Department of Health & Human Services Centers for Medicare & Medicaid Services 61 Forsyth St., Suite 4T20 Atlanta, Georgia 30303-8909

March 11, 2010

Ms. Emma Forkner, Director South Carolina Department of Health and Human Services Post Office Box 8206 Columbia, South Carolina 29202-8206

Re: South Carolina Title XIX State Plan Amendment, Transmittal #09-010

Dear Ms. Forkner:

We have reviewed South Carolina’s State Plan Amendment (SPA) 09-010, which was submitted to the Atlanta Regional Office on December 18, 2009. This amendment updates the effective date of the physician services fee schedule to October 1, 2009.

Based on the information provided, we are pleased to inform you that South Carolina SPA 09-010 was approved on March 10, 2010. The effective date is October 1, 2009. The signed CMS-179 and the approved plan pages are enclosed. If you have any questions regarding this amendment, please contact Tandra Hodges at (404) 562-7409 or Michelle White at (404) 562-7328.

Sincerely,

/s/

Jackie Glaze

Acting Associate Regional Administrator

Division of Medicaid & Children's Health Operations

Enclosures

ATTACHMENT 4.19-B PAGE 1a.2

b. an updated outpatient cost-to-charge ratio;

c. an analysis reflecting the financial impact of the reimbursement change effective October 1, 2008.

The provider request will be reviewed by SCDHHS staff to determine if an interim settlement adjustment is justified based upon the best available information at the time.

This methodology will expire September 30, 2010.

Upper Payment Limits:

Outpatient hospital reimbursement shall be made in accordance with the upper payment limit requirements defined in 42 CFR 447.321.

Cost Report Requirements:

Cost report requirements under the prospective payment system and retrospective reimbursement system will conform to Medicare cost reporting principles and use as their basis the Medicare Cost Report Form - CMS-2552. In addition, providers must comply with Medicaid specific cost report requirements as published by the DHHS.

Audit Requirements:

All cost report financial and statistical information, the medical information contained on claims and information contained on supplemental worksheets such as the DSH survey, are subject to audit by the DHHS or its designee. The audited information will be used for future rate calculations, retrospective cost settlements, disproportionate share program requirements, utilization review contractor requirements and other analyses.

Co-payment Requirements:

Effective for dates of service March 31, 2004, there is a standard co- payment (42 CFR 447.55) of $3.00 per outpatient non-emergency service furnished in a hospital emergency room when co-payment is applicable (42 CFR 447.53). Emergency services are not subject to co-payment. The outpatient cost settlement payment calculation will include uncollected Medicaid co- payment amounts in accordance with 42 CFR 447.57.

B. Objectives

Implementation of the reimbursement methodology provided herein has the following objectives:

• To encourage outpatient resources be used when they are appropriate substitute for inpatient hospital services.

• To discourage the inappropriateness of outpatient hospital resources as a substitute for physician office and clinic services.

• To ensure the continued existence and stability of the core providers who serve the Medicaid population. SC 09-008 EFFECTIVE DATE: 09/01/09 RO APPROVAL: SUPERCEDES: SC 08-033

DEPARTMENT OF HEALTH AND HUMAN SERVICES REVISED ON 2-11-10

HEALTH CARE FINANCING ADMINISTRATION

FORM APPROVED OMB NO. 0938-0193

TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL

FOR: HEALTH CARE FINANCING ADMINISTRATION

1. TRANSMITTAL NUMBER: SC 09-010

2. STATE South Carolina

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 October 1, 2009

5. TYPE OF PLAN MATERIAL (Check One):

(1) NEW STATE PLAN

(J AMENDMENT TO BE CONSIDERED AS NEW PLAN

[] AMENDMENT

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

6. FEDERAL STATUTE/REGULATION CITATION:

7. FEDERAL BUDGET IMPACT: a. FFY 2009 $-0- b. FFY 2010 $10,219,270

8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:

Attachment 3.1-A, Limitation Supplement, Pages 3a and 3a.1 Attachment 4.19-B Page 2a.2

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

Attachment 3.1-A, Limitation Supplement, Page 3a Attachment 4.19-B, Page 2a.2

10. SUBJECT OF AMENDMENT: Revised Fee Schedule Effective Date

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

XJ OTHER, AS SPECIFIED: Mrs. Forkner was designated by the Governor to review and approve all State Plans

12. SIGNATURE OF STATE AGENCY OFFICIAL:

13. TYPED NAME: Emma Forkner

14. TITLE: Director

15. DATE SUBMITTED: December 18, 2009

16. RETURN TO:

South Carolina Department of Health and Human Services Post Office Box 8206 Columbia, South Carolina 29202-8206

FOR REGIONAL OFFICE USE ONLY

17. DATE RECEIVED: 12/18/09

18. DATE APPROVED: 03/10/10

PLAN APPROVED — ONE COPY ATTACHED

19. EFFECTIVE DATE OF APPROVED MATERIAL:

CN EOF TONAL OFFICIAL:

10/01/09 21. TYPED NAME: 2@/7TITLE: ae Acting Associate Regional Administrator Jackie Glaze Division of Medicaid & Children-s-HealthOp

23. REMARKS:

FORM HCFA-179 (07-92)

Department of Health & Human Services Centers for Medicare & Medicaid Services 61 Forsyth Street, SW, Suite 4T20 Atlanta, Georgia 30303-8909 December 21, 2011 Mr. Anthony E. Keck, Director South Carolina Department of Health and Human Services Post Office Box 8206 Columbia, South Carolina 29202-8206 Re: South Carolina Title XIX State Plan Amendment, Transmittal #11-019 Dear Mr. Keck: We have reviewed South Carolina's State Plan Amendment (SPA) 11-019, which was submitted to the Atlanta Regional Office on September 22, 2011. South Carolina submitted the proposed State Plan Amendment to eliminate a 50 mile radius limitation for discharges from hospitals to nursing facilities. Based on the information provided, we would like to inform you that South Carolina SPA 11-019 was approved on December 21, 2011. The effective date is October 1, 2011. The signed HCFA form 179 and the approved plan pages are enclosed. Ifyou have any questions regarding this amendment please contact Tandra Hodges at (404) 562-7409. Sincerely, ~ttC~~ Jackie Glaze Associate Regional Administrator Division ofMedicaid & Children's Health Operations Enclosures

Attachment 3.1-A Limitation Supplement Page 1 The services listed below must be medically necessary and are subject to utilization review by the South Carolina Department of Health and Human Services (SCDHHS) personnel, and must meet Federal and State laws and regulations. Prior authorization from the South Carolina Department of Health and Human Services is required before payment will be made for services covered by Medicaid and rendered by an out-of-state provider, excluding those located within a twenty-five (25) mile radius of the South Carolina border. For referrals out-of-state, the referring physician must obtain PRIOR APPROVAL before out-of-state services are reimbursed. A written request must be submitted to the South Carolina Department of Health and Human Services personnel. Referrals should be made to an out-of-state provider only when the procedure or service is not available within the South Carolina Medical Service Area. All available resources must have been considered and indicated in the request to SCDHHS for the out of state referral. Out-of-state providers must meet Medicaid enrollment criteria before payment may be made. Payment to out-of-state providers follows federal and state regulations and guidelines as promulgated. 1. INPATIENT HOSPITAL SERVICES. Inpatient Hospital Services must be provided in a general acute care institution licensed as a hospital by the applicable South Carolina licensing authority and certified for participation in the Medicare (Title XVIII) program. Hospital services are subject to the following cost containment measures: 1. Utilization review for appropriateness of treatment and length of stay. 2. Preadmission screening of selected services/procedures. 3. A mandatory outpatient surgery list per fiscal year. The following procedures are noncovered services: Hospital stays related to clinically unproven procedures and/or experimental procedures, plastic surgical procedures performed for cosmetic reasons, and other procedures determined not be medically necessary. Abortions and sterilizations are reimbursable in accordance with Federal and State requirements. Coverage for induced abortions is provided when the physician certifies that the pregnancy was a result of rape or incest or the woman suffers from a physical disorder, injury or illness, including a life­ endangering physical condition cause or arising from the pregnancy itself, that would place the woman in danger of death unless an abortion is performed. Effective July 1, 1989 the South Carolina Department of Health and Human Services will sponsor Administrative Day services to recipients who no longer require acute hospital care, but are in need of nursing home placement which is not available at the time. The patient must meet nursing facility level of care. Administrative Days must follow a hospital stay and will be covered in any hospital as long as such care is not available in a nursing home. Swing bed hospitals may furnish Administrative Days provided all swing beds in the hospital are occupied. 2.a OUTPATIENT HOSPITAL SERVICES. Outpatient non-emergency clinic services will be covered. SC 11-019 EFFECTiVE DATE: 10/01/11 RO APPROVAL: 12/21/11 SUPERSEDES: MA 93-012

JEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED ~IEALTH CARE FINANCING ADMINISTRA liON OMB NO. 0938"'()19: 2. STATE South Carolina TRANSMITTAL AND NOTICE OF APPROVAL OF I. TRANSMITTAL NUMBER: STATE PLAN MATERIAL SC 11-019 3. PROGRAM IDENTIFICA nON: TITLE XIX OF THE FOR: HEALTH CARE FINANCING ADMINISTRATION SOCIAL SECURITY ACT (MEDICAID) TO: REGIONAL ADMINISTRATOR 4. PROPOSED EFFECTIVE DATE . HEALTH CARE FINANCING ADMINISTRAnON 10/01111· DEPARTMENT OF HEALTH AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL (Check One): o NEW STATE PLAN 0 AMENDMENT TO BE CONSIDERED AS NEW PLAN lEI AMENDMENT COMPLETE BLOCKS 6 THRU )0 IF THIS IS AN AMENDMENT 'Se arate Transmittal or each amendment 6. FEDERAL STATUTEIREGULATION CIT A TION: No Federal StatutelRegulation citation 8. PAGE NUMBER OF THE PLAN SECTlON OR ATTACHMENT: Attachment 3.I-A, page I 10. SUBJECT OF AMENDMENT: 7. FEDERAL BUDGET IMPACT: FMAP a. FFY 2011 $337,009 b. FFY 2012 $400,000 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (IfApplicable): Attachment 3.l-A, page I Limiting patient discharges from hospitals to nursing facility within a 50 mile radius only will be eliminated. II. GOVERNOR'S REVIEW (Check One): o GOVERNOR'S OFFICE REPORTED NO COMMENT o COMMENTS OF GOVERNOR'S OFFICE ENCLOSED o NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL [8'l OTHER, AS SPECIFIED: Mr. Keck was designated by the Governor to review and approve all State Plans 16. RETURN TO: --:-::~~~:;:~:::====___________~. Soutb Carolina Department of Health and Human Services Post Office Box 8206 --~~~~~~----------------------------~ Columbia, SC 29202-8206

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Atlanta Regional Office 61 Forsyth Street, Suite 4T20 Atlanta, Georgia 30303

DIVISION OF MEDICAID & CHILDREN’S HEALTH OPERATIONS

June 10, 2013

Mr. Anthony E. Keck Director SC Department of Health and Human Services Post Office Box 8206 Columbia, South Carolina 29202-8206

Attention: Sheila Chavis

RE: Title XIX State Plan Amendment, SC 13-001

Dear Mr. Keck:

We have reviewed the proposed State Plan Amendment, SC 13-001, which was submitted to the Atlanta Regional Office on March 28, 2013. This state plan amendment allows primary care physicians that practice in family medicine, general internal medicine, pediatric medicine, and related subspecialists to receive increased payments for certain primary care services and vaccine administration in calendar years 2013 and 2014. This amendment is in compliance with the requirements of Section1202 of the Affordable Care Act.

Based on the information provided, the Medicaid State Plan Amendment SC 13-001 was approved on June 10, 2013. The effective date of this amendment is January 1, 2013. We are enclosing the approved HCFA-179 and the plan pages.

As we are working in partnership to implement this important provision, we would greatly appreciate if you can inform us when your state begins to pay the increased rates to your providers. Additionally, to the extent you have information regarding the number of providers receiving the enhanced payments; we would appreciate that information as well.

If you have any additional questions or need further assistance, please contact Cheryl Wigfall at (803) 252-7299 or Cheryl.Wigfall@cms.hhs.gov.

Sincerely,

/s/

Jackie Glaze

Associate Regional Administrator

Division of Medicaid & Children's Health Operations

Enclosures

Supplement 3 to Attachment 4.19-B page 1 Reimbursement Template -Physician Services

Increased Primary Care Service Payment 42 CFR 447.405, 447.410, 447.415

Attachment 4,19-B: Physician Services 42 CFR 447.405 Amount of Minimum Payment

The state reimburses for services provided by physicians meeting the requirements of 42 CFR 447.400(a) at the Medicare Part B fee schedule rate using the Medicare physician fee schedule rate in effect in calendar years 2013 and 2014 or, if greater, the payment rates that would be applicable in those years using the calendar year 2009 Medicare physician fee schedule conversion factor. If there is no applicable rate established by Medicare, the state uses the rate specified in a fee schedule established and announced by CMS.

& The rates reflect all Medicare site of service and locality adjustments.

D The rates do not reflect site of service adjustments, but reimburse at the Medicare rate applicable to the office setting.

O The rates reflect all Medicare geographic/locality adjustments.

© The rates are statewide and reflect the mean value over all counties for each of the specified evaluation and management and vaccine billing codes.

The following formula was used to determine the mean rate over all counties for each code:

Method of Payment

& The state has adjusted its fee schedule to make payment at the higher rate for each E&M and vaccine administration code.

0 The state reimburses a supplemental amount equal to the difference between the Medicaid rate in effect on July 1, 2009 and the minimum payment required at 42 CFR 447.405.

Supplemental payment is made: ( monthly ( quarterly Qsemi-annually Dannually

Primary Care Services Affected by this Payment Methodology

0 This payment applies to all Evaluation and Management (E&M) billing codes 99201 through 99499.

& The State did not make payment as of July 1, 2009 for the following codes and will not make payment for those codes under this SPA (specify codes).

sc 13-001

EFFECTIVE: DATE:01/01/13 RO APPROVED: @- /6-¢3 SUPERSEDES: New Page

Supplement 3 to Attachment 4.19-B page 2

99224 E/M SUBSEQ OBS CARE PER DAY,LEVEL 1

: 99225 E/M SUBSEQ OBS CARE PER DAY,LEVEL 2

' 99226 E/M SUBSEQ OBS CARE PER DAY, LEVEL 3 99340 MD SUPV PT HM,DOM/RST HM/MONTH/30+ MIN 99355 PROLONGED PHY SERV OFF OR OP EAADD 30M 99357 PROLONGED PHY SERV IP EA ADD 30 MIN

' 99358 PROLONGED EVAL & MANAGEMENT SERV 1 HR 99359 PROLONGED EVAL & MANGEMENT EA ADD 30 MIN 99363 ANTICOAGULANT MGMT,WARFARIN,|NIT 90 DAYS

: 99364 ANTICOAGULANT MGMT,WARFARIN,EA SUBSEQ 90

| 99366 TEAM CONF PROF W/PAT/FAM,30 MIN OR MORE

' 99367 TEAM CONF PROF W/PAT/FAM,30 MIN W/ PHYS 99368 TEAM CONF PROF NO PAT/FAM PRESENT,30MIN

_ 99374 PHY CARE OVERSIGHT-HOM HLTH PAT;15-29MIN

, 99375 PHY CARE PLAN OVERSIGHT SERV 30-60 MIN

, 99377 PHY CARE OVERSIGHT-HOSPICE PAT;15-29MIN 99378 PHY CARE OVERSIGHT-HOSPICE PAT;30+ MINUT 99379 PHY CARE OVERSIGHT-NURS FAC PAT; 15-29MIN

; 99380 PHY CARE OVERSIGHT-NURS FAC PAT;30+ MINU 99411 E/M PREVENT MED SERV GRP COUNSEL @ 30MIN 99412 E/M PREVENT MED SERV GRP COUNSEL @ 60MIN 99420 E/M OTHR PREV MED SERV ADMIN & INTERPRET 99429 E/M UNLISTED PREVENTIVE MEDICINE SERVICE 99441 PHONE E/M BY PHYS,EST PATIENT,5-10 MIN 99442 PHONE E/M BY PHYS,EST PATIENT,11-20 MIN 99443 PHONE E/M BY PHYS,EST PATIENT,21-30 MIN 99444 ONLINE E/M PHY,EST PT,NO VIS W/IN 7 DAY

, 99450 BASIC LIFE AND/OR DISABILITY EXAM

: 99455 WORK RELATED OR DISABILITY EX, TREAT PHY 99456 WORK RELATED/DISABILITY EX,NOT TREAT PHY

(Primary Care Services Affected by this Payment Methodology — continued)

& The state will make payment under this SPA for the following codes which have been added to the fee schedule since July 1, 2009 (specify code and date added).

sc 13-001

EFFECTIVE: DATE:01/01/13 RO APPROVED: 6 +fO-/3 SUPERSEDES: New Page

Supplement 3 to Attachment 4.19-B

page 3 99224 E/M SUBSEQ OBS CARE PER DAY,LEVEL 1 - 1/1/2011 99225 E/M SUBSEQ OBS CARE PER DAY,LEVEL 2 1/1/2011 99226 E/M SUBSEQ OBS CARE PER DAY, LEVEL 3 1/1/2011 99406 SMOK/TOBACCO CESSATION COUNS, 3-10 MIN 2/1/2012 98407 SMOK/TOBAC CESSATION, INTENSIVE<10MIN 2/1/2012 90460 IMMUN ADMIN <=AGE 18; ANY ROUTE,1ST VACC 1/1/2011 90461 IMMUN ADMIN <=AGE 18; ANY ROUTE,EA ADD'L 1/1/2011

Physician Services — Vaccine Administration

For calendar years (CYs) 2013 and 2014, the state reimburses vaccine administration services furnished by physicians meeting the requirements of 42 CFR 447.400(a) at the lesser of the state regional maximum administration fee set by the Vaccines for Children (VFC) program or the Medicare rate in effect in CYs 2013 and 2014 or, if higher, the rate using the CY 2009 conversion factor.

0 Medicare Physician Fee Schedule rate & State regional maximum administration fee set by the Vaccines for Children program

D Rate using the CY 2009 conversion factor

Documentation of Vaccine Administration Rates in Effect 7/1/09

The state uses one of the following methodologies to impute the payment rate in effect at 7/1/09 for code 90460, which was introduced in 2011 as a successor billing code for billing codes 90465 and 90471.

UO The imputed rate in effect at 7/1/09 for code 90460 equals the rate in effect at 7/1/09 for billing codes 90465 and 90471 times their respective claims volume for a 12 month period which encompasses July 1, 2009. Using this methodology, the imputed rate in effect for code 90460 at 7/1/09 is: :

®& A single rate was in effect on 7/1/09 for all vaccine administration services, regardless of billing code. This 2009 rate is: $13.00.

sc 13-001 EFFECTIVE: DATE: 01/01/13 RO APPROVED: @~ /0-/7 SUPERSEDES: New Page

Supplement 3 to Attachment 4.19-B page 4

D Alternative methodology to calculate the vaccine administration rate in effect TA{09:

Note: This section contains a description of the state’s methodology and specifies the affected billing codes.

Effective Date of Payment

E & M Services

This reimbursement methodology applies to services delivered on and after January 1, 2013, ending on Decenibe.31, 2014 but not prior to December 31, 2014. All rates are published at www.scdhhs.gov. The state is using a fee schedule that was developed using the tools provided by Deloitte. The fee schedule will not be adjusted for changes in Medicare’s rates throughout

the year. We will update the fee schedule in December to reflect the changes effective January 1, 2014.

Vaccine Administration This reimbursement methodology applies to services delivered on and after January 1, 2013, ending on December 31, 2014 but not prior to December 31, 2014. All rates are published at

www.scdhhs.gov.

Supercedes Page: None

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 # 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 20 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.

sc 13-001 EFFECTIVE: DATE: 01/01/13 RO APPROVED: & - /O-/3 SUPERSEDES: New Page

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

Atlanta Regional Office 61 Forsyth Street, Suite 4T20 Atlanta, Georgia 30303 CENTERS FOR MEDICARE & MEDICAID SERVICES

DIVISION OF MEDICAID & CHILDREN’S HEALTH OPERATIONS

June 10, 2013

Mr. Anthony E. Keck

Director

SC Department of Health and Human Services Post Office Box 8206

Columbia, South Carolina 29202-8206

Attention: Sheila Chavis RE: Title XIX State Plan Amendment, SC 13-001 Dear Mr. Keck:

We have reviewed the proposed State Plan Amendment, SC 13-001, which was submitted to the Atlanta Regional Office on March 28, 2013. This state plan amendment allows primary care physicians that practice in family medicine, general internal medicine, pediatric medicine, and related subspecialists to receive increased payments for certain primary care services and vaccine administration in calendar years 2013 and 2014. This amendment is in compliance with the requirements of Section1202 of the Affordable Care Act.

