

Attachment 2.6-A, Page 2, Item 3, Subparagraphs (a), (b), and (c), TN 09-006 Attachment 2.6-A, Page 2a, TN 09-006 Attachment 2.6-A, Page 3, Item 3, Subparagraphs (d) and (e), TN 92-02

Page 1 of 3 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Non-Financial Eligibility Citizenship and Non-Citizen Eligibility S89 1902(a)(46)(B) 8 U.S.C. 1611, 1612, 1613, and 1641 1903(v)(2),(3) and (4) 42 CFR 435.4 42 CFR 435.406 42 CFR 435.956 Citizenship and Non-Citizen Eligibility The state provides Medicaid to citizens and nationals of the United States and certain non-citizens consistent with requirements of 42 CFR 435.406, including during a reasonable opportunity period pending verification of their citizenship, national status or satisfactory immigration status. ✔ The state provides Medicaid eligibility to otherwise eligible individuals: ■ Who are citizens or nationals of the United States; and

■ Who are qualified non-citizens as defined in section 431 of the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) (8 U.S.C. §1641), or whose eligibility is required by section 402(b) of PRWORA (8 U.S.C. §1612(b)) and is not prohibited by section 403 of PRWORA (8 U.S.C. §1613); and ■ Who have declared themselves to be citizens or nationals of the United States, or an individual having satisfactory immigration status, during a reasonable opportunity period pending verification of their citizenship, nationality or satisfactory immigration status consistent with requirements of 1903(x), 1137(d), 1902(ee) of the SSA and 42 CFR 435.406, and 956.

■ The reasonable opportunity period begins on and extends 90 days from the date the notice of reasonable opportunity is received by the individual. The agency provides for an extension of the reasonable opportunity period if the individual is making a good faith effort to resolve any inconsistencies or obtain any necessary documentation, or the agency needs more time to complete the verification process. Yes No The agency begins to furnish benefits to otherwise eligible individuals during the reasonable opportunity period on a date earlier than the date the notice is received by the individual. Yes No The date benefits are furnished is: First of the month in which person applies for benefits containing the declaration of citizenship or immigration status. The date of application containing the declaration of citizenship or immigration status. The date the reasonable opportunity notice is sent. Other date, as described: TN: 13-022 Rhode Island Approval date: 03/11/2014 Effective Date: 01/01/2014

Page 2 of 3 Medicaid Eligibility The state provides Medicaid coverage to all Qualified Non-Citizens whose eligibility is not prohibited by section 403 of PRWORA (8 U.S.C. §1613). Yes No The state elects the option to provide Medicaid coverage to otherwise eligible individuals under 21 and pregnant women, lawfully residing in the United States, as provided in section 1903(v)(4) of the Act. Yes No Pregnant women Individuals under age 21: Individuals under age 21 Individuals under age 20 Individuals under age 19 An individual is considered to be lawfully residing in the United States if he or she is lawfully present and otherwise meets the eligibility requirements in the state plan. ■ An individual is considered to be lawfully present in the United States if he or she: ■ 1. Is a qualified non-citizen as defined in 8 U.S.C. 1641(b) and (c); 2. Is a non-citizen in a valid nonimmigrant status, as defined in 8 U.S.C. 1101(a)(15) or otherwise under the immigration laws (as defined in 8 U.S.C. 1101(a)(17)); 3. Is a non-citizen who has been paroled into the United States in accordance with 8 U.S.C. 1182(d)(5) for less than 1 year, except for an individual paroled for prosecution, for deferred inspection or pending removal proceedings; 4. Is a non-citizen who belongs to one of the following classes: Granted temporary resident status in accordance with 8 U.S.C. 1160 or 1255a, respectively; ■ Granted Temporary Protected Status (TPS) in accordance with 8 U.S.C. §1254a, and individuals with pending applications for TPS who have been granted employment authorization; ■ Granted employment authorization under 8 CFR 274a.12(c); ■ Family Unity beneficiaries in accordance with section 301 of Pub. L. 101-649, as amended; ■ Under Deferred Enforced Departure (DED) in accordance with a decision made by the President; ■ Granted Deferred Action status; ■ Granted an administrative stay of removal under 8 CFR 241; ■ Beneficiary of approved visa petition who has a pending application for adjustment of status; ■ 5. Is an individual with a pending application for asylum under 8 U.S.C. 1158, or for withholding of removal under 8 U.S.C.1231, or under the Convention Against Torture who - Has been granted employment authorization; or ■ Is under the age of 14 and has had an application pending for at least 180 days; ■ TN: 13-022 Rhode Island Approval date: 03/11/2014 Effective Date: 01/01/2014

Page 3 of 3 Medicaid Eligibility 6. Has been granted withholding of removal under the Convention Against Torture; 7. Is a child who has a pending application for Special Immigrant Juvenile status as described in 8 U.S.C. 1101(a)(27)(J); 8. Is lawfully present in American Samoa under the immigration laws of American Samoa; or 9. Is a victim of severe trafficking in persons, in accordance with the Victims of Trafficking and Violence Protection Act of 2000, Pub. L. 106-386, as amended (22 U.S.C. 7105(b)); 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. Other The state assures that it provides limited Medicaid services for treatment of an emergency medical condition, not related to an organ transplant procedure, as defined in 1903(v)(3) of the SSA and implemented at 42 CFR 440.255, to the following individuals who meet all Medicaid eligibility requirements, except documentation of citizenship or satisfactory immigration status and/or present an SSN: ✔ Qualified non-citizens subject to the 5 year waiting period described in 8 U.S.C. 1613; ■ Non-qualified non-citizens, unless covered as a lawfully residing child or pregnant woman by the state under the option in accordance with 1903(v)(4) and implemented at 435.406(b). ■ PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN: 13-022 Rhode Island Approval date: 03/11/2014 Effective Date: 01/01/2014

_____________________________________________________________________________

Table of Contents State/Territory Name: Rhode Island State Plan Amendment (SPA) #:13-0030MM1 This file contains the following documents in the order listed: 1) Approval Letter 2) Summary Form (with 179-like data) 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services JFK Federal Building, Government Center Room 2275 Boston, Massachusetts 02203

Division of Medicaid and Children’s Health Operations / Boston Regional Office

December 13, 2013

Steven M. Costantino, Secretary Executive Office of Health and Human Services State of Rhode Island and Providence Plantations 57 Howard Avenue, LP Building Cranston, RI 02920

Dear Secretary Costantino:

We are pleased to enclose a copy of approved Rhode Island State Plan Amendment (SPA) No.13- 0030MM1, submitted December 13, 2013. This SPA grants MAGI-Based Eligibility Group-Medicaid coverage for individuals with incomes below 133% of the FPL, effective January 1, 2014.

If you have any questions regarding this matter you may contact Lynn DelVecchio (617) 565-1201 or by e-mail at Lynn.DelVecchio@cms.hhs.gov

Sincerely,

/s/

Richard R. McGreal Associate Regional Administrator

logged in as LYNNDELVECCHIO(CMS RO Staff) read only mode application rev c01 Medicaid State Plan Eligibility RI.0601.R00.00 - Jan 01, 2014 Home Logout Finder Save Validate Print Help Control Panel General Information File Management Tribal Input Summary (CMS179) State/Territory name: Rhode Island Medicaid State Plan Eligibility: Summary Page (CMS 179) Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. 13-030 Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation 42 CFR 435.110, 435.116, 435.118, 435.119, 435.150, 435.214, 435.218, 435.220, 435.222, 435 Federal Budget Impact Federal Fiscal Year Amount First Year 2014 $ 153728865.00 Second Year 2015 $ 329370054.00 Subject of Amendment Character Count:51 out of 2000 Individuals Below 133% of the Federal Poverty Level Governor's Office Review Governor's office reported no comment Comments of Governor's office received Describe: No reply received within 45 days of submittal Other, as specified Describe: Character Count:324 out of 2000 Page 1 of 2 MacPro Reporting System: Summary Page (CMS 179) 12/17/2013 http://157.199.113.99/MMDL/faces/protected/mac/c01/pages/mac_01.jsp

Submitted By: Jodi DiBernardo Last Revision Date: Dec 13, 2013 Submit Date: Dec 13, 2013 This amendment has not been reviewed specifically with the Governor’s Office. Under the Rhode Island Medicaid State Plan, the Governor has elected not to review the details of state plan materials. However, in accordance with Rhode Island law and practice, the Governor is kept apprised of j h i th t t l Signature of State Agency Official FAQs | Form Support | Contact | Medicaid.gov | CMS.gov Page 2 of 2 MacPro Reporting System: Summary Page (CMS 179) 12/17/2013 http://157.199.113.99/MMDL/faces/protected/mac/c01/pages/mac_01.jsp

Page 1 of 2 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups - Mandatory Coverage Adult Group S32 1902(a)(10)(A)(i)(VIII) 42 CFR 435.119 The state covers the Adult Group as described at 42 CFR 435.119. Yes No Adult Group - Non-pregnant individuals age 19 through 64, not otherwise mandatorily eligible, with income at or below 133% FPL. ■ The state attests that it operates this eligibility group in accordance with the following provisions: ✔ Individuals qualifying under this eligibility group must meet the following criteria: ■ Have attained age 19 but not age 65. ■ Are not pregnant. ■ Are not entitled to or enrolled for Part A or B Medicare benefits. ■ Are not otherwise eligible for and enrolled for mandatory coverage under the state plan in accordance with 42 CFR 435, subpart B. ■ Note: In 209(b) states, individuals receiving SSI or deemed to be receiving SSI who do not qualify for mandatory Medicaid eligibility due to more restrictive requirements may qualify for this eligibility group if otherwise eligible. Have household income at or below 133% FPL. ■ MAGI-based income methodologies are used in calculating household income. Please refer as necessary to S10 MAGI-Based Income Methodologies, completed by the state. ■ There is no resource test for this eligibility group. ■ Parents or other caretaker relatives living with a child under the age specified below are not covered unless the child is receiving benefits under Medicaid, CHIP or through the Exchange, or otherwise enrolled in minimum essential coverage, as defined in 42 CFR 435.4. ■ Under age 19, or A higher age of children, if any, covered under 42 CFR 435.222 on March 23, 2010: Presumptive Eligibility ■ The state covers individuals under this group when determined presumptively eligible by a qualified entity. The state assures it also covers individuals under the Pregnant Women (42 CFR 435.116) and/or Infants and Children under Age 19 (42 CFR 435.118) eligibility groups when determined presumptively eligible. Yes No PRA Disclosure Statement TN# RI-13-0030MM1 Superseses: (new) Approved: 12/13/2013 Effective date: 01/01/2014

Page 2 of 2 Medicaid 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 0938‐1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4‐26‐05, Baltimore, Maryland 21244‐1850. TN# RI-13-0030MM1 Superseses: (new) Approved: 12/13/2013 Effective date: 01/01/2014

_____________________________________________________________________________

Table of Contents State/Territory Name: Rhode Island State Plan Amendment (SPA) #:13-0032 This file contains the following documents in the order listed: 1) Approval Letter 2) Summary Form (with 179-like data) 3) Superseding Pages Notice 4) Approved SPA Pages

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

JFK Federal Building, Government Center

Room 2275

Boston, Massachusetts 02203

CMS

CENTERS FOR MEDICARE & MEDICAID SERVICES

Division of Medicaid and Children's Health Operations / Boston Regional Office

January 10, 2014

Steven M. Costantino, Secretary Office of Health & Human Services 57 Howard Avenue

Louis Pasteur Building

Cranston, RI 02920

Dear Secretary Costantino:

We are pleased to enclose a copy of approved State plan amendment (SPA) No. 13-032. This SPA is effective January 1, 2014, as requested.

This SPA transmitted a proposed amendment to Rhode Island’s approved Title XIX State plan to provide coverage to Reasonable Categories of Individuals Under the Age of 21 pursuant to 42 C.F.R. §435.222 as reflected in pdf $52.

If there are questions, please contact Lynn Del Vecchio at (617) 565-1201.

Sincerely, /s/ Richard R. McGreal Associate Regional Administrator

Enclosure

ce: Elena Nicolella, Medicaid Director Darren J. McDonald, Ph.D., Interdepartmental Project Manager

logged in as LYNNDELVECCHIO(CMS RO Staff) read only mode application rev c01 Medicaid State Plan Eligibility RI.0724.R00.00 - Jan 01, 2014 Home Logout Finder Save Validate Print Help Control Panel General Information File Management Tribal Input Summary (CMS179) State/Territory name: Rhode Island Medicaid State Plan Eligibility: Summary Page (CMS 179) Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. 13-032 Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation 42 CFR 435.222, 1902(a)(10)(A)(ii)(I),1902(a)(10)(A)(ii)(IV) Federal Budget Impact Federal Fiscal Year Amount First Year 2014 $ 0.00 Second Year 2015 $ 0.00 Subject of Amendment Character Count:29 out of 2000 MAGI Based Eligibility Groups Governor's Office Review Governor's office reported no comment Comments of Governor's office received Describe: No reply received within 45 days of submittal Other, as specified Describe: Character Count:324 out of 2000 Page 1 of 2 MacPro Reporting System: Summary Page (CMS 179) 01/28/2014 http://157.199.113.99/MMDL/faces/protected/mac/c01/pages/mac_00.jsp

Submitted By: Jodi DiBernardo Last Revision Date: Jan 7, 2014 Submit Date: Jan 2, 2014 This amendment has not been reviewed specifically with the Governor’s Office. Under the Rhode Island Medicaid State Plan, the Governor has elected not to review the details of state plan materials. However, in accordance with Rhode Island law and practice, the Governor is kept apprised of j h i th t t l Signature of State Agency Official FAQs | Form Support | Contact | Medicaid.gov | CMS.gov Page 2 of 2 MacPro Reporting System: Summary Page (CMS 179) 01/28/2014 http://157.199.113.99/MMDL/faces/protected/mac/c01/pages/mac_00.jsp

1

SUPERSEDING PAGES OF STATE PLAN MATERIAL

TRANSMITTAL NUMBER:

13-032

STATE:

Rhode Island

Pages or sections of pages being superseded by S52

State Plan Section

Complete Pages Removed

Partial Pages Removed Attachment 2.2-A

Page 13 Page 13a

Page 12, B.7 Supplement 1 to Attachment 2.2-A Page 1

Supplement 8a to Attachment 2.6-A Page 2

Page 1 of 3 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups - Options for Coverage Reasonable Classification of Individuals under Age 21 S52 42 CFR 435.222 1902(a)(10)(A)(ii)(I) 1902(a)(10)(A)(ii)(IV) Reasonable Classification of Individuals under Age 21 - The state elects to cover one or more reasonable classifications of individuals under age 21 who are not mandatorily eligible and who have income at or below a standard established by the state and in accordance with provisions described at 42 CFR 435.222. Yes No The state attests that it operates this eligibility group in accordance with the following provisions: ✔ Individuals qualifying under this eligibility group must qualify under a reasonable classification by meeting the following criteria: ■ Be under age 21, or a lower age, as defined within the reasonable classification. ■ Have household income at or below the standard established by the state, if the state has an income standard for the reasonable classification. ■ Not be eligible and enrolled for mandatory coverage under the state plan. ■ MAGI-based income methodologies are used in calculating household income. Please refer as necessary to S10 MAGI- Based Income Methodologies, completed by the state. ■ The state covered at least one reasonable classification under this eligibility group under its Medicaid state plan as of December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013, with income standards higher (including disregarding all income) than the current mandatory income standards for the individual's age. Yes No The state also covered at least one reasonable classification under this group in the Medicaid state plan as of March 23, 2010 with income standards higher (including disregarding all income) than the current mandatory income standards for the individual's age. Yes No Reasonable Classifications Previously Covered The state elects the option to include in this eligibility group reasonable classifications that were covered under the Medicaid state plan as of December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013. Yes No The state covers all children under a specified age limit, no higher than any age limit and/or income standard covered in the state plan as of December 31, 2013 or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013, provided the income standard is higher than the current mandatory income standard for the individual's age. Higher income standards may include the disregard of all income. Yes No TN: 13-0032 Rhode Island Approved: 01/10/2014 S52-1 Effective:01/01/2014

Page 2 of 3 Medicaid Eligibility The state covers reasonable classifications of children that were covered under the Medicaid state plan as of December 31, 2013 or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013 with an income standard higher than the current mandatory income standard for the age group. Yes No The previously covered reasonable classifications to be included are: Previously Covered Reasonable Classifications Included Reasonable Classifications of Children S11 Individuals for whom public agencies are assuming full or partial financial responsibility. Individuals in adoptions subsidized in full or part by a public agency Individuals in nursing facilities, if nursing facility services are provided under this plan Individuals receiving active treatment as inpatients in psychiatric facilities or programs, if such services are provided under this plan Other reasonable classifications Name of classification Description Age Limit + 2101(f)-like children 2101(f)-like children who were enrolled in Medicaid on 12/31/13 and would otherwise become ineligible for Medicaid at their first redetermination using MAGI methodologies solely due to the loss of income disregards will remain Medicaid eligible until their next redetermination using MAGI methodologies. Under age 19 x Enter the income standard used for these classifications (which may be no higher than the highest standard used in the Medicaid state plan as of December 31, 2013 or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013). Click here once S11 form above is complete to view the income standards form. 2101(f)-like children Income standard used ■ Minimum income standard ■ The minimum income standard for this classification of children must exceed the lowest income standard chosen for children under this age under the Infants and Children under Age 19 eligibility group. Maximum income standard ■ TN: 13-0032 Rhode Island Approved: 01/10/2014 S52-2 Effective:01/01/2014

Page 3 of 3 Medicaid Eligibility No income test was used (all income was disregarded) for this classification either in the Medicaid state plan as of December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013. Yes No The state's maximum standard for this classification of children is no income test (all income is disregarded). Income standard chosen ■ Individuals qualify under this classification under the following income standard: This classification does not use an income test (all income is disregarded). Another income standard higher than the minimum income standard. New reasonable classifications covered If the state has not elected to cover the Adult Group (42 CFR 435.119), it may elect to cover additional new age groups or reasonable classifications that have not been covered previously. If the state covers the Adult Group, this additional option is not available, as the standard for the new age groups or classifications is lower than that used for mandatory coverage. The state does not cover the Adult Group and elects the option to include in this eligibility group additional age groups or reasonable classifications that have not been covered previously in the state plan or under a Medicaid 1115 Demonstration. Any additional age groups or reasonable classifications not previously covered are restricted to the AFDC income standard from July 16, 1996, not converted to a MAGI-equivalent standard. Yes No There is no resource test for this eligibility group. ■ PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN: 13-0032 Rhode Island Approved: 01/10/2014 S52-3 Effective:01/01/2014

_____________________________________________________________________________ Table of Contents State/Territory Name: Rhode Island State Plan Amendment (SPA) #: 14-003 This file contains the following documents in the order listed: 1) Approval Letter 2) Companion Letter 3) CMS 179 Form/Summary Form (with 179-like data) 4) Approved SPA Pages 5) Attachments

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services JFK Federal Building, Government Center Room 2275 Boston, Massachusetts 02203 Division of Medicaid and Children’s Health Operations / Boston Regional Office May 10, 2016 Elizabeth Roberts, Secretary Executive Office of Health and Human Services State of Rhode Island and Providence Plantations 74 West Road, Hazard Building Cranston, RI 02920 Dear Secretary Roberts: We are pleased to enclose a copy of approved Rhode Island State Plan Amendment (SPA) No. 14-003, submitted March 28, 2014. Effective January 1, 2014 this SPA grants authority to implement hospital presumptive eligibility in accordance with the Affordable Care Act. This approval is accompanied by a companion letter outlining the need for systems changes that are necessary to achieve full compliance with hospital presumptive eligibility requirements. We look forward to your response and are happy to provide any technical assistance needed as you move forward. If you have any questions regarding this matter you may contact Lynn DelVecchio (617) 565-1201 or by e-mail at Lynn.DelVecchio@cms.hhs.gov Sincerely, /s/ Richard R. McGreal Associate Regional Administrator Enclosure Cc: Dr. Anya RadarWallack, MD, Medicaid Director Melody Lawrence Health Services Manager MD-S-30-RI

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

JFK Federal Building, Government Center

Room 2275

Boston, Massachusetts 02203

CMS

CENTERS FOR MEDICARE & MEDICAID SERVICES

Division of Medicaid and Children's Health Operations / Boston Regional Office

May 10, 2016

Ms. Elizabeth Roberts, Secretary

Executive Office of Health & Human Services State of Rhode Island & Providence Plantations 74 West Road, Hazard Building

Cranston, Rhode Island 02920

Dear Secretary Roberts:

This letter is being sent as a companion to our approval of Rhode Island State Plan Amendment (SPA) RI-14-0003MM7, which proposes to implement presumptive eligibility (PE) conducted by hospitals in the Medicaid state plan in accordance with the Affordable Care Act. Rhode Island (“the state”) submitted this amendment on March 28, 2014, with an effective date of January 1, 2014.

Section 1902(a) of the Social Security Act (the Act) requires that states have a State Plan for medical assistance that meets certain Federal requirements that set out a framework for the State program. Implementing regulations at 42 Code of Federal Regulations (CFR) 430.10 require that the State Plan be a comprehensive written statement describing the nature and scope of the State’s Medicaid Program and that it contain all information necessary for the Centers for Medicare & Medicaid Services (CMS) to determine whether the plan can be approved to serve as the basis for Federal financial participation (FFP) in the state program. While the SPA is approvable, CMS’ analysis determined that additional changes related to the state’s implementation of the hospital PE provision are needed. This companion letter memorializes the changes, as detailed below.

Coverage for Children in the Optional Targeted Low Income (OLTI) Group

Rhode Island is currently operating a hospital PE program that does not allow hospitals to make PE determinations for children with income above 190% (for children under age 1), 142% (for children age 1-5),

and 133% (for children age 16-18), of the FPL, even though these children are eligible in the state’s Optional Targeted Low-income (OTLI) group (defined at 42 CFR 435.229). Rhode Island has a combination CHIP program and covers the Medicaid expansion optional targeted low income (OTLI) children group populations under its Medicaid state plan. Children in the OTLI group are Medicaid-eligible and also eligible for hospital PE, as codified in 42 CFR 435.1102(a). The eligibility level has been incorrectly coded in the system logic for the state’s hospital PE system. While hospitals are not expected to narrow eligibility specific to the OLTI group, they do perform the PE determinations using the state’s system. Thus, discrepancies in the state’s system prevent the hospitals from accurately determining presumptive eligibility for children referenced above with income up to 261 percent of the Federal Poverty Level (FPL). Further, the state’s training for hospital qualified entities has not included correct income limits for children, as it did not incorporate the income limits of this OTLI group.