Based on the information provided, the Medicaid State Plan Amendment SC 13-001 was approved on June 10, 2013. The effective date of this amendment is January 1, 2013. We are enclosing the approved HCFA-179 and the plan pages.

As we are working in partnership to implement this important provision, we would greatly appreciate if you can inform us when your state begins to pay the increased rates to your providers. Additionally, to the extent you have information regarding the number of providers receiving the enhanced payments; we would appreciate that information as well.

If you have any additional questions or need further assistance, please contact Cheryl Wigfall at (803) 252-7299 or Cheryl. Wigfall@cms.hhs.gov.

Sincerely,

Qacks Rho.

Jackie Glaze Associate Regional Administrator Division of Medicaid & Children's Health Operations

Enclosures

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

FOR: HEALTH CARE FINANCING ADMINISTRATION

SC 13-001 South Carolina

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 January 1, 2013

5. TYPE OF PLAN MATERIAL (Check One):

(J NEW STATE PLAN

(J AMENDMENT TO BE CONSIDERED AS NEW PLAN

&] AMENDMENT

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

6. FEDERAL STATUTE/REGULATION CITATION: 42 CFR 447.405, 447.410, 447.415

7, FEDERAL BUDGET IMPACT:

a. FFY 2013 $18,109,000 b. FFY 2014 $24,292,000

8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:

Supplement 3 to Attachment 4.19-B, page 1, 2, 3, & 4

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

10. SUBJECT OF AMENDMENT:

The state reimburses for services provided by physicians meeting the requirements of 42 CFR 447.400(a) at the Medicare Part B fee schedule rate using the Medicare physician fee schedule rate in effect in calendar years 2013 and 2014 or, if greater, the payment rates that would be applicable in those years using the calendar year 2009 Medicare physician fee schedule conversion factor. If there is no applicable rate established by Medicare, the state uses the rate

specified in a fee schedule established and announced by CMS.

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

{XJ OTHER, AS SPECIFIED: Mr. Keck was designated by the Governor to review and approve all State Plans

12. SIGN. RE OF STATE AGENCY OFFICIAL:

13. TYPED NAME: Anthony E. Keck

14. TITLE: Director

15. DATE SUBMITTED: March 27, 2013

16, RETURN TO:

South Carolina Department of Health and Human Services Post Office Box 8206 Columbia, SC 29202-8206

FOR REGIONAL OFFICE USE ONLY

17. DATE RECEIVED: 03/28/13

18. DATE APPROVED: 06/10/13

PLAN APPROVED — ONE COPY ATTACHED

19. EFFECTIVE DATE OF APPROVED MATERIAL: 01/01/13

20. SIG OF REGIONAL OFFICIAL: a Chee Oboe

21. TYPED NAME: Jackie Glaze

22. TITHE: Associate Regional Administrator Division of Medicaid & Children Health Opns

23. REMARKS:

Approved with the following changes to item7a and 7b as authorized by State Agency e-mails dated 06/07/13: Block # 7a changed to read: FFY 13 $17,821,781 and Block # 7b changed to read : FFY 14 $20,912,245.

Supplement 3 to Attachment 4.19-B page 1

Reimbursement Template -Physician Services Increased Primary Care Service Payment 42 CFR 447.405, 447.410, 447.415

Attachment 4.19-B: Physician Services 42 CFR 447.405 Amount of Minimum Payment

The state reimburses for services provided by physicians meeting the requirements of 42 CFR 447.400(a) at the Medicare Part B fee schedule rate using the Medicare physician fee schedule rate in effect in calendar years 2013 and 2014 or, if greater, the payment rates that would be applicable in those years using the calendar year 2009 Medicare physician fee schedule conversion factor. If there is no applicable rate established by Medicare, the state uses the rate specified in a fee schedule established and announced by CMS.

& The rates reflect all Medicare site of service and locality adjustments.

O The rates do not reflect site of service adjustments, but reimburse at the Medicare rate applicable to the office setting.

D The rates reflect all Medicare geographic/locality adjustments.

0 The rates are statewide and reflect the mean value over all counties for each of the specified evaluation and management and vaccine billing codes.

The following formula was used to determine the mean rate over all counties for each code:

Method of Payment

& The state has adjusted its fee schedule to make payment at the higher rate for each E&M and vaccine administration code.

O The state reimburses a supplemental amount equal to the difference between the Medicaid rate in effect on July 1, 2009 and the minimum payment required at 42 CFR 447.405.

Supplemental payment is made: [1 monthly D quarterly Qsemi-annually Dannually

Primary Care Services Affected by this Payment Methodology

O This payment applies to all Evaluation and Management (E&M) billing codes 99201 through 99499,

& The State did not make payment as of July 1, 2009 for the following codes and will not make payment for those codes under this SPA (specify codes).

sc 13-001

EFFECTIVE: DATE:01/01/13 RO APPROVED: @= /6-¢3 SUPERSEDES: New Page

Supplement 3 to Attachment 4.19-B page 2

99224 E/M SUBSEQ OBS CARE PER DAY,LEVEL 1 | 99225 E/M SUBSEQ OBS CARE PER DAY,LEVEL 2

99226 E/M SUBSEQ OBS CARE PER DAY, LEVEL 3

99340 MD SUPV PT HM,DOM/RST HM/MONTH/30+ MIN

99355 PROLONGED PHY SERV OFF OR OP EAADD 30M

99357 PROLONGED PHY SERV IP EA ADD 30 MIN

99358 PROLONGED EVAL & MANAGEMENT SERV 1 HR

99359 PROLONGED EVAL & MANGEMENT EA ADD 30 MIN

99363 ANTICOAGULANT MGMT,WARFARIN, INIT 90 DAYS

99364 ANTICOAGULANT MGMT,WARFARIN,EA SUBSEQ 90 _ 99366 TEAM CONF PROF W/PAT/FAM,30 MIN OR MORE _ 99367 TEAM CONF PROF W/PAT/FAM,30 MIN W/ PHYS 99368 TEAM CONF PROF NO PAT/FAM PRESENT,30MIN 99374 PHY CARE OVERSIGHT-HOM HLTH PAT;15-29MIN 99375 PHY CARE PLAN OVERSIGHT SERV 30-60 MIN 99377 PHY CARE OVERSIGHT-HOSPICE PAT;15-29MIN 99378 PHY CARE OVERSIGHT-HOSPICE PAT;30+ MINUT 99379 PHY CARE OVERSIGHT-NURS FAC PAT;15-29MIN 99380 PHY CARE OVERSIGHT-NURS FAC PAT;30+ MINU 99411 E/M PREVENT MED SERV GRP COUNSEL @ 30MIN 99412 E/M PREVENT MED SERV GRP COUNSEL @ 60MIN 99420 E/M OTHR PREV MED SERV ADMIN & INTERPRET 99429 E/M UNLISTED PREVENTIVE MEDICINE SERVICE 99441 PHONE E/M BY PHYS,EST PATIENT,5-10 MIN 99442 PHONE E/M BY PHYS,EST PATIENT,11-20 MIN 99443 PHONE E/M BY PHYS,EST PATIENT,21-30 MIN 99444 ONLINE E/M PHY,EST PT,NO VIS W/IN 7 DAY 99450 BASIC LIFE AND/OR DISABILITY EXAM 99455 WORK RELATED OR DISABILITY EX, TREAT PHY 99456 WORK RELATED/DISABILITY EX,NOT TREAT PHY

Primary Care Services Affected by this Payment Methodology — continued

& The state will make payment under this SPA for the following codes which have been added to the fee schedule since July 1, 2009 (specify code and date added).

sc 13-001 EFFECTIVE: DATE:01/01/13 RO APPROVED: 6 +f0-/3 SUPERSEDES: New Page

Supplement 3 to Attachment 4.19-B

page 3 99224 E/M SUBSEQ OBS CARE PER DAY,LEVEL 1 - 1/1/2011 99225 E/M SUBSEQ OBS CARE PER DAY,LEVEL 2 1/1/2011 99226 E/M SUBSEQ OBS CARE PER DAY, LEVEL 3 1/1/2011 99406 SMOK/TOBACCO CESSATION COUNS, 3-10 MIN 2/1/2012 99407 SMOK/TOBAC CESSATION, INTENSIVE<10MIN 2/1/2012 90460 IMMUN ADMIN <=AGE 18; ANY ROUTE,1ST VACC 1/1/2011 90461 IMMUN ADMIN <=AGE 18; ANY ROUTE,EA ADD'L 1/1/2011

Physician Services — Vaccine Administration

For calendar years (CYs) 2013 and 2014, the state reimburses vaccine administration services furnished by physicians meeting the requirements of 42 CFR 447.400(a) at the lesser of the state regional maximum administration fee set by the Vaccines for Children (VFC) program or the Medicare rate in effect in CYs 2013 and 2014 or, if higher, the rate using the CY 2009 conversion factor.

0 Medicare Physician Fee Schedule rate & State regional maximum administration fee set by the Vaccines for Children program

D Rate using the CY 2009 conversion factor

Documentation of Vaccine Administration Rates in Effect 7/1/09

The state uses one of the following methodologies to impute the payment rate in effect at 7/1/09 for code 90460, which was introduced in 2011 as a successor billing code for billing codes 90465 and 90471.

O The imputed rate in effect at 7/1/09 for code 90460 equals the rate in effect at 7/1/09 for billing codes 90465 and 90471 times their respective claims volume for a 12 month period which encompasses July 1, 2009. Using this methodology, the imputed rate in effect for code 90460 at 7/1/09 is: .

A single rate was in effect on 7/1/09 for all vaccine administration services, regardless of billing code. This 2009 rate is: $13.00.

SC 13-001

EFFECTIVE: DATE:01/01/13 RO APPROVED: @~ /0-/3 SUPERSEDES: New Page

Supplement 3 to Attachment 4.19-B page 4

O Alternative methodology to calculate the vaccine administration rate in effect 7/1/09:

Note: This section contains a description of the state’s methodology and specifies the affected billing codes.

Effective Date of Payment

E & M Services

This reimbursement methodology applies to services delivered on and after January 1, 2013, ending on Decenibe&.31, 2014 but not prior to December 31, 2014. All rates are published at www.scdhhs.gov. The state is using a fee schedule that was developed using the tools provided by Deloitte. The fee schedule will not be adjusted for changes in Medicare’s rates throughout

the year. We will update the fee schedule in December to reflect the changes effective January 1, 2014. :

Vaccine Administration This reimbursement methodology applies to services delivered on and after January 1, 2013, ending on December 31, 2014 but not prior to December 31, 2014. All rates are published at

www.scdhhs.gov.

Supercedes Page: None

P isclosure Statemen: 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 20 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.

sc 13-001 EFFECTIVE: DATE: 01/01/13 RO APPROVED: SUPERSEDES: New Page

------------------- -- Table of Contents State/Territory Name: South Carolina State Plan Amendment (SPA) #: 13-006 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 Atlanta Regional Office 61 Forsyth Street, Suite 4T20 Atlanta, Georgia 30303 DIVISION OF MEDICAID & CHILDREN'S HEALTH OPERATIONS January 27,2014 Mr. Anthony E. Keck Director South Carolina Department of Health and Human Services Post Office Box 8206 Columbia, South Carolina 29202-8206 Attention: Sheila Chavis RE: Title XIX State Plan Amendment, SC 13-006 Dear Mr. Keck: CMS CENTERS FOR MEDICARE & MEDICAID SERVICES We have reviewed the proposed State Plan Amendment, SC 13-006, which was submitted to the Atlanta Regional Office on November 8, 2013. This amendment allow dual eligible (Medicare/Medicaid) beneficiaries to voluntarily enroll in managed care; revise state plan language to have beneficiaries under one (1) year of age enroll in a health plan and revise state plan language to reflect SCDHHS will perform the face to face informed choice counseling with beneficiaries who are selecting a managed care option. Based on the information provided, the Medicaid State Plan Amendment SC 13-006 was approved on January 27, 2014. The effective date of this amendment is October 1, 2013. We are enclosing the approved HCF A-179 and the plan pages. If you have any additional questions or need further assistance, please contact Maria Drake at (404) 562-3697 or Maria.Drake@cms.hhs.gov. Sincerely, //s// Jackie Glaze Associate Regional Administrator Division of Medicaid & Children's Health Operations Enclosures

DEPARTMENT OF HEALTH AND HUMAN SERVICES • HEALTH CARE FINANCING ADMINISTRATION FORM APPROVED OMB NO 0938-0193 TRANSMITTAL AND NOTICE OF APPROVAL OF l. TRANSMIITAL NUMBER: 2. STATE South Carolina STATE PLAN MATERIAL sc 13-006 .·· FGR: HE.i{LTH CARE FINANCING ADMINISTRATION TO: REGIONAL ADMINISTRATOR HEALTH CARE FINANCING ADMINISTRATION DEPARTMENT OF HEALTH AND HUMAN SERVICES 5. TYPE OF PLAN MA TEIUAL (Check One): 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITYACT(MEDICAID) 4. PROPOSED EFFECTIVE DATE October 1, 2013 0 NEW STATE PLAN 0 AMENDMENT TO BE CONSIDERED AS NEW PLAN [g) AMENDMENT --'==----. C-O-M-PL_E_T_E_B-LO_C_K_S_6_T_H-:R=U=---10-I...,F_T_H_I_S_lS_A_N .AMENDMENT Se arate Transmittal for each amendment 6.:FEDERALSTATUTE/REGULATION CITATION: 7. FEDERAL BUDGET IMPACT: l9,32(a)(2)(B)42CFR438(d){l) a.FFY2013 $0 • 42CFR43S.50 •. b.FFY2014 $0 I 932(a)(4)42 CFR 438.50 ---------.-,-t-:--~-==~::---==---:....:: ' :8. PAGE NUMBER OF THE PLAN SECTION OR A IT ACHMENT: 19. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION , OR ATTACHMENT (If Applicable): AMcl>mo.rH· ,,,tt '· 9 & 10 . -·--J A"'''m'"' ,H, '"'"' '· 9, & 1-=0:---::-::---:-:---:--::--::-:-:-:-:-c- 1 0 •. SUBJECT OF AMENDMENT: This State Plan changes the following: removes check mark in State Plan allowing dual eligible <f1edicaidJMedicare) beneficiaries to voluntarily enroll into Managed Care; revises State Plan language to make beneficiaries under . OQ.~ :Cl) year of age, where SCDHHS cannot determine the mother's enrollment in a health plan, a mandatory managed care eligible 'group; and revises State Plan language to reflect current language in the scope of service for the Request For Proposal (RFP) which st<ltes SCPHHS will perform the face to face informed choice counseling with beneficiaries who are selecting a managed care option. 11. GOVE~OR'S REVIEW (Check One): .~ 0 O:O:vERNOR~S OFFICE REPORTED NO COMMENT 0 COMMENTS OF GOVERNOR'S OFFICE ENCLOSED ·o NO,, REPLY RECEIVED WITHIN 45 DAYS OF SUBMIITAL 12. SIGNATURE OF STATE AGENCY OFFICIAL: !g) OTHER, AS SPECIFIED; Mr. Keck was designated by the Govemor to review and approve all State Plans 1-:-1-:-3.-=T=Y:-::P=-E=D:::-cN-AM-=E-:----------------South Carolina Department of Health and Human Services Post Office Box 8206 · r---:-:A:.::n:.::th:-:oc::n:.:-,::E:.:.h..:,K:::.:e:..::c:.:.k ___________________ columbia, sc 29202-8206 14. TITLE: Director 15. DATE SUBMITTED: November 8, 2013 17. DATE RECEIVED: 11/08/13 19. EFFECTIVE DATE OF :APPROVED MATERIAL: 10/01/13 21. TYPED NAME: Jackie Glaze 23. REMARKS: FORM HCFA-179 (07-92) • j . ~ • 18. DATE APPROVED: 01127/14 OF REGIONAL OFFICIAL: Its! I 22. TITLE: AssOciate Regional Administrator Division ofMedicaid & Children Health ns

CMS-PM-10120 Date: State: Citation 1932(a)(2)(B) 42 CFR 438(d)( I) 1932(a)(2)(C) 42 CFR 438(d)(2) 1932(a)(2)(A)(i) 42 CFR 438.SO(d)(3)(i) l932(a)(2)(A)(iii) 42 CFR 438.50(d)(3)(ii) TN No. SC 13-006 Supersedes TN No.: SC I 0-004 South Carolina Condition or Requirement ATTACHMENT 3.1-F Page 5 OMB No.:0938-933 ix. Aged or disabled beneficiaries (ABD) who have countable monthly income at or below l 00% of the Federal Poverty level and resources below a defined limit. x. Working Disabled beneficiaries who meet the Social Security definition of disabled and are working who also meet financial criteria. xi. Beneficiaries who are uninsured women diagnosed and found to need treatment for breast and/or cervical cancer or pre-cancerous lesions. 2. Mandatory exempt groups identified in l932(a)(J )(A){i) and 42 CFR 438.50. Use a check mark to affirm if there is voluntary enrollment any of the following mandatory exempt groups. i. __ Recipients who are also eligible for Medicare. If enrollment is voluntary, describe the circumstances of enrollment. (Example: Recipients who become Medicare eligible during mid- enrollment, remain eligible for managed care and are not disenrolled into fee-for-service.) ii. ..,[ Indians who are members of Federally recognized Tribes except when the MCO or PCCM is operated by the Indian Health Service or an Indian Health program operating under a contract, grant or cooperative agreement with the Indian Health Service pursuant to the Indian Self Determination Act; or an Urban Indian program operating under a contract or grant with the Indian Health Service pursuant to title V of the Indian Health Care Improvement Act. Tribal members are identified by Indian Health Service providers and associated claims are paid under the fee-for-service system. iii.:-l._Children under the age of 19 years, who are eligible for Supplemental Security Income (SSI) under title XVI. iv.L_Children under the age of 19 years who are eligible under 1902(e)(3) ofthe Act. Approval Date: 01-27-14 Effective Date: 10/01113

CMS-PM-10120 Date: State: South Carolina ATTACHMENT 3.1-F Page 9 OMB No.:0938-933 ------·----·---~------------------ Citation Condition or Requirement --·-·-·-------------- 42 CFR 438.50 42 CFR 438.50 F. List other eligible groups (not previously mentioned) who will be exempt from mandatory enrollment The following eligible groups will be excluded from enrolling in managed care: l. Beneficiaries in a nursing home or institutional long-term care facility. 2. Beneficiaries hospitalized for an extended period longer than thirty (30) days. 3. Beneficiaries receiving family planning services only. 4. Beneficiaries that are considered refugees. G. List all other eligible groups who will be permitted to enroll on a voluntary basis Other eligible groups that will be excluded from mandatory enrollment into managed care but may enroll on a voluntary basis include the following categories of beneficiaries: 1. Beneficiaries in home and community waiver programs. 2. Beneficiaries who reside in a residential care facility or a community long- term care facility. H. Enrollment process. 1932(a)(4) I. Definitions 42 CFR 438.50 1932(a)(4) 42 CFR 438.50 TN No. SC 13-006 Supersedes TN No.: SC 10-004 1. An extstmg provider-recipient relationship is one in which the provider was the main source of Medicaid services for the recipient during the previous year. This may be established through state records of previous managed care enrollment or fee-for-service experience, or through contact with the recipient. ii. A provider is considered to have "traditionally served" Medicaid recipients if it has experience in serving the Medicaid population. 2. State process for enrollment by default. Describe how the state's default enrollment process will preserve: Approval Date: 01-27-14 Effective Date: I 0/01113

CMS-PM-10120 Date: State: Citation ----~-·-·---- l932(a)(4) 42 CFR 438.50 TN No. SC 13-006 Supersedes TN No.: SC 12-022 3. South Carolina Condition or Requirement ATTACHMENT 3.1-F Page 10 OMB No.:0938-933 t. the existing provider-recipient relationship (as defined in H.l.i). ii. the relationship with providers that have traditionally served Medicaid recipients (as defined in H.2.ii). iii. the equitable distribution of Medicaid recipients among qualified MCOs and PCCMs available to enroll them, (excluding those that are subject to intermediate sanction described in 42 CFR 438.702(a)(4)); and disenrollment for cause in accordance with 42 CFR 438.56 (d)(2). (Example: No auto-assignments will be made if MCO meets a certain percentage of capacity.) The State utilizes an Enrollment Broker to provide enrollment assistance in an unbiased, informative manner. The Enrollment Broker assists the beneficiary's plan selection by matching the Plan's providers, services and locations with the beneficiary's needs and preferences by discussing participating providers and special services offered by the various plans. The Enrollment Package that is issued to each eligible beneficiary provides directions that enable them to make an informed choice regarding their managed care plan and provider; preserving the beneficiary's current provider relationship if desired. The SCDHHS offers each beneficiary, including non-English speaking beneficiaries, an opportunity to personally visit with an Enrollment Counselor within regions, or by appointment in each county, to complete the Enrollment process or provide other assistance. The Enrollment Broker also provides training opportunities to the provider community that emphasizes the opportunities managed care offers to their patients. Educational campaigns emphasizing the benefits of a medical home are also directed to the beneficiaries. When qualified beneficiaries fail to select a managed care health plan, the Enrollment Broker will assign them to a plan. The assignment of beneficiaries to a health plan incorporates algorithms that ensure an equitable distribution of beneficiaries to each plan eligible to receive new members. The assignment process includes logic that assures the beneficiary of a secondary choice, should the assigned plan not meet their needs. As part of the state's discussion on the default enrollment process, include the following information: i. The state willlL/will not __ .. use a lock-in for managed care. ii. The time frame for recipients to choose a health plan before being auto-assigned will be 30 days Approval Date: 01-27-14 Effective Date: 10/01/13

Table of Contents State/Territory Name: South Carolina State Plan Amendment (SPA) #:13-0014-MM1 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 Atlanta Regional Office 61 Forsyth Street, Suite 4T20 Atlanta, Georgia 30303

DIVISION OF M EDICAID & CHILDREN’S HEALTH OPERATIONS

January 13, 2014

Mr. Anthony E. Keck Director SC Department of Health and Human Services Post Office Box 8206 Columbia, South Carolina 29202-8206

Attention: Sheila Chavis

RE: Title XIX State Plan Amendment, SC 13-0014-MM1

Dear Mr. Keck:

Enclosed is an approved copy of South Carolina’s State Plan Amendment (SPA) 13-0014-MM1, which was received by CMS on November 18, 2013. SPA 13-0014-MM1 incorporates the MAGI- Based Eligibility Group SPA into South Carolina’s State Plan in accordance with the Affordable Care Act. The SPA was approved on January 10, 2013 and the effective date is January 1, 2014.

Enclosed is a copy of the new State Plan pages to be incorporated within a separate section at the back of South Carolina’s approved State Plan:

• S14, Pages S14-1 through S14-6 • S25, Pages S25-1 through S25-3 • S28, Pages S28-1 through S28-2 • S30, Pages S30-1 through S30-5 • S32, Page S32-1 • S33, Page S33-1 • S50, Page S50-1 • S51, Page S51-1 • S52, Page S52-1 through S52-8 • S53, Page S53-1 through S53-3 • S54, Page S54-1 through S54-3 • S55, Page S55-1 • S57, Page S57-1 • S59, Page S59-1 through S59-2 • Attachment to S59 Individuals Eligible for Family Planning Services

Anthony E. Keck Page 2

In addition, enclosed is a summary of State Plan pages which are superseded by SPA 13-0014-MM1, which should also be incorporated into a separate section in the front of the State Plan:

• Superseding Pages of State Plan Material, 13-0014-MM1

Notwithstanding any other provisions of the South Carolina Medicaid State Plan, the financial eligibility methodologies described in SPA SC 13-0014-MM1 will apply to all MAGI-based eligibility groups covered under South Carolina’s 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 SPA supersedes the current financial eligibility provisions of the Medicaid State Plan only with respect to the MAGI- based eligibility groups.

Congratulations to you and your staff for your hard work and strong collaboration. If you have any questions, please contact Maria Drake at 404-562-3697 or by e-mail at Maria.Drake@cms.hhs.gov.

Sincerely,

//s//

Jackie Glaze

Associate Regional Administrator

Division of Medicaid & Children’s Health Operations

Enclosures

Medicaid State Plan Eligibility: Summary Page (CMS 179)

State/Territory name: South Carolina

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.

| SC-13-001

Proposed Effective Date

10/01/2012 (mm/dd/yyyy)

Federal Statute/ Regulation Citation

| 42 CFR 43t

Federal Budget Impact

Federal Fiscal Year Amount

First Year 2014 $l 2.70

Second Year 2015 $ 3.60

Subject of Amendment

Character count out of 2000

13-014=MAGHBased Bigibitty G +

| Lt | J

Governor's Office Review

c Governor's office reported no comment

Cc Comments of Governor's office received

Describe:

7

|

Lt a

c No reply received within 45 days of submittal

E Other, as specified

Describe:

M. Anthony E Keck was ee

| Lt _I

Signature of State Agency Official

Submitted By: Sheila Chavis Last Revision Date: Nov 18, 2013

Submit Date: Nov 18, 2013

Character Count: out of 2000

1

SUPERSEDING PAGES OF STATE PLAN MATERIAL

TRANSMITTAL NUMBER:

13-0014 MM1

STATE:

South Carolina

Pages or sections of pages being superseded by S25, S28, S30, S51, S52, S53, S54, S59 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 12 Page 13 Page 13a Page 14 Page 14a Page 23 Page 23b Page 28

Page 2, A.2.b Page 2, A.2.c Page 2a, A. 3. Page 5, A.10. Page 9c, B.1 remove “caretaker relatives & pregnant women” Page 20, B.14 Page 23c, B.19 and B.21 Page 23d, B.23 Page 25, C.4.

Supplement 1 to Attachment 2.2-A

Page 1

Attachment 2.6-A

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

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

Supplement 1 to Attachment

Pages 1-4

2

2.6-A

Supplement 2 to Attachment 2.6-A

Pages 1-5

Supplement 8a to Attachment 2.6-A

Page 5

Page 1, B and C Page 2 related to qualified children and pregnant women; poverty level pregnant women, infants, and children; Reasonable categories of AFDC- 1905(a)(i)related children, State subsidized adoption children, and Independent foster care adolescents

Supplement 12 to Attachment 2.6-A

Pages 1-3

Ms Medicaid Eligibility

CONTE Pom Me ECARE A RCRD ESTICTE

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

S14

AFDC Income Standards

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.

MAGL-equivalent AFDC P

ent Standard in Effect As of May 1, 1988

Income Standard Entry - Dollar Amount

IncreaseOption . —Si3a

The standard is as follows: (@ Statewide standard C Standard varies by region C Standard varies by living arrangement

C Standard varies in some other way

[Enter the statewide standard = : ee 2 : | TN No: SC-13-0014-MM1 Approval Date: 01/10/14 Effective Date: 01/01/14

South Carolina $14-1

Ss Medicaid Eligibility

crerteh Poe Macpacaat & ee DACA NT

Household size | Standard ($) ae amen moun’ Col 163 xX) Increment amount $ +/2 219 xX +) 3 276 x #l4 332 X +)5 388 x +\6 445 x +17 501 xX *#/s 558 x +#lo 614 D4 +] 10 671 x dei 727 Xx *#/12 783 x #113 839 x #4 397 x #15 953 xX

The dollar amounts increase automatically each year C Yes (@ No

The standard is as follows:

@ Statewide standard C Standard varies by region

C Standard varies by living arrangement

TN No: SC-13-0014-MM1 Approval Date: 01/10/14 Effective Date: 01/01/14 South Carolina $14-2

CcmMs Medicaid Eligibility

C Standard varies in some other way

Enter the statewide standard Household size | Standard ($) a “ee ow mount +1 119 x Increment amount $ +)2 160 x +#)3 : 201 xX #4 242 x +15 283 x +16 324 xX +17 365 x +] 407 x +/9 448 xX +110 489 x iu 530 x 112 571 x #13 612 x | + 14 654 x 115 695 x

The dollar amounts increase automatically each year C Yes (@ No

The standard is as follows:

@ Statewide standard

TN No: SC-13-0014-MM1 Approval Date: 01/10/14 Effective Date: 01/01/14 South Carolina 514-3

Cems eset

Medicaid Eligibility

C Standard varies by region

C Standard varies in some other way

C Standard varies by living arrangement

Additional incremental amount C Yes @No

Increment amount $

[Enter the statewide standard _ Household size | Standard ($)

+1 163 x +)2 219 x +/3 276 xX +i4 332 4 ls 388 xX #16 445 xX +17 501 X

| ys 558 x +9 614 xX #} 10 671 x 1 727 xX +] 12 783 x

pe] 13 839 x His 897 x 15 953 %

C Yes (@ No

The dollar amounts increase automatically each year

The standard is as follows:

TN No: SC-13-0014-MM1 South Carolina

Approval Date: 01/10/14 $14-4

Effective Date: 01/01/14

cCcmMs Medicaid Eligibility

C Statewide standard C Standard varies by region C Standard varies by living arrangement

C Standard varies in some other way

The dollar amounts increase automatically each year

C Yes (No

ARDE Payment Standard in Effect As increase in the Consumer Price Ind

ners (CPI-U) since such

‘more than the percentage date.

Income Standard Entry - Dollar Amount

The standard is as follows: C Statewide standard C Standard varies by region C Standard varies by living arrangement

C Standard varies in some other way

The dollar amounts increase automatically each year

C Yes (No

MAGT-equivalent AFDC Payment Standard than the percentage _— the Consun such date :

The standard is as follows: C Statewide standard C Standard varies by region C Standard varies by living arrangement

C Standard varies in some other way

The dollar amounts increase automatically each year

C Yes (C No

TN No: SC-13-0014-MM1 Approval Date: 01/10/14 South Carolina $14-5

Effective Date: 01/01/14

cCcmMs Medicaid Eligibility

TANF payment standard |

Income Standard Entry - Dollar Amount - Automatic Increase'Option _ S13a

The standard is as follows: C Statewide standard C Standard varies by region C Standard varies by living arrangement

C Standard varies in some other way

The dollar amounts increase automatically each year

C Yes (© No

MAGL-equivalent TANF payment standard

Income Standard Entry - Dollar Amount - Automatic Increase Option __ Si3a

The standard is as follows: C Statewide standard C Standard varies by region C Standard varies by living arrangement

C Standard varies in some other way

The dollar amounts increase automatically each year

C Yes C 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.

N -135- a ate: 01/10/14 ective Date: 14 N No: SC-13-0014. MM1 Approval D:

Medicaid Eligibility

STMT POS MEARE A MOC AIO ICTY

OMB Control Number 0938-1148

Parents and Other Caretaker Relatives

OMB Expiration date: 10/31/2014 $25

roups - Mandatory C

42 CFR 435.110 1902(a)(10)(A)G)(1) 1931(b) and (d)

a

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: [M] Individuals qualifying under this eligibility group must meet the following criteria:

iw 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):

Oo 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 The standard definition of caretaker relative at 42 CFR 435.4 as well as cousin relatives: lonce removed.

oO 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 No: SC-13-0014-MM1 Approval Date: 01/10/14 Effective Date: 01/01/14 Saiith Carolina S7S-1

Ss Medicaid Eligibility

CR tet 10m ecru ane A ant ND MEIC

[M] Have household income at or below the standard established by the state.

im 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 $14 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.

[B] 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.

Cc 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 C demonstration as of March 23, 2010, converted toa 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 C 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 No: SC-13-0014-MM1 Approval Date: 01/10/14 Effective Date: 01/01/14 Cniith Carolina $25-2

Ss Medicaid Eligibility

CONIA tO MeDeCAE bet ERIN

@ A percentage of the federal poverty level: |62 %

The state's AFDC payment standard in effect as of July 16, 1996, converted to a MAGI-equivalent standard. The

c 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 C 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 $14 AFDC Income Standards.

Cc The state's TANF payment standard, converted to a MAGI-equivalent standard. The standard is described in $14 AFDC Income Standards.

C Other dollar amount

[mM] Income standard chosen: Indicate the state's income standard used for this eligibility group: C 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 C increase in the Consumer Price Index for urban consumers (CPI-U) since such date. The standard is described in S14 AFDC Income Standards.

C Another income standard in-between the minimum and maximum standards allowed [m] There is no resource test for this eligibility group.

[m 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.

C 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 No: SC-13-0014-MM1 A pproval Date: 01/1 F . South Carolina coe a /10/14 Effective Date: 01/01/14

ccms Medicaid Eligibility

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

$28

Eligibility Groups - Msadatory: Cove! Pregnant Women :

;

42 CFR 435.116 1902(a)(10)(A)(i)(IH) and (1V) 1902(a)(10)(A)(ii)(1), (IV) and (IX) 1931(b) and (d)

1920

[m) 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: [m) 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 C No

iw MAGI-based income methodologies are used in calculating household income. Please refer as necessary to S10 MAGI-Based Income Methodologies, completed by the state.

[MJ Income standard used for this group [m) 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

[m] 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)(ILI) (qualified pregnant women), 1902(a)(10)(A)(i)(IV) (mandatory poverty level- related pregnant women), 1902(a)(10)(A)(ii)(LX) (optional poverty level-related pregnant women), 1902(a)(10) (A\(ii)(1) (pregnant women who meet AFDC financial eligibility criteria) and 1902(a)(10)(A)(ii)(1V) (institutionalized pregnant women) in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL.

TN No: SC-13-0014-MM1

South Carolina Approval Date: 01/10/14

Effective Date: 01/01/14 ©7904

a Medicaid Eligibility

CTT OM MACABRE MOC

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-

Cc related pregnant women), 1902(a)(10)(A)(ii)(IX) (optional poverty level-related pregnant women), 1902(a)(10) (AXii)(1) (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.

Cc 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.

Cc 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.

C 185% FPL

The amount of the maximum income standard is:| 194 % FPL

[| Income standard chosen Indicate the state's income standard used for this eligibility group: C The minimum income standard (* The maximum income standard C Another income standard in-between the minimum and maximum standards allowed. [@ There is no resource test for this eligibility group. [m) 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.

[mw] Presumptive Eligibility

The state covers ambulatory prenatal care for individuals under this group when determined presumptively eligible by a qualified entity.

C 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 No: SC-13-0014-MM1

South Carolina Approval Date: 01/10/14 Effective Date: 01/01/14 $28-2

Medicaid Eligibility

OMB Control Number 0938-1148

Eligibility Groups - Mandatory C. erage Infants and Children under Age 1

OMB Expiration date: 10/31/2014

42 CFR 435.118

1902(a)(10)(A)(i)(II), (IV), (VI) and (VII) 1902(a)(10)(A )(ii)(TV) and (1X)

1931(b) and (d)

the state based on age group.

[M] Are under age 19 [@] Have household income at or below the standard established by the state.

iw MAGI-based income methodologies are used in calculating household income Based Income Methodologies, completed by the state.

[mM] Income standard used for infants under age one

[S] Minimum income standard

(@ Yes (CC No

[i Maximum income standard

for infants under age one.

i Infants and Children under Age 19 - Infants and children under age 19 with household income at or below standards established by

The state attests that it operates this eligibility group in accordance with the following provisions:

[M) Children qualifying under this eligibility group must meet the following criteria:

. Please refer as necessary to S10 MAGI-

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.

Enter the amount of the minimum income standard (no higher than 185% FPL):|185 % FPL

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

An attachment is submitted. ©

The state's maximum income standard for this age group is:

equivalent percent of FPL.

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)(II1) (qualified children), 1902(a)(10)(A)(i)(IV) (mandatory poverty level-related

@ infants), 1902(a)(10)(A)(ii)(1X) (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-

TN No: SC-13-0014-MM1

+ carolina Approval Date: 01/10/14 South Car

$30-1

Effective Date: 01/01/14

ccms Medicaid Eligibility

C

Cc

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)(LX) (optional poverty level-related infants) and 1902(a)( 10)(A )(ii)(1V) (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: }194 % FPL

[mM] Income standard chosen

The state's income standard used for infants under age one is:

@

Cc

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)(IIL) (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)(LV) (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.

[mM] Income standard for children age one through age five, inclusive

[=| Minimum income standard

TN No: SC-13-0014-MM1 South Carolina Approval Date: 01/10/14 Effective Date: 01/01/14

S207

ccms Medicaid Eligibility

e

The minimum income standard used for this age group is 133% FPL.

[B) 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)( V1) (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(aX10)(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: |143 % FPL

[m_ 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)(V1) (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)(iXIII) (qualified children), 1902(a)(10)(A)(iX 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 No: SC-13-0014-MM1 South Carolina Approval Date: 01/10/14

oral Effective Date: 01/01/14

PUTIN POE MADACARD h mSDIC AIO MaNCRR

Medicaid Eligibility

Cc

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.

[M]_ Income standard for children age six through age eighteen, inclusive

{| Minimum income standard

a

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:

Cc

@

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)(II]) (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 [115 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 No: SC-13-0014-MM1 South Carolina Approval Date: 01/10/14 Effective Date: 01/01/14

Clana

Ss Medicaid Eligibility

CrA1es ron MOKA A OA ECR

@ 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)(II1) (qualified children),

C 1902(a)(10)(A)(i)(VI) (mandatory poverty level-related children age six through eighteen) and 1902(a)(10)(A) (ii)(TV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGIl-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)(IIL) (qualified children), 1902(a)( 10)(A)(i)(VIL) (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.

Cc {m] There is no resource test for this eligibility group. [m] Presumptive Eligibility

The state covers children when determined presumptively eligible by a qualified entity.

C 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 No: SC-13-0014-MM1 Approval Date: 01/10/14 Effective Date: 01/01/14 South Carolina 530-5

Medicaid Eligibility

TONTENL FO Macca & ENC AND ICKY

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

iY

Eligibility Groups - Mandatory Coverage | Adult Group ae ae

1902(a)(10)(A)(i)(VIIL) 42 CFR 435.119

The state covers the Adult Group as described at 42 CFR 435.119. C 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 No: SC-13-0014-MM1 . South Carolina APP Date: 01/10/14 Effective Date: 01/01/14

(CONES PO Maca A AREA ANE EK

Medicaid Eligibility

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

$33

Eligibility Groups - Mandatory Coverage Former Foster Care C

42 CFR 435.150 1902(a)(10)(A)(i)(IX)

ae

iw 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: y [@] Are under age 26. iw 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 {mj 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.

C 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.

C 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 No: SC-13-0014-MM1

Approval Date: South Carolina Pproval Date: 01/10/14

Effective Date: 533-1 01/01/14

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

Bigibally Groups Individuals above | 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.

C 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 No: SC-13-0014-MM1

South Carolina Approval Date: 01/10/14 Effective Date: 01/01/14 $50-1

Ss Medicaid Eligibility

CPUS FOE MA ACADH bE VCR

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

42 CFR 435.220 1902(a)(10)(A)(ii)(1)

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.

C 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 No: SC-13-0014-MM1

Approval Date: 01/10/14 South Carolina ’

Effective Date: 01/01/14 $51-1

Medicaid Eligibility

OMB Control Number 0938-1148 MB Expirati 10/31/2014

42 CFR 435.222 1902(a)(10)(A)(ii)(1) 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:

wl Individuals qualifying under this eligibility group must qualify under a reasonable classification by meeting the following criteria:

[lM] Be under age 21, or a lower age, as defined within the reasonable classification.

im Have household income at or below the standard established by the state, if the state has an income standard for the reasonable classification.

[i] Not be eligible and enrolled for mandatory coverage under the state plan.

iw 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 (C 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 CNo

Reasonable Classification: red in the Medicaid State Plan f

The state attaches the approved pages from the Medicaid state plan as of March 23, 2010 to indicate the age groups, reasonable classifications, and income standards used at that time for this eligibility group.

Current Coverage of All Children under a Specified Age

SC-13-0014-MM1

Approval Date: South Carolina ° ate: 02/10/14

Effective D 552-1 ate 01/01/14

Medicaid Eligibility

The state covers all children under a specified age limit, equal to or higher than the age limit and/or income standard used in the Medicaid.state plan as of March 23, 2010, provided the income standard is higher than the current mandatory income standard for the individual's age. The age limit and/or income standard used must be no higher than any age limit and/or income standard covered 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. Higher income standards may include the disregard of all income.

C Yes (@~-No

Current Coverage of Reasonable Classifications Covered in the Medicaid State Plan as of March 23, 2010

The state covers reasonable classifications of children previously covered in the Medicaid state plan as of March 23, 2010, with income standards higher than the current mandatory income standard for the age group. Age limits and income standards are equal to or higher than the Medicaid state plan as of March 23, 2010, but no higher than any age limit and/or income standard for this classification covered 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. Higher income standards may include the disregard of all income.

@ Yes © No

Indicate the reasonable classifications of children that were covered in the state plan in effect as of March 23, 2010 with income standards higher than the mandatory standards used for the child's age, using age limits and income standards that are not more restrictive than used in the state plan as of as March 23, 2010 and are not less restrictive than 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.

Current Coverage of Reasonable Classifications Covered in the Medicaid State Plan as of March 23, 2010

[X] Individuals for whom public agencies are assuming full or partial financial responsibility.