The state has acknowledged its deficiency in providing hospital PE determinations to children up to 261 percent of the FPL and has said that it needs time to implement system and training changes to the program.

Page 2 - Ms. Elizabeth Roberts, Secretary We understand the state is implementing all other aspects of hospital PE in accordance with federal regulations and guidance. We are approving this SPA with the understanding that the state will be fixing this issue. Due to competing systems priorities, the state reports that system fixes will not be in place until July 2016. CMS requests that the state make efforts to expedite these fixes to an earlier release. In the interim, we understand that the state makes the full single streamlined application available through the hospitals and that the state is able to process 87 percent of Medicaid eligibility determinations in real-time. Following system fixes, the state will conduct education and/or re-training with hospitals as needed to ensure that the income limit for children is 261 percent of the FPL. CMS reviews hospital PE applications as part of SPA approvals. When Rhode Island begins work on the hospital PE system and determines what changes may be made to the user interface, pursuant to the above, please contact CMS to talk about the need for an amendment. Within 30 days of this letter, please respond to formally acknowledge this companion letter and confirm the state's timeline for fixing these issues. To stay apprised of the state's progress in implementing this fix, CMS may request verbal updates from the state periodically. During the 30 days and after, CMS will remain available to provide technical assistance, as needed or required. If you have any questions, please contract Lynn DelVecchio ofmy staff at 617-565-1201 or by e-mail at Lynn.delvecchio@cms.hhs.gov. cc: Dr. Anya Wallack, Medicaid Director Melody Lawrence Health Services Sincerely, f'Richard R. McGreal Associate Regional Administrator

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

JFK Federal Building, Government Center

Room 2275

Boston, Massachusetts 02203

CMS

CENTERS FOR MEDICARE & MEDICAID SERVICES

Division of Medicaid and Children’s Health Operations / Boston Regional Office

May 10, 2016

Elizabeth Roberts, Secretary

Executive Office of Health and Human Services State of Rhode Island and Providence Plantations 74 West Road, Hazard Building

Cranston, RI 02920

Dear Secretary Roberts:

We are pleased to enclose a copy of approved Rhode Island State Plan Amendment (SPA) No. 14-003, submitted March 28, 2014. Effective January 1, 2014 this SPA grants authority to implement hospital presumptive eligibility in accordance with the Affordable Care Act.

This approval is accompanied by a companion letter outlining the need for systems changes that are necessary to achieve full compliance with hospital presumptive eligibility requirements. We look forward to your response and are happy to provide any technical assistance needed as you move forward.

If you have any questions regarding this matter you may contact Lynn DelVecchio (617) 565- 1201 or by e-mail at Lynn.DelVecchio@cms.hhs.gov

Sincerely,

Richard’ R. McGreal Associate Regional Administrator

t

Enclosure

Ge: Dr. Anya RadarWallack, MD, Medicaid Director Melody Lawrence Health Services Manager

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

JFK Federal Building, Government Center

Room 2275

Boston, Massachusetts 02203

CMS

CENTERS FOR MEDICARE & MEDICAID SERVICES

Division of Medicaid and Children’s Health Operations / Boston Regional Office

May 10, 2016

Elizabeth Roberts, Secretary

Executive Office of Health and Human Services State of Rhode Island and Providence Plantations 74 West Road, Hazard Building

Cranston, RI 02920

Dear Secretary Roberts:

We are pleased to enclose a copy of approved Rhode Island State Plan Amendment (SPA) No. 14-003, submitted March 28, 2014. Effective January 1, 2014 this SPA grants authority to implement hospital presumptive eligibility in accordance with the Affordable Care Act.

This approval is accompanied by a companion letter outlining the need for systems changes that are necessary to achieve full compliance with hospital presumptive eligibility requirements. We look forward to your response and are happy to provide any technical assistance needed as you move forward.

If you have any questions regarding this matter you may contact Lynn DelVecchio (617) 565- 1201 or by e-mail at Lynn.Del Vecchio@cms.hhs.gov

Sincerely, /s/ Richard R. McGreal Associate Regional Administrator Enclosure

ce: Dr. Anya RadarWallack, MD, Medicaid Director Melody Lawrence Health Services Manager

State/Territory name: Rhode Island Submitted By: Melody Lawrence Last Revision Date: Apr 27, 2016 Submit Date: Mar 28, 2014 Medicaid State Plan Eligibility: Summary Page (CMS 179) Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. 14-003 Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation 42 CFR 435.1110 Federal Budget Impact Federal Fiscal Year Amount First Year 2014 $ 756000.00 Second Year 2015 $ 3024000.00 Subject of Amendment The budget impact was derived based on anticipated enrollment in Medicaid hospital presumptive eligibility. Governor's Office Review Governor's office reported no comment Comments of Governor's office received Describe:   No reply received within 45 days of submittal Other, as specified Describe: This amendment has not been reviewed specifically with the Governor's Office. Under the Rhode Island Medicaid State Plan, the Governor has elected not to review the details of state plan materials. However, in accordance with Rhode Island law and practice, the Governor is kept apprised of major changes in the state plan. Signature of State Agency Official RI.0859.R00.00 - Jan 01, 2014

OFFICIAL

Presumptive Eligibility Screen 1

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Primary Applicant Information

First Name Middle Name Last Name

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City State Zip Code

Date of Birth Social Security Number (SSN)

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Entering your Social Security Numbe: ful in processing your application

Are you a US citizen or a national? Yes No Do you have an eligible immigration status? ” Yes No

Was this person in the Rhode Island foster care system on his or her 18th Yes © No birthday?

Was this person in the Rhode Island foster care system on his or her 18th

Yes No birthday? Household Current Gross Household Total Monthly Monthly Income Deductions

How many additional people are in the household. excluding the applicant(s) above? Please also indicate unborn children not included above

Electronic Signature

By signing this application electronically. | certify under penalty and false swearing that my answers are correct and complete to the best of my knowledge

* lunderstand the questions and statements on this application * understand the penalties for providing false information or breaking the rules | understand that the State may contact other persons or organizations on my behalf

| understand that an electronic signature has the same legal effect and can be enforced in the same way as a written signature

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OFFICIAL

Executive Office of Health and Human Services April 11, 2016

Agenda

Hospital Presumptive Eligibility (HPE) as part of the Continuum of Coverage

HPE Overview How Hospitals Can Participate in HPE

Who is Eligible to Enroll in Medicaid through HPE? What are the Benefits?

How the HPE Process Works

Contact Information

HPE as part of the Continuum of Coverage

ACA Coverage Changes

¢ The Affordable Care Act (ACA) was signed into law in March 2010; it makes major changes to how people secure health coverage in the United States. Coverage changes include:

¢ Medicaid and CHIP expansion and improvements ° Health insurance marketplaces for individuals and small businesses

¢ Private insurance market reforms

The New Vision for Medicaid and CHIP

Medicaid Coverage Expansion

* Covers adults 19-64 with incomes up to 133% FPL who are not eligible for Rite Care or Medicaid through a Disability characteristic

¢ Single, Streamlined Application

¢ Individuals can apply for Marketplace coverage and all insurance affordability programs (Medicaid, CHIP, premium tax credits) on one application

¢ Simplified Eligibility and Enrollment Rules

¢ Modified Adjusted Gross Income (MAGI) is the new income methodology based on IRS- defined concepts of income and household to determine Medicaid and CHIP eligibility for children, pregnant women, parents and caretaker relatives, and adults 19-64

Different from past Medicaid/Rlte Care eligibility formula ¢ Modernized Eligibility Systems

e Increases use of automated rules engines to enable real-time eligibility determinations; individuals can apply for coverage online, by telephone, in-person or on paper

* Children’s Coverage Improvements ° All children up to age 19 with family incomes up to 133% FPL are now Medicaid-eligible In Rhode Island - Rite Care covers kids up to 250% ¢ Hospital Presumptive Eligibility

* Hospitals can now determine certain individuals to be presumptively eligible (PE) for pedal. This eligibility determination does not include hospital’s determining eligibility osm for CHIP.

Overview of the Affordable Care Act through a Medicaid lens CMS Learning Collaborative has produced a comprehensive training

power point regarding the new continuum of coverage and changes to Medicaid and CHIP. This document is located at:

http://www.medicaid.gov/State-Resource-Center/MAC-Learning- Collaboratives/Downloads/Primer-for-Eligibility-Workers.pdf

This link was sent to you from HARI

HPE Overview

What Is Hospital Presumptive Eligibility (HPE)?

* As of March 1, 2014, Rhode Island hospitals can immediately determine Medicaid eligibility for certain individuals who are likely to be eligible

¢ Eligibility under HPE is temporary

¢ Eligibility is immediate

* Hospitals that elect to participate must comply with Rhode Island

State and Federal laws, regulations, policies and procedures or will forfeit HPE authorization

How HPE Works to Get People Connected to Coverage and Care

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HPE improves individuals’ access to Medicaid and necessary services by providing another channel to apply for coverage

It ensures the hospital will be reimbursed for services provided, just as if the individual was enrolled in standard Medicaid

HPE is not about short-term coverage; it provides individuals with an opportunity to get connected to longer-term coverage options

The State strongly encourages hospitals to assist patients in applying for and obtaining full health care coverage through HSRI (Medicaid or QHP)

How Hospitals Can Participate in HPE

How Hospitals Can Participate in HPE

¢ Hospital participation in HPE is optional, but states must provide a mechanism for a hospital to become qualified to conduct PE and the hospital must agree to make determinations in accordance with the federal and state requirements.

¢ To make HPE determinations, a hospital must:

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Participate in the Medicaid program

Notify the state of its election to make HPE determinations by completing a “Notice of Intent to Participate”

Agree to make HPE determinations consistent with policies and procedures of the state by executing a Memorandum of Agreement with the State of Rhode Island.

Execute a Business Associate Agreement

Submit executed MOU, Notice and BAA to State for review and approval

Memorandum of Understanding

Each hospital that elects to participate in HPE shall execute a MOU with the State that includes the following agreements:

Comply with the State of RI policies and procedures regarding Hospital PE.

Comply with the State of RI training and certification requirements for hospital PE staff prior to participation.

Will not permit non-hospital employees to make PE determinations. Will submit performance reports as required.

In the event the hospital does not meet proficiency requirements, the hospital agrees to submit a corrective action plan.

Agrees to assist PE applicant to submit a full application within 5 days.

Comply with all federal and state privacy and security requirements.

Hospital Notice of Intent to Participate

Hospital shall sign the Notice and attach it to the signed MOU.

¢ The notice provides affirmation of the agreements in the MOU and also provides the following:

¢ Hospital will provide to EOHHS the outcome of the PE determination using a State approved format.

* Hospital PE staff will be knowledgeable regarding Medicaid eligibility criteria

¢ Hospital PE staff will explain PE to applicant

¢ Hospital PE staff will explain and assist patient with full the Medicaid application

¢ The hospital will maintain all records of PE decisions for 10 years.

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Business Associate Agreement

¢ Hospital shall sign the BAA and attach it to the signed MOU and Notice.

¢ This document provides assurance that the hospital will comply with relevant HIPAA requirements.

14

Hospital Staff Eligible to Make HPE Determinations

° Once a hospital is approved:

¢ Only those hospital employees who are properly trained and certified can make HPE determinations

* This includes employees in hospital-owned physician practices or clinics, including those in off-site locations

¢ Participating hospitals shall not delegate HPE determinations to non- hospital staff

¢ Third party vendors or contractors may not make PE determinations

* Third party vendors may assist with filling out PE applications so long as the hospital takes responsibility for the PE determinations that result.

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Staff Training and Certification

The State will require the following training and certification process:

eIn-person training

Computer based training

Proficiency testing and certification

*Training and testing must be completed annually and at specific intervals as indicated by the State

In Person training

° Conduct of 2.5 hour training session

Computer based training will be provided via the following

*CMS training PPT — provided to you by HAIR is also online for federal overview of ACA and eligibility requirements.

State of RI HPE module — for overview, eligibility requirement and presumptive eligibility system training.

Proficiency Testing and Certification *Hospital staff must achieve a minimum certification testing score of 85 out of 100 eAnnual Training and testing information will be provided at a later date.

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16

HPE Performance Standards

° The State plans to monitor and oversee HPE activities and expects RI hospitals to meet the following proficiency standards:

* Hospital shall submit a full application within 5 calendar days of submission of PE application. Hospitals will comply with this requirement 95% of the time

¢ Hospital PE determinations will become fully Medicaid eligible 90% of the time

¢ March 2014 through June 30,2014, RI will gather data on the hospitals compliance with the above standards and will provide reports to the hospitals regarding their compliance with performance standards, but will not impose sanctions on hospitals for failure to meet standards until July 1, 2014.

¢ Standards for performance will be published in Medicaid provider bulletins and on the provider website. Hospitals are expected to know and maintain performance standards.

° Failure to meet standards will result in re-training or reasonable corrective action by the State. Re-training will be mandatory. Continued failure could lead to disqualification.

* The State reserves the right to revoke specific hospital staff privileges in the event a specific individual is not meeting performance standards.

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Who is Eligible to Enroll in Medicaid through HPE? What are the Benefits?

18

Populations Eligible for Medicaid via HPE Determinations

¢ Individuals who do not currently receive Medicaid benefits. ¢ Individuals are limited to one PE period in a 12 month timeframe. ¢ Pregnant women are limited to one PE determination per pregnancy.

* State requires PE applicants to attest to being Rhode Island residents and to their citizenship or eligible noncitizenship status.

¢ Additional information regarding noncitizen eligibility is provided on the handout

* PE determinations may be made for the following Medicaid eligible groups only:

¢ Children (Non CHIP) up to 261% FPL; Parents/Caretaker relatives; Pregnant Women (Non CHIP); newly eligible Adults with income up to 133% FPL

¢ Breast and Cervical Cancer Treatment Program participants are technically eligible for PE, but none of the state’s screening sites are at hospitals.

Hobe

spear 5% income disregard can be applied to Hospital PE income eligibility determinations

19

Rhode Island HPE Income Eligibility Chart

Medicaid Pregnant/PP

Less than or equal to 190% FPL

Medicaid parent or caretaker whose income is less than 133%;

Less than or equal to 133% FPL

Expansion adult without dependent child whose income is less than 133%

Less than or equal to 133% FPL

Medicaid Child whose income is less than or equal to 261%

Less than or equal to 261% FPL

Please note: A5% income disregard can be applied to Hospital PE income eligibility

determinations

20

Duration of Eligibility under HPE

* The HPE period is limited to one time per 12 months, and once per pregnancy for pregnant women

¢ HPE period begins with, and includes, the day on which the hospital makes the HPE determination

° HPE period ends with:

¢ The day on which the state makes the eligibility determination for full Medicaid, or

¢ The last day of the month following the month in which the hospital makes the HPE determination, if the individual does not file a full application by that time.

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Fone

Determining Household Size

¢ Hospital PE worker may accept verbal information from applicant regarding who is a household member

¢ Relationships between different family members based on individual’s answers to questions about themselves and other family members applying for coverage.

¢ Construct a household for each individual listed on the application (this is because eligibility is determined at the individual level).

¢ Income of all the household members forms the basis for establishing eligibility.

* Family size adjustment needs to be made if individual is pregnant or individual has a pregnant woman in their household.

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Determining Financial Eligibility Income Sources

* Hospital PE Workers may accept verbal information from applicant regarding income * Three high level steps

¢ Step 1 - Identify members of family who are household members and determine family size.

* Step 2 - Add the income of relevant members of the household — use current monthly income

* Step 3 - Compare total household income to federal poverty level -

Please refer to the “Household and MAGI Income Training Manual”, which can be found at https://(www.medicaid.gov/state-resource-center/mac-learning- collaboratives/expanding-coverage.html

* If unable to complete the full on-line application, use minimal information required to determine presumptive eligibility. * Total household income is used to determine whether the individual is financially eligible for .Medicaid.

a must submit a full Medicaid application within 5 days of the PE application. 23

Sone

Covered Services Under PE

* Benefits are the same as those provided under the Medicaid group for which the individual is determined presumptively eligible

¢ Important Exception

* Pregnant women - benefits limited to ambulatory prenatal care (birthing expenses are not covered)

¢ These benefits are different from the benefits a pregnant woman is eligible for when she is found to be fully eligible for Medicaid. Thus, conversion to full Medicaid as soon as practicable will be optimal for pregnant women.

MHODE)

How the HPE Process Works

The HPE Determination Process

At individual’s initial visit to the hospital, A properly credentialed and trained Hospital PE worker will take the following steps:

A. Assist individual with completing HPE application

1. Request individual to provide any existing Medicaid number or insurance information. 2. Check the MMIS/HP Provider Portal to do Medicaid eligibility checks:

° https:/Awww.eohhs.ri.gov/secure/logon.do

3. PE worker shall access the system and the PE Application using the PE worker sign-on credentials. (http:/Avww.healthsourceri.com )

4. Request individual to assist with completion of the application and have applicant attest to accuracy of information by signing the application ( person is a resident of RI and provides citizenship /eligible noncitizenship status).

5. PE worker shall assist with completing required questions:

Hospital name

Applicant's first and last name

Date of birth

Parent/caretaker status

Immigration status

Foster care on 18 birthday

Household current gross monthly income and total monthly deductions Household members

_ 6. PE worker shall assist individual with calculating monthly family income and household sizé* eae" and put the total into the application.

Ta*9Qa29009

The HPE Determination Process (cont.)

B. Determine if individual meets HPE criteria

1. PE worker shall submit the PE Application and wait for a decision from the system. The system will provide a decision in real time.

a. If yes:

i. Inform applicant orally of outcome and inform them that their Medicaid card will arrive in the mail. Also provide a written notice of

the decision. ii. Summarize benefits and answer any questions iii. Assist individual with application for full Medicaid b. If no:

i. Provide the written notice and explain the denial notice and provide resources for applying for all insurance affordability programs.

27

a

How to Use the HPE/Medicaid Application

¢ The HPE application is a shortened application.

* The CBT Module provides training regarding how to download the application from HealthSourceri.gov and proceed through the process.

http://www.healthsourceri.com/

RNOdE se law a “Nope”

28

Verification of Eligibility Criteria for HPE

¢ Individual cannot be required to provide proof/documentation of any PE eligibility criteria

° (e.g., can’t require medical verification of pregnancy)

¢ Applicant must affirmatively attest to being a Rhode Island resident and to their citizenship or eligible noncitizenship status

¢ Hospital/state must accept self-attestation.

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he tai, x 29

Approval and Denial Notices

* Hospitals must provide individuals with a notice after the HPE determination is made, which includes:

¢ Whether HPE was approved or denied

° If approved, beginning and ending dates of the HPE period, which will be extended if the individuals files a Medicaid application and eligibility is not determined by then

¢ If denied, the reason for the denial and the option to submit a regular Medicaid application

¢ Hospital PE Worker shall print the notice and provide to the individual

° Hospital must notify state agency of PE approvals (and date range for the HPE period) within [5 or fewer] days; it should do this by submitting monthly reports using State approved format.

WHO aan Sea ‘XN 30 “Sone”

Connecting to Full Medicaid Coverage

* Hospital shall assist PE applicant with completion of the full application. This is done by:

* Accessing a new application on behalf of applicant online. ¢ Completion of a paper application and submission by mail.

* Hospitals have a performance requirements to assist applicant with full application, however, If the hospital is not successful at assisting with and submitting a full application within 5 days, it shall provide information regarding how an individual may apply for full Medicaid coverage:

° Online at http:/Awww.healthsourceri.com/

* In-person at DHS field offices or HSRI contact center (70 Royal Little Drive Providence, RI)

* Calling - Contact Center at 1-855-840-HSRI (4774) ° By mailing the paper application to:

HealthSource RI

HZD Mailroom

74 West Road, Suite 900

cL Cranston, RI 02920-8413 31

PSE ES SII Se em RP RR ISI IRS ah ZV ERR Er a SL i a MEER OS SI ESSER state Hospital Presumptive Eligibility Contact and Additional Resources

* For questions on Rhode Island’s Hospital Presumptive Eligibility Policies, contact:

¢ Deb.Florio@ohhs.ri.gov Deborah J. Florio Administrator

Executive Office of Health and Human Service

For Technical Support — Log on, Passwords, Web site, HPE Portal issues, contact:

HSRI Contact Center - 1-855-840-HSRI (4774)

Hoon ths

i 32

Table of Contents

State/Territory Name: Rhode Island State Plan Amendment (SPA) #: 18-001 This file contains the following documents in the order listed: 1) Approval Letter

2) CMS 179 Form

3) Approved SPA Pages

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

JFK Federal Building, Government Center Room 2275 Boston, Massachusetts 02203

Division of Medicaid and Children's Health Operations / Boston Regional Office

May 14, 2018

Eric Beane, Secretary Executive Office of Health and Human Services State of Rhode Island and Providence Plantations 3 West Rd Virks Building Cranston, RI 02920

Dear Secretary Beane (via e-mail):

We are pleased to enclose a copy of approved State plan amendment (SPA) No. 18-001. This SPA is effective January 1, 2018 as requested.

SPA 18-001 transmitted a proposed amendment to your Department’s approved Title XIX State plan to increase the Medically Needy Income Limits for 2018.

If there are questions, please contact Robert Cruz. He can be reached at (781) 335-3455 or at robert.cruz@cms.hhs.gov.

Sincerely,

Richard R. McGreal Associate Regional Administrator

Enclosure

cc: Patrick Tigue, Medicaid Director (via e-mail) Melody Lawrence, Regulatory Oversight (via e-mail)

/s/

March 30, 2018 May 14, 2018 January 1, 2018 Richard R. McGreal Associate Regional Administrator, Division of Medicaid and Children's Health Operations, Boston Regional Office /s/ /s/

5/14/18 OFFICIAL

Table of Contents

State/Territory Name: Rhode Island State Plan Amendment (SPA) #: 18-004 This file contains the following documents in the order listed: 1) Approval Letter

2) CMS 179 Form

3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services JFK Federal Building, Government Center

Room 2275 Boston, Massachusetts 02203

Division of Medicaid and Children's Health Operations / Boston Regional Office

July 6, 2018

Eric Beane, Secretary Executive Office of Health and Human Services State of Rhode Island and Providence Plantations 3 West Rd Virks Building Cranston, RI 02920

Dear Secretary Beane (via e-mail):

We are pleased to enclose a copy of approved State plan amendment (SPA) No. 18-004. This SPA is effective September 1, 2018 as requested.

This SPA transmitted a proposed amendment to Rhode Island’s approved Title XIX State plan to implement an electronic Asset Verification System (AVS) that will verify the assets of aged, blind, and disabled applicants and recipients of Medicaid as required by Section 1940(a) of the Social Security Act.

If there are questions, please contact Robert Cruz. He can be reached at (781) 335-3455 or at robert.cruz@cms.hhs.gov.

Sincerely,

Richard R. McGreal Associate Regional Administrator

Enclosure

cc: January Angeles (via e-mail) Melody Lawrence (via e-mail) John Bonin (via e-mail) Patrick Tigue (via e-mail)

/s/

The state and CMS agreed to a pen and ink change to the Form 179. The proposed effective date in Box 4 was updated from June 1, 2018 to September 1, 2018. September 1, 2018 April 19, 2018 July 6, 2018 September 1, 2018 Richard R. McGreal Associate Regional Administrator, Division of Medicaid and Children's Health Operations, Boston Regional Office /s/ /s/

Revision:

SUPPLEMENT 16 TO ATTACHMENT 2.6-A Page 1

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State: Rhode Island

ASSET VERIFICATION SYSTEM

TN No. __18-004__ Approval Date: __________ Effective Date: _September 1, 2018__ Supersedes TN No. __New__

1940(a) 1. The agency will provide for the verification of assets for purposes of of the Act determining or re-determining Medicaid eligibility for aged, blind and disabled Medicaid applicants and recipients using an Asset Verification System (AVS) that meets the following minimum requirements.

A. The request and response system must be electronic:

(1) Verification inquiries must be sent electronically via the internet or similar means from the agency to the financial institution (FI). (2) The system cannot be based on mailing paper-based requests. (3) The system must have the capability to accept responses electronically.

B. The system must be secure, based on a recognized industry standard of security (e.g., as defined by the U.S. Commerce Department’s National Institute of Standards and Technology, or NIST).

C. The system must establish and maintain a database of FIs that participate in the agency’s AVS.

D. Verification requests also must be sent to FIs other than those identified by applicants and recipients, based on some logic such as geographic proximity to the applicant’s home address, or other reasonable factors whenever the agency determines that such requests are needed to determine or re-determine the individual’s eligibility.

E. The verification requests must include a request for information on both open and closed accounts, going back up to 5 years as determined by the State.

2. System Development

_____ A. The agency itself will develop an AVS.

In 3 below, provide any additional information the agency wants to include.

__X__ B. The agency will hire a contractor to develop an AVS.

July 6, 2018

Revision:

SUPPLEMENT 16 TO ATTACHMENT 2.6-A Page 2

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State: Rhode Island

ASSET VERIFICATION SYSTEM

______________________________________________________________________________

TN No. __18-004__ Approval Date: __________ Effective Date: _September 1, 2018__ Supersedes TN No. __New__

In 3 below provide any additional information the agency wants to include.

_____ C. The agency will be joining a consortium to develop an AVS.

In 3 below, identify the States participating in the consortium. Also, provide any other information the agency wants to include pertaining to how the consortium will implement the AVS requirements.

_____ D. The agency already has a system in place that meets the requirements for an acceptable AVS.

In 3 below, describe how the existing system meets the requirements in Section 1.

_____ E. Other alternative not included in A. – D. above.

In 3 below, describe this alternative approach and how it will meet the requirements in Section 1.

3. Provide the AVS implementation information requested for the implementation approach checked in Section 2, and any other information the agency may want to include.

OVERVIEW The State of Rhode Island will be contracting with New England States Consortium Systems Organization (NESCSO) to implement an electronic Asset Verification Service (e-AVS). NESCSO has entered into contract with Public Consulting Group, INC (PCG) for the purposes of providing e-AVS services. The contract allows for multi-state buy-in as participating states, allowing for expedited implementation.

NESCSO pursued this initiative with the sole purpose of facilitating State access to e-AVS and other tools. These services are ideal candidates for multi-State procurements for several reasons. The services support relatively straight-forward processes, not requiring significant customization. There are only a few vendors offering these services. Lastly, the costs are primarily volume-based, providing an opportunity for cost-savings that would not be available to States with individual contracts. Participation in this effort will enable a State to implement e-AVS within 60 – 90 days. Rhode Island plans to implement by September 1, 2018.

PCG has mapped a comprehensive project management plan for states entering into the existing contract. The contract would reflect state-specific deliverables as an attachment. Rhode Island will submit requests for asset verification through the Accuity Asset Verification Services, Inc. stand-alone web based portal. Electronic Asset Verification Services will enable the State to automate the manual process of sending requests to banks July 6, 2018

Revision:

SUPPLEMENT 16 TO ATTACHMENT 2.6-A Page 3

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State: Rhode Island

ASSET VERIFICATION SYSTEM

______________________________________________________________________________ TN No. __18-004__ Approval Date: __________ Effective Date: _September 1, 2018__

Supersedes TN No. __New__

or applicants for information regarding their assets including national and local financial institution account data such as checking, savings, CDs, Christmas clubs, IRAs, money markets, etc. Responses are displayed through the web-based portal. It is anticipated that 85% of the results will be returned in five (5) days, and 90% will be returned in ten (10) days. This implementation requires no modifications to the current eligibility system.

IMPLEMENTATION TIMELINE

EOHHS proposes a two-phase approach for implementation to ensure timely compliance.

Phase I Requests for asset verification will be submitted through a stand-alone web based portal. Responses are displayed through the web-based portal. It is anticipated that 85% of the results will be returned in five (5) days, and 90% will be returned in ten (10) days. This implementation requires no modifications to the current eligibility system.

The project set up phase will begin immediately, with coordination with PCG to define the project requirements. During this period, reports will be defined, and a reporting schedule created. The implementation phase will include a communication plan, training of staff, as well as the development of the related business processes.

A 30-day period will focus on configuring the portal to meet Rhode Island rules and regulations, as well as testing in the UAT environment. A stakeholder meeting schedule will be established.

Following successful testing, training materials will be developed by PCG and submitted to the State for approval. A training schedule will be developed, and training of staff will be conducted. At go-live, support will be provided on-site as needed, and remotely for the duration of the project. The targeted implementation date for Phase I is September 1, 2018.

Phase II This phase would allow field workers to flag applicants that require asset verifications, which in turn would be included in a batch request. The batch would then be sent to the web-based portal. This will require one or two data interfaces with the existing eligibility system and therefore will be implemented at a future date.

July 6, 2018

Table of Contents

State/Territory Name: Rhode Island State Plan Amendment (SPA) #: 19-0002 This file contains the following documents in the order listed: 1) Approval Letter 2) Summary Form 3) Approved SPA Pages

CMS-10434 OMB 0938-1188 Package Information Package ID RI2019MS0002O Program Name N/A SPA ID RI-19-0002 Version Number 4 Submitted By Maria Petrillo Package Disposition Priority Code P2 Submission Type OŰcial State RI Region Boston, MA Package Status Approved Submission Date 3/29/2019 Approval Date 6/4/2019 12:10 PM EDT

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Boston Regional OŰce JFK Federal Building, Government Center, Room 275 Boston, MA 02203 Division of Medicaid and Children's Health Operations Lisa Vura-Weis Acting Secretary Executive OŰce of Health and Human Services State of Rhode Island and Providence Plantations 3 West Road Cranston, RI 02920 Re: Approval of State Plan Amendment RI-19-0002 Dear Lisa Vura-Weis: On March 29, 2019, the Centers for Medicare and Medicaid Services (CMS) received Rhode Island State Plan Amendment (SPA) RI-19-0002 to update the Medically Needy Income Levels and to also update the standards for the Optional State Supplement Beneţciaries eligibility group. We approve Rhode Island State Plan Amendment (SPA) RI-19-0002 on June 04, 2019 with an eſective date(s) of January 01, 2019. Name Date Created No items available If you have any questions regarding this amendment, please contact Robert Cruz at 7813353455 or robert.cruz@cms.hhs.gov. Sincerely, Francis T. McCullough Director Division of Medicaid Field Operations East (Boston) Regional Operations Group Division of Medicaid and Children's Health Operations Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | RI2019MS0002O | RI-19-0002 Package Header Package ID RI2019MS0002O Submission Type OŰcial Approval Date 6/4/2019 Superseded SPA ID N/A SPA ID RI-19-0002 Initial Submission Date 3/29/2019 Eſective Date N/A State Information State/Territory Name: Rhode Island Medicaid Agency Name: Executive OŰce of Health and Human Services

Submission Component State Plan Amendment Medicaid CHIP

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | RI2019MS0002O | RI-19-0002 Package Header Package ID RI2019MS0002O Submission Type OŰcial Approval Date 6/4/2019 Superseded SPA ID N/A SPA ID RI-19-0002 Initial Submission Date 3/29/2019 Eſective Date N/A SPA ID and Eſective Date SPA ID RI-19-0002 Reviewable Unit Proposed Eſective Date Superseded SPA ID Eligibility Determinations of Individuals Age 65 or Older or Who Have Blindness or a Disability 1/1/2019 New Non-MAGI Methodologies 1/1/2019 92-02 Medically Needy Income Level 1/1/2019 18-001 Handling of Excess Income (Spenddown) 1/1/2019 92-02 Medically Needy Resource Level 1/1/2019 92-02 Mandatory Eligibility Groups 1/1/2019 13-018 Optional Eligibility Groups 1/1/2019 13-018 Optional State Supplement Beneţciaries 1/1/2019 18-002

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | RI2019MS0002O | RI-19-0002 Package Header Package ID RI2019MS0002O Submission Type OŰcial Approval Date 6/4/2019 Superseded SPA ID N/A SPA ID RI-19-0002 Initial Submission Date 3/29/2019 Eſective Date N/A Executive Summary Summary Description Including Goals and Objectives Annual update to the Medicaid State Plan to reŤect guidance from the federal government regarding the Medically Needy Income Limit as well as the annual update to the Optional State Supplementary Payments. Federal Budget Impact and Statute/Regulation Citation Federal Budget Impact Federal Fiscal Year Amount First 2019 $401520 Second 2020 $535361 Federal Statute / Regulation Citation 42 CFR 435.811, 435.814, 435.1007, 435.232 Supporting documentation of budget impact is uploaded (optional). Name Date Created No items available

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | RI2019MS0002O | RI-19-0002 Package Header Package ID RI2019MS0002O Submission Type OŰcial Approval Date 6/4/2019 Superseded SPA ID N/A SPA ID RI-19-0002 Initial Submission Date 3/29/2019 Eſective Date N/A Governor's OŰce Review Describe This amendment has not been reviewed speciţcally with the Governor’s OŰce. Under the Rhode Island Medicaid State Plan, the Governor has elected not to review the details of state plan materials. However, in accordance with Rhode Island law and practice, the Governor is kept apprised of major changes in the state plan. No comment Comments received No response within 45 days Other

Submission - Public Comment MEDICAID | Medicaid State Plan | Eligibility | RI2019MS0002O | RI-19-0002 Package Header Package ID RI2019MS0002O Submission Type OŰcial Approval Date 6/4/2019 Superseded SPA ID N/A SPA ID RI-19-0002 Initial Submission Date 3/29/2019 Eſective Date N/A Indicate whether public comment was solicited with respect to this submission. Indicate how public comment was solicited: Date of Email or other electronic notiţcation: Feb 26, 2019 Description of mailing list, in particular parties and organizations included, and, if not email, description of similar mechanism used: Interested Parties, including providers, advocates and sister state agencies. Select the type of website Date of Posting: Feb 26, 2019 Website URL: http://www.eohhs.ri.gov/ReferenceCent er/MedicaidStatePlanand1115Waiver/S PAand1115WaiverChanges.aspx Upload copies of public notices and other documents used Name Date Created 19-002 Notice to Public w SPA pages 5/7/2019 1:02 PM EDT 19-002 Interested Parties MNIL_SSP 5/7/2019 1:02 PM EDT Upload with this application a written summary of public comments received (optional) Name Date Created No items available Indicate the key issues raised during the public comment period (optional) Public notice was not federally required and comment was not solicited Public notice was not federally required, but comment was solicited Public notice was federally required and comment was solicited Newspaper Announcement Publication in state's administrative record, in accordance with the administrative procedures requirements Email to Electronic Mailing List or Similar Mechanism Website Notice Website of the State Medicaid Agency or Responsible Agency Website for State Regulations Other Public Hearing or Meeting Other method Access Quality Cost Payment methodology Eligibility

Beneţts Service delivery Other issue

Submission - Tribal Input MEDICAID | Medicaid State Plan | Eligibility | RI2019MS0002O | RI-19-0002 Package Header Package ID RI2019MS0002O Submission Type OŰcial Approval Date 6/4/2019 Superseded SPA ID N/A SPA ID RI-19-0002 Initial Submission Date 3/29/2019 Eſective Date N/A One or more Indian health programs or Urban Indian Organizations furnish health care services in this state This state plan amendment is likely to have a direct eſect on Indians, Indian health programs or Urban Indian Organizations Complete the following information regarding any solicitation of advice and/or tribal consultation conducted with respect to this submission: Solicitation of advice and/or Tribal consultation was conducted in the following manner: Date of solicitation/consultation: Method of solicitation/consultation: 2/26/2019 Email and a hard copy via US Postal Service States are not required to consult with Indian tribal governments, but if such consultation was conducted voluntarily, provide information about such consultation below: The state must upload copies of documents that support the solicitation of advice in accordance with statutory requirements, including any notices sent to Indian Health Programs and/or Urban Indian Organizations, as well as attendee lists if face-to-face meetings were held. Also upload documents with comments received from Indian Health Programs or Urban Indian Organizations and the state's responses to any issues raised. Alternatively indicate the key issues and summarize any comments received below and describe how the state incorporated them into the design of its program. Name Date Created Tribal Notice - MNIL and SSP 3/25/2019 2:59 PM EDT Indicate the key issues raised (optional) Yes No Yes No The state has solicited advice from Indian Health Programs and/or Urban Indian Organizations, as required by section 1902(a)(73) of the Social Security Act, prior to submission of this SPA All Indian Health Programs All Urban Indian Organizations All Indian Tribes Access Quality Cost Payment methodology Eligibility Beneţts Service delivery Other issue

Medicaid State Plan Eligibility Income/Resource Methodologies Eligibility Determinations of Individuals Age 65 or Older or Who Have Blindness or a Disability MEDICAID | Medicaid State Plan | Eligibility | RI2019MS0002O | RI-19-0002 Package Header Package ID RI2019MS0002O Submission Type OŰcial Approval Date 6/4/2019 Superseded SPA ID New User-Entered SPA ID RI-19-0002 Initial Submission Date 3/29/2019 Eſective Date 1/1/2019 A. Eligibility Determinations of Individuals Who Are Age 65 or Older or Who Have Blindness or a Disability Eligibility determinations of individuals who are age 65 or older or who have blindness or a disability are based on one of the following: The state has an agreement under section 1634 of the Social Security Act for the Social Security Administration to determine Medicaid eligibility of SSI beneţciaries. For all other individuals who seek Medicaid eligibility on the basis of being age 65 or older or having blindness or a disability, the state requires a separate Medicaid application and determines ţnancial eligibility based on SSI income and resource methodologies. The state requires all individuals who seek Medicaid eligibility on the basis of being age 65 or older or having blindness or a disability, including SSI beneţciaries, to ţle a separate Medicaid application, and determines ţnancial eligibility based on SSI income and resource methodologies. The state requires all individuals who seek Medicaid eligibility on the basis of being age 65 or older or having blindness or a disability, including SSI beneţciaries, to ţle a separate Medicaid application, and determines ţnancial eligibility using income and resource methodologies more restrictive than SSI. B. Additional information (optional) 1. SSA Eligibility Determination State (1634 State) 2. State Eligibility Determination (SSI Criteria State) 3. State Eligibility Determination (209(b) State)

Medicaid State Plan Eligibility Income/Resource Methodologies Non-MAGI Methodologies MEDICAID | Medicaid State Plan | Eligibility | RI2019MS0002O | RI-19-0002 Package Header Package ID RI2019MS0002O Submission Type OŰcial Approval Date 6/4/2019 Superseded SPA ID 92-02 User-Entered SPA ID RI-19-0002 Initial Submission Date 3/29/2019 Eſective Date 1/1/2019 The state will apply the methodologies as described below, and consistent with 42 CFR 435.601, 435.602, and 435.831.

A. Basic Financial Methodology 1. The state applies the income and resource methodologies of the SSI program when determining eligibility for a population based on age (65 or older) or having blindness or a disability, with the exceptions described below in B. through G. 2. The state applies the ţnancial methodologies of either the SSI program or the AFDC program in eſect as of July 16, 1996 (whichever is most closely related) when determining eligibility for a population based on age (as a child), pregnancy, or status as a caretaker relative, with the exceptions described below in B. through G. B. Use of Less Restrictive Methodologies 1. The state elects to apply income and/or resources methodologies that are less restrictive than those used under the cash assistance programs, in accordance with 42 CFR 435.601(d). 2. The less restrictive income and resource methodologies are described on the RU for each applicable eligibility group.

Yes No

Non-MAGI Methodologies MEDICAID | Medicaid State Plan | Eligibility | RI2019MS0002O | RI-19-0002 Package Header Package ID RI2019MS0002O Submission Type OŰcial Approval Date 6/4/2019 Superseded SPA ID 92-02 User-Entered SPA ID RI-19-0002 Initial Submission Date 3/29/2019 Eſective Date 1/1/2019 C. Financial Responsibility of Relatives 1. In determining ţnancial eligibility for an individual, the state does not include income and resources from anyone other than the individual's spouse, and for individuals under age 21 or who have blindness or disability, the individual's parent. a.The state includes the income and resources of a spouse or parent only when they are living with the individual in the same household, except as follows: i. In the case of spouses who are age 65 or older or who have blindness or disability and who share the same room in a Medicaid institution, the state: ii. Where applicable, the state determines income and resource eligibility consistent with the spousal impoverishment rules of section 1924 of the Act, as described in the Resource Assessment and Eligibility reviewable unit. b. In the case of individuals under age 21 for whom AFDC is the most closely related cash assistance program, the income and resources of parents and spouses are included only if the individual would have been considered a dependent under the state's approved AFDC state plan in eſect as of July 16, 1996. (1) Considers these couples either as living together or as living separately for the purpose of counting income and resources, whichever is more advantageous to the couple. (2) Considers these couples as living separately for the purpose of counting income and resources.

Non-MAGI Methodologies MEDICAID | Medicaid State Plan | Eligibility | RI2019MS0002O | RI-19-0002 Package Header Package ID RI2019MS0002O Submission Type OŰcial Approval Date 6/4/2019 Superseded SPA ID 92-02 User-Entered SPA ID RI-19-0002 Initial Submission Date 3/29/2019 Eſective Date 1/1/2019 D. Family Size 1. The family size of an individual for whom the SSI income and resource methodologies are used (as described in section A) includes the persons identiţed below: a. The individual applying, or b. If the individual lives together with his or her spouse, the individual applying and the spouse, or c. If the individual lives together with his or her parent(s) and the individual is under 21 or has blindness or a disability, the individual applying and the parent(s). 2. The family size of an individual for whom the AFDC income and resource methodologies are used (as described in section A.), includes the persons who would have been included in the family under the state's July 16, 1996 AFDC state plan, except where the state has elected to use the MAGI-like methodologies (as described in section E). 3. The state deţnes family size for one or more of the following FPL eligibility groups to include others beyond those identiţed in D.1. and D.2. Yes No

Non-MAGI Methodologies MEDICAID | Medicaid State Plan | Eligibility | RI2019MS0002O | RI-19-0002 Package Header Package ID RI2019MS0002O Submission Type OŰcial Approval Date 6/4/2019 Superseded SPA ID 92-02 User-Entered SPA ID RI-19-0002 Initial Submission Date 3/29/2019 Eſective Date 1/1/2019 E. Use of MAGI-like Methodologies 1. The state uses MAGI-like methodologies for one or more populations for whom the most closely related cash assistance program would be the AFDC program in eſect as of July 16, 1996. Yes No

Non-MAGI Methodologies MEDICAID | Medicaid State Plan | Eligibility | RI2019MS0002O | RI-19-0002 Package Header Package ID RI2019MS0002O Submission Type OŰcial Approval Date 6/4/2019 Superseded SPA ID 92-02 User-Entered SPA ID RI-19-0002 Initial Submission Date 3/29/2019 Eſective Date 1/1/2019 F. Countable Income Deductions for the Medically Needy In determining countable income for individuals who are age 65 or older or who have blindness or a disability, the state deducts: 1. Amounts that would be deducted in determining eligibility under SSI. 2. The highest amounts that would be deducted in determining eligibility for optional state supplements if these supplements are paid to all individuals who are receiving SSI or would be eligible for SSI except for their income.

Non-MAGI Methodologies MEDICAID | Medicaid State Plan | Eligibility | RI2019MS0002O | RI-19-0002 Package Header Package ID RI2019MS0002O Submission Type OŰcial Approval Date 6/4/2019 Superseded SPA ID 92-02 User-Entered SPA ID RI-19-0002 Initial Submission Date 3/29/2019 Eſective Date 1/1/2019 G. Additional Information (optional)

Medicaid State Plan Eligibility Income/Resource Standards Medically Needy Income Level MEDICAID | Medicaid State Plan | Eligibility | RI2019MS0002O | RI-19-0002 Package Header Package ID RI2019MS0002O Submission Type OŰcial Approval Date 6/4/2019 Superseded SPA ID 18-001 User-Entered SPA ID RI-19-0002 Initial Submission Date 3/29/2019 Eſective Date 1/1/2019 A. Income Level Used 1. The state employs a single income level for the medically needy. 2. The income level varies based on diſerences between shelter costs in urban and rural areas. 3. The level used is: Household size Standard 5 $1517.00 6 $1717.00 7 $1883.00 8 $2075.00 9 $2233.00 10 $2425.00 1 $917.00 2 $958.00 3 $1183.00 4 $1350.00 The state uses an additional incremental amount for larger household sizes. Incremental Amount: $175.00 The dollar amounts increase automatically each year Yes No Yes No Yes No

Medically Needy Income Level MEDICAID | Medicaid State Plan | Eligibility | RI2019MS0002O | RI-19-0002 Package Header Package ID RI2019MS0002O Submission Type OŰcial Approval Date 6/4/2019 Superseded SPA ID 18-001 User-Entered SPA ID RI-19-0002 Initial Submission Date 3/29/2019 Eſective Date 1/1/2019 B. Basis for Income Level 1. Minimum Income Level The minimum income level for this eligibility group is the lower of the state’s July 1996 AFDC payment standard or the state’s income standard for the Parents and Other Caretaker Relatives eligibility group. 2. Maximum Income Level The maximum income level for this eligibility group is 133 1/3 percent of the higher of the state's 1996 AFDC payment standard or the state's income standard for the Parents and Other Caretaker Relatives eligibility group.