[X] Individuals placed in foster care homes by public agencies Indicate the age which applies: @ Under age 21 (Underage 20 (Underage 19 (7 Under age 18

| (J Individuals placed in foster care homes by private, non-profit agencies

Individuals placed in private institutions by public agencies Indicate the age which applies: @ Under age 21 (Underage 20 (> Underage 19 (Under age 18

(J Individuals placed in private institutions by private, non-profit agencies

(J Individuals in adoptions subsidized in full or part by a public agency

(J Individuals in nursing facilities, if nursing facility services are provided under this plan

Oo Individuals receiving active treatment as inpatients in psychiatric facilities or programs, if such services are provided under this plan

SC-13-0014-MM1 Approval Date: 01/10/14 Effective Date 01/01/14 South Carolina $52-2

Carers 108 OCA 8 OCAID MEIER

Medicaid Eligibility

(J Other reasonable classifications

Enter the income standard used for these classifications. The income standard must be higher than the mandatory standard for the child's age. It may be no lower than the income standard used in the state plan as of March 23,

2010 and 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.

[] Income standard used

[®] 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 $14 AFDC Income Standards.

[=] Maximum income standard 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.

C Yes @No

The state certifies that it has submitted and received approval for its converted income standards 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.

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 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 the Medicaid state plan C: 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 C Demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size.

SC-13-0014-MM1 South Carolina $52-3

Approval Date: 01/10/14 Effective Date 01/01/14

Medicaid Eligibility

The state's effective income level for this classification of children under a Medicaid 1115 C 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:

@ A percentage of the federal poverty level: 62| %

The state's AFDC payment standard in effect as of July 16, 1996, converted to a MAGI-

Cc equivalent standard. This standard is described in $14 AFDC Income Standards. This option should only be selected for children 19 and older, and only if the state has not elected to cover the Adult Group.

The state's TANF payment standard, converted to a MAGI-equivalent standard. This standard is

C. described in $14 AFDC Income Standards. This option should only be selected for children 19 and older, and only if the state has not elected to cover the Adult Group.

C Other dollar amount [| Income standard chosen Individuals qualify under this classification under the following income standard: C The minimum standard. (@ The maximum income standard.

If not chosen as the maximum income standard, the state's effective income level for this C: classification under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size.

If not chosen as the maximum income standard, and if higher than the effective income level used under the Medicaid state plan as of March 23, 2010, the state's effective income level for this classification under the Medicaid state plan as of December 31, 2013, converted to a MAGI- equivalent percent of FPL or amounts by household size.

If not chosen as the maximum income standard, and if higher than the effective income level used under the Medicaid state plan as of March 23, 2010, the state's effective income level for this classification under a Medicaid 1115 Demonstration as of March 23, 2010, converted to a MAGI- equivalent percent of FPL or amounts by household size.

If not chosen as the maximum income standard, and if higher than the effective income level used

Cc under the Medicaid state plan as of March 23, 2010, the state's effective income level for this classification under a Medicaid 1115 Demonstration as of December 31, 2013, converted to a MAGI- equivalent percent of FPL or amounts by household size.

Another income standard in-between the minimum and maximum standards allowed, provided it is C higher than the effective income level for this classification in the state plan as of March 23, 2010, converted to a MAGI equivalent.

SC-13-0014-MM1 Approval Date: 01/10/14 Effective Date 01/01/14 South Carolina $52-4

s Medicaid Eligibility

OEERS TOR MECCA 8 CAND BNE

[@] Income standard used

[®) 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 $14 AFDC Income Standards.

[§) Maximum income standard 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.

C Yes @No

The state certifies that it has submitted and received approval for its converted income standards 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.

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 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 the Medicaid state plan Cas 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 C. 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 C 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:

SC-13-0014-MM1 Approval Date: 01/10/14 Effective Date 01/01/14 South Carolina $52-5

Medicaid Eligibility

Cc Ce

@ A percentage of the federal poverty level: 62| %

The state's AFDC payment standard in effect as of July 16, 1996, converted to a MAGI-

C equivalent standard. This standard is described in $14 AFDC Income Standards. This option should only be selected for children 19 and older, and only if the state has not elected to cover the Adult Group.

The state's TANF payment standard, converted to a MAGI-equivalent standard. This standard is C. described in $14 AFDC Income Standards. This option should only be selected for children 19 and older, and only if the state has not elected to cover the Adult Group.

C. Other dollar amount

[m] Income standard chosen

Individuals qualify under this classification under the following income standard:

The minimum standard. The maximum income standard.

If not chosen as the maximum income standard, the state's effective income level for this classification under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size.

If not chosen as the maximum income standard, and if higher than the effective income level used under the Medicaid state plan as of March 23, 2010, the state's effective income level for this classification under the Medicaid state plan as of December 31, 2013, converted to a MAGI- equivalent percent of FPL or amounts by household size.

If not chosen as the maximum income standard, and if higher than the effective income level used under the Medicaid state plan as of March 23, 2010, the state's effective income level for this classification under a Medicaid 1115 Demonstration as of March 23, 2010, converted to a MAGI- equivalent percent of FPL or amounts by household size.

If not chosen as the maximum income standard, and if higher than the effective income level used under the Medicaid state plan as of March 23, 2010, the state's effective income level for this classification under a Medicaid 1115 Demonstration as of December 31, 2013, converted to a MAGI- equivalent percent of FPL or amounts by household size.

Another income standard in-between the minimum and maximum standards allowed, provided it is higher than the effective income level for this classification in the state plan as of March 23, 2010, converted to a MAGI equivalent.

Other Reasonable Classifications Previously Covered

The state covers reasonable classifications of children not covered in the Medicaid state plan as of March 23, 2010, but covered under the Medicaid state plan as of December 31, 2013 or under a Medicaid | 115 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

C-13-0014-MM1

South Carolina

C No

Approval Date: 01/10/14 Effective Date 01/01/14 $52-6

Medicaid Eligibility

The additional previously covered reasonable classifications to be included are:

Additional Previously Covered Reasonable Classifications Included

(J Individuals for whom public agencies are assuming full or partial financial responsibility. (1 Individuals in adoptions subsidized in full or part by a public agency (J Individuals in nursing facilities, if nursing facility services are provided under this plan

gO 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

Children who were enrolled in Medicaid on 12/31/2013 and would otherwise become ineligible for Medicaid at their first redetermination 2101(f)-Like Children using MAGI methodologies solely due ||Under age 19 to the loss of income disregards will remain Medicaid eligible until their next redetermination using MAGI methodologies

Enter the income standard used for these classifications (which must be higher than the mandatory standard for the child's age but may be no higher than the highest standard used in the state plan as of December 31, 2013 or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013).

[B] 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

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

[B] No income test was used (all income was disregarded) for this classification under:

SC-13-0014-MM1 Approval Date: 01/10/14

Effective Date 01/01/14 South Carolina $52-7

Medicaid Eligibility

(check all that apply)

(2) The Medicaid state plan as of March 23, 2010.

The Medicaid state plan as of December 31, 2013.

CD A Medicaid 1115 Demonstration as of March 23, 2010.

DD A Medicaid 1115 Demonstration as of December 31, 2013.

The state's maximum standard for this classification of children is no income test (all income is disregarded).

[m] 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 both the minimum income standard and the effective income level for this classification in the state plan as of March 23, 2010, converted to a MAGI equivalent.

Additional new age groups or reasonable classifications covere

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.

C Yes @No

{m] 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.

SC-13-0014-MM1 Approval Date: 01/10/14

Effective D South Carolina S59-2 ve Date 01/01/14

Medicaid Eligibility

TMU FOE MCCABE b MORAN LICE

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

S53

r

42 CFR 435.227 1902(a)(10)(A (ii) VII)

Children with Non IV-E Adoption Assistance - The state elects to cover children with special needs for whom there is a non 1V-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:

[Mi] Individuals qualifying under this eligibility group must meet the following criteria:

iw The state adoption agency has determined that they cannot be placed without Medicaid coverage because of special needs for medical or rehabilitative care;

[mM] Are under the following age (see the Guidance for restrictions on the selection of an age): (@ Under age 21 C Under age 20 C Under age 19 C Under age 18

iw 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 (C No

The state also covered this eligibility group in the Medicaid state plan as of March 23, 2010. @ Yes ( No

oy 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 [mM] Income standard used for this eligibility group

[&] Minimum income standard

The minimum income standard for this eligibility group 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.

[fm] Maximum income standard

TN No: SC-13-0014-MM1

South Carolina Approval Date: 01/10/14

Effective Date: 0: 553-1 1/01/14

Medicaid Eligibility

TN No: SC-13-0014-MM1 Approval Date: 01/10/14 South Carolina $53-2

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.

C Yes (@ No

The state certifies that it has submitted and received approval for its converted income standard(s) for this eligibility group to MAGI-equivalent standards and the determination of the maximum income standard to be used for individuals under this eligibility group.

ment is submitted.

The state's maximum income standard for this eligibility group (which must exceed the minimum) is:

@ The state's effective income level for this eligibility group under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size.

Cc The state's effective income level for this eligibility group under the Medicaid state plan as of December 31, 2013, converted toa MAGI-equivalent percent of FPL or amounts by household size.

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 or amounts by household size.

The state's effective income level for this eligibility group under a Medicaid 1115 Demonstration as of

c December 31, 2013, converted to a MAGI-equivalent percent of FPL or amounts by household size.

Enter the amount of the maximum income standard:

@ A percentage of the federal poverty level: 62|%

The state's AFDC payment standard in effect as of July 16, 1996, converted to a MAGI-equivalent

Cc standard. This standard is described in $14 AFDC Income Standards. This option should be selected only if Under age 21 or Under age 20 was selected, and if the state has not elected to cover the Adult Group.

The state's TANF payment standard, converted to a MAGI-equivalent standard. This standard is C described in $14 AFDC Income Standards. This option should be selected only if Under age 21 or Under age 20 was selected, and if the state has not elected to cover the Adult Group.

(C Other dollar amount

Income standard chosen

Individuals qualify under this eligibility group under the following income standard, which must be higher than the minimum for this child's age:

C The minimum standard. (@ The maximum income standard.

If not chosen as the maximum income standard, the state's effective income level for this eligibility group C under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size.

If not chosen as the maximum income standard, and if higher than the effective income level used under the Medicaid state plan as of March 23, 2010, 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, or amounts by household size.

Cc

Effective Date: 01/01/14

Corn roe Macoacane & aabDar AND METS

Medicaid Eligibility

C

If not chosen as the maximum income standard, and if higher than the effective income level used under the Medicaid state plan as of March 23, 2010, 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 or amounts by household size.

If not chosen as the maximum income standard, and if higher than the effective income level used under the Medicaid state plan as of March 23, 2010, 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 or amounts by household size.

Another income standard in-between the minimum and maximum standards allowed, provided it is higher than the effective income level for this eligibility group in the state plan as of March 23, 2010, converted to a MAGI-equivalent.

[@) 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 No: SC-13-0014-MM1 Approval Date: 01/10/14 Effective Date: 01/01/14

South Carolina

$53-3

cCcmMs. Medicaid Eligibility

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

$54

Eligibility Groups - Options for Cov Optional’ Targeted Low Income Childr 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: [m] Individuals qualifying under this eligibility group must not be eligible for Medicaid under any mandatory eligibility group.

ml 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 (C No

i Until October 1, 2019, states must include at least those individuals covered as of March 23, 2010, but may cover additional individuals. Effective October 1, 2019, states may reduce or eliminate coverage for this group.

[mJ Individuals are covered under this eligibility group, as follows: @ All children under age 18 or 19 are covered: @ Under age 19

C Under age 18

C The reasonable classification of children covered is: [| Income standard used for this classification [8] Minimum income standard

The 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

TN No: SC-13-0014-MM1 Approval Date: 01/10/14 Effecti : ective Date: South Carolina S54-1 @ Date: 01/01/14

Cccms Medicaid Eligibility

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.

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 March 23, 2010, converted to a MAGI-equivalent percent of FPL.

7 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.

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.

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.

C 200% FPL.

Cc 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.

i The state's maximum income standard for this classification of children (which must exceed the minimum for the classification) is:

208 % FPL

fl Income standard chosen, which must exceed the minimum income standard Individuals qualify under the following income standard:

(© The maximum income standard.

Cc The state's effective income level for this eligibility group under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL.

If higher than the effective income level used under the state plan as of March 23, 2010, the state's effective C income level for this eligibility group under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL.

If higher than the effective income level used under the state plan as of March 23, 2010, the state's effective C income level for this eligibility group under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL.

If higher than the effective income level used under the state plan as of March 23, 2010, the state's effective C income level for this eligibility group under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL.

C If higher than the effective income level used under the state plan as of March 23, 2010, 200% FPL.

TN No: SC-13-0014-MM1

A : : South Carolina pproval Date: 01/10/14 Effective Date: 01/01/14

$54-2

Medicaid Eligibility

ONS FO DACA A ORD ICTY

If higher than the effective income level used under the state plan as of March 23, 2010, a percentage of the C 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, provided it is higher than the effective income level for this eligibility group in the state plan as of March 23, 2010.

The income standard for this eligibility group is: {208 % FPL

[MW There is no resource test for this eligibility group. [M] 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 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 No: SC-13-0014-MM1 Approval Date: 01/10/14 Effective Date: 01/01/14 South Carolina $54-3

CcmMs Medicaid Eligibility

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

Eligibility Groups - Options for a Individuals with Tuberculosis

1902(a)(10)(A (ii) XID) 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.

C 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 No: SC-13-0014-MM1 Approval Date: 01/10/14

Effective Date: 01/01/14 South Carolina $55-1

Ss Medicaid Eligibility

CONTA FOE ME ACARE & MD SENICHE

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

$57

Eligibility Groups Independent Foster

42 CFR 435.226 1902(a)(10)(A)(ii)( XVI)

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.

C 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 No: SC-13-0014-MM1

South Carolina Approval Date: 01/10/14 Effective Date: 01/01/14

$57-1

| Medicaid Eligibility

CCT POR ROCA 6 MEDHCAND BESTICHE

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

1902(a)(10)(A)(ii)(XX1) 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

The state attests that it operates this eligibility group in accordance with the following provisions: [| The individual may be a male or a female. [@] Income standard used for this group [B] 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 this eligibility group.

The state's maximum income standard for this eligibility group is the highest of the following:

; The state's current effective income level for the Pregnant Women eligibility group (42 CFR 435.116) under the Medicaid state plan.

C The state's current effective income level for pregnant women under a Medicaid 1115 demonstration. C The state's current effective income level for Targeted Low-Income Pregnant Women under the CHIP state plan.

C The state's current effective income level for pregnant women under a CHIP 1115 demonstration.

The amount of the maximum income standard is:]194 % FPL

[B] Income standard chosen The state's income standard used for this eligibility group is: @ The maximum income standard C Another income standard less than the maximum standard allowed.

Ty MAGI-based income methodologies are used in calculating household income. Please refer as necessary to S10 MAGI- Based Income Methodologies, completed by the state.

TN No: SC-13-0014-MM1 Approval Date: 01/10/14 Effective Date: 01/01/14 South Carolina S59-1

Medicaid Eligibility

[Mf] In determining eligibility for this group, the state uses the following household size: All of the members of the family are included in the household LJ Only the applicant is included in the household LD The state increases the household size by one [m] In determining eligibility for this group, the state uses the following income methodology:

A The state considers the income of the applicant and all legally responsible household members (using MAGI-based methodology).

C The state considers only the income of the applicant. [| Benefits for this eligibility group are limited to family planning and related services described in the Benefit section. [@| Presumptive Eligibility

The state makes family planning services and supplies available to individuals covered under this group when determined presumptively eligible by a qualified entity.

C 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 No: SC-13-0014-MM1 Approval Date: 01/10/1 : 4 i : oath onalnn ees / Effective Date: 01/01/14

Table of Contents

State/Territory Name: South Carolina State Plan Amendment (SPA) #: 13-0015-MM2

This file contains the following documents in the order listed:

1) Approval Letter

2) Additional 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

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

Atlanta Regional Office

61 Forsyth Street, Suite 4T20

Atlanta, Georgia 30303 CENTERS FOR MEDICARE & MEDICAID SERVICES

DIVISION OF MEDICAID & CHILDREN’S HEALTH OPERATIONS

February 18, 2014

Mr. Anthony E. Keck

Director

SC Department of Health and Human Services Post Office Box 8206

Columbia, South Carolina 29202-8206

Attention: Sheila Chavis RE: S-94 — Eligibility Process State Plan Amendment (SPA), SC-13-0015-MM2 Dear Mr. Keck:

Enclosed is an approved copy of South Carolina’s state plan amendment (SPA) SC-13-0015-MM2, which was submitted to the Centers for Medicare & Medicaid Services (CMS) on November 18, 2013. SPA SC-13-0015-MM2 incorporates the MAGI-based eligibility process requirements, including the single streamlined application, into South Carolina’s Medicaid state plan in accordance with the Affordable Care Act. This SPA was approved on February 12, 2014. The effective date of this SPA is October 1, 2013.

The approval of SC-13-0015-MM2 includes full approval of your state’s alternative single streamlined paper application. The state is using an interim alternative single streamlined online application and by March 31, 2014 will implement a revised alternative single streamlined online application that addresses CMS concerns outlined in the companion letter issued with this SPA approval.

Enclosed is a copy of the following S94 state plan pages and attachments to be incorporated within a separate section at the end of South Carolina’s approved state plan:

e $94, pages S94-1 and $94-2 Attachment 1 — State of South Carolina’s alternative single streamlined paper application Attachment 2 — Statement of use with respect to the alternative single streamlined online application

e Attachment 3 — Statement regarding Agreements Related to Coordination of Eligibility and Enrollment

In addition, enclosed is a summary of state plan pages which are superseded by SPA SC-13-0015-MM2, which should also be incorporated into a separate section in the front of the state plan.

e Superseding Pages of State Plan Material, SC-13-0015-MM2

Mr. Anthony E. Keck Page 2

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 Maria Drake at (410) 562 — 3697 or at Maria.Drake@cms.hhs.gov

Sincerely,

/Is//

Jackie Glaze

Associate Regional Administrator

Division of Medicaid & Children’s Health Operations

Enclosures

“CMS

CENTERS FOR MEDICARE & MEDICAID SERVICES

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

Atlanta Regional Office

61 Forsyth Street, Suite 4T20

Atlanta, Georgia 30303

DIVISION OF MEDICAID & CHILDREN’S HEALTH OPERATIONS

February 18, 2014

Mr. Anthony E. Keck

Director

SC Department of Health and Human Services Post Office Box 8206

Columbia, South Carolina 29202-8206

Attention: Sheila Chavis

RE: S-94 — Eligibility Process State Plan Amendment (SPA), SC-13-0015-MM2

Dear Mr. Keck:

This letter is being sent as a companion to the Centers for Medicare & Medicaid Services (CMS) approval of South Carolina’s state plan amendment (SPA) transmittal SC-13-0015-MM2, which was submitted to CMS on November 18, 2013. Our review of this submission included a review

of the online alternative single streamlined application developed by the state.

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

Necessary Changes Date by which changes will be completed:

Tobacco use question will be removed from March 31, 2014 the online Medicaid application.

Reference to worker’s compensation as a wage | March 31, 2014 type will be removed from the household income information section.

Please submit the revised alternative single streamline online application to CMS for review no later than March 1, 2014 to ensure approval by March 31, 2014. We continue to be available to provide technical assistance.

Mr. Anthony E. Keck Page 2

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 additional questions or require any further assistance, please contact Maria Drake at (404) 562-3697 or at Maria.Drake@cms.hhs.gov.

Sincerely, /Is//

Jackie Glaze Associate Regional Administrator

Medicaid State Plan Eligibility: Summary Page (CMS 179)

State/Territory name: South Carolina

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.

| SC-13-001

Proposed Effective Date

| 10/01/2012 (mm/dd/yyyy)

Federal Statute/Regulation Citation

| 42 CFR 43:

Federal Budget Impact

Federal Fiscal Year Amount

First Year [2014 gl 200 Second Year 2015 gl 0.00

Subject of Amendment

Character count # out of 2000

$94= Bigibility Process +

aL on

Governor's Office Review

Governor's office reported no comment

Comments of Governor's office received

4 aL a

No reply received within 45 days of submittal

Describe:

& Other, as specified

Describe:

Character count i out of 2000

Mr. Anthony E. Keck was desig a

=i isl a

Signature of State Agency Official

Submitted By: Sheila Chavis Last Revision Date: Feb 11, 2014

Submit Date: Nov 18, 2013

SUPERSEDING PAGES OF STATE PLAN MATERIAL

TRANSMITTAL NUMBER:

13-0015-MM2

STATE:

South Carolina

PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:

$94 - Eligibility Process

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

Section 2.1 (d) TN MA 92-07, Effective Date 01/01/92, Approved 06/04/92

Section 2.1 (a) MA 92-07, Effective Date 01/01/92, Approved 06/04/92

Medicaid Eligibility

rym oe were asa iN

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

$94

General Eligibility Requirements Eligibility Process ; f

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.

oO 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.