Medically Needy Income Level MEDICAID | Medicaid State Plan | Eligibility | RI2019MS0002O | RI-19-0002 Package Header Package ID RI2019MS0002O Submission Type OŰcial Approval Date 6/4/2019 Superseded SPA ID 18-001 User-Entered SPA ID RI-19-0002 Initial Submission Date 3/29/2019 Eſective Date 1/1/2019 C. Additional Information (optional)

Medicaid State Plan Eligibility Income/Resource Standards Handling of Excess Income (Spenddown) MEDICAID | Medicaid State Plan | Eligibility | RI2019MS0002O | RI-19-0002 Package Header Package ID RI2019MS0002O Submission Type OŰcial Approval Date 6/4/2019 Superseded SPA ID 92-02 User-Entered SPA ID RI-19-0002 Initial Submission Date 3/29/2019 Eſective Date 1/1/2019 If countable income exceeds the income standard, the state must deduct from income medical expenses incurred by the individual or family or ţnancially responsible relatives that are not subject to payment by a third party, in accordance with 42 CFR 435.831 and 42 CFR 435.121. A. Budget Periods Income in excess of the appropriate income standard is considered available for payment of medical or remedial care expenses in budget periods that do not exceed six months. 1. In determining income eligibility, countable income is reduced by the amount of incurred medical or remedial care expenses during the budget period speciţed below: Length of budget period: Length of budget period: 2. The state includes part or all of the retroactive period in the budget period. a. One budget period of: b. More than one budget period, as described below: i. Community budget period (1) 6 months (2) 5 months (3) 4 months (4) 3 months (5) 2 months (6) 1 month ii. Institutional budget period (1) 6 months (2) 5 months (3) 4 months (4) 3 months (5) 2 months (6) 1 month iii. Other budget period Yes No

Handling of Excess Income (Spenddown) MEDICAID | Medicaid State Plan | Eligibility | RI2019MS0002O | RI-19-0002 Package Header Package ID RI2019MS0002O Submission Type OŰcial Approval Date 6/4/2019 Superseded SPA ID 92-02 User-Entered SPA ID RI-19-0002 Initial Submission Date 3/29/2019 Eſective Date 1/1/2019 B. Types of Eligible Expenses 1. In determining incurred expenses to be deducted from income, the state includes: a. Medicare, Medicaid, and other health insurance premiums and enrollment fees. b. Cost sharing, including copayments, coinsurance, and deductibles, imposed by Medicare, Medicaid or other health insurance. c. Expenses for necessary medical and remedial services recognized by state law but not included in the state plan. d. Expenses for necessary medical and remedial services included in the state plan, including those that exceed limitations on the amount, duration, and scope of services. 2. The state also includes medical institutional expenses projected to the end of the budget period at the Medicaid reimbursement rate. 3. Incurred expenses subject to payment by a third party are not deducted unless the third party is a public program (other than Medicaid) of a state and the program is ţnanced by the state. Yes No

Handling of Excess Income (Spenddown) MEDICAID | Medicaid State Plan | Eligibility | RI2019MS0002O | RI-19-0002 Package Header Package ID RI2019MS0002O Submission Type OŰcial Approval Date 6/4/2019 Superseded SPA ID 92-02 User-Entered SPA ID RI-19-0002 Initial Submission Date 3/29/2019 Eſective Date 1/1/2019 C. Timeframe of Deduction of Expenses In determining incurred expenses to be deducted from income, the state deducts: 1. For retroactive budget periods and a budget period that includes both retroactive and prospective budget, the state deducts: a. Eligible expenses incurred during the budget period, whether paid or unpaid. b. Payments made during the budget period on eligible expenses incurred at any time prior to the budget period, if not previously deducted in establishing eligibility. c. Unpaid eligible expenses, which have not been deducted previously in establishing eligibility, and were incurred: 2. For prospective budget period(s), the state deducts: a. Eligible expenses incurred during the budget period, whether paid or unpaid. b. Payments made during the budget period on eligible expenses incurred at any time prior to the budget period, if not previously deducted in establishing eligibility. c. Unpaid eligible expenses that are carried over from the prior budget period and have not been deducted previously in establishing eligibility. i. At any time prior to the budget period. ii. Prior to the third month before the month of application, but no earlier than: iii. No earlier than the third month before the month of application.

Handling of Excess Income (Spenddown) MEDICAID | Medicaid State Plan | Eligibility | RI2019MS0002O | RI-19-0002 Package Header Package ID RI2019MS0002O Submission Type OŰcial Approval Date 6/4/2019 Superseded SPA ID 92-02 User-Entered SPA ID RI-19-0002 Initial Submission Date 3/29/2019 Eſective Date 1/1/2019 D. Order of Deduction of Expenses Incurred medical or remedial care expenses are deducted in the following order: a. Premiums, deductibles, coinsurance and co-payments. b. Expenses for necessary medical or remedial care services that are recognized under state law but not included in the State Plan. c. Expenses for necessary medical or remedial care services that are included in the state Plan that exceed agency limitations on amount, duration, or scope of services. d. Expenses for necessary medical or remedial care services that are included in the state Plan that are within the agency limitations on amount, duration, or scope of services. 1. By the type of service, in the following order: 2. In chronological order by the date of the service, or the date cost sharing payments are due. 3. In chronological order by the date the bill is submitted to the state by the individual.

Handling of Excess Income (Spenddown) MEDICAID | Medicaid State Plan | Eligibility | RI2019MS0002O | RI-19-0002 Package Header Package ID RI2019MS0002O Submission Type OŰcial Approval Date 6/4/2019 Superseded SPA ID 92-02 User-Entered SPA ID RI-19-0002 Initial Submission Date 3/29/2019 Eſective Date 1/1/2019 E. Reasonable Limitations The state sets reasonable limits on the amount to be deducted for expenses. Yes No

Handling of Excess Income (Spenddown) MEDICAID | Medicaid State Plan | Eligibility | RI2019MS0002O | RI-19-0002 Package Header Package ID RI2019MS0002O Submission Type OŰcial Approval Date 6/4/2019 Superseded SPA ID 92-02 User-Entered SPA ID RI-19-0002 Initial Submission Date 3/29/2019 Eſective Date 1/1/2019 F. Spenddown Payments Made by Individuals The state permits individuals to pay-in their spenddown liability. Yes No

Handling of Excess Income (Spenddown) MEDICAID | Medicaid State Plan | Eligibility | RI2019MS0002O | RI-19-0002 Package Header Package ID RI2019MS0002O Submission Type OŰcial Approval Date 6/4/2019 Superseded SPA ID 92-02 User-Entered SPA ID RI-19-0002 Initial Submission Date 3/29/2019 Eſective Date 1/1/2019 G. Additional Information (optional)

Medicaid State Plan Eligibility Income/Resource Standards Medically Needy Resource Level MEDICAID | Medicaid State Plan | Eligibility | RI2019MS0002O | RI-19-0002 Package Header Package ID RI2019MS0002O Submission Type OŰcial Approval Date 6/4/2019 Superseded SPA ID 92-02 User-Entered SPA ID RI-19-0002 Initial Submission Date 3/29/2019 Eſective Date 1/1/2019 A. Medically Needy Resource Level Structure 1. The state employs a single resource level for the medically needy. 2. The resource level is equal to or higher than the lowest resource standard used under the most closely related cash assistance program.

Medically Needy Resource Level MEDICAID | Medicaid State Plan | Eligibility | RI2019MS0002O | RI-19-0002 Package Header Package ID RI2019MS0002O Submission Type OŰcial Approval Date 6/4/2019 Superseded SPA ID 92-02 User-Entered SPA ID RI-19-0002 Initial Submission Date 3/29/2019 Eſective Date 1/1/2019 B. Resource Level Used The level used is: Household size Standard 1 $4000.00 2 $6000.00 3 $6100.00 4 $6200.00 5 $6300.00 6 $6400.00 7 $6500.00 8 $6600.00 9 $6700.00 10 $6800.00 The state uses an additional incremental amount for larger household sizes. Incremental Amount: $100.00 Yes No

Medically Needy Resource Level MEDICAID | Medicaid State Plan | Eligibility | RI2019MS0002O | RI-19-0002 Package Header Package ID RI2019MS0002O Submission Type OŰcial Approval Date 6/4/2019 Superseded SPA ID 92-02 User-Entered SPA ID RI-19-0002 Initial Submission Date 3/29/2019 Eſective Date 1/1/2019 C. Additional Information (optional) Life Insurance $4000 each individual over 18 (Aged, Blind, Disabled). $4000 each parent in a family case $1500 each dependent child in a family case

This information has been entered pending completion of the Less Restrictive Resource Methodologies under 1902(r)(2) Reviewable Unit (RU) for the relevant eligibility groups in a future State Plan Amendment.

Medicaid State Plan Eligibility Mandatory Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | RI2019MS0002O | RI-19-0002 Package Header Package ID RI2019MS0002O Submission Type OŰcial Approval Date 6/4/2019 Superseded SPA ID 13-018 System-Derived SPA ID RI-19-0002 Initial Submission Date 3/29/2019 Eſective Date 1/1/2019 Mandatory Coverage A. The state provides Medicaid to mandatory groups of individuals. The mandatory groups covered are: Families and Adults Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Infants and Children under Age 19 CONVERTED Parents and Other Caretaker Relatives CONVERTED Pregnant Women CONVERTED Deemed Newborns NEW Children with Title IV-E Adoption Assistance, Foster Care or Guardianship Care NEW Former Foster Care Children NEW Transitional Medical Assistance NEW Extended Medicaid due to Spousal Support Collections NEW Aged, Blind and Disabled Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  SSI Beneţciaries NEW Closed Eligibility Groups NEW Individuals Deemed To Be Receiving SSI NEW Working Individuals under 1619(b) NEW Qualiţed Medicare Beneţciaries NEW Qualiţed Disabled and Working Individuals NEW Speciţed Low Income Medicare Beneţciaries NEW

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

Mandatory Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | RI2019MS0002O | RI-19-0002 Package Header Package ID RI2019MS0002O Submission Type OŰcial Approval Date 6/4/2019 Superseded SPA ID 13-018 System-Derived SPA ID RI-19-0002 Initial Submission Date 3/29/2019 Eſective Date 1/1/2019 B. The state elects the Adult Group, described at 42 CFR 435.119. Families and Adults Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Adult Group CONVERTED C. Additional Information (optional) Eligibility Groups Deselected from Coverage The following eligibility groups were previously covered in the source approved version of the state plan and deselected from coverage as part of this submission package: N/A Yes No

Medicaid State Plan Eligibility Optional Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | RI2019MS0002O | RI-19-0002 Package Header Package ID RI2019MS0002O Submission Type OŰcial Approval Date 6/4/2019 Superseded SPA ID 13-018 System-Derived SPA ID RI-19-0002 Initial Submission Date 3/29/2019 Eſective Date 1/1/2019 A. Options for Coverage The state provides Medicaid to speciţed optional groups of individuals. The optional eligibility groups covered in the state plan are (elections made in this screen may not be comprehensive during the transition period from the paper- based state plan to MACPro): Families and Adults Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Optional Coverage of Parents and Other Caretaker Relatives NEW Reasonable Classiţcations of Individuals under Age 21 CONVERTED Children with Non-IV-E Adoption Assistance CONVERTED Independent Foster Care Adolescents CONVERTED Optional Targeted Low Income Children CONVERTED Individuals above 133% FPL under Age 65 NEW Individuals Needing Treatment for Breast or Cervical Cancer NEW Individuals Eligible for Family Planning Services NEW Individuals with Tuberculosis NEW Individuals Electing COBRA Continuation Coverage NEW Aged, Blind and Disabled Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Individuals Eligible for but Not Receiving Cash Assistance NEW Individuals Eligible for Cash Except for Institutionalization NEW Yes No

Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Individuals Receiving Home and Community- Based Waiver Services under Institutional Rules NEW Optional State Supplement Beneţciaries APPROVED Individuals in Institutions Eligible under a Special Income Level NEW PACE Participants NEW Individuals Receiving Hospice NEW Children under Age 19 with a Disability NEW Age and Disability- Related Poverty Level NEW Work Incentives NEW Ticket to Work Basic NEW Ticket to Work Medical Improvements NEW Family Opportunity Act Children with a Disability NEW Individuals Receiving State Plan Home and Community-Based Services NEW Individuals Receiving State Plan Home and Community-Based Services Who Are Otherwise Eligible for HCBS Waivers NEW

Optional Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | RI2019MS0002O | RI-19-0002 Package Header Package ID RI2019MS0002O Submission Type OŰcial Approval Date 6/4/2019 Superseded SPA ID 13-018 System-Derived SPA ID RI-19-0002 Initial Submission Date 3/29/2019 Eſective Date 1/1/2019 B. Medically Needy Options for Coverage The state provides Medicaid to speciţed groups of individuals who are medically needy. The medically needy eligibility groups covered in the state plan are: 1. Mandatory Medically Needy: Families and Adults Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Medically Needy Pregnant Women NEW Medically Needy Children under Age 18 NEW Aged, Blind and Disabled Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Protected Medically Needy Individuals Who Were Eligible in 1973 NEW 2. Optional Medically Needy: Families and Adults Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Medically Needy Reasonable Classiţcations of Individuals under Age 21 NEW Medically Needy Parents and Other Caretaker Relatives NEW Aged, Blind and Disabled Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Medically Needy Populations Based on Age, Blindness or Disability NEW Yes No

Optional Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | RI2019MS0002O | RI-19-0002 Package Header Package ID RI2019MS0002O Submission Type OŰcial Approval Date 6/4/2019 Superseded SPA ID 13-018 System-Derived SPA ID RI-19-0002 Initial Submission Date 3/29/2019 Eſective Date 1/1/2019 C. Additional Information (optional) Eligibility Groups Deselected from Coverage The following eligibility groups were previously covered in the source approved version of the state plan and deselected from coverage as part of this submission package: N/A

Medicaid State Plan Eligibility Eligibility Groups - Options for Coverage Optional State Supplement Beneţciaries MEDICAID | Medicaid State Plan | Eligibility | RI2019MS0002O | RI-19-0002 Individuals who receive an optional state supplementary payment. Package Header Package ID RI2019MS0002O Submission Type OŰcial Approval Date 6/4/2019 Superseded SPA ID 18-002 User-Entered SPA ID RI-19-0002 Initial Submission Date 3/29/2019 Eſective Date 1/1/2019 The state covers the Optional State Supplement Beneţciaries eligibility group in accordance with the following provisions: A. Characteristics Individuals qualifying under this eligibility group must meet the following criteria: 1. Receive an optional state supplement that meets the conditions described in sections C and D. 2. Except for income, would be eligible for SSI. 3. Do not have gross income exceeding 300% of the SSI Federal Beneţt Rate (FBR).

Optional State Supplement Beneţciaries MEDICAID | Medicaid State Plan | Eligibility | RI2019MS0002O | RI-19-0002 Package Header Package ID RI2019MS0002O Submission Type OŰcial Approval Date 6/4/2019 Superseded SPA ID 18-002 User-Entered SPA ID RI-19-0002 Initial Submission Date 3/29/2019 Eſective Date 1/1/2019 B. Individuals Covered 1. The state covers all individuals who meet the characteristics described in section A. Yes No

Optional State Supplement Beneţciaries MEDICAID | Medicaid State Plan | Eligibility | RI2019MS0002O | RI-19-0002 Package Header Package ID RI2019MS0002O Submission Type OŰcial Approval Date 6/4/2019 Superseded SPA ID 18-002 User-Entered SPA ID RI-19-0002 Initial Submission Date 3/29/2019 Eſective Date 1/1/2019 C. Optional State Supplement Program 1. The optional state supplement program is administered: Classiţcations administered by the state: Insitutionalized Individuals (ABD) and Community ABD Living Independently or Living in the Home of Another. 2. Payments under the optional state supplement program are: a. Based on need and paid in cash on a regular basis; b. Equal to the diſerence between the individual's countable income and the income standard used to determine eligibility for supplement; and c. Available to all individuals in each population selected in section B. a. Solely by the federal government. The state has an agreement with the Social Security Administration under section 1616 of the Act regarding the administration of optional state supplementary payments. b. By a combination of federal and state administration. The state has an agreement with the Social Security Administration under section 1616 of the Act regarding the administration of optional state supplementary payments for some classiţcations of individuals, while state supplementary payments for other classiţcations of individuals are administered by the state. c. Solely by the state.

Optional State Supplement Beneţciaries MEDICAID | Medicaid State Plan | Eligibility | RI2019MS0002O | RI-19-0002 Package Header Package ID RI2019MS0002O Submission Type OŰcial Approval Date 6/4/2019 Superseded SPA ID 18-002 User-Entered SPA ID RI-19-0002 Initial Submission Date 3/29/2019 Eſective Date 1/1/2019 D. Income Standard of Optional State Supplement Program 1. The income standard for the optional state supplement: a. Varies by political subdivision. b. Varies by payment classiţcation. The payment classiţcations used are: Income Standard I n d iv i d u a l $ 8 1 0. 9 2 C o u p l e $ 1 2 3 6. 0 0 Income Standard I n d iv i d u a l $ 5 6 5. 9 2 C o u p l e $ 8 6 8. 6 4 Yes No Yes No i. All individuals age 65 or older, regardless of living arrangement. ii. All individuals who have blindness, regardless of living arrangement. iii. All individuals who have a disability, regardless of living arrangement. iv. Independent living. v. Living in household of another. vi. Independent living and receiving non-medical care outside the home.

Name of Classiţcation Residential Care and Assisted Living Description: Individuals residing in residential care or Assisted Living Facilities Individual $1568.00 Couple $1568.00 Name of Classiţcation LTSS Living in a Community Support Living Program Description: Cat F Individual $1568.00 Couple $1568.00 vii. Living in household of another and receiving non-medical care outside the home. viii. Living in a domiciliary facility or other group living arrangement. ix. Other payment classiţcation.

Optional State Supplement Beneţciaries MEDICAID | Medicaid State Plan | Eligibility | RI2019MS0002O | RI-19-0002 Package Header Package ID RI2019MS0002O Submission Type OŰcial Approval Date 6/4/2019 Superseded SPA ID 18-002 User-Entered SPA ID RI-19-0002 Initial Submission Date 3/29/2019 Eſective Date 1/1/2019 E. Additional Information (optional)

PRA Disclosure Statement: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance OŰcer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. This view was generated on 6/5/2019 1:19 PM EDT

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Table of Contents State/Territory Name: Rhode Island State Plan Amendment (SPA) #:19-005 This file contains the following documents in the order listed: 1) Approval Letter 2) Summary 179-like Form 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services JFK Federal Building, Government Center Room 2275 Boston, Massachusetts 02203 Boston Regional Operations Group August 9, 2019 Ms. Womazetta Jones, Secretary Executive Office of Health and Human Services State of Rhode Island and Providence Plantations 3 West Road Cranston, RI 02920 Dear Secretary Jones: On June 28, 2019 the Centers for Medicare and Medicaid Services (CMS) received Rhode Island State Plan Amendment (SPA) transmittal number 19-005 proposing to update cost-sharing pages in the State Plan to reflect current practice. We are pleased to inform you that RI 19-005 was approved on August 6, 2019 with an effective date of July 1, 2019. If you have any questions regarding this matter you may contact Lynn DelVecchio (401) 380-5604 or by e-mail at Lynn.DelVecchio@cms.hhs.gov Sincerely, Francis T. McCullough Director, Boston Regional Operations Group Cc: Patrick Tigue, Medicaid Director Melody Lawrence, Interdepartmental Project Manager

State/Territory name: Rhode Island Submitted By: Melody Lawrence Last Revision Date: Jul 31, 2019 Submit Date: Jun 28, 2019   Other Issue Medicaid Premiums and Cost Sharing: Summary Page (CMS 179) Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. RI-19-0005 Proposed Effective Date 04/01/2019 (mm/dd/yyyy) Federal Statute/Regulation Citation 42 CFR § 447.52 Federal Budget Impact Federal Fiscal Year Amount First Year 2019 $ 0.00 Second Year 2020 $ 0.00 Subject of Amendment This amendment updates the states cost sharing State Plan pages to reflect current practice. Governor's Office Review Governor's office reported no comment Comments of Governor's office received Describe:   No reply received within 45 days of submittal Other, as specified Describe: This amendment has not been reviewed specifically with the Governor’s Office. Under the Rhode Island Medicaid State Plan, the Governor has elected not to review the details of state plan materials. However, in accordance with Rhode Island law and practice, the Governor is kept apprised of major changes in the state plan. Signature of State Agency Official

State/Territory name: Rhode Island Transmittal Number: RI-19-0005 Medicaid Premiums and Cost Sharing Medicaid Premiums and Cost Sharing: General Information, Public Notice and Comment General Information: Submission Title: short (under 100 characters) label used to identify this submission in the web application RI MPC PDFs superseded by this SPA (Include Transmittal Number): Attachment 4.18-A Pages 1 - 3 TN: 93-018 Attachment 4.18-C Pages 1 - 3 TN: 93-018 Attachment 4.18-D Pages 1 - 2 TN: 92-02 Attachment 4.18-E Pages 1 - 2 TN: 92-02 Section 4, pages 54-56f TN 92-02 Description: This SPA updates RI Cost Sharing information. Public Notice and Comment:  ublic notice has been conducted prior to the SPA submission pursuant to 42 CFR 447.57(c Indicate how the public notice was issued and public comment was solicited: Newspaper Announcement (in newspapers with wide circulation)  ormal notice and comment in accordance with the state's admin Date of Publicatio 05/28/2019 (mm/dd/yyyy)  e Website Date of Posting: 05/28/2019 (mm/dd/yyyy) Website URL: http://www.eohhs.ri.gov/ Public Hearing or Meeting Media specifically designed to reach racial, ethnic and linguistic minorities Other method Upload copies of public notices, documents, or other information providing evidence of the methods selected above. Document Uploaded Document Name: Date Uploaded: Notice to Public - Premiums and Cost Sharing.pdf Uploaded Document Name: Date Uploaded: Interested Parties - Cost Sharing.pdf Provide a written summary of public comments received and how the state incorporated them into the design of its premium or cost sharing proposal. No public comments were received.

State/Territory name: Rhode Island Transmittal Number: RI-19-0005 Form Description:   Uploaded Form: Date Uploaded: Cost Sharing G1.pdf Medicaid Premiums and Cost Sharing: File Management Summary Type of SPA Form Code Form Name/Description Uploaded? Cost Sharing G1 Cost Sharing Requirements yes Cost Sharing G2a Cost Sharing Amounts - Categorically Needy Individuals no Cost Sharing G2b Cost Sharing Amounts - Medically Needy Individuals no Cost Sharing G2c Cost Sharing Amounts - Targeting no Cost Sharing G3 Cost Sharing Limitations no Medicaid Premiums and Cost Sharing: File Management Detail Form G1: Cost Sharing Requirements Support Documents Document Please provide a short description of this support document: Attachment 4.18-C pages 1-3 Uploaded Document Name: Date Uploaded: Attachment 4.18-C page 1-3.pdf Please provide a short description of this support document: Attachment 4.18-A pages 1-3 Uploaded Document Name: Date Uploaded: Attachment 4.18-A page 1-3.pdf Please provide a short description of this support document: Attachment 4.18-E pages 1-2 Uploaded Document Name: Date Uploaded: Attachment 4.18-E page 1-2.pdf Please provide a short description of this support document: Attachment 4.18-D pages 1-2 Uploaded Document Name:

Form Description:   Uploaded Form: Date Uploaded: Form Description:   Uploaded Form: Date Uploaded: Form Description:   Uploaded Form: Date Uploaded: Document Date Uploaded: Attachment 4.18-D page 1-2.pdf Please provide a short description of this support document: Section 4 pages 54-56f Uploaded Document Name: Date Uploaded: Section 4 page 54-56f.pdf Form G2a: Cost Sharing Amounts - Categorically Needy Individuals Support Documents Document Form G2b: Cost Sharing Amounts - Medically Needy Individuals Support Documents Document Form G2c: Cost Sharing Amounts - Targeting Support Documents Document

Form Description:   Uploaded Form: Date Uploaded: State/Territory name: Rhode Island Transmittal Number: RI-19-0005 Form G3: Cost Sharing Limitations Support Documents Document Medicaid Premiums and Cost Sharing: Tribal Input  One or more Indian Health Programs or Urban Indian Organizations furnish health ca State.  dment is likely to have a direct effect on Indians, Indian h Urban Indian Organizations  State has solicited advice from Indian Health Programs, Urban Indian Organizations, an Tribal governments prior to submission of this State Plan Amend Complete the following information regarding any tribal consultation conducted with respect to this submission: Tribal consultation was conducted in the following manner. States are not required to consult with Indian tribal governments, but if such consultation was conducted voluntarily, provide information about such consultation below: Indian Tribes  Indian Health Programs Indian Health Programs Name of Indian Health Programs: Narragansett Indian Health Center Date of consultation: 05/28/2019 (mm/dd/yyyy) Method/Location of consultation: Email and notice sent via USPS. Urban Indian Organization The state must upload copies of documents that support the solicitation of advice in accordance with statutory requirements, including any notices sent to Indian Health Programs and/or Urban Indian Organizations, as well as attendee lists if face-to-face meetings were held. Also upload documents with comments received from Indian Health Programs or Urban Indian Organizations and the state's responses to any issues raised. Alternatively indicate the key issues and summarize any comments received below and describe how the state incorporated them into the design of its program. Document Please provide a short description of this support document: Tribal notification sent via email and USPS. Uploaded Document Name:

Document Date Uploaded: Tribal Notice - Premiums and Cost Sharing.pdf Indicate the key issues raised in Indian consultative activities: Access Summarize Comments   Summarize Response   Quality Summarize Comments   Summarize Response   Cost Summarize Comments   Summarize Response   Payment methodology Summarize Comments   Summarize Response   Eligibility Summarize Comments   Summarize Response   Benefits Summarize Comments   Summarize Response   Service delivery Summarize Comments   Summarize Response

Page 1 of 1 Medicaid Premiums and Cost Sharing State Name: Rhode Island OMB Control Number: 0938-1148 Transmittal Number: RI - 19 - 0005 Cost Sharing Requirements G1 1916 1916A 42 CFR 447.50 through 447.57 (excluding 447.55) The state charges cost sharing (deductibles, co-insurance or co-payments) to individuals covered under Medicaid. No PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. V.20160722

Revision: HCFA-PM-85-14 (BERC) Attachment 4.18-A September 1985 Page 1 OMB NO.: 0938-0193 STAE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: RHODE ISLAND TN No. 19-005 Approval Date Effective Date: 7/1/19 Supersedes HCFA ID: 0053C/0061E TN No. 93-018 This Page Intentionally Left Blank : 8/7/19

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Revision: HCFA-PM-85-14 (BERC) Attachment 4.18-C September 1985 Page 1 OMB NO.: 0938-0193 STAE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: RHODE ISLAND TN No. 19-005 Approval Date Effective Date: 7/1/19 Supersedes HCFA ID: 0053C/0061E TN No. 93-018 This Page Intentionally Left Blank : 8/7/19

Revision: HCFA-PM-85-14 (BERC) Attachment 4.18-C September 1985 Page 2 OMB NO.: 0938-0193 STAE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: RHODE ISLAND TN No. 19-005 Approval Date Effective Date: 7/1/19 Supersedes HCFA ID: 0053C/0061E TN No. 93-018 This Page Intentionally Left Blank : 8/7/19

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Revision: HCFA-PM-91-4 (BPD) Attachment 4.18-D August 1991 Page 1 OMB NO.: 0938- STAE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: RHODE ISLAND TN No. 19-005 Approval Date Effective Date: 7/1/19 Supersedes HCFA ID: 7986E TN No. 92-02 This Page Intentionally Left Blank : 8/7/19

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Revision: HCFA-PM-91-4 (BPD) Attachment 4.18-E August 1991 Page 1 OMB NO.: 0938- STAE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: RHODE ISLAND TN No. 19-005 Approval Date Effective Date: 7/1/19 Supersedes HCFA ID: 7986E TN No. 92-02 This Page Intentionally Left Blank : 8/7/19

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Table of Contents

State/Territory Name: RI State Plan Amendment (SPA) #: 19-0010 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-2G72 Baltimore, Maryland n24-7850 tvts cÊNftßs Fo¡ MeD¡c^tt & MËDtc rD st¡vrcÌs cEllTEn ron ilEDtcatD & ctlrp sE¡vrcE8 Financial Management Group October 23,2019 Womazetta Jones, Secretary Executive Offrce of Health and Human Services State of Rhode Island 3 West Road, Virks Building Cranston, RI02920 RE: Rhode Island SPA l9-0010 Dear Secretary Jones: We have reviewed the proposed amendment to Attachment 4.19-A of your Medicaid State plan submitted under transmittal number (TN) 19-0010. Effective July I,2019, this amendment eliminates inpatient hospital Upper Payment Limit supplemental payments. We conducted our review of your submiffal according to the statutory requirements at sections 1902(a)(2), 1902(a)(13), 1902(a)(30), 1903(a) and 1923 of the Social Security Act and the implementing Federal regulations at 42 CFR 447 Subpart C. We are pleased to inform you that Medicaid State plan amendment l9-0010 is approved effective July l, 2019. We are enclosing the CMS-179 and the amended plan pages. If you have any questions, please call Novena James-Hailey at (617) 565-129I. Sincerely, Kristin Fan Director cc: Avery Stahlecker Novena James-Hailey

DEPARTMENT OF HEALTII AND HUMAN SERVICES TRANSMITTAL ÄND NOTICE OF'APPROVAL OF STATE PLAN MATERJAL FOR: CENTERS FOR MEDICARE A¡ID MEDICAID SERVICES FORMAPPROVED 2. STATE RI 3. PROGRAM IDENTIFICATION: TITLE )(D( OF THE socrAl, SECLJRTTY ACT (MEDTCATD) TO: REGIONAL ADMIMSTRATOR , CENTERS FORMEDICAREAND MEDICA]D SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL (Check One): f] New STATEPLAN 4. PROPOSED EFFECTIVE DATE July 1,2019 n etvmNptvmNT To BE coNSTDERED AS NEw ILAN XXN AMENDMENT 1. TRANSMITTALNUMBER: 19-010 COMPLETEBLOCKS 6 IO IF THIS IS AN AMENDMENT 6. FEDERAL STATUTE/REGULATION CITATION Tt'ansmitlal each 7. FEDERAL BUDGET IMPACT: 42CFR447.27t a. FFY 2019 b. FFY 2020 - $ 1,456,283 - s 5,796,272 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: Supplement 3 to Attachment 4.1 9-A page 1 10. SI.]BJECT OF AMENDMENT: Lrpatient Hospital Supplemental Payments 9. PAGE NUMBER OF TFIE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable) : Supplement 3 to Attachment 4.19-A page I 11. GOVERNOR'S REVIEW (CheckOne) GOVERNOR'S OFFICE REPORTED NO COMMENT COMMENTS OF GOVERNOR'S OFFICE ENCLOSED NO REPLY RECEWED WITHIN 45 DAYS OF SUBMITTAL OF STATE 14. TITLE: Secretary 15. DATE SUBMITTED; August 15,2019 )O( [] OTHER" AS SPECIFIED: See Attached Letter t2 16. RETURN TO: EOHHS 3 West R4 Virks Building Cranston, RI 02920 FORM CMS-179 (07192)

Supplement 3 to Attachment 4.19-A Page 1 STATE PLAN LTNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE: Rhode Island INPATIENT HOSPITAL SUPPLEMENTARY PAYMENT Suppremental pâvments made toinï?,tf:rü;iii."i,i,ìî;"0",ï"0* tne Medicaid state Plan are TN# 19-0010 Supersedes TN# l5-007 Approval Date: Effective Date: July l,2019

Table of Contents State/Territory Name: Rhode Island State Plan Amendment (SPA) #: 20-0003 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-26-12 Baltimore, Maryland 21244-1850 April 8, 2020 Womazetta Jones, Secretary Rhode Island Executive Office of Health and Human Services 3 West Road Cranston, Rhode Island 02920 Re: Rhode Island State Plan Amendment (SPA) 20-0003 Dear Secretary Jones: We have reviewed the proposed amendment to add section 7.4 Medicaid Disaster Relief for the COVID-19 National Emergency to your Medicaid state plan, as submitted under transmittal number (TN) 20-0003. This amendment proposes to implement temporary policies, which are different from those policies and procedures otherwise applied under your Medicaid state plan, during the period of the Presidential and Secretarial emergency declarations related to the COVID-19 outbreak (or any renewals thereof). On March 13, 2020, the President of the United States issued a proclamation that the COVID-19 outbreak in the United States constitutes a national emergency by the authorities vested in him by the Constitution and the laws of the United States, including sections 201 and 301 of the National Emergencies Act (50 U.S.C. 1601 et seq.), and consistent with section 1135 of the Social Security Act (Act). On March 13, 2020, pursuant to section 1135(b) of the Act, the Secretary of the United States Department of Health and Human Services invoked his authority to waive or modify certain requirements of titles XVIII, XIX, and XXI of the Act as a result of the consequences of the COVID-19 pandemic, to the extent necessary, as determined by the Centers for Medicare & Medicaid Services (CMS), to ensure that sufficient health care items and services are available to meet the needs of individuals enrolled in the respective programs and to ensure that health care providers that furnish such items and services in good faith, but are unable to comply with one or more of such requirements as a result of the COVID-19 pandemic, may be reimbursed for such items and services and exempted from sanctions for such noncompliance, absent any determination of fraud or abuse. This authority took effect as of 6PM Eastern Standard Time on March 15, 2020, with a retroactive effective date of March 1, 2020. The emergency period will terminate, and this state plan provision will no longer be in effect, upon termination of the public health emergency, including any extensions. The State of Rhode Island requested a modification of the requirement to submit SPAs related to the COVID-19 emergency by March 31, 2020, to obtain a SPA effective date during the first calendar quarter of 2020, pursuant to 42 C.F.R. §430.20. CMS is approving this request pursuant to section 1135(b)(5) of the Act.

The State of Rhode Island also requested a waiver of public notice requirements applicable to the state plan amendment (SPA) submission process. Public notice for SPAs is required under 42 C.F.R §447.205 for changes in statewide methods and standards for setting Medicaid payment rates, 42 C.F.R. §447.57 for changes to premiums and cost sharing, and 42 C.F.R. §440.386 for changes to ABPs. These requirements help to ensure that the affected public has reasonable opportunity to comment on these SPAs. CMS recognizes that during this public health emergency, Rhode Island must act expeditiously to protect and serve the general public. Therefore, under section 1135(b)(1)(C) of the Act, CMS is approving the state’s request to waive these notice requirements applicable to this SPA. The State of Rhode Island also requested a waiver to modify the tribal consultation timeline applicable to this SPA submission process. Under section 1135(b)(5) of the Act, CMS is also approving the State of Rhode Island’s request for flexibility to modify the timeframes associated with tribal consultation required under section 1902(a)(73) of the Act, including shortening the number of days before submission or conducting consultation after submission of the SPA. These approvals under section 1135 only apply with respect to SPAs that provide or increase beneficiary access to items and services related to COVID-19 (such as cost sharing waivers, payment rate increases, or amendments to ABPs to add services or providers) and that would not restrict or limit payment or services or otherwise burden beneficiaries and providers, and that are temporary, with a specified sunset date that is not later than the last day of the declared COVID-19 emergency (or any extension thereof). Even though CMS is approving this waiver, we encourage the state to make all relevant information available to the public so they are aware of the changes. We conducted our review of your submittal according to the statutory requirements at section 1902(a) of the Act and implementing regulations. This letter is to inform you that Rhode Island Medicaid SPA Transmittal Number 20-0003 is approved effective March 1, 2020. Please note that the new eligibility group under section 1905(a)(10)(A)(ii)(XX) of the Act can only be approved with a March 18, 2020 effective date. Enclosed is a copy of the CMS-179 summary form and the approved state plan pages. Please contact Joyce Butterworth at 857-338-0554 or by email at Joyce.Butterworth@cms.hhs.gov if you have any questions about this approval. We appreciate the efforts of you and your staff in responding to the needs of the residents of the State of Rhode Island and the health care community. Sincerely, Anne Marie Costello Deputy Director Center for Medicaid & CHIP Services Enclosures Anne M. Costello -S Digitally signed by Anne M. Costello -S Date: 2020.04.08 17:29:31 -04'00'

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB No. 0938-0193 FORM CMS-179 (07/92) TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL FOR: CENTERS FOR MEDICARE AND MEDICAID SERVICES 1. TRANSMITTAL NUMBER: 20-003 2. STATE RI 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) TO: REGIONAL ADMINISTRATOR CENTERS FOR MEDICARE AND MEDICAID SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES 4. PROPOSED EFFECTIVE DATE March 1, 2020 5. TYPE OF PLAN MATERIAL (Check One): NEW STATE PLAN AMENDMENT TO BE CONSIDERED AS NEW PLAN XX AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate Transmittal for each amendment) 6. FEDERAL STATUTE/REGULATION CITATION: Section 1135 SSA 7. FEDERAL BUDGET IMPACT: a. FFY 2020 $ 0 b. FFY 2021 $ 0 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: Section 7.4 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable): NEW 10. SUBJECT OF AMENDMENT: Medicaid Disaster Relief for the COVID-19 National Emergency 11. GOVERNOR’S REVIEW (Check One): GOVERNOR’S OFFICE REPORTED NO COMMENT XX OTHER, AS SPECIFIED: COMMENTS OF GOVERNOR’S OFFICE ENCLOSED See Attached Letter NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL 12. SIGNATURE OF STATE AGENCY OFFICIAL: 16. RETURN TO: EOHHS 3 West Rd, Virks Building Cranston, RI 02920 13. TYPED NAME: Womazetta Jones 14. TITLE: Secretary 15. DATE SUBMITTED: March 25, 2020 FOR REGIONAL OFFICE USE ONLY 17. DATE RECEIVED: PLAN APPROVED – ONE COPY ATTACHED 19. EFFECTIVE DATE OF APPROVED MATERIAL: 20. SIGNATURE OF REGIONAL OFFICIAL: 21. TYPED NAME: 22. TITLE: 23. REMARKS: $QQH0DULH&RVWHOOR 'HSXW\'LUHFWRU &HQWHUVIRU0HGLFDLGDQG&KLS6HUYLFHV 0DUFK 18. DATE APPROVED: $SULO 0DUFK Anne M. Costello -S Digitally signed by Anne M. Costello -S Date: 2020.04.08 17:30:01 -04'00'

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

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State/Territory: ___Rhode Island______ ApprovalDate: Effective Date: DĂƌĐŚϭ͕ϮϬϮϬ TN: ___20-003_______ Supersedes TN:__New c. ___¥__ Tribal consultation requirements – the agency requests modification of tribal consultation timelines specified in Rhode Island Medicaid state plan, as described below: Rhode Island EOHHS will conduct its tribal consultation via a letter and email, concurrently with the submission of the SPA to CMS. Section A – Eligibility 1. __я___ The agency furnishes medical assistance to the following optional groups of individuals described in section 1902(a)(10)(A)(ii) or 1902(a)(10)(c) of the Act. This may include the new optional group described at section 1902(a)(10)(A)(ii)(XXIII) and 1902(ss) of the Act providing coverage for uninsured individuals. EOHHS elects to cover all uninsured individuals as defined under 1902(ss) of the Act pursuant to Section 1902(a)(10)(A)(ii)(XXIII) of the Act effective March 18, 2020. 2. _____ The agency furnishes medical assistance to the following populations of individuals described in section 1902(a)(10)(A)(ii)(XX) of the Act and 42 CFR 435.218: a. _____ All individuals who are described in section 1905(a)(10)(A)(ii)(XX) Income standard: _____________ -or-

b. _____ Individuals described in the following categorical populations in section 1905(a) of the Act: Income standard: _____________ 3. _____ The agency applies less restrictive financial methodologies to individuals excepted from financial methodologies based on modified adjusted gross income (MAGI) as follows. Less restrictive income methodologies: Ɖƌŝůϴ͕ϮϬϮϬ

State/Territory: ___Rhode Island______ Approval Date: __ Effective Date: DĂƌĐŚϭ͕ϮϬϮϬ TN: ___20-003_______ Supersedes TN:__New____ Less restrictive resource methodologies: 4. __¥___ The agency considers individuals who are evacuated from the state, who leave the state for medical reasons related to the disaster or public health emergency, or who are otherwise absent from the state due to the disaster or public health emergency and who intend to return to the state, to continue to be residents of the state under 42 CFR 435.403(j)(3). 5. _____ The agency provides Medicaid coverage to the following individuals living in the state, who are non-residents: 6. ___¥__ The agency provides for an extension of the reasonable opportunity period for non- citizens declaring to be in a satisfactory immigration status, if the non-citizen is making a good faith effort to resolve any inconsistences or obtain any necessary documentation, or the agency is unable to complete the verification process within the 90-day reasonable opportunity period due to the disaster or public health emergency. Section B – Enrollment 1. _____ The agency elects to allow hospitals to make presumptive eligibility determinations for the following additional state plan populations, or for populations in an approved section 1115 demonstration, in accordance with section 1902(a)(47)(B) of the Act and 42 CFR 435.1110, provided that the agency has determined that the hospital is capable of making such determinations. Please describe the applicable eligibility groups/populations and any changes to reasonable limitations, performance standards or other factors. 2. _____ The agency designates itself as a qualified entity for purposes of making presumptive eligibility determinations described below in accordance with sections 1920, 1920A, 1920B, and 1920C of the Act and 42 CFR Part 435 Subpart L. Please describe any limitations related to the populations included or the number of allowable PE periods. Ɖƌŝůϴ͕ϮϬϮϬ

State/Territory: ___Rhode Island______ Approval Date: Ɖƌŝůϴ͕ϮϬϮϬ Effective Date: DĂƌĐŚϭ͕ϮϬϮϬ TN: ___20-003_______ Supersedes TN:__New___ 3. _____ The agency designates the following entities as qualified entities for purposes of making presumptive eligibility determinations or adds additional populations as described below in accordance with sections 1920, 1920A, 1920B, and 1920C of the Act and 42 CFR Part 435 Subpart L. Indicate if any designated entities are permitted to make presumptive eligibility determinations only for specified populations. Please describe the designated entities or additional populations and any limitations related to the specified populations or number of allowable PE periods. 4. __¥___ The agency adopts a total of __12___ months (not to exceed 12 months) continuous eligibility for children under age enter age __19___ (not to exceed age 19) regardless of changes in circumstances in accordance with section 1902(e)(12) of the Act and 42 CFR 435.926. 5. _____ The agency conducts redeterminations of eligibility for individuals excepted from MAGI- based financial methodologies under 42 CFR 435.603(j) once every _____ months (not to exceed 12 months) in accordance with 42 CFR 435.916(b). 6. _____ The agency uses the following simplified application(s) to support enrollment in affected areas or for affected individuals (a copy of the simplified application(s) has been submitted to CMS). a. _____ The agency uses a simplified paper application. b. _____ The agency uses a simplified online application. c. _____ The simplified paper or online application is made available for use in call-centers or other telephone applications in affected areas. Section C – Premiums and Cost Sharing 1. _____ The agency suspends deductibles, copayments, coinsurance, and other cost sharing charges as follows: Please describe whether the state suspends all cost sharing or suspends only specified deductibles, copayments, coinsurance, or other cost sharing charges for specified items and services or for specified eligibility groups consistent with 42 CFR 447.52(d) or for specified income levels consistent with 42 CFR 447.52(g). 2. _____ The agency suspends enrollment fees, premiums and similar charges for: a. _____ All beneficiaries b. _____ The following eligibility groups or categorical populations:

State/Territory: ___Rhode Island______ Approval Date: Ɖƌŝůϴ͕ϮϬϮϬ Effective Date: DĂƌĐŚϭ͕ϮϬϮϬ TN: ___20-003_______ Supersedes TN:__New______ Please list the applicable eligibility groups or populations. 3. _____ The agency allows waiver of payment of the enrollment fee, premiums and similar charges for undue hardship. Please specify the standard(s) and/or criteria that the state will use to determine undue hardship. Section D – Benefits Benefits: 1. _____ The agency adds the following optional benefits in its state plan (include service descriptions, provider qualifications, and limitations on amount, duration or scope of the benefit): 2. _____ The agency makes the following adjustments to benefits currently covered in the state plan: 3. _____ The agency assures that newly added benefits or adjustments to benefits comply with all applicable statutory requirements, including the statewideness requirements found at 1902(a)(1), comparability requirements found at 1902(a)(10)(B), and free choice of provider requirements found at 1902(a)(23). 4. _____ Application to Alternative Benefit Plans (ABP). The state adheres to all ABP provisions in 42 CFR Part 440, Subpart C. This section only applies to states that have an approved ABP(s). a. _____ The agency assures that these newly added and/or adjusted benefits will be made available to individuals receiving services under ABPs. b. _____ Individuals receiving services under ABPs will not receive these newly added and/or adjusted benefits, or will only receive the following subset: Please describe.