Oo 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 C No

TN No. 13-0015-MM2 Approval Date: 02-12-14 Effective Date: 10-01-14 South Carolina _ $94-1 a a

cCcomMsS Medicaid Eligibility

Indicate the other electronic means below:

Name of Method Description + Facsimile Fax version of paper application x 4 | Electronic Transfer XML version of paper 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 1V-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:

[m) 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 {m] 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):

EX] Once every 12 months

(1) Once every 6 months

(1) 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 No. 13-0015-MM2 Approval Date: 02-12-14 Effective Date: 10-01-14 South Carolina $94-2

COORDINATION OF ELIGIBILITY AND ENROLLMENT

TRANSMITTAL NUMBER: STATE:

SC-13-0015-MM2 South Carolina

Notwithstanding the final checked statement on page 2, South Carolina has not entered into an agreement with the Federally-facilitated Marketplace to date. South Carolina will make a good faith effort to enter into a memorandum of agreement with the Federally-facilitated Marketplace before March 31, 2014. At such time the agreement is signed, it will be incorporated by reference into this attachment.

USE OF THE ALTERNATIVE SINGLE STREAMLINED APPLICATION

O Paper Application EX] Online Application

TRANSMITTAL NUMBER: STATE:

SC-13-0015-MM2 South Carolina

Through March 31, 2014, the state is using an interim alternative single streamlined application. After March 31, 2014, the state will use a revised alternative single streamlined application. The revised application will address the issues outlined in the CMS letter, which was issued with the approval of this state plan amendment, concerning the state’s application. The revised application will be incorporated by reference into the state plan.

U Application for Medicaid Healthy Connections % and/or Affordable South Carolina Department of Health and Human Services Health Coverage

Use this application + Affordable private health insurance plans that offer comprehensive to see what coverage to help you stay well : + Anew tax credit that can immediately help pay your premiums for health coverage choices coverage you qualify for + Free or low-cost insurance from Medicaid or the Children’s Health Insurance Program (CHIP) You may qualify for a free or low-cost program even if you earn as much as $94,000 a year (for a family of 4).

33) Who can use this + Use this application to apply for anyone in your family.

appl ication? + Apply even if you or your child already has health coverage. You could be

eligible for lower-cost or free coverage.

+ If you're single, you may be able to use a short form. Visit HealthCare.gov.

* Families that include immigrants can apply. You can apply for your child even if you aren't eligible for coverage. Applying won't affect your immigration status or chances of becoming a permanent resident or citizen.

+ If someone is helping you fill out this application, you may need to complete Appendix C.

Apply faster Apply faster online at SCDHHS.gov or HeaithCare.gov. online

What you may + Social Security Numbers (or document numbers for any legal immigrants

who need insurance) need to apply + Employer and income information for everyone in your family (for

example, from paystubs, W-2 forms, or wage and tax statements) * Policy numbers for any current health insurance * Information about any job-related health insurance available to your family

things to know

4) Why do we ask for We ask about income and other information to let you know what coverage

aaa A you qualify for and if you can get any help paying for it. We'll keep all the this information? information you provide private and secure, as required by law. To view the Privacy Act Statement, go to www.healthcare.gow/privacy/.

If you don't have all the information we ask for, sign and submit your application anyway. We'll follow-up with you within 1-2 weeks. You'll get instructions on the next steps to complete your application for health coverage. If you don’t hear from us, visit SCDHHS.gov or call 1-888-549-0820. Filling out this application doesn’t mean you have to buy health coverage.

i) What happens mext? Send your complete, signed application to the address on page 7.

Get help with this * Online: SCDHHS. gov application * Phone: Call our Help Center at 1-888-549-0820. + In person: There may be counselors in your area who can help. Visit our website or call 1-888-549-0820 for more information. + En Espafiol: Llame a nuestro centro de ayuda gratis al 1-888-549-0820.

NEED HELP WITH YOUR APPLICATION? Visit SCDHHS.goy or call us at 1-888-549-0820. Para obtener una copia de este formulario en Espafiol, llame 1-888-549-0820. If you need help in a language other than English, call 1-888-549-0820 and tell the customer service representative the language you need. We'll get you help at no cost to you. TTY users should call 1-800-753-8583.

DHHS Form 3400 (October 2013)

| STEP 1 | Tell us about yourself.

(We need one adult in the family to be the contact person for your application.)

1. First name, Middle name, Last name, & Suffix

2. Home address (Leave blank if you don't have one.) 3. Apartment or suite number 4. City 5. State 6. ZIP code 7. County 8. Mailing address (if different from home address) 9. Apartment or suite number 10. City 11. State 12. ZIP code 13. County 14. Phone number 15. Other phone number

(__)_—_-____ (eee

16. Do you want to get information about this application by email? L]Yes L]No

Email address:

17. What is your preferred spoken or written language (if not English)?

| STEP 2 | Tell us about your family.

Who do you need to include on this application? Tell us about all the family members who live with you. If you file taxes, we need to know about everyone on your tax return. (You don't need to file taxes to get health coverage.)

DO Include: You DON'T have to include: + Yourself + Your unmarried partner who doesn’t need health coverage + Your spouse + Your unmarried partner's children * Your children under 21 who live with you * Your parents who live with you, but file their own tax return + Your unmarried partner who needs health coverage (if you're over 21) + Anyone you include on your tax return, even if they don't * Other adult relatives who file their own tax return live with you + Anyone else under 21 who you take care of and lives with you

The amount of assistance or type of program you qualify for depends on the number of people in your family and their incomes. This information helps us make sure everyone gets the best coverage they can.

Complete Step 2 for each person in your family. Start with yourself, then add other adults and children. If you have more than 2 people in your family, you'll need to make a copy of the pages and attach them. You don't need to provide immigration status or a Social Security Number (SSN) for family members who don't need health coverage. We'll keep all the information you provide private and secure as required by law. We'll use personal information only to check if you're eligible for health coverage.

NEED HELP WITH YOUR APPLICATION? Visit SCD HHS.gov or call us at 1-888-549-0820. Para obtener una copia de este formulario en Espafiol, llame 1-888-549-0820. if you need help in a language other than English, call 1-888-549-0820 and tell the customer service representative the language you need. We'll get you help at no cost to you. TTY users should call 1-800-753-8583.

DHHS Form 3400 (October 2013) Page 1 of 7

STEP: 2: PERSON (Start with yourself)

Complete Step 2 for yourself, your spouse/partner and children who live with you and/or anyone on your same federal income tax return if you file one. See page 1 for more information about who to include. If you don't file a tax return, remember to still add family members who live with you.

1. First name, Middle name, Last name, & Suffix 2. Relationship to you? SELF

3. Date of birth (mm/dd/yyyy) 4.Sex []Male [] Female

5. Social Security number (SSN) _ —_ __ - _. —_ -

We need this if you want health coverage and have an SSN. Providing your SSN can be helpful if you don’t want health coverage too since it can speed up the application process. We use SSNs to check income and other information to see who's eligible for help with health coverage costs. If Someone wants help getting an SSN, call 1-800-772-1213 or visit sociaisecurity.gov. TTY users should call 1-800-325-0778.

6. Do you plan to file a federal income tax return NEXT YEAR? (You can still apply for health insurance even if you don't file a federal income tax return.)

C1 Yes. If yes, please answer questions a-c. C1 NO. If no, SKIP to question c. a. Will you file jointly with a spouse? L] Yes [] No

If yes, name of spouse: — — b. Will you claim any dependents on your tax return? []Yes [_]No

If yes, list name(s) of dependents: c. Will you be claimed as a dependent on someone's tax return? []Yes C]No

If yes, please list the name of the tax filer —

How are you related to the tax filer ——

7. Are you pregnant? []Yes L]No Ifyes, a. How many babies are expected during this pregnancy? ———.$___

8. Do you need health coverage? (Even if you have insurance, there might be a program with better coverage or lower costs.)

C YEs. If yes, answer all the questions below. +) (1 NO. If no, SKIP to the income questions on page 3. >) Leave the rest of this page blank.

UYes LNo

ical Lesion (CIN'2/3)

12. Are you a U.S. citizen or U.S. national? []Yes []No

13. If you aren't a U.S. citizen or U.S. national, do you have eligible immigration status? LYes. Fill in your document type and ID number below. a. Immigration document type —___ b. Document ID number

c. Have you lived in the U.S. since 1996? [] Yes oO No d. Are you, or your spouse or parent a veteran or an active-duty member of the U.S. military? Cves LINo

14. Do you want help paying for medical bills from the last 3 months? []Yes []No

15. Do you live with at least one child under the age of 19, and are you the main person taking care of this child? Dyes LINo 16. Are youa full-time student? [Yes CINo |17, wave yowvin foster care Bor oider? Ces LINo

18. If Hispanic/Latino, ethnicity (OPTIONAL—check all that apply.) (Mexican []Mexican American []Chicano/a [Puerto Rican []Cuban ([]JOther —

19, Race (OPTIONAL—check all that apply.)

OU White 0 American indian or Alaska [1] Filipino 0 Vietnamese (J Guamanian or Chamorro 0 Black or African Native CO Japanese C Other Asian 1 samoan American 0) Asian Indian 0) Korean C1 Native Hawaiian CI Other Pacific Islander 0 Chinese CO other _

Q NEED HELP WITH YOUR APPLICATION? Visit SCDHHS. gov or call us at 1-888-549-0820. Para obtener una copia de este formulario en Espafiol, llame 1-888-549-0820. If you need help in a language other than English, call 1-888-549-0820 and tell the customer service representative the language you need. We'll get you help at no cost to you. TTY users should call 1-800-753-8583.

DHHS Form 3400 (October 2013) Page 2 of 7

STEP 2: PERSON (Continue with yourself)

Current Job & Income Information

UC Employed CJ Not employed C) Self-employed If you're currently employed, tell us about your SKIP to question 30. SKIP to question 29. income. Start with question 20.

CURRENT JOB 1: 20, Employer name and address 21. Employer phone number

(LL - L 22, Wages/tips (before taxes) [Hourly []Weekly [Every 2 weeks []Twiceamonth []Monthly [] Yearly $

23. Average hours worked each Week

CURRENT JOB 2: (If you have more jobs and need more space, attach another sheet of paper.) 24. Employer name and address 25. Employer phone number

ee ee eee

26. Wages/tips (before taxes) []Hourly [Weekly [Every 2 weeks []Twiceamonth []Monthly [Yearly $_

27. Average hours worked each Week

28. In the past year, did you: [(_] Change jobs (] Stop working [J Start working fewer hours [_] None of these

29. If self-employed, answer the following questions:

a. Type of work b. How much net income (profits once business expenses are paid) will you get from this self-employment this month?

$

30, OTHER INCOME THIS MONTH: Check all that apply, and give the amount and how often you get it. NOTE: You don't need to tell us about child support, veteran's payment, or Supplemental Security Income (SSI).

(None

(J Unemployment $________ How often? (Net farming/fishing $__ How often? _ Pensions $__ How often? _ CNet rental/royalty $ How often? __ O1Social Security $ _.__ How often? ___-_ ( Other income

ORetirement accounts $_—_ How often? __ Type: =

CAlimony received $_______ How often? ___ Type:

31. DEDUCTIONS: check all that apply, and give the amount and how often you get it.

If you pay for certain things that can be deducted on a federal income tax return, telling us about them could make the cost of health coverage a little lower

NOTE: You shouldn't include a cost that you already considered in your answer to net self-employment (question 29b).

DiAlimony paid $. How often? (other deductions $ How often?

(Student loan interest $ ___ Howooften?__ Type:

32. YEARLY INCOME: Complete only if your income changes from month to month. If you don't expect changes to your monthly income, skip to the next person. ©

Your total income this year Your total income next year (if you think it will be different)

$ $ THANKS! This is all we need to know about you.

NEED HELP WITH YOUR APPLICATION? Visit SCDHHS.gov or call us at 1-888-549-0820. Para obtener una copia de este formulario en Espajiol, llame 1-888-549-0820. If you need help in a language other than English, call 1-888-549-0820 and tell the customer service representative the language you need. We'll get you help at no cost to you. TTY users should call 1-800-753-8583.

DHHS Form 3400 (October 2013) Page 3 of 7

STEP 2: PERSON

Complete Step 2 for yourself, your spouse/partner, and children who live with you and/or anyone on your same federal income tax return if you file one. See page 1 for more information about who to include. If you don't file a tax return, remember to still add family members who live with you.

1, First name, Middle name, Last name, & Suffix 2. Relationship to you?

3. Date of birth (mm/dd/yyyy) 4.Sex []Male []Female

5. Social Security number (SSN) - -

We need this if you want health coverage and have an SSN. 6. Does PERSON 2 live at the same address as you? []Yes []No

If no, list address:

7. Does PERSON 2 pian to file a federal income tax return NEXT YEAR? (You can still apply for health insurance even if you don't file a federal income tax return.)

LIYES. If yes, please answer questions a-c. CANO. If no, skip to question c. a. Will PERSON 2 file jointly with a spouse? []Yes []No

If yes, name of spouse: — b. Will PERSON 2 claim any dependents on his or her tax return? L]Yes [No

If yes, list name(s) of dependents: c. Will PERSON 2 be claimed as a dependent on someone's tax return? []Yes L]No

If yes, please list the name of the tax filer How is PERSON 2 related to the tax filer

8. Is PERSON 2 pregnant? []Yes LINo If yes, a. How smany babies are expected during this pregnancy? ‘b. What

9. Does PERSON 2 need health coverage? (Even if they have insurance, there might be a program with better coverage or lower costs.)

C1 Yes. If yes, answer all the questions below. r+) C1 No. If no, SKIP to the income questions on page 5. © Leave the rest of this page blank.

13. Is PERSON 2 a USS. citizen or U.S. national? [JYes []No

14, If PERSON 2 isn‘t a U.S. citizen or U.S. national, do they have eligible immigration status? Yes. Fill in their document type and ID number below.

a. Document type b. Document ID number - c. Has PERSON 2 lived in the U.S. since 1996? []Yes []No d. Is PERSON 2, or their spouse or parent a veteran or an active- duty member in the U.S. ae Oves CINo 15. Does PERSON 2 want help paying for 16. Does PERSON 2 live with at st least one child under medical bills from the last 3 months? the age of 19, and are they the main person ‘ x Oves CNo taking care of this child? LyYes LJNo Oo Yes [No 1 i

18. If Hispanic/Latino, ethnicity (OPTIONAL—check all that apply.) (Mexican []Mexican American []Chicano/a [Puerto Rican [)Cuban [JOther —

19, Race (OPTIONAL—check all that apply.)

D white OO American indian or Alaska [] Filipino 1 Vietnamese (0 Guamanian or Chamorro 2 Black or African Native 0 Japanese ( other Asian (0 samoan American C Asian Indian OO Korean C0 Native Hawaiian (1 Other Pacific Islander O Chinese O other

Now, tell us about any income from PERSON 2 on the back. =>)

NEED HELP WITH YOUR APPLICATION? Visit SCDHHS.gov or call us at 1-888-549-0820. Para obtener una copia de este formulario en Espafiol, llame 1-888-549-0820. If you need help in a language other than English, call 1-888-549-0820 and tell the customer service representative the language you need. We'll get you help at no cost to you. TTY users should call 1-800-753-8583.

DHHS Form 3400 (October 2013) Page 4 of7

P.2: PERSON 2

Current Job & Income Information

OC Employed CJ Not employed OU Self-employed If PERSON 2 is currently employed, tell us Skip to question 30. Skip to question 29. about this income. Start with question 20.

CURRENT JOB 1: 20. Employer name and address 21. Employer phone number

22. Wages/tips (before taxes) []Hourly []Weekly [] Every 2 weeks []Twiceamonth []Monthly [Yearly $__

23. Average hours worked each Week

CURRENT JOB 2: (If PERSON 2 has more jobs and need more space, attach another sheet of paper.) 24, Employer name and address {25. Employer phone number

26. Wages/tips (before taxes) []Hourly []Weekly [] Every 2weeks []Twiceamonth []Monthly [] Yearly $0

27. Average hours worked each Week

28. In the past year, did PERSON 2: [_] Change jobs (] Stop working [1] Start working fewer hours [_] None of these

29. If self-employed, answer the following questions:

a. Type of work b. How much net income (profits once business expenses are paid) will you get from this self-employment this month?

$e

30. OTHER INCOME THIS MONTH: Check all that apply, and give the amount and how often you get it. NOTE: You don't need to tell us about child support, veteran's payment, or Supplemental Security Income (SSI).

ONone

Oo Unemployment $ How often? _ Cnet farming/fishing $___ ss How often? —_ CL) Pensions $_______ Howoften?__——s Nett rental/royalty $_____ Howoften?___ CSocial Security $ ___ How often? _ (other income

(Retirement accounts $__ How often? _ ype

LD Alimony received $ _ How often? Typ

31, DEDUCTIONS: Check all that apply, and give the amount and how often you get it.

If PERSON 2 pays for certain things that can be deducted on a federal income tax return, telling us about them could make the cost of health coverage a little lower.

NOTE: You shouldn't include a cost that you already considered in your answer to net self-employment (question 29b).

DAlimony paid $___s Howoften?_ CJ other deductions $s Howoften?__ Lstudent loan interest $—____ How often? ___ Type:

32. YEARLY INCOME: Complete only if PERSON 2's income changes from month to month. If you don't expect changes to PERSON 2's monthly income, add another person or skip to the next section. PERSON 2's total income this year PERSON 2's total income next year (if you think it will be different)

$ $

THANKS! This is all we need to know about PERSON 2. people tain fional. atid compl NEED HELP WITH YOUR APPLICATION? Visit SCDHHS. gov or call us at 1-888-549-0820. Para obtener una copia de este formulario en Espajiol, lame 1-888-549-0820. If you need help in a language other than English, call 1-888-549-0820 and tell the customer service

representative the language you need. We'll get you help at no cost to you. TTY users should call 1-800-753-8583. DHHS Form 3400 (October 2013) Page 5 of 7

| STEP 3 | American Indian or Alaska Native (AI/AN) family member(s)

1. Are you or is anyone in your family American Indian or Alaska Native?

Ulf No, skip to Step 4. UYes. If yes, go to Appendix B.

| STEP 4 | Your Family's Health Coverage

Answer these questions for anyone who needs health coverage.

1. Is anyone enrolled in health coverage now from the following? If available, please provide a copy of the insurance card. COVES. If yes, check the type of coverage and write the person(s)’ name(s) next to the coverage they have. [] NO.

O Medicaid Oo Employer insurance — 0 cup Name of health insurance: _ _ OO Medicare Policy number:

Is this COBRA coverage? [] Yes [] No Is this a retiree health plan? (] Yes [] No overage started: O other

Name of health insurance:

Glaittinu

(D TRICARE (Don't check if you have direct care or Line of Duty)

Policy number: Is this a limited-benefit plan (like a school accident policy)? 0 VA health care programs - Cves [No

OU Peace Corps —

2. Is anyone listed on this application offered health coverage from a job? Check yes even if the coverage is from someone else's job, such as a parent or spouse. LYES. If yes, you'll need to complete and include Appendix A. Is this a state employee benefit plan? [] Yes [] No

LING. If no, continue to Step 5.

| STEP 5 | Read & sign this application.

3. = ” ud maeealtmy ad thew ead . ey NEED HE YOUR) or call us at 1-888-549-0820. Para obtener una copia de este formulario en

Espanol, llame 1-888-549-0820. If you need help in a language other than English, call 1-888-549-0820 and tell the customer service representative the language you need. We'll get you help at no cost to you. TTY users should call 1-800-753-8583.

DHHS Form 3400 (October 2013) Page 6 of 7

* I confirm that no one applying for health insurance on this application is incarcerated (detained or jailed). If not,

_is incarcerated.

(name of person)

Renewal of coverage in future years

To make it easier to determine my eligibility for help paying for health coverage in future years, | agree to allow Medicaid or the Health Insurance Marketplace to use income data, including information from tax returns. Medicaid will send me a notice, let me make any changes, and | can opt out at any time.

Yes, renew my eligibility automatically for the next

(15 years (the maximum number of years allowed), or for a shorter number of years: Ci4years [)3years [j2years [J1 year [Don't use information from tax returns to renew my coverage.

Sign this application. The person who filled out Step 1 should sign this application. If you're an authorized representative you may sign here, as long as you have provided the information required in Appendix C.

Signature Date (mm/dd/yyyy)

| STEP 6: | mail completed application.

Mail your signed application to:

SCDHHS - CEP PO Box 100101 Columbia, SC 29202-3101

If you want to register to vote, you can complete a voter registration form at scvetes.org.

NEED HELP WITH YOUR APPLICATION? Visit SCDHHS.gov or call us at 1-888-549-0820. Para obtener una copia de este formulario en Espafiol, llame 1-888-549-0820. If you need help in a language other than English, call 1-888-549-0820 and tell the customer service representative the language you need. We'll get you help at no cost to you. TTY users should call 1-800-753-8583.

DHHS Form 3400 (October 2013) Page 7 of 7

APPENDIX A Health Coverage from Jobs

You DON'T need to answer these questions unless someone in the household is eligible for health coverage from a job. Attach a copy of this page for each job that offers coverage.

Tell us about the job that offers coverage.

Take the Employer Coverage Tool on the next page to the employer who offers coverage to help you answer these questions. You only need to include this page when you send in your application, not the Employer Coverage Tool.

EMPLOYEE Information

1.Employee name (First, Middle, Last) | 2. Employee Social Security number i

EMPLOYER Information

3. Employerjname 4. Employer Identification Number (EIN) |

1

5. Employer:address 6. Employer phone number

7cy (8, State 9, ZIP code

10. Who can,we contact about employee health coverage at this job?

11.Phone number (if different from above) 12. Email address

413. Are you currently eligible for coverage offered by this ‘employer, or will you i become eligible i in then next 3 months? ' C1 Yes (Continue)

13a. If you're in a waiting or probationary period, when can you enroll in coverage?

wi i (mm/dd/yy) List the names of anyone else who is eligible for coverage from this job.

Name: Name:

Tell us about the health plan offered byt this employer.

14. Does thelemployer offer a health plan that meets the minimum value standard*? [JYes. [No

15, For the lowest-cost plan that meets the minimum value standard* offered only to the employee (don't include family plans): If the employer has wellness programs, provide the premium that the employee would pay if he/ she received the maximum discount for any tobacco cessation programs, and did not receive any other discounts based on wellness programs.

a. How much would the employee have to pay in premiums for this plan? $= : b. How often? []Weekly Clévery2weeks [Itwiceamonth [Jonceamonth []Quarte

Clyearly

16, What change will the employer make for the new plan year (if known)? C1 Employer won't offer health coverage

Ci Employer will start offering health coverage to employees or change the premium for the lowest-cost plan available only to the employee that meets the minimum value standard.* (Premium should reflect the discount for wellness programs. See question 15.)

b. How often? [JWeekly [every 2 weeks [J] Twice a month Clonee a! amonth [_]Quarterly (Yearly

a. How much will the employee have to pay in premiums for that plan? $

Date of change (mm/dd/yyyy):

*An employer-sponsored health plan meets the “minimum value standard” if the plan’s share of the total allowed benefit costs covered by the plan is no less than 60 percent of such costs (Section 36B(c)(2)(C)(ii) of the Internal Revenue Code of 1986)

NEED HELP WITH YOUR APPLICATION? Visit SCDHHS.gov or call us at 1-888-549-0820. Para obtener una copia de este formulario en Espanol, llame 1-888-549-0820. If you need help in a language other than English, call 1-888-549-0820 and tell the customer service representative the language you need. We'll get you help at no cost to you. TTY users should call 1-800-753-8353.

EMPLOYER COVERAGE TOOL

—_ a a a

Use this tool to help answer questions in Appendix A about any employer health coverage that you're eligible for (even if it's from another person's job, like a parent or spouse). The information in the numbered boxes below match the boxes on Appendix A. For example, the answer to question 14 on this page should match question 14 on Appendix A.

Write your name and Social Security number in boxes 1 and 2 and ask the employer to fill out the rest of the form. Complete one tool for each employer that offers health coverage.

EMPLOYEE Information

The employee needs to fill out this section.

1,Employee name (First, Middle, Last) 2. Social Security Number

EMPLOYER Information

Ask the employer for this information. 3. Employeriname 5 ae : : ea |4, Employer identification Number (EIN)

; jae

5. Employer address (the Marketplace will send notices to this address) '6. Employer phone number

7. City : ae 8. State :

10. Who can we contact about employee health coverage at this job?

11. Phone number (if different from above) 12. Email address Ce he

.ls the employee currently eligible for coverage offered by this employer, or will the employee be eligible i ni

Dyes (Answer 13a)

13a. If the employee is not eligible today, including as a result of a waiting or probationary period, when is the employee eligible for coverage? ___ _ mm /dd/yyyy) (Continue)

(No (STOP and return this form to employee)

413

me ae

Tell us about the health plan offered by this employer. Does the employer offer a health plan that covers an employee’s spouse or dependent? (Yes. Which people? []Spouse []Dependent(s) CNo

(Go to question 14)

14, Does the employer offer a health plan that meets the minimum value standard*?, (Cl Yes (Go to question 15) LJNo (STOP and return form to employee)

15. For the lowest-cost plan that meets the minimum value standard* offered only to the employee (don't include family plans): If the employer has wellness programs, provide the premium that the employee would pay if he/ she received the maximum discount for any tobacco ¢essation programs, and didn’t receive any other discounts based on wellness programs.

a. How much would the employee have to pay in premiums for this plan? $C : b, How often? C]Weekly (lEvery2weeks ([JtTwiceamonth []Onceamonth (iQuarterly (yearly

if the plan year will end soon and you know that the health plans offered will change, go to question 16. If you don’t know, STOP and return form to employee.

16, What change will the employer make for the new plan year? ClEmployer won't offer health coverage

[7] Employer will start offering health coverage to employees or change the premium for the lowest-cost plan available only to the employee that meets the minimum value standard.* (Premium should reflect the discount for wellness programs. See question 15.)

a, How much will the employee have to pay in premiums for that plan? $

b. How often? []Weekly (Cl every2weeks [JTwiceamonth [JOnceamonth []Quarterly [[] Yearly Date of change (mm/dd/yyyy):

*An employer-sponsored health plan meets the “minimum value standard” if the plan's share of the total allowed benefit costs covered by the plan is no less than 60 percent of such costs (Section 36B(c)(2)(C\(ii) of the Internal Revenue Code of 1986)

NEED HELP WITH YOUR APPLICATION? Visit SCDHHS.gov or call us at 1-888-549-0820. Para obtener una copia de este formulario en Espafiol, llame 1-888-549-0820. If you need help in a language other than English, call 1-888-549-0820 and tell the customer service representative the language you need. We'll get you help at no cost to you. TTY users should call 1-800-753-8353.

APPENDIX B

American Indian or Alaska Native Family Member (AI/AN)

Complete this appendix if you or a family member are American Indian or Alaska Native. Submit this with your Application for Health Coverage & Help Paying Costs.

Tell us about your American Indian or Alaska Native family member(s).

American Indians and Alaska Natives can get services from the Indian Health Services, tribal health programs, or urban Indian health programs. They also may not have to pay cost sharing and may get special monthly enrollment periods. Answer the following questions to make sure your family gets the most help possible.

NOTE: If you have more people to include, make a copy of this page and attach.

AI/AN PERSO AI/AN PERSO 1. Name First Middle First Middle (First name, Middle name, Last name) Last Last Member of a federally recognized tribe? Dyes Dyes

If yes, tribe name

If yes, tribe name

CNo CNo . Has this person ever gotten a service from oO Yes Olyes the Indian Health Service, a tribal health program, or urban Indian health program, OONo OONo

or through a referral from one of these

If no, is this person eligible to get If no, is this person eligible to get

programs? services from the Indian Health services from the Indian Health Service, tribal health programs, or Service, tribal health programs, or urban Indian health programs, or urban Indian health programs, or through a referral from one of these through a referral from one of these programs? programs? CyYes CINo Oves No

4. Certain money received may not be $ $ counted for Medicaid or the Children’s | © es as Health Insurance Program (CHIP). List any How often?. __ How often?____ :

income (amount and how often) reported

on your application that includes money

from these sources:

* Per capita payments from a tribe that come from natural resources, usage rights, leases, or royalties

* Payments from natural resources, farming, ranching, fishing, leases, or royalties from land designated as Indian trust land by the Department of Interior (including reservations and former reservations)

* Money from selling things that have cultural significance

NEED HELP WITH YOUR APPLICATION? Visit SCOHHS.gov or call us at 1-888-549-0820. Para obtener una copia de este formulario en Espafiol, llame 1-888-549-0820. If you need help in a language other than English, call 1-888-549-0820 and tell the customer service representative the language you need. We'll get you help at no cost to you. TTY users should call 1-800-753-8353.

APPENDIX C

Assistance with Completing this Application

You can choose an authorized representative.

You can give a trusted person permission to talk about this application with us, see your information, and act for you on matters related to this application, including getting information about your application and signing your application on your behalf. This person is called an “authorized representative.” If you ever need to change your authorized representative, contact the Marketplace. If you're a legally appointed representative for someone on this application, submit proof with the application.

1. Name of authorized representative (First name, Middle name, Last name)

2. Address 3. Apartment or suite number

4. City 5. State 6. ZIP code

7. Phone number

8. Organization name 9. 1D number (if applicable)

By signing, you allow this person to sign your application, get official information about this application, and act for you on all future matters with this agency.

10. Your signature Nl. Date (mm/dd/yyyy)

For certified application counselors, navigators, agents, and brokers only.

Complete this section if you’re a certified application counselor, navigator, agent, or broker filling out this application for somebody else.

1. Application start date (mm/dd/yyyy)

2. First name, Middle name, Last name, & Suffix

3. Organization name 4. 1D number Cif applicable)

NEED HELP WITH YOUR APPLICATION? Visit SCDHHS.gov or call us at 1-888-549-0820. Para obtener una copia de este formulario en Espajiol, tlame 1-888-549-0820. If you need help in a language other than English, call 1-888-549-0820 and tell the customer service representative the language you need. We'll get you help at no cost to you. TTY users should call 1-800-753-8353.

Table of Contents

State/Territory Name: South Carolina State Plan Amendment (SPA) #:13-0017-MM5

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

Atlanta Regional Office 61 Forsyth Street, Suite 4T20 Atlanta, Georgia 30303

CENTERS FOR MEDICARE & MEDICAID SERVICES. DIVISION OF MEDICAID & CHILDREN’S HEALTH OPERATIONS

May 16, 2014

Mr. Anthony E. Keck, Director Department of Health and Human Services P.O. Box 8206

Columbia, South Carolina 29202-8206

Attention: Sheila Chavis RE: State Plan Amendment (SPA) 13-0017-MM5 Dear Mr. Keck:

Enclosed is an approved copy of South Carolina’s state plan amendment (SPA) 13-0017-MMS, which was submitted to CMS on November 18, 2013. SPA 13-0017-MM5 affirms state residency regulations and addresses interstate agreements and temporary absence in accordance with the Affordable Care Act. This SPA was approved on May 14, 2014. The effective date of the SPA is January 1, 2014.

Enclosed is a copy of the new state plan pages and attachments to be incorporated within a separate section at the back of South Carolina’s approved state plan, as well as a summary of the state plan pages which are superseded by SPA 13-0017-MM5S, which should be incorporated into a separate section in the front of the state plan.

Congratulations to you and your staff for your hard work and strong collaboration. If you have any additional questions or need further assistance, please contact Maria Drake at (404) 562-3697 or Maria.Drake@cms.hhs.gov.

Sincerely,

//s//

Jackie Glaze

Associate Regional Administrator

Division of Medicaid & Children's Health Operations

Enclosures

Medicaid State Plan Eligibility: Summary Page (CMS 179)

State/Territory name: South Carolina

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.

| SC-13-001

Proposed Effective Date

01/01/2014 (mm/dd/yyyy)

Federal Statute/Regulation Citation

| 42 CFR 43t

Federal Budget Impact

Federal Fiscal Year Amount

First Year 2014 $l 0.00 Second Year 2015 gl 0.00

Subject of Amendment

Character count out of 2000

S88= State Residency 5

~|

Ll | ma

Governor's Office Review

c Governor's office reported no comment

c Comments of Governor's office received

4

ia

Describe:

{ of C No reply received within 45 days of submittal

E Other, as specified

Describe:

Character Count: out of 2000

Mr. Anthony E Keck was mul

mal om 2

Signature of State Agency Official Submitted By:

Sheila Chavis

Last Revision Date: Apr 11, 2014 Submit Date: Nov 18, 2013

SUPERSEDING PAGES OF

STATE PLAN MATERIAL TRANSMITTAL NUMBER: STATE: 13-0017 MMS South Carolina PAGE NUMBER OF THE PLAN SECTION OR PAGE NUMBER OF THE SUPERSEDED PLAN SECTION ATTACHMENT: OR ATTACHMENT (If Applicable): S88 Non-Financial Eligibility- State Residency Section 2, Item 2.3, Page 13, TN 87-16 Attachment 2.6-A: Page 3, item (4), TN 13-0018 MM6

ccms Medicaid Eligibility

ret (OS Marre aad a ee TS

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

Non-Figancial Eligibility State Residency S88 42 CFR 435.403

State Residency

The state provides Medicaid to otherwise eligible residents of the state, including residents who are absent from the state under certain conditions.

Individuals are considered to be residents of the state under the following conditions:

®

™ @ © @

Non-institutionalized individuals age 21 and over, or under age 21, capable of indicating intent and who are emancipated or married, if the individual is living in the state and:

[@] Intends to reside in the state, including without a fixed address, or {@] Entered the state with a job commitment or seeking employment, whether or not currently employed.

Individuals age 21 and over, not living in an institution, who are not capable of indicating intent, are residents of the state in which they live.

Non-institutionalized individuals under 21] not described above and non IV-E beneficiary children: Co} Residing in the state, with or without a fixed address, or

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

Individuals living in institutions, as defined in 42 CFR 435.1010, including foster care homes, who became incapable of indicating intent before age 21 and individuals under age 21 who are not emancipated or married:

cl Regardless of which state the individual resides, if the parent or guardian applying for Medicaid on the individual's behalf resides in the state, or

Regardless of which state the individual resides, if the parent or guardian resides in the state at the time of the individual's placement, or

cy}

If the individual applying for Medicaid on the individual's behalf resides in the state and the parental rights of the {Mf institutionalized individual's parent(s) were terminated and no guardian has been appointed and the individual is institutionalized in the state.

Individuals living in institutions who became incapable of indicating intent at or after age 21, if physically present in the state, unless another state made the placement.

Individuals who have been placed in an out-of-state institution, including foster care homes, by an agency of the state.

Any other institutionalized individual age 21 or over when living in the state with the intent to reside there, and not placed in the institution by another state.

IV-E eligible children living in the state, or

TN: 13-0017-MM5 Approval Date: 05/14/14 Effective Date: 01/01/14 South Carolina a ; S88-1

Medicaid Eligibility

{®) Otherwise meet the requirements of 42 CFR 435.403.

TN: 13-0017-MM5 Approval Date: 05/14/14 Effective Date: 01/01/14 South Carolina S88-2

Medicaid Eligibility

8 sad a A cr ath

Meet the criteria specified in an interstate agreement. @ Yes C No

[m) The state has interstate agreements with the following selected states:

Alabama [X] Mlinois [X] Montana Rhode Island Alaska x] Indiana Nebraska (J South Carolina [X] Arizona K] lowa [\X] Nevada South Dakota Arkansas [X] Kansas {K] New Hampshire {X] Tennessee [x] California Kentucky [KX] New Jersey KK] Texas Colorado X] Louisiana [Xx] New Mexico Utah

[Xx] Connecticut KK] Maine (1 New York {X] Vermont

[xX] Delaware Maryland [X] North Carolina Virginia District of Columbia {K] Massachusetts (J North Dakota [X] Washington [X} Florida Michigan Ohio (KX) West Virginia Georgia KK] Minnesota [X] Oklahoma Wisconsin [<] Hawaii Mississippi [x] Oregon [J Wyoming

[xX] Idaho [KX] Missouri [X] Pennsylvania

i The interstate agreement contains a procedure for providing Medicaid to individuals pending resolution of their residency status and criteria for resolving disputed residency of individuals who (select all that apply):

Are IV-E eligible LJ Are in the state only for the purpose of attending school (J) Are out of the state only for the purpose of attending school [LD Retain addresses in both states (J) Other type of individual The state has a policy related to individuals in the state only to attend school.

C Yes @ No

{m] Otherwise meet the criteria of resident, but who may be temporarily absent from the state.

The state has a definition of temporary absence, including treatment of individuals who attend school in another state.

@ Yes C No

TN: 13-0017-MMS Approval Date: 05/14/14 Effective Date: 01/01/14 South Carolina $88-3

Medicaid Eligibility

PATH ree Maer 8 A ane ar EN

Provide a description of the definition:

An individual cannot be denied Medicaid due to residency if the individual is temporarily absent from the state and intends to return when the purpose of the absence has been accomplished, unless another state has accepted him/her as a resident for Medicaid purposes.

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: 13-0017-MMS Approval Date: 05/14/14 Effective Date: 01/01/14 South Carolina $88-4

State/Territory Name: South Carolina State Plan Amendment (SPA) #:13-0018-MM6

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

Atlanta Regional Office 61 Forsyth Street, Suite 4T20 Atlanta, Georgia 30303

CENTERS FOR MEDICARE & MEDICAID SERVICES DIVISION OF MEDICAID & CHILDREN’S HEALTH OPERATIONS

February 18, 2014

Mr. Anthony E. Keck

Director

SC Department of Health and Human Services Post Office Box 8206

Columbia, South Carolina 29202-8206

Attention: Sheila Chavis RE: S-89— Citizenship and Immigration Status State Plan Amendment (SPA), SC-13-0018-MM6 Dear Mr. Keck:

Enclosed is an approved copy of South Carolina’s state plan amendment (SPA) 13-0018-MM6, which was submitted to CMS on November 18, 2013. SPA 13-0018-MM6 affirms citizenship regulations, specifies reasonable opportunity options, and specifies policy options related to immigrant eligibility in accordance with the Affordable Care Act. This SPA was approved on February 14, 2014. The effective date of the SPA is January 1, 2014.

Enclosed is a copy of the new state plan pages and attachments to be incorporated within a separate section at the back of South Carolina’s approved state plan, as well as a summary of the state plan pages which are superseded by SPA 13-0018-MM6, which should be incorporated into a separate section in the front of the state plan.

Congratulations to you and your staff for your hard work and strong collaboration. If you have any additional questions or need further assistance, please contact Maria Drake at (404) 562-3697 or Maria. Drake@cms.hhs.gov.

Sincerely,

//s//

Jackie Glaze

Associate Regional Administrator

Division of Medicaid & Children’s Health Operations

Enclosures

Medicaid State Plan Eligibility: Summary Page (CMS 179)

State/Territory name: South Carolina

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.

| SC-13-001

Proposed Effective Date

{ 10/01/2012 (mm/dd/yyyy)

Federal Statute/Regulation Citation

1902(a) (4€

Federal Budget Impact

Federal Fiscal Year Amount

First Year

2014

Second Year

ii

2015

$l 0.00

Subject of Amendment

Character count out of 2000

S89= Citizenship and Non-Citize «|

faa L«t | ma

Governor's Office Review

Governor's office reported no comment

~

Comments of Governor's office received

Describe: ea «iJ ma

No reply received within 45 days of submittal

° Other, as specified

Describe:

Character count out of 2000

Mr. Anthony E Keck was mas)

a im ma Signature of State Agency Official Submitted By:

Sheila Chavis Last Revision Date: Feb 10, 2014

Submit Date: Nov 18, 2013

SUPERSEDING PAGES OF

STATE PLAN MATERIAL TRANSMITTAL NUMBER: STATE: 13-0018 MM6 South Carolina PAGE NUMBER OF THE PLAN SECTION OR PAGE NUMBER OF THE SUPERSEDED PLAN SECTION ATTACHMENT: OR ATTACHMENT (If Applicable):

$89 Non-Financial Eligibility- Citizenship and Non-citizen Eligibility Attachment 2.6-A: Page 2, Item (3), paragraphs (a) , (b), and (c), TN 92-07

Attachment 2.6-A: Page 3, Item (3), paragraphs (d) and (e), TN 92-07

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

f

11902(a)(46)(B)

8 US.C. 1611, 1612, 1613, and 1641 | 1903(v)(2),(3) and (4) | 42 CFR 435.4

42 CFR 435.406

42. CFR 435.956

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

i) 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 are qualified non-citizens as defined in section 431 of the Personal Responsibility and Work Opportunity 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.

i @ Yes ©No

The agency begins to furnish benefits to otherwise eligible individuals during the reasonable opportunity period ona date | earlier than the date the notice is received by the individual. }

@ Yes ©No The date benefits are furnished is: (@ The date of application containing the declaration of citizenship or immigration status. C The date the reasonable opportunity notice is sent.

C Other date. as described:

TN No: 13-0018-MM6 Approval Date: 02-14-14 Effective Date: 01/01/14 South Carolina $89-1

CcomMsS 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).

C Yes (@No Indicate which requirements apply:

The state requires Lawful Permanent Residents to have 40 qualifying work quarters under Title II of the Social Security Act.

@ Yes CNo

The state limits eligibility to 7 years for certain non-citizens.

@ Yes (No

Check all that apply: [X] Non-citizens admitted to the U.S. as a refugee under section 207 of the INA Non-citizens granted asylum under section 208 of the INA Non-citizens whose deportation is withheld under section 243(h) or 241(b)(3) of the INA

Non-citizens granted status as a Cuban-Haitian Entrant, as defined in section 501(e) of the Refugee Education Assistance Act of 1980

Non-citizens admitted to the U.S. as Amerasian

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.