State/Territory: ___Rhode Island______ Approval Date: Ɖƌŝůϴ͕ϮϬϮϬ Effective Date:  DĂƌĐŚϭ͕ϮϬϮϬ TN: ___20-003_______ Supersedes TN:New______ Telehealth: 5. _____ The agency utilizes telehealth in the following manner, which may be different than outlined in the state’s approved state plan: Please describe. Drug Benefit: 6. _____ The agency makes the following adjustments to the day supply or quantity limit for covered outpatient drugs. The agency should only make this modification if its current state plan pages have limits on the amount of medication dispensed. Please describe the change in days or quantities that are allowed for the emergency period and for which drugs. 7. __¥___ Prior authorization for medications is expanded by automatic renewal without clinical review, or time/quantity extensions. 8. _____ The agency makes the following payment adjustment to the professional dispensing fee when additional costs are incurred by the providers for delivery. States will need to supply documentation to justify the additional fees. Please describe the manner in which professional dispensing fees are adjusted. 9. __¥___ The agency makes exceptions to their published Preferred Drug List if drug shortages occur. This would include options for covering a brand name drug product that is a multi-source drug if a generic drug option is not available. Section E – Payments Optional benefits described in Section D: 1. _____ Newly added benefits described in Section D are paid using the following methodology: a. _____ Published fee schedules – Effective date (enter date of change): _____________ Location (list published location): _____________

State/Territory: ___Rhode Island______ Approval Date: Ɖƌŝůϴ͕ϮϬϮϬ Effective Date: DĂƌĐŚϭ͕ϮϬϮϬ TN: ___20-003_______ Supersedes TN:__New____ b. _____ Other: Describe methodology here. Increases to state plan payment methodologies: 2. _____ The agency increases payment rates for the following services: a. _____ Payment increases are targeted based on the following criteria: Please describe criteria. b. Payments are increased through: i. _____ A supplemental payment or add-on within applicable upper payment limits: Please describe. ii. _____ An increase to rates as described below. Rates are increased: _____ Uniformly by the following percentage: _____________ _____ Through a modification to published fee schedules – Effective date (enter date of change): _____________ Location (list published location): _____________ _____ Up to the Medicare payments for equivalent services. _____ By the following factors: Please describe.

State/Territory: ___Rhode Island______ Approval Date: _Ɖƌŝůϴ͕ϮϬϮϬ

Ĩfective Date: DĂƌĐŚϭ͕ϮϬϮϬ TN: ___20-003_______ Supersedes TN: __New_ Payment for services delivered via telehealth: 3. _____ For the duration of the emergency, the state authorizes payments for telehealth services that: a. _____ Are not otherwise paid under the Medicaid state plan; b. _____ Differ from payments for the same services when provided face to face; c. _____ Differ from current state plan provisions governing reimbursement for telehealth; Describe telehealth payment variation. d. _____ Include payment for ancillary costs associated with the delivery of covered services via telehealth, (if applicable), as follows: i. _____ Ancillary cost associated with the originating site for telehealth is incorporated into fee-for-service rates. ii. _____ Ancillary cost associated with the originating site for telehealth is separately reimbursed as an administrative cost by the state when a Medicaid service is delivered. Other: 4. _____ Other payment changes: Section F – Post-Eligibility Treatment of Income 1. _____ The state elects to modify the basic personal needs allowance for institutionalized individuals. The basic personal needs allowance is equal to one of the following amounts: a. _____ The individual’s total income b. _____ 300 percent of the SSI federal benefit rate c. _____ Other reasonable amount: _________________ 2. ___X__ The state elects a new variance to the basic personal needs allowance. (Note: Election of this option is not dependent on a state electing the option described the option in F.1. above.) The state protects amounts exceeding the basic personal needs allowance for individuals who have the following greater personal needs:

State/Territory: ___Rhode Island______ Approval Date: Ɖƌŝůϴ͕ϮϬϮϬ Effective Date: DĂƌĐŚϭ͕ϮϬϮϬ TN: ___20-003_______ Supersedes TN:__New__ EOHHS will extend the Home Maintenance of Need Allowance for more than six months to institutionalized individuals who demonstrate a greater need due to the COVID-19 emergency. Individuals eligible for an extended Home Maintenance of Need Allowance will meet the following criteria: they were institutionalized for less than 6 months as of March 1, 2020; they were unable to discharge home in six months or less due to restrictions on transportation, in- home assessments, availability of services in the home, and/ or facility quarantine instructions. The Home Maintenance Allowance will be continued for the duration of their stay in the facility or until the end of the COVID-19 emergency, whichever comes first. This extension of Home Maintenance Allowance does not apply to members that have been in an institution for greater than 6 months prior to the beginning of the COVID-19 emergency, nor those individuals that have been in an institution for less than 6 months as of March 1, 2020 for which there was no discharge plan to return home. Section G – Other Policies and Procedures Differing from Approved Medicaid State Plan /Additional Information PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148 (Expires 03/31/2021). The time required to complete this information collection is estimated to average 1 to 2 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. Your response is required to receive a waiver under Section 1135 of the Social Security Act. All responses are public and will be made available on the CMS web site. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. ***CMS Disclosure*** Please do not send applications, claims, payments, medical records or any documents containing sensitive information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information collection burden approved under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please contact the Centers for Medicaid & CHIP Services at 410-786-3870.

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Table of Contents State/Territory Name: Rhode Island State Plan Amendment (SPA) #: 20-0004 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

Records / Submission Packages - View All RI - Submission Package - RI2020MS0001O - (RI-20-0004) - Eligibility CMS-10434 OMB 0938-1188 Package Information Package ID RI2020MS0001O Program Name N/A SPA ID RI-20-0004 Version Number 1 Submitted By Gretchen Bell Package Disposition Priority Code P2 Submission Type Official State RI Region Boston, MA Package Status Approved Submission Date 3/31/2020 Approval Date 4/18/2020 12:53 AM EDT Summary Reviewable Units Versions Compare Doc Change Report Analyst Notes Review Assessment Report Approval Letter Transaction Logs News Related Actions Page 1 of 25 Medicaid State Plan Print View 04/20/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Division of Medicaid Field Operations – North, Kansas City 602 E. 12th St., Room 355 Kansas City, MO 64106 Center for Medicaid & CHIP Services April 18, 2020 Womazetta Jones Secretary of Health and Human Services Executive Office of Health and Human Services 74 West Road Cranston, RI 02920 Re: Approval of State Plan Amendment RI-20-0004 Dear Secretary Jones: On March 31, 2020, the Centers for Medicare and Medicaid Services (CMS) received Rhode Island State Plan Amendment (SPA) RI-20-0004 to to update the Medically Needy Income Levels and to also update the standards for the Optional State Supplement Beneficiaries eligibility group. . We approve Rhode Island State Plan Amendment (SPA) RI-20-0004 on April 18, 2020 with an effective date(s) of January 01, 2020. If you have any further questions, please contact Joyce Butterworth at (857) 338-0554 or by e-mail at Joyce.Butterworth@cms.hhs.gov. Name Date Created No items available If you have any questions regarding this amendment, please contact Joyce Butterworth at joyce.butterworth@cms.hhs.gov. Sincerely, James Scott, Director Division of Program Operations Center for Medicaid & CHIP Services Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | RI2020MS0001O | RI-20-0004 Package Header Package ID RI2020MS0001O Submission Type Official Approval Date 4/18/2020 Superseded SPA ID N/A SPA ID RI-20-0004 Initial Submission Date 3/31/2020 Effective Date N/A Page 2 of 25 Medicaid State Plan Print View 04/20/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

State Information State/Territory Name: Rhode Island Medicaid Agency Name: Executive Office of Health and Human Services Submission Component State Plan Amendment Medicaid CHIP Page 3 of 25 Medicaid State Plan Print View 04/20/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | RI2020MS0001O | RI-20-0004 Package Header Package ID RI2020MS0001O Submission Type Official Approval Date 4/18/2020 Superseded SPA ID N/A SPA ID RI-20-0004 Initial Submission Date 3/31/2020 Effective Date N/A SPA ID and Effective Date SPA ID RI-20-0004 Reviewable Unit Proposed Effective Date Superseded SPA ID Medically Needy Income Level 1/1/2020 RI-19-0002 Optional Eligibility Groups 1/1/2020 RI-19-0002 Optional State Supplement Beneficiaries 1/1/2020 RI-19-0002 Page 4 of 25 Medicaid State Plan Print View 04/20/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | RI2020MS0001O | RI-20-0004 Package Header Package ID RI2020MS0001O Submission Type Official Approval Date 4/18/2020 Superseded SPA ID N/A SPA ID RI-20-0004 Initial Submission Date 3/31/2020 Effective Date N/A Executive Summary Summary Description Including Goals and Objectives EOHHS is submitting the annual State Plan Amendments to update the following: • State Supplementary Payments to reflect the 1.6% COLA increase • Medically Needy Income Limits to reflect the 1.6% COLA increase Federal Budget Impact and Statute/Regulation Citation Federal Budget Impact Federal Fiscal Year Amount First 2020 $535361 Second 2021 $544500 Federal Statute / Regulation Citation 42 CFR 435.811 42 CFR 435.814 42 CFR 435.1007 42 CFR 435.232 Supporting documentation of budget impact is uploaded (optional). Name Date Created No items available Page 5 of 25 Medicaid State Plan Print View 04/20/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | RI2020MS0001O | RI-20-0004 Package Header Package ID RI2020MS0001O Submission Type Official Approval Date 4/18/2020 Superseded SPA ID N/A SPA ID RI-20-0004 Initial Submission Date 3/31/2020 Effective Date N/A Governor's Office Review No comment Comments received No response within 45 days Other Page 6 of 25 Medicaid State Plan Print View 04/20/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

Submission - Public Comment MEDICAID | Medicaid State Plan | Eligibility | RI2020MS0001O | RI-20-0004 Package Header Package ID RI2020MS0001O Submission Type Official Approval Date 4/18/2020 Superseded SPA ID N/A SPA ID RI-20-0004 Initial Submission Date 3/31/2020 Effective Date N/A Indicate whether public comment was solicited with respect to this submission. Public notice was not federally required and comment was not solicited Public notice was not federally required, but comment was solicited Public notice was federally required and comment was solicited Indicate how public comment was solicited: Newspaper Announcement Publication in state's administrative record, in accordance with the administrative procedures requirements  Email to Electronic Mailing List or Similar Mechanism Date of Email or other electronic notification: Feb 21, 2020 Description of mailing list, in particular parties and organizations included, and, if not email, description of similar mechanism used: Email to interested parties list.  Website Notice Select the type of website  Website of the State Medicaid Agency or Responsible Agency Date of Posting: Feb 21, 2020 Website URL: http://www.eohhs.ri.gov/Refere nceCenter/MedicaidStatePlana nd1115Waiver/SPAand1115Wai verChanges.aspx Website for State Regulations Other Public Hearing or Meeting Other method Upload copies of public notices and other documents used Name Date Created SSP20-002 Notice to Public posted 2.21.20 with ssp 3/30/2020 2:24 PM EDT Upload with this application a written summary of public comments received (optional) Name Date Created No items available Indicate the key issues raised during the public comment period (optional) Page 7 of 25 Medicaid State Plan Print View 04/20/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

Access Quality Cost Payment methodology Eligibility Benefits Service delivery Other issue Page 8 of 25 Medicaid State Plan Print View 04/20/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

Submission - Tribal Input MEDICAID | Medicaid State Plan | Eligibility | RI2020MS0001O | RI-20-0004 Package Header Package ID RI2020MS0001O Submission Type Official Approval Date 4/18/2020 Superseded SPA ID N/A SPA ID RI-20-0004 Initial Submission Date 3/31/2020 Effective Date N/A One or more Indian Health Programs or Urban Indian Organizations furnish health care services in this state Yes No This state plan amendment is likely to have a direct effect on Indians, Indian Health Programs or Urban Indian Organizations, as described in the state consultation plan. Yes No  The state has solicited advice from Indian Health Programs and/or Urban Indian Organizations, as required by section 1902(a)(73) of the Social Security Act, and in accordance with the state consultation plan, prior to submission of this SPA. Complete the following information regarding any solicitation of advice and/or tribal consultation conducted with respect to this submission: Solicitation of advice and/or Tribal consultation was conducted in the following manner:  All Indian Health Programs Date of solicitation/consultation: Method of solicitation/consultation: 2/21/2020 Email and mailed All Urban Indian Organizations States are not required to consult with Indian tribal governments, but if such consultation was conducted voluntarily, provide information about such consultation below: All Indian Tribes The state must upload copies of documents that support the solicitation of advice in accordance with statutory requirements, including any notices sent to Indian Health Programs and/or Urban Indian Organizations, as well as attendee lists if face-to-face meetings were held. Also upload documents with comments received from Indian Health Programs or Urban Indian Organizations and the state's responses to any issues raised. Alternatively indicate the key issues and summarize any comments received below and describe how the state incorporated them into the design of its program. Name Date Created Tribal Notice MNIL-SSP 2020 3/26/2020 11:05 AM EDT Indicate the key issues raised (optional) Access Quality Cost Payment methodology Page 9 of 25 Medicaid State Plan Print View 04/20/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

Eligibility Benefits Service delivery Other issue Page 10 of 25 Medicaid State Plan Print View 04/20/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

Medicaid State Plan Eligibility Income/Resource Standards Medically Needy Income Level MEDICAID | Medicaid State Plan | Eligibility | RI2020MS0001O | RI-20-0004 Package Header Package ID RI2020MS0001O Submission Type Official Approval Date 4/18/2020 Superseded SPA ID RI-19-0002 System-Derived SPA ID RI-20-0004 Initial Submission Date 3/31/2020 Effective Date 1/1/2020 A. Income Level Used 1. The state employs a single income level for the medically needy. 2. The income level varies based on differences between shelter costs in urban and rural areas. Yes No 3. The level used is: Household size Standard 5 $1550.00 6 $1742.00 7 $1917.00 8 $2117.00 9 $2275.00 10 $2467.00 1 $933.00 2 $975.00 3 $1208.00 4 $1375.00 The state uses an additional incremental amount for larger household sizes. Yes No Incremental Amount: $175.00 The dollar amounts increase automatically each year Yes No Page 11 of 25 Medicaid State Plan Print View 04/20/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

Medically Needy Income Level MEDICAID | Medicaid State Plan | Eligibility | RI2020MS0001O | RI-20-0004 Package Header Package ID RI2020MS0001O Submission Type Official Approval Date 4/18/2020 Superseded SPA ID RI-19-0002 System-Derived SPA ID RI-20-0004 Initial Submission Date 3/31/2020 Effective Date 1/1/2020 B. Basis for Income Level 1. Minimum Income Level The minimum income level for this eligibility group is the lower of the state’s July 1996 AFDC payment standard or the state’s income standard for the Parents and Other Caretaker Relatives eligibility group. 2. Maximum Income Level The maximum income level for this eligibility group is 133 1/3 percent of the higher of the state's 1996 AFDC payment standard or the state's income standard for the Parents and Other Caretaker Relatives eligibility group. Page 12 of 25 Medicaid State Plan Print View 04/20/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

Medically Needy Income Level MEDICAID | Medicaid State Plan | Eligibility | RI2020MS0001O | RI-20-0004 Package Header Package ID RI2020MS0001O Submission Type Official Approval Date 4/18/2020 Superseded SPA ID RI-19-0002 System-Derived SPA ID RI-20-0004 Initial Submission Date 3/31/2020 Effective Date 1/1/2020 C. Additional Information (optional) Page 13 of 25 Medicaid State Plan Print View 04/20/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

Medicaid State Plan Eligibility Optional Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | RI2020MS0001O | RI-20-0004 Package Header Package ID RI2020MS0001O Submission Type Official Approval Date 4/18/2020 Superseded SPA ID RI-19-0002 System-Derived SPA ID RI-20-0004 Initial Submission Date 3/31/2020 Effective Date 1/1/2020 A. Options for Coverage The state provides Medicaid to specified optional groups of individuals. Yes No The optional eligibility groups covered in the state plan are (elections made in this screen may not be comprehensive during the transition period from the paper-based state plan to MACPro): Families and Adults Eligibility Group Name Covered In State Plan Include RU In Package ? Included in Another Submission Package Source Type ? Optional Coverage of Parents and Other Caretaker Relatives NEW Reasonable Classifications of Individuals under Age 21 CONVERTED Children with Non- IV-E Adoption Assistance CONVERTED Independent Foster Care Adolescents CONVERTED Optional Targeted Low Income Children CONVERTED Individuals above 133% FPL under Age 65 NEW Individuals Needing Treatment for Breast or Cervical Cancer NEW Individuals Eligible for Family Planning Services NEW Individuals with Tuberculosis NEW Individuals Electing COBRA Continuation Coverage NEW Aged, Blind and Disabled      Page 14 of 25 Medicaid State Plan Print View 04/20/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

Eligibility Group Name Covered In State Plan Include RU In Package ? Included in Another Submission Package Source Type ? Individuals Eligible for but Not Receiving Cash Assistance NEW Individuals Eligible for Cash Except for Institutionalization NEW Individuals Receiving Home and Community- Based Waiver Services under Institutional Rules NEW Optional State Supplement Beneficiaries APPROVED Individuals in Institutions Eligible under a Special Income Level NEW PACE Participants NEW Individuals Receiving Hospice NEW Children under Age 19 with a Disability NEW Age and Disability- Related Poverty Level NEW Work Incentives NEW Ticket to Work Basic NEW Ticket to Work Medical Improvements NEW Family Opportunity Act Children with a Disability NEW Individuals Receiving State Plan Home and Community-Based Services NEW Individuals Receiving State Plan Home and Community-Based Services Who Are Otherwise Eligible for HCBS Waivers NEW            Page 15 of 25 Medicaid State Plan Print View 04/20/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

Optional Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | RI2020MS0001O | RI-20-0004 Package Header Package ID RI2020MS0001O Submission Type Official Approval Date 4/18/2020 Superseded SPA ID RI-19-0002 System-Derived SPA ID RI-20-0004 Initial Submission Date 3/31/2020 Effective Date 1/1/2020 B. Medically Needy Options for Coverage The state provides Medicaid to specified groups of individuals who are medically needy. Yes No The medically needy eligibility groups covered in the state plan are: 1. Mandatory Medically Needy: Families and Adults Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Medically Needy Pregnant Women NEW Medically Needy Children under Age 18 NEW Aged, Blind and Disabled Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Protected Medically Needy Individuals Who Were Eligible in 1973 NEW 2. Optional Medically Needy: Families and Adults Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Medically Needy Reasonable Classifications of Individuals under Age 21 NEW Medically Needy Parents and Other Caretaker Relatives NEW Aged, Blind and Disabled      Page 16 of 25 Medicaid State Plan Print View 04/20/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Medically Needy Populations Based on Age, Blindness or Disability NEW  Page 17 of 25 Medicaid State Plan Print View 04/20/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

Optional Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | RI2020MS0001O | RI-20-0004 Package Header Package ID RI2020MS0001O Submission Type Official Approval Date 4/18/2020 Superseded SPA ID RI-19-0002 System-Derived SPA ID RI-20-0004 Initial Submission Date 3/31/2020 Effective Date 1/1/2020 C. Additional Information (optional) Eligibility Groups Deselected from Coverage The following eligibility groups were previously covered in the source approved version of the state plan and deselected from coverage as part of this submission package: • N/A Page 18 of 25 Medicaid State Plan Print View 04/20/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

Medicaid State Plan Eligibility Eligibility Groups - Options for Coverage Optional State Supplement Beneficiaries MEDICAID | Medicaid State Plan | Eligibility | RI2020MS0001O | RI-20-0004 Individuals who receive an optional state supplementary payment. Package Header Package ID RI2020MS0001O Submission Type Official Approval Date 4/18/2020 Superseded SPA ID RI-19-0002 System-Derived SPA ID RI-20-0004 Initial Submission Date 3/31/2020 Effective Date 1/1/2020 The state covers the Optional State Supplement Beneficiaries eligibility group in accordance with the following provisions: A. Characteristics Individuals qualifying under this eligibility group must meet the following criteria: 1. Receive an optional state supplement that meets the conditions described in sections C and D. 2. Except for income, would be eligible for SSI. 3. Do not have gross income exceeding 300% of the SSI Federal Benefit Rate (FBR). Page 19 of 25 Medicaid State Plan Print View 04/20/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

Optional State Supplement Beneficiaries MEDICAID | Medicaid State Plan | Eligibility | RI2020MS0001O | RI-20-0004 Package Header Package ID RI2020MS0001O Submission Type Official Approval Date 4/18/2020 Superseded SPA ID RI-19-0002 System-Derived SPA ID RI-20-0004 Initial Submission Date 3/31/2020 Effective Date 1/1/2020 B. Individuals Covered 1. The state covers all individuals who meet the characteristics described in section A. Yes No Page 20 of 25 Medicaid State Plan Print View 04/20/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

Optional State Supplement Beneficiaries MEDICAID | Medicaid State Plan | Eligibility | RI2020MS0001O | RI-20-0004 Package Header Package ID RI2020MS0001O Submission Type Official Approval Date 4/18/2020 Superseded SPA ID RI-19-0002 System-Derived SPA ID RI-20-0004 Initial Submission Date 3/31/2020 Effective Date 1/1/2020 C. Optional State Supplement Program 1. The optional state supplement program is administered: a. Solely by the federal government. The state has an agreement with the Social Security Administration under section 1616 of the Act regarding the administration of optional state supplementary payments. b. By a combination of federal and state administration. The state has an agreement with the Social Security Administration under section 1616 of the Act regarding the administration of optional state supplementary payments for some classifications of individuals, while state supplementary payments for other classifications of individuals are administered by the state. Classifications administered by the state: Insitutionalized Individuals (ABD) and Community ABD Living Independently or Living in the Home of Another. c. Solely by the state. 2. Payments under the optional state supplement program are: a. Based on need and paid in cash on a regular basis; b. Equal to the difference between the individual's countable income and the income standard used to determine eligibility for supplement; and c. Available to all individuals in each population selected in section B. Page 21 of 25 Medicaid State Plan Print View 04/20/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

Optional State Supplement Beneficiaries MEDICAID | Medicaid State Plan | Eligibility | RI2020MS0001O | RI-20-0004 Package Header Package ID RI2020MS0001O Submission Type Official Approval Date 4/18/2020 Superseded SPA ID RI-19-0002 System-Derived SPA ID RI-20-0004 Initial Submission Date 3/31/2020 Effective Date 1/1/2020 D. Income Standard of Optional State Supplement Program 1. The income standard for the optional state supplement: a. Varies by political subdivision. Yes No b. Varies by payment classification. Yes No The payment classifications used are: i. All individuals age 65 or older, regardless of living arrangement. ii. All individuals who have blindness, regardless of living arrangement. iii. All individuals who have a disability, regardless of living arrangement.  iv. Independent living. Income Standard I n d i v i d u a l $ 8 2 2 . 9 2 C o u p l e $ 1 2 5 4 . 3 8  v. Living in household of another. Income Standard I n d i v i d u C o u p l e Page 22 of 25 Medicaid State Plan Print View 04/20/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

a l $ 5 7 3 . 9 2 $ 8 8 0 . 3 2 vi. Independent living and receiving non-medical care outside the home. vii. Living in household of another and receiving non-medical care outside the home. viii. Living in a domiciliary facility or other group living arrangement.  ix. Other payment classification. Name of Classification Residential Care and Assisted Living Description: Individuals residing in residential care or Assisted Living Facilities Individual $1580.00 Couple $1580.00 Name of Classification LTSS Living in a Community Support Living Program Description: Cat F Individual $1580.00 Couple $1580.00 Page 23 of 25 Medicaid State Plan Print View 04/20/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

Optional State Supplement Beneficiaries MEDICAID | Medicaid State Plan | Eligibility | RI2020MS0001O | RI-20-0004 Package Header Package ID RI2020MS0001O Submission Type Official Approval Date 4/18/2020 Superseded SPA ID RI-19-0002 System-Derived SPA ID RI-20-0004 Initial Submission Date 3/31/2020 Effective Date 1/1/2020 E. Additional Information (optional) Page 24 of 25 Medicaid State Plan Print View 04/20/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

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 0938-1188. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. This view was generated on 4/20/2020 4:44 PM EDT Page 25 of 25 Medicaid State Plan Print View 04/20/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

_____________________________________________________________________________ Table of Contents State/Territory Name: Rhode Island State Plan Amendment (SPA) #: 20-0011 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-26-12 Baltimore, Maryland 21244-1850 August 2, 2020 Womazetta Jones, Secretary Executive Office of Health and Human Services 6WDWH RI 5KRGH ,VODQG 3 West Road Cranston, Rhode Island 02920 Re: Rhode Island State Plan Amendment (SPA) 20-0011 Dear Secretary Jones: We have reviewed the proposed amendment to add section 7.4.A. Rescissions to the State’s Disaster Relief Policies for the COVID-19 National Emergency to your state plan, as submitted under transmittal number (TN) 20-0011. This amendment proposes to rescind the temporary election, in section 7.4. Medicaid Disaster Relief for the COVID-19 National Emergency, of the COVID-19 testing group described at 1902(a)(10)(A)(ii)(XXIII) of the Social Security Act (the Act). We conducted our review of your submittal according to the statutory requirements at section 1902(a) of the Act and implementing regulations. Section 7.4 of the Medicaid state plan provides temporary authority and is intended to be in effect only for the duration of the COVID-19 public health emergency. Due to the temporary nature of this provision, and because the state has not yet implemented the COVID-19 testing group and no individuals have been enrolled for coverage, TN 20-0011 is approved effective March 18, 2020 pursuant to 42 CFR 430.20(b)(3). 7KLV 63$ VXSHUVHGHV 'LVDVWHU 5HOLHI 63$  5,  6HFWLRQ $ ,WHP  3DJH  DSSURYHG RQ $SULO   7KLV GRHV QRW VXSHUVHGH DQ\ RWKHU LWHPV LQ 'LVDVWHU 5HOLHI 63$V DSSURYHG RQ $SULO   $SULO   DQG RQ 0D\   Please note that if Rhode Island wishes to cover the COVID-19 testing group after it is removed from the state plan, you may submit a new Medicaid Disaster Relief for the COVID-19 National Emergency SPA at any time during the public health emergency.

EnclosureV (QFORVHG LV D FRS\ RI WKH &06 VXPPDU\ IRUP DQG WKH DSSURYHG VWDWH SODQ SDJH 3OHDVH FRQWDFW -R\FH %XWWHUZRUWK DW   RU E\ HPDLO DW -R\FH%XWWHUZRUWK#FPVKKVJRY LI \RX KDYH DQ\ TXHVWLRQV DERXW WKLV DSSURYDO $QQH 0DULH &RVWHOOR $FWLQJ &HQWHU 'LUHFWRU &HQWHU IRU 0HGLFDLG &+,3 6HUYLFHV Anne M. Costello -S Digitally signed by Anne M. Costello -S Date: 2020.08 25 11:13:07 -04'00'

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB No. 0938-0193 TRANSMITTAL AND NOTICE OF APPROVAL OF | 1. TRANSMITTAL NUMBER: 2. STATE

STATE PLAN MATERIAL

FOR: CENTERS FOR MEDICARE AND MEDICAID SERVICES

20-0011 RI

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

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

4. PROPOSED EFFECTIVE DATE April, 2620, March 18, 2020

5. TYPE OF PLAN MATERIAL (Check One):

[_] NEW STATE PLAN

[_] AMENDMENT TO BE CONSIDERED AS NEW PLAN

XX[_] AMENDMENT

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

6. FEDERAL STATUTE/REGULATION CITATION: 1902(a)(10)(A)(4i)XXIIT) ; Title 19 of the Social Security Act

7. FEDERAL BUDGET IMPACT:

a.FFY 2020 $0 b.FFY 2021 $0

8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:

Section 7.4.4

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

Section 7.4 > Section A., Item 1., Page 5

10. SUBJECT OF AMENDMENT:

Rescission to the State’s Disaster Relief Policies for the COVID-19 National Emergency: Optional Eligibility Group described at section

1902(a)(10)(A)(ii)(XXIID) of the Social Security Act

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

XX [_] OTHER, AS SPECIFIED: See Attached Letter

12, SIGNATURE OF STATE AGENCY OFFICIAL:

13. TYPED NAME: Womazetta Jones

14. TITLE: Secretary

15. DATE SUBMITTED: August 3, 2020

16. RETURN TO:

EOHHS 3 West Rd, Virks Building Cranston, RI 02920

FOR REGIONAL OFFICE USE ONLY

17. DATE RECEIVED: August 3, 2020

18. DATE APPROVED: August 25, 2020

PLAN APPROVED — ONE COPY ATTACHED

19, EFFECTIVE DATE OF APPROVED MATERIAL:

20. SIGNATURE OF REGIONAL OFFICIAL:

March 18, 2020 Anne M. Costello -S Datu snes by Ame M. Cosieio -S 21. TYPED NAME: Anne Marie Costello 22. TITLE: Acting Center Director, Center for Medicaid & CHIP

Services

23. REMARKS:

Pen & ink change to include missing reference in box 6, "Title 19 of the Social Security Act"

Pen & ink change in box 4 from April 1, 2020 to March 18, 2020 Pen & ink change to add page number in box 9.

FORM CMS-179 (07/92)

State/Territory: _Rhode Island Disaster Relief SPA #4 7.4.A. Rescissions to the State’s Disaster Relief Policies for the COVID-19 National Emergency Effective March 18, 2020, the agency rescinds the election at A.1. of section 7.4 (approved on 04/08/2020 in SPA Number RI-20-0003) of the state plan to furnish medical assistance to the optional eligibility group described at section 1902(a)(10)(A)(ii)(XXIII) of the Social Security Act. Approval Date: 08/2ϱͬ2020 Effective Date: March 18, 2020 dŚŝƐ ^W ƐƵƉĞƌƐĞĚĞƐ ŝƐĂƐƚĞƌ ZĞůŝĞĨ ^W ηϭ Z/ ϮϬͲϬϬϬϯ͕ ^ĞĐƚŝŽŶ ͕͘ /ƚĞŵ ϭ͕͘ WĂŐĞ ϱ͕ ĂƉƉƌŽǀĞĚ ŽŶ Ɖƌŝů ϴ͕ ϮϬϮϬ͘ dŚŝƐ ĚŽĞƐ ŶŽƚ ƐƵƉĞƌƐĞĚĞ ĂŶLJ ŽƚŚĞƌ ŝƚĞŵƐ ŝŶ ŝƐĂƐƚĞƌ ZĞůŝĞĨ ^WƐ ĂƉƉƌŽǀĞĚ ŽŶ Ɖƌŝů ϴ͕ ϮϬϮϬ͕ Ɖƌŝů ϭϱ͕ ϮϬϮϬ ĂŶĚ ŽŶ DĂLJ ϭϯ͕ ϮϬϮϬ͘ WĂŐĞ ϯϮ TN: RI-20-0011 ^ƵƉĞƌƐĞĚĞƐ Z/ ϮϬͲϬϬϬϯ͕ ^ĞĐƚŝŽŶ ͕͘ /ƚĞŵ ϭ͕͘ WĂŐĞ ϱ

Table of Contents State/Territory Name: ZŚŽĚĞ /ƐůĂŶĚ State Plan Amendment (SPA) #: 21-00Ϭϰ This file contains the following documents in the order listed: 1) Approval Letter 2) CMS-179 3) Approved SPA Pages

5/16/22, 12:01 PM Medicaid State Plan Print View Records I Submission Packages - View All RI - Submission Package - Rl2021MS0001O - (Rl-21-0004) - Eligibility Summary Reviewable Units Versions Compare Doc Change Report Analyst Notes Review Assessment Report Approval Letter Transaction Logs News Related Actions CMS-10434 0MB 0938-1188 Package Information ,.. Package ID Rl2021 MS00010 Program Name N/A SPA ID Rl-21--0004 Version Number 2 Submitted By Melody Lawrence Package Disposition Priority Code P1 Submission Type Official State RI Region Boston. MA Package Status Approved Submission Date 3/30/2021 Approval Date 5/28/2021 12:52 PM EDT https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1 iljGeHwXRmZtl2Llcjf-vAM0-BtAWpTgO6QfW7sfytGJjTskhdvPqCEg80q3... 1/16

5/16/22, 12:01 PM DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Medicaid and CHIP Operations Group 601 E. 12th St. Room 355 Kansas City. MO 64106 Center for Medicaid & CHIP Services May 28. 2021 Womazetta Jones Secretary Executive OffJCe of Health and Human Services State of Rhode Island 3WestRoad Cranston. RI 02920 Re: Approval of State Plan Amendment Rl-21-0004 Dear Womazetta Jones. Medicaid State Plan Print View On March 30. 2021, the Centers for Medicare and Medicaid Services (CMS) received Rhode Island State Plan Amendment (SPA) Rl-21-0004 to make the annual update to the Medicaid State Plan to reflect the 1.3% cost-of-living increase for 2021 on the State Supplementary Payments and the Medically Needy Income Limit. We approve Rhode Island State Plan Amendment (SPA) Rl-21-0004 with an effective date(s) of January 01. 2021. If you have any questions regarding this amendment. please contact Joyce Butterworth at joyce.butterworth@cms.hhs.gov Medicaid State Plan Eligibility Income/Resource Standards Medically Needy Income Level MEDICAID J Medicaid State Plan J Eligibility I Rl2021MS0001O I Rl-21-0004 Package Header Package ID Rl2021 MS0001O Submission Type Official Approval Date 5/28/2021 Superseded SPA ID Rl-20-0004 User-Entered A. Income Level Used 1. The state employs a single income level for the medically needy. Sincerely, SPA ID Rl-21--0004 Initial Submission Date 3/30/2021 Effective Date 11112021 2. The income level varies based on differences between shelter costs in urban and rural areas. Q Yes 0 No 3. The level used is: Household size 5 6 7 Standard $1565.00 $1767.00 $1942.00 The state uses an additional incremental amount for larger household sizes. 0 Yes 0 No Incremental Amount: S175.00 The dollar amounts increase automatically each year https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1 iljGeHwXRmZtl2Llcjf-vAM0-BtAWp T gO6QfW7 sfytGJjTskhdvPqCEg80q3 2/16

5/16/22, 12:01 PM Medicaid State Plan Print View Household size Standard Q Yes 0 No 8 $2142.00 9 $2300.00 10 $2S00.00 $9S0.00 2 $992.00 3 $1225.00 4 $1400.00 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1 il jGeHwXRmZtl2Llcjf-vAM0-BtAWp T gO6QfW7 sfytGJjTskhdvPqCEg80q3... 3/16

5/16/22, 12:01 PM Medically Needy Income Level MEDICAID I Medicaid State Plan I Eligibility I Rl2021MS0001O I Rl-21-0004 Package Header Package ID Rl2021 MS0001O Submission Type Official Approval Date 5/28/2021 Superseded SPA ID Rl-20-0004 User-Entered B. Basis for Income Level 1. Minimum Income Level Medicaid State Plan Print View SPA ID Rl-21-0004 Initial Submission Date 3/30/2021 Effective Date 11112021 The minimum income level for this eligibility group is the lower of the state's July 1996 AFDC payment standard or the state's income standard for the Parents and Other caretaker Relatives eligibility group. 2. Maximum Income Level The maximum income level for this eligibility group is 133 1 /3 percent of the higher of the state"s 1996 AFDC payment standard or the state's income standard for the Parents and Other caretaker Relatives eligibility group. https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1 iljGeHwXRmZtl2Llcjf-vAM0-BtAWp T gO6QfW7 sfytGJjTskhdvPqCEg80q3... 4/16

5/16/22, 12:01 PM Medically Needy Income Level MEDICAID I Medicaid State Plan I Eligibility I Rl2021MS0001O I Rl-21-0004 Package Header Package ID Rl2021 MS0001O Submission Type Official Approval Date 5/28/2021 Superseded SPA ID Rl-20-0004 User-Entered c. Additional Information (optional) Medicaid State Plan Print View SPA ID Rl-21-0004 Initial Submission Date 3/30/2021 Effective Date 11112021 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1 il jGeHwXRmZtl2Llcjf-vAM0-BtAWp T gO6QfW7 sfytGJjTskhdvPqCEg80q3... 5/16

5/16/22, 12:01 PM Medicaid State Plan Eligibility Optional Eligibility Groups MEDICAID J Medicaid State Plan J Eligibility I Rl2021MS0001O I Rl-21-0004 Package Header Package ID Rl2021 MS0001O Submission Type Official Approval Date 5/28/2021 Superseded SPA ID Rl-20-0004 User-Entered A. Options for Coverage The state provides Medicaid to specified optional groups of individuals. 0 Yes 0 No Medicaid State Plan Print View SPA ID Rl-21--0004 Initial Submission Date 3/30/2021 Effective Date 11112021 The optional eligibility groups covered in the state plan are (elections made in this screen may not be comprehensive during the transition period from the paper- based state plan to MACPro): Families and Adults Eligibility Group Name Optional Coverage of Parents and Other Caretaker Relatives Reasonable Classifications of Individuals under Age 21 Children with Non-lV-E Adoption Assistance Independent Foster Care Adolescents Optional Targeted Low Income Children Individuals above 133% FPL under Age 65 Individuals Needing Treatment for Breast or Cervical cancer Individuals Eligible for Family Planning Services Individuals with Tuberculosis Individuals Electing COBRA Continuation Coverage Aged, Blind and Disabled Eligibility Group Name Individuals Eligible for but Not Receiving Cash Assistance Covered In State Plan □ C C C C □ □ □ □ Covered In State Plan Include RU In Package t) □ □ □ □ □ □ □ □ □ □ Include RU In Package t) □ Included in Another Submission Package 0 0 0 0 0 0 0 0 0 0 Included in Another Submission Package 0 Source Type 8 NEW CONVERTED CONVERTED CONVERTED CONVERTED NEW NEW NEW NEW NEW Source Type 8 NEW https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1 iljGeHwXRmZtl2Llcjf-vAM0-BtAWp T gO6QfW7 sfytGJjTskhdvPqCEg80q3... 6/16

5/16/22, 12:01 PM Medicaid State Plan Print View Eligibility Group Name Covered In State Plan Include RU In Package Included in Another Source Type O 0 Submission Package Individuals Eligible for ~ Cash Except for C □ 0 NEW Institutionalization Individuals Receiving Home and Community- ~ 0 Based Waiver Services □ NEW under Institutional Rules Optional State ~ • Supplement APPROVED Beneficiaries Individuals in Institutions Eligible ~ C □ 0 NEW under a Special Income Level PACE Participants ~ C □ 0 NEW Individuals Receiving ~ □ □ 0 NEW Hospice Children under Age 19 ~ C □ 0 NEW with a Disability Age and Disability- ~ C □ 0 NEW Related Poverty Level Work Incentives ~ C □ 0 NEW Ticket to Work Basic ~ □ □ 0 NEW Ticket to Work Medical ~ □ □ 0 NEW Improvements Family Opportunity Act ~ 0 Children with a C □ NEW Disability Individuals Receiving State Plan Home and ~ □ □ 0 NEW Community-Based Services Individuals Receiving State Plan Home and Community-Based ~ □ □ 0 NEW Services Who Are Otherwise Eligible for HCBS Waivers https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1 iljGeHwXRmZtl2Llcjf-vAM0-BtAWpTgO6QfW7sfytGJjTskhdvPqCEg80q3... 7/16

5/16/22, 12:01 PM Medicaid State Plan Print View Optional Eligibility Groups MEDICAID I Medicaid State Plan I Eligibility I Rl2021MS0001O I Rl-21-0004 Package Header Package ID Rl2021 MS0001O Submission Type Official Approval Date 5/28/2021 Superseded SPA ID Rl-20-0004 User-Entered B. Medically Needy Options for Coverage SPA ID Rl-21-0004 Initial Submission Date 3/30/2021 Effective Date 11112021 The state provides Medicaid to specified groups of individuals who are medically needy. 0 Yes 0 No The medically needy eligibility groups covered in the state plan are: 1. Mandatory Medically Needy: Families and Adults Eligibility Group Name Covered In State Plan Include RU In Package Included in Another 0 Submission Package Medically Needy ~ C □ 0 Pregnant Women Medically Needy ~ C □ 0 Children under Age 18 Aged, Blind and Disabled Eligibility Group Name Covered In State Plan Include RU In Package Included in Another 0 Submission Package Protected Medically ~ 0 Needy Individuals Who □ Were Eligible in 1973 2. Optional Medically Needy: Families and Adults Eligibility Group Name Covered In State Plan Include RU In Package Included in Another 0 Submission Package Medically Needy Reasonable ~ Classifications of □ 0 Individuals under Age 21 Medically Needy ~ 0 Parents and Other □ Caretaker Relatives Aged, Blind and Disabled Eligibility Group Name Covered In State Plan Include RU In Package Included in Another 0 Submission Package Medically Needy Populations Based on ~ □ 0 Age. Blindness or Disability Source Type O NEW NEW Source Type O NEW Source Type O NEW NEW Source Type O NEW https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1 il jGeHwXRmZtl2Llcjf-vAM0-BtAWp T gO6QfW7 sfytGJjTskhdvPqCEg80q3... 8/16

5/16/22, 12:01 PM Optional Eligibility Groups MEDICAID I Medicaid State Plan I Eligibility I Rl2021MS0001O I Rl-21-0004 Package Header Package ID Rl2021 MS0001O Submission Type Official Approval Date 5/28/2021 Superseded SPA ID Rl-20-0004 User-Entered c. Additional Information (optional) Eligibility Groups Deselected from Coverage Medicaid State Plan Print View SPA ID Rl-21-0004 Initial Submission Date 3/30/2021 Effective Date 11112021 The following eligibility groups were previously covered in the source approved version of the state plan and deselected from coverage as part of this submission package: • N/A https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1 iljGeHwXRmZtl2Llcjf-vAM0-BtAWp T gO6QfW7 sfytGJjTskhdvPqCEg80q3... 9/16

5/16/22, 12:01 PM Medicaid State Plan Print View Medicaid State Plan Eligibility Eligibility Groups - Options for Coverage Optional State Supplement Beneficiaries MEDICAID J Medicaid State Plan J Eligibility I Rl2021MS0001O I Rl-21-0004 Individuals who receive an optional state supplementary payment. Package Header Package ID Rl2021 MS0001O Submission Type Official Approval Date 5/28/2021 Superseded SPA ID Rl-20-0004 User-Entered SPA ID Rl-21--0004 Initial Submission Date 3/30/2021 Effective Date 11112021 The state covers the Optional State Supplement Beneficiaries eligibility group in accordance with the following provisions: A. Characteristics Individuals qualifying under this eligibility group must meet the following criteria: 1. Receive an optional state supplement that meets the conditions described in sections C and D. 2. Except for income. would be eligible for 551. 3. Do not have gross income exceeding 300% of the 551 Federal Benefit Rate (FBR). https://macpro cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1 il jGeHwXRmZtl2Llcjf-vAM0-BtAWp T gO6QfW7 sfytGJjTskhdvPqCEg80q... 10/16