C Yes (@No

i 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.

[M) 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 anon-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: {W] Granted temporary resident status in accordance with 8 U.S.C. 1160 or 1255a, respectively;

a 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;

{M] Granted employment authorization under 8 CFR 274a.12(c);

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

[M) Under Deferred Enforced Departure (DED) in accordance-with a decision made by the President;

TN No: 13-0018-MM6 Approval Date: 02-14-14 Effective Date: 01/01/14 South Carolina $89-2

a Ss Medicaid Eligibility

CONTIN Ree CARD & DOCS EIT

[@] Granted Deferred Action status; [lM] 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 -

[m] Has been granted employment authorization; or

[M] Is under the age of 14 and has had an application pending for at least 180 days; 6. Has been granted withholding of removal under the Convention Against Torture; 7. 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.

(1) 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:

[lM] Qualified non-citizens subject to the 5 year waiting period described in 8 U.S.C. 1613;

im 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 No: 13-0018-MM6 Approval Date: 02-14-14 Effective Date: 01/01/14 South Carolina $89-3

Table of Contents

State/Territory Name: South Carolina State Plan Amendment (SPA) #: 13-0019-MM4

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 Atlanta Regional Office 61 Forsyth Street, Suite 4T20 Atlanta, Georgia 30303 CENTERS FOR MEDICARE & MEDICAID SERVICES

DIVISION OF MEDICAID & CHILDREN’S HEALTH OPERATIONS

February 18, 2014

Mr. Anthony E. Keck

Director

SC Department of Health and Human Services Post Office Box 8206

Columbia, South Carolina 29202-8206

Attention: Sheila Chavis RE: Al, A2 and A3 — Single State Agency State Plan Amendment (SPA), SC-13-0019-MM4 Dear Mr. Keck:

Enclosed is an approved copy of South Carolina’s state plan amendment (SPA) 13-0019-MM4, which was submitted to the Centers for Medicare & Medicaid Services (CMS) on November 18, 2013. SPA 13-0019-MM4 establishes the single state agency and entities responsible for determinations of eligibility and appeals/fair hearings in accordance with the Affordable Care Act. This SPA was approved on February 12, 2014. The effective date of this SPA is January 1, 2014.

Enclosed is a copy of the new state plan pages and attachments to be incorporated within a separate section at the back of South Carolina’s approved state plan, as well as a summary of the state plan pages which are superseded by SPA 13-0019-MM4, which should be incorporated into a separate section in the front of 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 Maria Drake, at either 404- 562-3697 or by email at Maria.Drake@cms.hhs.gov.

Sincerely,

/sif

Jackie Glaze

Associate Regional Administrator

Division of Medicaid & Children’s Health Operations

Enclosures

Medicaid State Plan Eligibility: Summary Page (CMS 179)

State/Territory name: South Carolina

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.

SC-13-001

Proposed Effective Date

| 10/01/2012 (mm/dd/yyyy)

Federal Statute/Regulation Citation

[aare

Federal Budget Impact

Federal Fiscal Year Amount

First Year 2014 $ 0.00 Second Year 2015 $ 0.00

Subject of Amendment

Character Count: out of 2000

fo}

ce}

A2= Organization and Administ: A3= Assurances

Governor's Office Review

A1=Designation and Authority “|

|

c Governor's office reported no comment

Cc Comments of Governor's office received

Describe:

c No reply received within 45 days of submittal

E Other, as specified

Describe:

M.. Anthony E Keck was core]

Signature of State Agency Official

Submitted By: Sheila Chavis Last Revision Date: Feb 11, 2014

Submit Date: Nov 18, 2013

Character count :| out of 2000

SUPERSEDING PAGES OF STATE PLAN MATERIAL

TRANSMITTAL NUMBER:

SC-0019-MM4 STATE:

South Carolina

PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:

A1 – A3

COMPLETE PAGES SUPERSEDED:

Page 1

Section 1.1 (pages 2-6)

Section 1.2 (page 7)

Section 1.3 (page 8)

Attachment 1.1-A (pages 2-6)

Attachment 1.2-A (Organizational chart)

Attachment 1.2-B (Description of the functions of the single state agency)

Attachment 1.2-C (Description of professional medical and supporting staff)

PARTIAL PAGES SUPERSEDED:

Section 1.4 (page 9) (State Medical Care Advisory Committee section only. Tribal consultation will remain in the state plan.)

Cccms Medicaid Administration

CONE RMAC AE BBCI LECT

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

x

42 CFR 431.10

Designation and Authority

State Name: South Carolina

As a condition for receipt of Federal funds under title XIX of the Social Security Act, the single state agency named below submits the following state plan for the medical assistance program, and hereby agrees to administer the program in accordance with the provisions of this state plan, the requirements of titles XI and XIX of the Act, and all applicable Federal regulations and other official issuances of the! Department.

Name of single state agency: Department of Health and Human Services

Type of Agency: C Title IV-A Agency @ Health C Human Resources

C Other

Type of Agency

The above named agency is the single state agency designated to administer or supervise the administration of the Medicaid program under title XIX of the Social Security Act. (All references in this plan to "the Medicaid agency" mean the agency named as the single state agency.)

The state statutory citation for the legal authority under which the single state agency administers the state plan is:

§ 44-6-30, SC Code, 1976, as amended

The single state agency supervises the administration of the state plan by local political subdivisions. Cc Yes (@No

The certification signed by the state Attorney General identifying the single state agency and citing the legal authority under which it administers or supervises administration of the program has been provided.

An attachment is submitted.

The state plan may be administered solely by the single state agency, or some portions may be administered by other agencies.

The single state agency administers the entire state plan under title XIX (i.e., no other agency or organization administers any portion of it).

@ Yes (No

TN No: 13-0019-MM4 Approval Date: 02-12-14

South Carolina Al Effective Date: 10/01/13

ms Medicaid Administration

CONOR HOE MECHA ANCA BCS

The entity or entities that have responsibility for determinations of eligibility for families, adults, and for individuals under 21 are:

The entity that has responsibility for determinations of eligibility for the aged, blind, and disabled are:

The entity or entities that have responsibility for conducting fair hearings with respect to denials of eligibility based on the applicable modified adjusted gross income standard are:

The agency has established a review process whereby the agency reviews appeals decisions made by the Exchange or Exchange appeals entity or other state agency, but only with respect to conclusions of law, including interpretations of state or federal policies.

C Yes

The Medicaid agency

oO Single state agency under Title IV-A (in the 50 states or the District of Columbia) or under Title | or XVI (AABD) in Guam, Puerto Rico, or the Virgin Islands

[An Exchange that is a government agency established under sections 1311(b)(1) or 1321(c)(1) of the Affordable Care Act

The Medicaid agency

oO Single state agency under Title IV-A (in the 50 states or the District of Columbia) or under Title | or XVI (AABD) in Guam, Puerto Rico, or the Virgin Islands

oO An Exchange that is a government agency established under sections 131 1(b)(1) or 1321(c)(1) of the Affordable Care Act The Federal agency administering the SS] program Indicate which agency determines eligibility for any groups whose eligibility is not determined by the Federal agency: Medicaid agency [1 Title 1V-A agency

(7 An Exchange

Medicaid agency (An Exchange that is a government agency established under sections 1311(b)(1) or 1321(c)(1) of the Affordable Care Act

(J An Exchange appeals entity, including an entity established under section 1411(f) of the Affordable Care Act

@ No

Si

42 CFR 431.10 42 CFR 431.11

Organization and Administration

Provide a description of the organization and functions of the Medicaid agency.

SCDHHS is authorized under State Law to perform statewide health planning and be the single State Agency administering Medicaid. The purpose of SCDHHS is to develop a unified system of planning, financing and administering of the Medicaid program and to assure that essential services provided by the program are delivered in the most effective and efficient manner. SCDHHS mission is to purchase the most health for our citizens in need at the least possible cost to the taxpayer.

With specific regard to administration of Medicaid, DHHS intends to:

TN No: 13-0019-MM4 Approval Date: 02-12-14 Effective Date: 10/01/13 South Carolina A-2

ee Ss Medicaid Administration

MEAGRE A ODOT SEATICY

oma

« Succeed financially

* Innovate and be flexible to change + Excel operationally

* Achieve quality health outcomes.

Following is a description of the organization of SCDHHS:

Director: The Director's function is to ensure the coordinated, economical, efficient delivery of Medicaid health services to eligible South Carolinians. The Director serves as the chief administrative officer and has the responsibility of executing policies, directives and actions of the Department, either personally or by issuing appropriate directives to Department employees. The Director has the sole authority to employ and discharge Department employees subject to such personnel policies and funding available for that purpose. The SCDHHS Director is appointed by the Governor and confirmed by the Senate.

Office of the Chief of Staff: The Chief of Staff has the overall responsibility for the coordination of agency functions, including the establishment of goals, performance monitoring and general supervision.

The basic functions are to establish goals in broad terms, suggest initiatives, monitor performance and furnish general supervision. The Chief of Staff will also oversee the legislative and communications functions of the agency.

Office of General Counsel: The General Counsel provides legal representation for the Department in actions in the state and federal courts and administrative hearings. This office also renders legal advice and opinions concerning administration of Medicaid, including the drafting and interpretation of statutes and regulations. The Office of Compliance and Performance Review, which performs internal and external audits, is also under the supervision of the General Counsel.

Office of Operations and Information Management: The Deputy Director of Operations and Information Management oversees the Agency's eligibility policy and operations, claims operations and provider relations, project management, information technology and human resources administration. Eligibility, Enrollment and Member Services, which oversees Medicaid Eligibility is part of this office. The agency makes determinations for all eligibility groups, except for Supplemental Security Income recipients as described below. The Director for Eligibility, Enrollment and Member Services reports to the Deputy Director of Operations and Information Management.

Office of Fiscal Management and Administration (CFO): The Deputy Director of Fiscal Management and Administration manages the financial, budget and administrative operations for South Carolina’s $6 billion Medicaid program; works to ensure the accuracy and éfficiency of the strategic planning and budgeting forecasting process and program monitoring. The Bureau of Third Party Liability and Appeals houses fair hearings functions. The Director of this Bureau reports to the Deputy Director of Finance and Administration. The Bureau of Third Party Liability and Appeals issues decisions. There is no review within the agency. If the Petitioner OR Respondent does not agree with the decision it can be appealed to court.

Office of Health Programs: The Deputy Director for Health Programs oversees both the managed care and the medical services sections of the agency including physicians, hospitals, pharmacy, durable medical equipment, dental, transportation, managed care and medical support services. This team focuses on health outcomes, quality patient care, contract management and the development of innovative programs and policies that improve the overall health of our beneficiaries and the citizens of South Carolina.

Office of Behavioral Health and Long Term Care: The Deputy Director for Behavioral Health and Long Term Care , guides the long term care and behavioral health policies as SCDHHS transforms these critical services and systematically integrates community long term care, including nursing homes, and behavioral health with primary care services.

Upload an organizational chart of the Medicaid agency.

An attachment is submitted.

Provide a description of the structure of the state's executive branch which includes how the Medicaid agency fits in with other health, human service and public assistance agencies.

TN No: 13-0019-MM4 Approval Date: 02-12-14

Effecti : South Carolina A3 ective Date: 10/01/13

Cems Medicaid Administration

CTE FOS Mak anE & me DACAND ECE

Under the South Carolina Constitution, the Governor is the head of government, serving as the chief executive of the South Carolina executive branch. The Governor appoints directors to 14 cabinet agencies, who are shared with the General Assembly and approved by the Senate. The other state social service cabinet agencies include: Department of Alcohol and Other Drug Abuse Services; Department of Social Services; and Department of Mental Health.

In an effort to efficiently utilize community resources, SCDHHS has entered into agreements with other agencies, including SCVRD, SCDHEC, SCCB, HeadStart, HUD, SCDSS, and SCDMH and SC DDSN to exchange services and enforce a cooperative agency relationship. The purpose of the agreements is to clarify the roles of the agencies, prevent duplication of services, improve communication, and ensure effective and efficient health care services.

SCDHHS and the South Carolina Vocational Rehabilitation Department (SCVRD) entered into an agreement with the purpose of creating a cooperative relationship between the two agencies. SCDHHS and SCVRD agreed to use the facilities of each agency for rehabilitating applicants and Medicaid beneficiaries, collaborate on cases and share information about clients, and respect the confidential nature of information by either agency. SCDHHS makes provisions for early access to medical and remedial care available through Medicaid, and provides for early identification and referral of vocational rehabilitation clients. SCVRD helps identify children who are enrolled in their programs and are eligible for Medicaid and the Early Periodic Screening and Diagnosis Treatment Program (EPSDT). SCDHHS accepts the referrals, determines the children’s eligibility, assists the parents in scheduling la screening appointment if requested, and notifies SCVRD of any missed screening appointments. SCVRD provides medical transportation to and from the screening facility for EPSDT children enrolled in their programs.

SCDHHS and the South Carolina Department of Health and Environmental Control (SCDHEC) have entered into several agreements to provide services to beneficiaries. These services include Family Planning Services, Physician Services, Home Health Services, and EPSDT. Both agencies have agreed to collaborate to improve the health status of Medicaid eligible children with elevated blood lead levels, and SCDHEC has agreed to provide hearing aids to Medicaid recipients under the age of 21. SCDHEC is also required to survey and certify skilled nursing facilities for compliance with Federal standards for participation with Medicaid.

SCDHHS and the SC Commission for the Blind (SCCB) have agreed to engage in an exchange of services. In an effort to grant disabled persons opportunities for rehabilitation and assistance, each agency shares information regarding clients and programs, makes joint referrals, and respects the confidential nature of information available by either agency. SCDHHS has agreed to work with SCCB to ensure that Medicaid is used as a resource to service eligible clients who are being served by the SCCB.

SCDHHS and Head Start are both concerned with the early detection and treatment of childhood illnesses and disabilities. Many children enrolled in Head Start are also eligible for EPSDT services through Medicaid. The agencies are committed to communicating clearly with each other to ensure each child receives the health care they require. Head Start helps identify children in its program who are eligible for Medicaid services, explains the EPSDT Program to the children’s parents, and notifies SCDHHS of its findings. SCDHHS processes the child’s application and makes an eligibility determination. Upon request, SCDHHS schedules a screening appointment, and notifies Head Start of the appointment and the child’s transportation arrangement. Head Start offers transportation to children enrolled in Medicaid when resources are available.

SCDHHS and the Department of Housing and Urban Development (HUD) are concerned with the early detection and treatment of illnesses and disabilities. Many children living in public housing are entitled to EPSDT services through Medicaid. HUD helps to identify children living in public housing who are eligible for Medicaid services, informs the children’s parents about the EPSDT Program, and provides a list of children presumed eligible for EPSDT to SCDHHS. HUD encourages local housing authorities to provide medical transportation for EPSDT children living in public housing. SCDHHS accepts the list of referrals, and determines which children are eligible for EPSDT. Upon request, SCDHHS will assist the children’s parents with scheduling a screening appointment and arranging transportation to and from the screening facility. If requested, SCDHHS will notify HUD of children who have missed screening appointments.

SCDHHS and the South Carolina Department of Social Services (SCDSS) work cooperatively to provide necessary and appropriate medical services to children in foster care. SCDSS has collaborated with DHHS to establish a medical home led by a primary care physician (PCP) with the goal of promoting better health outcomes for children in foster care. All children in foster care now have a medical home in which they receive ongoing primary care, timely referrals to appropriate specialty care, and periodic reassessment of their health. In addition, children in foster care benefit from expedited Medicaid eligibility upon first entering SCDSS foster care, and SCDSS_ provides Medicaid eligibility information to foster care youth regarding continued

TN No: 13-0019-MM4 Approval Date: 02-12-14 Effective Date: 10/01/13 South Carolina A-4

Medicaid Administration

coverage until 2T years of age. SCDHHS also has an automated monthly data match with the SCDSS to identify children not 1! currently receiving Medicaid, but who are receiving Supplemental Nutrition Assistance Program (SNAP) and/or Family \| Independence (FI). This process is known as Express Lane Eligibility (ELE). Children who are not on Medicaid and receiving {| i SNAP and/or FI are automatically eligible for Medicaid under Partners for Healthy Children (PHC). |

SCDHHS and the South Carolina Department of Mental Health (SCDMH) share an expense agreement. allowing SCDMH to I; deploy entitlement specialists throughout the mental health system to ensure that clients are eligible and enrolled. or offered the opportunity to enroll, in Medicaid. This method provides an optimized environment for the client to acquire necessary enrollment | information at the time of service. In addition, the two agencies collaborate to relieve overcrowding of psychiatric patients in local i| hospital emergency departments. The SCDMH Telepsychiatry Program provides 24/7 behavioral health consulting services to | hospital emergency departments on a state-wide basis. The mission of the Program is to develop a telepsychiatry consultation | | system that provides best practice consultations in emergency departments throughout South Carolina. i| |

SCDHHS and the South Carolina Department Disabilities and Special Needs (SCDDSN) offer Home and Community Based (HCB) Waiver Services. SCDHHS, through its Community Long Term Care (CLTC) Division. administers HCB Waivers to serve || the elderly and disabled (Community Choices Waiver), people with HIV or AIDS (HIV/AIDS Waiver), and adults who are \| dependent on a life support system (Ventilator Dependent Waiver). In addition, SCDHHS partners with SCDDSN to offer waivers | to serve people with head or spinal cord injuries (HASCI Waiver), people with intellectual disabilities or related disabilities (ID/RD Waiver), and people with pervasive developmental disorders (PDD Waiver). SCDHHS and SCDDSN offer the Community Supports Waiver as an option, which allows individuals with intellectual disabilities or related disabilities to choose to receive care at home rather than in an Intermediate Care Facility for Persons with Intellectual Disabilities (IFC/ID).

Remove Type of entity that determines eligibility:

Single state agency under Title 1V-A (in the 50 states or the District of Columbia) or under Title | or XVI (AABD) in Guam. Puerto Rico, or the Virgin Islands

C An Exchange that is a government agency established under sections 131 1(b)(1) or 1321(c)(1) of the Affordable Care Act (@ The Federal agency administering the SSI program

Provide a description of the staff designated by the entity and the functions they perform in carrying out their responsibility.

The Social Security Administration is responsible for making eligibility determinations for Supplemental Security Income (SSI) | recipients. The South Carolina Department of Health and Human Services is responsible for certifying the Medicaid eligibility of SSI recipients by issuing a Medicaid Identification Card to the recipient for information transmitted through the State Data

Exchange (SDX) System. Pursuant to a 1634 agreement, the Social Security Administration determines Medicaid eligibility for | Supplemental Security Income recipients.

Remove

Type of entity that conducts fair hearings: C An Exchange that is a government agency established under sections 1311(b)(1) or 1321(c)(1) of the Affordable Care Act

(C An Exchange appeals entity. including an entity established under section 1411(f) of the Affordable Care Act

_ Provide a description of the stall designated by the entity and the Tunctions they Perform i in carrying out their responsibility.

TN No: 13-0019-MM4 Approval Date: 02-12-14 Effective Date: 10/01/13 South Carolina A-S

ccm Ss Medicaid Administration

COC roe warscans RaeDerAID EEOC

Add

Supervision of state plan administration by local political subdivisions (if described under Designation and Authority) Is the supervision of the administration done through a state-wide agency which uses local political subdivisions?

C Yes ( No

Assura

42 CFR 431.10 42 CFR 431.12 42 CFR 431.50

Assurances The state plan is in operation on a statewide basis, in accordance with all the requirements of 42 CFR 431.50. All requirements of 42 CFR 431.10 are met.

There is a Medical Care Advisory Committee to the agency director on health and medical services established in accordance with meeting all the requirements of 42 CFR 431.12.

The Medicaid agency does not delegate, to other than its own officials, the authority to supervise the plan or to develop or issue policies, rules, and regulations on program matters.

Assurance for states that have delegated authority to determine eligibility:

Oo There is a written agreement between the Medicaid agency and the Exchange or any other state or local agency that has been delegated authority to determine eligibility for Medicaid eligibility in compliance with 42 CFR 431.10(d).

Assurances for states that have delegated authority to conduct fair hearings:

oO There is a written agreement between the Medicaid agency and the Exchange or Exchange appeals entity that has been delegated authority to conduct Medicaid fair hearings in compliance with 42 CFR 431.10(d).

Oo When authority is delegated to the Exchange or an Exchange appeals entity, individuals who have requested a fair hearing are given the option to have their fair hearing conducted instead by the Medicaid agency.

Assurance for states that have delegated authority to determine eligibility and/or to conduct fair hearings:

The Medicaid agency does not delegate authority to make eligibility determinations or to conduct fair hearings to entities other than government agencies which maintain personnel standards on a merit basis.