5/16/22, 12:01 PM Medicaid State Plan Print View Optional State Supplement Beneficiaries MEDICAID I Medicaid State Plan I Eligibility I Rl2021MS0001O I Rl-21-0004 Package Header Package ID Rl2021 MS0001O Submission Type Official Approval Date 5/28/2021 Superseded SPA ID Rl-20-0004 User-Entered B. Individuals Covered 1. The state covers all individuals who meet the characteristics described in section A. 0 Yes Q No SPA ID Rl-21-0004 Initial Submission Date 3/30/2021 Effective Date 11112021 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1 iljGeHwXRmZtl2Llcjf-vAM0-BtAWpTgO6QfW7sfytGJjTskhdvPqCEg80q... 11/16

5/16/22, 12:01 PM Medicaid State Plan Print View Optional State Supplement Beneficiaries MEDICAID I Medicaid State Plan I Eligibility I Rl2021MS0001O I Rl-21-0004 Package Header Package ID Rl2021 MS0001O Submission Type Official Approval Date 5/28/2021 Superseded SPA ID Rl-20-0004 User-Entered c. Optional State Supplement Program 1. The optional state supplement program is administered: SPA ID Rl-21-0004 Initial Submission Date 3/30/2021 Effective Date 11112021 O a. Solely by the federal government. The state has an agreement with the Social Security Administration under section 1616 of the Act regarding the administration of optional state supplementary payments. O b. By a combination of federal and state administration. The state has an agreement with the Social Security Administration under section 1616 of the Act regarding the administration of optional state supplementary payments for some classifications of individuals. while state supplementary payments for other classifications of individuals are administered by the state. Classifications administered by the state: I nsitutionalized Individuals (ABO) and Community ABO Living Independently or Living in the Home of Another. O c. Solely by the state. 2. Payments under the optional state supplement program are: a. Based on need and paid in cash on a regular basis; b. Equal to the difference between the individual's countable income and the income standard used to determine eligibility for supplement and c. Available to all individuals in each population selected in section B. https://macpro cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1 il jGeHwXRmZtl2Llcjf-vAM0-BtAWp T gO6QfW7 sfytGJjTskhdvPqCEg80q... 12/16

5/16/22, 12:01 PM Medicaid State Plan Print View Optional State Supplement Beneficiaries MEDICAID I Medicaid State Plan I Eligibility I Rl2021MS0001O I Rl-21-0004 Package Header Package ID Rl2021 MS0001O Submission Type Official Approval Date 5/28/2021 Superseded SPA ID Rl-20-0004 User-Entered SPA ID Rl-21-0004 Initial Submission Date 3/30/2021 Effective Date 11112021 D. Income Standard of Optional State Supplement Program 1. The income standard for the optional state supplement: a. Varies by political subdivision. Q Yes O No b. Varies by payment classification. o ves Q No The payment classifications used are: D i. All individuals age 65 or older. regardless of living arrangement. D ii. All individuals who have blindness. regardless of living arrangement. D iii. All individuals who have a disability, regardless of living arrangement. C iv. Independent living. Income Standard C n 0 d u iv p i I d e u s a 1 I 2 s 7 8 0. 3 3 3. 8 9 2 C v. Living in household of another. Income Standard C n 0 d u iv p i I d e u s a 8 I 9 s 1. 5 3 7 0 9. 9 2 https://macpro cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1 iljGeHwXRmZtl2Llcjf-vAM0-BtAWp T gO6QfW7 sfytGJjTskhdvPqCEg80q... 13/16

5/16/22, 12:01 PM Medicaid State Plan Print View D vi. Independent living and receiving non-medical care outside the home. D vii. Living in household of another and receiving non-medical care outside the home. D viii. Living in a domiciliary facility or other group living arrangement. C ix. Other payment classification. Name of Classification Residential care and Assisted Living Individual S1126.00 Name of Classification LTSS Living in a Community Support Living Program Individual S1591.00 Description: Individuals residing in residential care or Assisted Living Facilities Couple S1126.00 Description: CatF Couple S1591.00 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1il jGeHwXRmZtl2Llcjf-vAM0-BtAWpTgO6QfW7sfytGJjTskhdvPqCEg80q... 14/16

5/16/22, 12:01 PM Optional State Supplement Beneficiaries MEDICAID I Medicaid State Plan I Eligibility I Rl2021MS0001O I Rl-21-0004 Package Header Package ID Rl2021 MS0001O Submission Type Official Approval Date 5/28/2021 Superseded SPA ID Rl-20-0004 User-Entered E. Additional Information (optional) Medicaid State Plan Print View SPA ID Rl-21-0004 Initial Submission Date 3/30/2021 Effective Date 11112021 https://macpro cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1 iljGeHwXRmZtl2Llcjf-vAM0-BtAWp T gO6QfW7 sfytGJjTskhdvPqCEg80q... 15/16

5/16/22, 12:01 PM Medicaid State Plan Print View PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatOf)' information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes. improve federal program management of Medicaid programs and Children's Health Insurance Program, and to standardize Medicaid program data which covers basic requirements. and individualized content that reflects the characteristics of the partirular state's program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children's Health Insurance Program in efforts to boost program integrity efforts. improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995. no persons are required to respond to a collection of information unless it displays a valid 0MB control number. The valid 0MB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), induding the time to review instructions. search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore. Maryland 21244-1850. This view was generated on 5/16/2022 12:01 PM EDT https://macpro cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1 iljGeHwXRmZtl2Llcjf-vAM0-BtAWp T gO6QfW7 sfytGJjTskhdvPqCEg80q... 16/16

_____________________________________________________________________________ Table of Contents State/Territory Name: Rhode Island State Plan Amendment (SPA) #: 22-0003 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

Records Submission Packages - View All RI Submission Package Rl2021 MS000SO {RI 22 0003) Eligibility Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter Transaction Logs News CMS-10434 0MB 0938-1188 Package Information Package ID Rl2021 MSOOOSO Program Name NIA SPA ID Rl-22-0003 Version Number 2 ubmitted By Kathryn Thomas Package Disposition Priority Code P2 Lead Division DMEP Submission Type State Region Package Status ubmission Date Approval Date Official RI Boston, MA Approved /14/ 0 I 41 0 4 Related Actions PM EDT

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Division of Program Operations 601 E 1 th treet Room 355 Kansas City. MO 64106 Center for Medicaid & CHIP Services May24. 2022 Ana P. Novais Acting Secretary of Health and Human Services Executive OffJCe of Health and Human Services West Road Virks Building Cranston. RI 02920 Re: Approval of State Plan Amendment Rl-22-0003 Dear Ana P. Novais. On March 14. 2022, the Centers for Medicare and Medicaid Services (CMS) received Rhode Island State Plan Amendment (SPA) Rl-22-0003 which proposed to update the State Supplementary Payment eligibility standards and the Medically Needy Income Umit We approve Rhode Island State Plan Amendment (SPA) Rl-22-0003 with an effective date(s) of January 01, 2022. If you have any questions regarding this amendment please contact Joyce Butterworth at joyce.butterworth@cms.hhs.gov Submission - Summary MEDICAID I Medicaid State Plan I Eligibility I Rl2021 MSOOOSO I Rl-22-0003 Package Header Package ID RI O 1 M 000 0 ubmission Type Official Approval Date 5/24/2022 Superseded SPA ID N/A State Information tate/Territory Name Rhode Island Submission Component O State Plan Amendment Sincerely, -- Director Center for Medicaid & CHIP Services PAID RI 000 Initial ubmission Date /14/ o Effective Date NIA Medicaid Agency Name Executive OffJCe of Health and Human Services O Medicaid CHIP

Submission - Summary MEDICAID I Medicaid State Plan I Eligibility I Rl2021 MSOO0SO I Rl-22-0003 Package Header Package ID Rl2021 MSOOOSO Submission Type Official Approval Date I 41 o uperseded PA ID N/A SPA ID and Effective Date SPA ID Rl-22-0003 Reviewable Unit Medically Needy Income Level Optional Eligibility Groups Optional State Supplement Beneficiaries Proposed Effective Date 1/1/2022 1/1/2022 1/1/2022 SPA ID Rl-22-0003 Initial Submission Date 3/14/2022 Effective Date N/ A Superseded SPA ID Rl-21-0004 Rl-21-0014 Rl-21-0014

Submission - Summary MEDICAID I Medicaid State Plan I Eligibility I Rl2021 MSOO0SO I Rl-22-0003 Package Header Package ID Rl2021 MS0005O Submission Type Official Approval Date 5/24/2022 Superseded SPA ID N/A Executive Summary SPA ID Rl-22-0003 Initial Submission Date 3/14/2022 Effective Date N/ A Summary Description Including EOHHS is making the annual update to the Medicaid State Plan to reflect the federal government's guidance on State Goals and Objectives Supplementary Payments and the Medically Needy Income Limit. The Social Security Administration approved a 5.9% cost- of-living increase for 2021. The state's supplementary payments and Medically Needy Income Limit have been adjusted to reflect that increase. These changes will yield an estimated annual increase of approximately $376,376.38 and will be effective January 1. 2022. Federal Budget Impact and Statute/Regulation Citation Federal Budget Impact First Second Federal Fiscal Year 2022 2023 Federal Statute I Regulation Citation 42 CFR 435 811 42CFR435814 42 CFR435.1007 42 CFR 435 232 Amount $376376 $0 Supporting documentation of budget impact is uploaded (optional). Name Date Created No items available

Submission - Summary MEDICAID I Medicaid State Plan I Eligibility I Rl2021 MSOOOSO I Rl-22-0003 Package Header Package ID Rl2021 MS0005O Submission Type Official Approval Date 5/24/2022 Superseded SPA ID N/A Governor's Office Review 0 Nocomment 0 Comments received O No response within 45 days 0 0ther SPA ID Rl-22-0003 Initial Submission Date 3/14/2022 Effective Date NIA Describe This amendment has not been reviewed specifically with the Governor's Office. Under the RI Medicaid State Plan. the Governor has elected not to review the details of the state plan materials. However. in accordance with the RI law and practice. the Governor is kept apprised of major changes in the state plan.

Medicaid State Plan Eligibility Income/Resource Standards Medically Needy Income Level MEDICAID I Medicaid State Plan I Eligibility I Rl2021 MSOO0SO I Rl-22-0003 Package Header Package ID Rl2021 MS0005O Submission Type Official Approval Date 5/24/2022 Superseded SPA ID Rl-21--0004 System-Derived A. Income Level Used 1. The state employs a single income level for the medically neecly. SPA ID Rl-22--0003 Initial Submission Date 3/14/2022 Effective Date 1/1/2022 2. The income level varies based on differences between shelter costs in urban and rural areas. Q Yes O No 3.Thelevelusedi~ Household size 5 6 7 8 9 10 2 3 4 Standard $1650.00 $1867.00 $2050.00 $2258.00 $2425.00 $2633.00 $1008.00 $1050.00 $1292.00 $1400.00 The state uses an additional incremental amount for larger household sizes_ o ves Q No Incremental Amount: $175.00 The dollar amounts increase automatically each year Q Yes O No

Medically Needy Income Level MEDICAID | Medicaid State Plan | Eligibility | RI2021MS0005O | RI-22-0003 Package Header Package ID RI2021MS0005O Submission Type Official Approval Date / 4/ 0 Superseded SPA ID RI-21-0004 System-Derived SPA ID RI-22-0003 Initial Submission Date 3/14/2022 Effective Date 1/1/20 B. Basis for Income Level 1. Minimum Income Level The minimum income level for this eligibility group is the lower of the state’s July 1996 AFDC payment standard or the state’s income standard for the Parents and Other Caretaker Relatives eligibility group. Maximum Income Level The maximum income level for this eligibility group is 1 1/ percent of the higher of the state s 1996 AFDC payment standard or the state s income standard for the Parents and Other Caretaker Relatives eligibility group

Medically Needy Income Level MEDICAID | Medicaid State Plan | Eligibility | RI2021MS0005O | RI-22-0003 Package Header Package ID RI2021MS0005O ubmission Type Official Approval Date / 4/ 0 Superseded SPA ID RI-21-0004 System-Derived SPA ID RI-22-0003 Initial ubmission Date /14/ 0 Effective Date 1/1/20 C. Additional Information (optional)

Medicaid State Plan Eligibility Optional Eligibility Groups MEDICAID I Medicaid State Plan I Eligibility I Rl2021 MSOO0SO I Rl-22-0003 Package Header Package ID Rl2021 MS0005O Submission Type Official Approval Date 5/24/2022 Superseded SPA ID Rl-21--0014 User-Entered A. Options for Coverage The state provides Medicaid to specified optional groups of individuals. 0 Yes 0 No SPA ID Rl-22--0003 Initial Submission Date 3/14/2022 Effective Date 1/1/2022 The optional eligibility groups covered in the state plan are (elections made in this screen may not be comprehensive during the transition period from the paper- based state plan to MACPro): Families and Adults Eligibility Group Name Optional Coverage of Parents and Other Caretaker Relatives Reasonable Classifications of Individuals under Age 21 Children with Non-lV-E Adoption Assistance Independent Foster Care Adolescents Optional Targeted Low Income Children Individuals above 133% FPL under Age 65 Individuals Needing Treatment for Breast or Cervical cancer Individuals Eligible for Family Planning Services Individuals with Tuberculosis Individuals Electing COBRA Continuation Coverage Aged, Blind and Disabled Eligibility Group Name Individuals Eligible for but Not Receiving Cash Assistance Covered In State Plan □ ~ □ □ □ □ Covered In State Plan Include RU In Package f) □ □ □ □ □ □ □ □ □ □ Include RU In Package f) □ Included in Another Submission Package 0 0 0 0 0 0 0 0 0 0 Included in Another Submission Package 0 Source Type 8 NEW CONVERTED CONVERTED CONVERTED CONVERTED NEW NEW NEW NEW NEW Source Type 8 NEW

Eligibility Group Name Covered In State Plan Include RU In Package Included in Another Source Type 9 9 Submission Package Individuals Eligible for [!] 0 Cash Except for □ NEW Institutionalization Individuals Receiving Home and Community- [!] Based Waiver Services under Institutional □ 0 NEW Rules Optional State [!] 0 Supplement APPROVED Beneficiaries Individuals in Institutions Eligible [!] □ 0 NEW under a Special Income Level PACE Participants [!] @ □ 0 NEW Individuals Receiving [!] □ □ 0 NEW Hospice Children under Age 19 [!] Sia □ 0 NEW with a Disability Age and Disability- [!] @ □ 0 NEW Related Poverty Level Work Incentives [!] Ii!! □ 0 NEW Ticket to Work Basic [!] □ □ 0 NEW Ticket to Work Medical [!] □ □ 0 NEW Improvements Family Opportunity Act [!] 0 Children with a □ NEW Disability Individuals Receiving State Plan Home and [!] □ □ 0 NEW Community-Based Services Individuals Receiving State Plan Home and Community-Based [!] □ □ 0 NEW Services Who Are Otherwise Eligible for HCBS Waivers

Optional Eligibility Groups MEDICAID I Medicaid State Plan I Eligibility I Rl2021 MSOO0SO I Rl-22-0003 Package Header Package ID Rl2021 MSOOOSO Submission Type Official Approval Date 5/24/2022 Superseded SPA ID Rl-21--0014 User-Entered B. Medically Needy Options for Coverage SPA ID Rl-22--0003 Initial Submission Date 3/14/2022 Effective Date 1/1/2022 The state provides Medicaid to specified groups of individuals who are medically needy. 0 Yes 0 No The medically needy eligibility groups covered in the state plan are: 1. Mandatory Medically Needy: Families and Adults Eligibility Group Name Covered In State Plan Include RU In Package Included in Another 9 Submission Package Medically Needy [!] @ □ 0 Pregnant Women Medically Needy [!] Sia □ 0 Children under Age 18 Aged, Blind and Disabled Eligibility Group Name Covered In State Plan Include RU In Package Included in Another 9 Submission Package Protected Medically [!] 0 Needy Individuals Who □ Were Eligible in 1973 2. Optional Medically Needy: Families and Adults Eligibility Group Name Covered In State Plan Include RU In Package Included in Another 9 Submission Package Medically Needy Reasonable [!] Classifications of Individuals under Age □ 0 21 Medically Needy [!] 0 Parents and Other □ Caretaker Relatives Aged, Blind and Disabled Eligibility Group Name Covered In State Plan Include RU In Package Included in Another 9 Submission Package Medically Needy Populations Based on [!] □ 0 Age. Blindness or Disability Source Type 9 NEW NEW Source Type 9 NEW Source Type 9 NEW NEW Source Type 9 NEW

Optional Eligibility Groups MEDICAID I Medicaid State Plan I Eligibility I Rl2021 MSOOOSO I Rl-22-0003 Package Header Package ID Rl2021 MSOOOSO Submission Type Official Approval Date 5/24/ 2022 Superseded SPA ID Rl-21-0014 User-Entered C. Additional Information (optional) Eligibility Groups Deselected from Coverage SPA ID Rl-22-0003 Initial Submission Date 3/14/ 2022 Effective Date 11112022 The following eligibility groups were previously covered in the source approved version of the state plan and deselected from coverage as part of this submission package: • N/A

Medicaid State Plan Eligibility Eligibility Groups - Options for Coverage Optional State Supplement Beneficiaries MEDICAID | Medicaid State Plan | Eligibility | RI2021MS0005O | RI-22-0003 Individuals who receive an optional state supplementary payment. Package Header Package ID RI2021MS0005O Submission Type Official Approval Date 5/24/2022 Superseded SPA ID RI-21-0014 User-Entered SPA ID RI-22-0003 Initial Submission Date 3/14/2022 Effective Date 1/1/2022 The state covers the Optional State Supplement Beneficiaries eligibility group in accordance with the following provisions: A. Characteristics Individuals qualifying under this eligibility group must meet the following criteria: 1. Receive an optional state supplement that meets the conditions described in sections C and D. 2. Except for income, would be eligible for SSI. 3. Do not have gross income exceeding 300% of the SSI Federal Benefit Rate (FBR).

Optional State Supplement Beneficiaries MEDICAID I Medicaid State Plan I Eligibility I Rl2021 MSOOOSO I Rl-22-0003 Package Header Package ID Rl2021 MSOOOSO Submission Type Official Approval Date 5/24/2022 Superseded SPA ID Rl-21-0014 User-Entered B. Individuals Covered 1. The state covers all individuals who meet the characteristics described in section A. 0 Yes Q No SPA ID Rl-22-0003 Initial Submission Date 3/14/2022 Effective Date 11112022

Optional State Supplement Beneficiaries MEDICAID I Medicaid State Plan I Eligibility I Rl2021 MSOOOSO I Rl-22-0003 Package Header Package ID Rl2021 MSOOOSO Submission Type Official Approval Date 5/24/2022 Superseded SPA ID Rl-21-0014 User-Entered C. Optional State Supplement Program 1. The optional state supplement program is administered: SPA ID Rl-22-0003 Initial Submission Date 3/14/2022 Effective Date 11112022 O a. Solely by the federal government. The state has an agreement with the Social Security Administration under section 1616 of the Act regarding the administration of optional state supplementary payments. 0 b. By a combination of federal and state administration. The state has an agreement with the Social Security Administration under section 1616 of the Act regarding the administration of optional state supplementary payments for some classifications of individuals. while state supplementary payments for other classifications of individuals are administered by the state. Classifications administered by the state: I nsitutionalized Individuals (ABO) and Community ABO Uving Independently or Living in the Home of Another. O c. Solely by the state. 2. Payments under the optional state supplement program are: a. Based on need and paid in cash on a regular basis; b. Equal to the difference between the individual's countable income and the income standard used to determine eligibility for supplement and c. Available to all individuals in each population selected in section B.

Optional State Supplement Beneficiaries MEDICAID I Medicaid State Plan I Eligibility I Rl2021 MSOOOSO I Rl-22-0003 Package Header Package ID Rl2021 MS0005O Submission Type Official Approval Date 5/24/2022 Superseded SPA ID Rl-21-0014 User-Entered SPA ID Rl-22-0003 Initial Submission Date 3/ 14/2022 Effective Date 11112022 D. Income Standard of Optional State Supplement Program 1. The income standard for the optional state supplement: a. Varies by political subdivision. Q Yes O No b. Varies by payment classification. O Yes 0 No The payment classifications used are: i. All individuals age 65 or older. regardless of living arrangement. ii. All individuals who have blindness. regardless of living arrangement. iii. All individuals who have a disability. regardless of living arrangement. iv. Independent living. Income Standard C n 0 d u iv p i I d e u s a I 3 s 4 8 0. 8 3 0. 8 9 2 v. Uving in household of another. Income Standard C n 0 d u iv p i I d e u s a 9 I 3 s 7. 6 9 7 2. 5 9

vi. Independent living and receiving non-medical care outside the home. vii. Uving in household of another and receiving non-medical care outside the home. viii. Living in a domiciliary facility or other group living arrangement. Iii ix. Other payment classification. Name of Classification Residential care and Assisted Living Individual S11 73.00 Description: Individuals residing in residential care or Assisted Living Facilities Couple S11 73.00

Optional State Supplement Beneficiaries MEDICAID | Medicaid State Plan | Eligibility | RI2021MS0005O | RI-22-0003 Package Header Package ID RI2021MS0005O Submission Type Official Approval Date 5/24/2022 Superseded SPA ID RI-21-0014 User-Entered SPA ID RI-22-0003 Initial Submission Date 3/14/2022 Effective Date 1/1/2022 E. Additional Information (optional)

PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state’s program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. This view was generated on 5/26/2022 7:05 AM EDT

Table of Contents

State/Territory Name: Rhode Island State Plan Amendment (SPA) #: 23-0004 This file contains the following documents in the order listed: 1) Approval Letter 2) Summary Form (with 179-like data) 3) Approved SPA Pages



  

 

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Table of Contents

State/Territory Name: Rhode Island State Plan Amendment (SPA) #: 23-0005 This file contains the following documents in the order listed: 1) Approval Letter 2) Summary Form (with 179-like data) 3) Approved SPA Pages



  

 

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State/Territory Name: Rhode Island State Plan Amendment (SPA) #: 23-0006 This file contains the following documents in the order listed: 1) Approval Letter 2) Summary Form (with 179-like data) 3) Approved SPA Pages



  

 

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