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.20130917 TN No: 13-0019-Mm4

Approval : 02-12- South Carolina Pproval Date: 02-12-14

E + . AG ffective Date: 10/01/13

Table of Contents

State/Territory Name: South Carolina State Plan Amendment (SPA) #:14-0004-MM1 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 Atlanta Regional Office 61 Forsyth Street, Suite 4T20 Atlanta, Georgia 30303

DIVISION OF MEDICAID & CHILDREN’S HEALTH OPERATIONS

March 11, 2015

Mr. Christian L. Soura, Director SC Department of Health and Human Services Post Office Box 8206 Columbia, South Carolina 29202-8206

Attention: Sheila Chavis

RE: Title XIX State Plan Amendment, SC 14-0004-MM1

Dear Mr. Soura:

Enclosed is an approved copy of South Carolina’s state plan amendment (SPA) 14-0004-MM1, which was submitted to CMS on December 19, 2014. The purpose of this amendment is to add the MAGI-Based Eligibility Group for Tuberculosis (TB) template S55. This SPA was approved on March 10, 2015. The effective date of the SPA is November 4, 2014.

We are enclosing the HCFA-179 and the approved plan pages. This SPA supersedes the S55 Eligibility template approved in SPA 13-0014-MM1. Please incorporate these approved plan pages within the separate section at the end of South Carolina’s approved state plan.

Congratulations to you and your staff for your hard work and strong collaboration. If you have any additional questions or need further assistance, please contact Maria Drake at (404) 562-3697 or Maria.Drake@cms.hhs.gov.

Sincerely,

//s//

Jackie Glaze

Associate Regional Administrator

Division of Medicaid & Children’s Health Operations

Enclosures

State/Territory name: South Carolina Submitted By: Sheila Chavis Last Revision Date: Jan 12, 2015 Submit Date: Dec 19, 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. SC-14-0004 Proposed Effective Date 11/04/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation 1902(a)(10)(A)(ii)(XII) 1902(z) Federal Budget Impact Federal Fiscal Year Amount First Year 2015 $ 2908317.00 Second Year 2016 $ 3207056.00 Subject of Amendment This State Plan provides coverage language for the Tuberculosis Program. This SPA supersedes the S55 Eligibility template approved in SPA 13-0014-MM1. 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: Mr. Soura was designated by the Governor to review and approve all State Plans. Signature of State Agency Official Page 1 of 2 SC.1457.R00.00 - Nov 04, 2014 03/11/2015 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/mac/c01/print/PrintSelector.jsp

CcCcmMs Medicaid Eligibility

State Name:

South Carolina | OMB Control Number: 0938-1148

1902(a)(10)(A)(ii)(XID) 1902(z)

Transmittal Number: SC - 14 - 0004 Expiration date: 10/31/2014

ml

Ly} Cy}

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 C 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 infected with tuberculosis.

[] Are not otherwise eligible for mandatory coverage under the Medicaid state plan. {m] Have household income under 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.

Income standard used for this group

[@] Maximum income standard

First indicate the maximum income standard that could be used for this group and then indicate the income standard the state uses for the group.

The state elects to convert the effective income level for coverage of this eligibility group in effect in the Medicaid state plan as of March 23, 2010 and December 31, 2013 to MAGI-equivalent standards.

C Yes @No The state's maximum income standard for this eligibility group is: @ The break-even point for earned income under the SSI program.

The effective income level for this eligibility group under the Medicaid state plan in effect as of March 23, 2010, not converted to a MAGI-equivalent standard.

The effective income level for this eligibility group under the Medicaid state plan in effect as of December 31, 2013, not converted to a MAGI-equivalent standard.

No income test (all income is disregarded), if no income test was used for this eligibility group under the Medicaid state plan in effect as of March 23, 2010 or December 31, 2013.

[| Income standard chosen

The state's income standard used for this eligibility group is:

C The maximum income standard.

C Ifnot chosen as the maximum income standard, the break-even point for earned income under the SSI program.

@ Another income standard less than the maximum standard allowed.

TN No: SC-14-0004-MM1 Approval Date: 03-10-15 Effective Date: 11-04-14 South Carolina $55-1

ccmMs Medicaid Eligibility

The amount of the income standard is:

@A percentage of the federal poverty level: |133 %

C A dollar amount

i Individuals qualifying under this group are eligible only for the following services, provided the service is related to the diagnosis, treatment or management of the individual's tuberculosis.

[lM] Prescribed drugs, described in 42 CFR 440.120

Physician services, described in 42 CFR 440.50

Outpatient hospital and rural health clinic described in 42 CFR 440.20 and Federally-qualified health center services Laboratory and x-ray services (including services to confirm the presence of the infection), described in 42 CFR 440.30

Clinic services, described in 42 CFR 440.90

eee

Case management services defined in 42 CFR 440.169

im Services other than room and board designed to encourage completion of regimens of prescribed drugs by out-patients, including services to observe directly the intake of prescription drugs.

[®] Limitations related to tuberculosis-related services may be found in the Benefits section.

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.20140415

TN No: SC-14-0004-MM1 Approval Date: 03-10-15 South Carolina S55-2

Effective Date: 11-04-14

a

Table of Contents

State/Territory Name: South Carolina State Plan Amendment (SPA) #: 14-0022-MM3 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 Atlanta Regional Office 61 Forsyth Street, Suite 4T20 Atlanta, Georgia 30303

DIVISION OF MEDICAID & CHILDREN’S HEALTH OPERATIONS

September 12, 2014

Mr. Anthony E. Keck Director SC Department of Health and Human Services Post Office Box 8206 Columbia, South Carolina 29202-8206

Attention: Sheila Chavis

Re: South Carolina State Plan Amendment (SPA) 14-0022-MM3

Dear Mr. Keck:

Enclosed is an approved copy of South Carolina’s state plan amendment (SPA) 14-0022-MM3, which was submitted to CMS on June 20, 2014. The purpose of this new amendment was to align the Reasonably Predictable Changes in income selections on the S10 plan page to what the state entered on their Federally Facilitated Marketplace (FFM) data collection tool. This SPA was approved on September 10, 2014. The effective date of the SPA is April 1, 2014.

We are enclosing the HCFA-179 and the approved plan pages. Please incorporate the approved plan pages within a separate section at the end of South Carolina’s approved state plan.

Congratulations to you and your staff for your hard work and strong collaboration. If you have any additional questions or need further assistance, please contact Maria Drake at (404) 562-3697 or Maria.Drake@cms.hhs.gov.

Sincerely,

//s//

Jackie Glaze

Associate Regional Administrator

Division of Medicaid & Children’s Health Operations

Enclosures

Medicaid State Plan Eligibility: Summary Page (CMS 179) • State/Territory name: South Carolina • 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. 14-0022 • Proposed Effective Date 04/01/2014 (mm/dd/yyyy) • Federal Statute/Regulation Citation I 1902(e)(14 • Federal Budget Impact Federal Fiscal Year First Year 11 2014 Second Year 11 2015 • Subject of Amendment Character Count: Amount $1 0.00 $1 0.00 out of 2000

Bigibility Te111Jiate S1 0--MAGI- • Governor's Office Review 0 r Governor's office reported no comment 0 r Comments of Governor's office received Describe: 0 r No reply received within 45 days of submittal 0 r. Other, as specified Describe: Mr. Anthony E Keckwas des • Signature of State Agency Official a Submitted By: Sheila Chavis a Last Revision Date: Aug 1, 2014 0 a Submit Date: Jul 16, 2014 Character Count: out of 2000

1902(e)(l4) 42 CFR 435.603 Medicaid Eligibility OMB Control Number 0938-1148 OMB date: 10/31/2014 [!] 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: (e' 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: (e' Current monthly household income and family size ('Projected annual household income and family size for the remaining months of the current calendar year 1n determining current monthly or projected annual household income, the state will use reasonable methods to: IX] Include a prorated portion of a reasonably predictable increase in future income and/or family size. IX] 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 ofthe 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(t)(2)(i) as a tax dependent. (e' Yes ('No TN No: 14-0022-MM3 South Carolina Approval Date: 09-10-14 510-1 Effective Date: 04/01/14

Medicaid Eligibility [i] The age used for children with respect to 42 CFR 435.603(f)(3)(iv) is: r. Age 19 r 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 No: 14-0022-MM3 South Carolina Approval Date: 09-10-14 510-2 Effective Date: 04/01/14 ..

Table of Contents

State/Territory Name: South Carolina State Plan Amendment (SPA) #:15-0009 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 Atlanta Regional Office 61 Forsyth Street, Suite 4T20 Atlanta, Georgia 30303

DIVISION OF MEDICAID & CHILDREN’S HEALTH OPERATIONS

November 10, 2015

Mr. Christian L. Soura Director SC Department of Health and Human Services Post Office Box 8206 Columbia, South Carolina 29202-8206

Attention: Sheila Chavis

Re: South Carolina State Plan Amendment 15-009

Dear Mr. Soura:

We have reviewed the proposed South Carolina state plan amendment, SC 15-009, which was submitted to the Centers for Medicare & Medicaid Services (CMS) on September 30, 2015. The purpose of this amendment is to limit allowable pre-eligibility medical expenses applied to reduce recurring income for long term care services to expenses incurred in the three months prior to the month of the Medicaid application.

Based on the information provided, the Medicaid State Plan Amendment SC 15-009 was approved on November 10, 2015. The effective date of this amendment is October 1, 2015. We are enclosing the approved HCFA-179 and a copy of the new state plan page.

If you have any additional questions or need further assistance, please contact Maria Drake at (404) 562-3697 or Maria.Drake@cms.hhs.gov.

Sincerely,

//s//

Jackie Glaze Associate Regional Administrator Division of Medicaid & Children’s Health Operations

Enclosures

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED HEALTH CARE FINANCING ADMINISTRATION OMB NO. 0938-0193 TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL

FOR: HEALTH CARE FINANCING ADMINISTRATION 1. TRANSMITTAL NUMBER: SC 15-009 2. STATE South Carolina 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 10/1/15 5. TYPE OF PLAN MATERIAL (Check One):

NEW STATE PLAN AMENDMENT TO BE CONSIDERED AS NEW PLAN AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate Transmittal for each amendment) 6. FEDERAL STATUTE/REGULATION CITATION: §435.725 7. FEDERAL BUDGET IMPACT: a. FFY 2016 $ minimal but unknown at this time b. FFY 2017 $ minimal but unknown at this time. 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:

Supplement 3 to Attachment 2.6-A, page 1 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable):

Supplement 3 to Attachment 2.6-A, page 1 10. SUBJECT OF AMENDMENT: Amend state plan to limit allowable pre-eligibility medical expenses applied to reduce recurring income for long term care services to expenses incurred in the retro period which is three calendar months prior to the Medicaid date of application.

11. GOVERNOR’S REVIEW (Check One): GOVERNOR’S OFFICE REPORTED NO COMMENT OTHER, AS SPECIFIED: COMMENTS OF GOVERNOR’S OFFICE ENCLOSED Mr. Soura was designated by the Governor NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL to review and approve all State Plans 12. SIGNATURE OF STATE AGENCY OFFICIAL:

16. RETURN TO:

South Carolina Department of Health and Human Services Post Office Box 8206 Columbia, SC 29202-8206 13. TYPED NAME: Christian L. Soura 14. TITLE: Director 15. DATE SUBMITTED: September 29, 2015 FOR REGIONAL OFFICE USE ONLY 17. DATE RECEIVED: 09-30-15

18. DATE APPROVED: 11-10-15 PLAN APPROVED – ONE COPY ATTACHED 19. EFFECTIVE DATE OF APPROVED MATERIAL: 10-01-15 20. SIGNATURE OF REGIONAL OFFICIAL:

21. TYPED NAME: Jackie Glazed

22. TITLE: Associate Regional Administrator Division of Medicaid & Children Health Opns 23. REMARKS:

FORM HCFA-179 (07-92)

SUPPLEMENT 3 TO ATTACHMENT 2.6-A

Page 1

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State: ______________South Carolina_________________

LIMITATIONS ON NON-COVERED MEDICAL EXPENSES

The following is a listing of Medical expenses which are allowable deductions from the recipient’s monthly recurring income:

• Prescription drugs above the four(4) prescriptions per month limit, not to exceed $54.00 per additional prescription per month.

• Eyeglasses not otherwise covered by the Medicaid Program, not to exceed a total of $108.00 per occurrence for lenses, frames and dispensing fee. The necessity for eyeglasses must be certified by a licensed practitioner of optometry or ophthalmology.

• Dentures - A one-time expense, not to exceed $651.00 per plate or $1320.00 for one full pair of new dentures. The necessity for dentures must be certified by a licensed dental practitioner. An expense for more than one pair of dentures must be approved by the staff of the South Carolina Department of Health and Human Services (SCDHHS).

• Denture repair which is justified as necessary by a licensed dental practitioner, not to exceed $77.00 per occurrence.

• Physician and other medical practitioner visits above the 12 visit limit per fiscal year, not to exceed $69.00 per visit.

• Hearing Aids - A one time expense, not to exceed $1000.00 for one or $2000.00 for both. The necessity for a hearing aid must be certified by a licensed practitioner. An expense for more than one hearing aid must be prior approved by the staff of SCDHHS.

• The deduction for medical and remedial care expenses that were incurred as the result of imposition of a transfer of assets penalty period is limited to zero.

• Reasonable and necessary medical and remedial care expenses not covered by Medicaid incurred in the 3 months prior to the month of application are allowable deductions. Expenses incurred prior to this three month period are not allowable deductions.

_____________________________________________________________________________ TN No. SC 15-009 Supersedes

Approval Date: 11-10-15 Effective Date 10/01/15 TN No. SC 06-017

HCFA ID: 7985E

Table of Contents

State/Territory Name: South Carolina State Plan Amendment (SPA) #17-0001-MM6 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 4) Additional Attachments that are part of the state plan

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Atlanta Regional Office 61 Forsyth Street, Suite 4T20 Atlanta, Georgia 30303

DIVISION OF MEDICAID & CHILDREN’S HEALTH OPERATIONS

May 11, 2017

Ms. Deirdra Singleton, Interim Director South Carolina Department of Health and Human Services Post Office Box 8206 Columbia, South Carolina 29202-8206

Attention: Sheila Chavis

RE: Title XIX State Plan Amendment (SPA), SC 17-0001-MM6

Dear Ms. Singleton;

Enclosed is an approved copy of South Carolina’s state plan amendment (SPA) 17-0001-MM6, which was submitted to the Centers for Medicare & Medicaid Services (CMS) on February 17, 2017. The purpose of this amendment is to allow for eligibility for certain pregnant women and children as described in section 1903(v)(4) and 2107 (e)(1)(J) of the Social Security Act and who are otherwise eligible for assistance under the state plan (template S89). We understand the state intends to implement this SPA on January 1, 2018. Should the state’s implementation date change, the state will contact CMS.

Based on the information provided, the Medicaid SPA SC 17-0001-MM6 was approved on May 11, 2017. The effective date of this amendment is January 1, 2018. We are enclosing the approved plan pages.

If you have any additional questions, please contact Maria Drake at (404) 562-3697 or Maria.Drake@cms.hhs.gov.

Sincerely,

//s//

Jackie Glaze

Associate Regional Administrator

Division of Medicaid & Children’s Health Operations

Enclosures

State/Territory name: South Carolina Submitted By: Sheila Chavis Last Revision Date: May 9, 2017 Submit Date: Feb 17, 2017 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. SC-17-0001 Proposed Effective Date 01/01/2018 (mm/dd/yyyy) Federal Statute/Regulation Citation 1903 (v)(4) and 2107(e)(1)(J) of the Social Security Act Federal Budget Impact Federal Fiscal Year Amount First Year 2017 $ 0.00 Second Year 2018 $ 0.00 Subject of Amendment SCDHHS will modify the State Plan to amend its coverage of certain pregnant women and children as described in section 1903(v) (4) and 2107(e)(1)(J)of the Social Security Act and who are otherwise eligible for assistance. 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: SCDHHS' Agency Director: Mr. Christian L. Soura was designated by the Governor to review and approve all State Plans. Signature of State Agency Official Page 1 of 2 SC.3337.R00.00 - Jan 01, 2018 05/12/2017 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/mac/c01/print/PrintSelector.jsp

Non-Financial Eligibility: Citizenship and Non-citizen Eligibility TRANSMITTAL NUMBER:

17-0001 STATE:

South Carolina

Notwithstanding the checked assurance on page 1 that the state provides for an extension of the reasonable opportunity period beyond 90 days for individuals declaring to be citizens and nationals of the United States and certain non-citizens, the state extends the reasonable opportunity period beyond 90 days for otherwise eligible individuals declaring to be in a satisfactory immigration status if the agency determines that the individual is making a good faith effort to obtain any necessary documentation or the agency needs more time to verify the individual's status through other available electronic data sources or to assist the individual in obtaining documents needed to verify his or her status in accordance with 42 CFR §435.956(b)(2)(ii)(B).

Page 1 of 4 Medicaid Eligibility Transmittal Number: SC State Name: South Carolina OMB Control Number: 0938‐1148 - 17 - 0001 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: 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 No: 17-0001-MM6 Approval Date: 05/11/17 Effective Date: 01/01/18 South Carolina S89-1

Page 2 of 4 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 Indicate which requirements apply: The state requires Lawful Permanent Residents to have 40 qualifying work quarters under Title II of the Social Security Act. Yes No The state limits eligibility to 7 years for certain non-citizens. Yes No Check all that apply: Non-citizens admitted to the U.S. as a refugee under section 207 of the INA Non-citizens granted asylum under section 208 of the INA Non-citizens whose deportation is withheld under section 243(h) or 241(b)(3) of the INA Non-citizens granted status as a Cuban-Haitian Entrant, as defined in section 501(e) of the Refugee Education Assistance Act of 1980 Non-citizens admitted to the U.S. as Amerasian 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: TN No: 17-0001-MM6 Approval Date: 05/11/17 Effective Date: 01/01/18 South Carolina S89-2

Page 3 of 4 Medicaid Eligibility 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; ■ 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). ■ TN NO: 17-0001-MM6 Approval Date: 05/11/17 Effective Date: 01/01/18 South Carolina S89-3

Page 4 of 4 Medicaid Eligibility PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938‐1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4‐26‐05, Baltimore, Maryland 21244‐1850. V.20160722 TN NO: 17-0001-MM6 Approval Date: 05/11/17 Effective Date: 01/01/18 South Carolina S89-4

Table of Contents

State/Territory Name: South Carolina State Plan Amendment (SPA) #: 17-0014 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 61 Forsyth Street S.W. Suite 4T20 Atlanta, Georgia 30303

Atlanta Regional Operations Group

November 20, 2019

Mr. Joshua D. Baker Director SC Department of Health and Human Services Post Office Box 8206 Columbia, South Carolina 29202-8206

Attention: Sheila Chavis

Re: South Carolina State Plan Amendment 17-0014

Dear Mr. Baker:

We have reviewed the proposed South Carolina State Plan Amendment, SC 17-0014, which was submitted to the Centers for Medicare & Medicaid Services (CMS) on September 21, 2017. This plan amendment increases South Carolina Department of Mental Health clinic service rates based upon the calendar year 2017 Medicare Economic Index trend rate of 1.2%.

Based on the information provided, the Medicaid State Plan Amendment SC 17-0014 was approved on November 20, 2019. The effective date of this amendment is July 1, 2017. We are enclosing the approved HCFA-179 and a copy of the new state plan page(s).

If you have any additional questions or need further assistance, please contact Cheryl Wigfall at (803) 252-7299 or Cheryl.wigfall@cms.hhs.gov.

Sincerely,

/s/

Davida R. Kimble Acting Deputy Director Division of Medicaid Field Operations South

Enclosures

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED HEALTH CARE FINANCING ADMINISTRATION OMB NO. 0938-0193 FORM HCFA-179 (07-92) TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL

FOR: HEALTH CARE FINANCING ADMINISTRATION 1. TRANSMITTAL NUMBER: 17-0014 2. STATE South Carolina 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 July 1, 2017 5. TYPE OF PLAN MATERIAL (Check One):

NEW STATE PLAN AMENDMENT TO BE CONSIDERED AS NEW PLAN AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate Transmittal for each amendment) 6. FEDERAL STATUTE/REGULATION CITATION: 42 CFR Part 447 – Subcharter C 7. FEDERAL BUDGET IMPACT: a. FFY 2017 $ 53,000 ($300,000 x .7130 x 3/12) b. FFY 2018 $ 215,000 ($300,000 x .7158) 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:

Attachment 4.19-B, page 3a.4

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

Attachment 4.19-B, page 3a.4 10. SUBJECT OF AMENDMENT: Updated SCDMH clinic Rates Effective July 1, 2017 11. GOVERNOR’S REVIEW (Check One): GOVERNOR’S OFFICE REPORTED NO COMMENT OTHER, AS SPECIFIED: COMMENTS OF GOVERNOR’S OFFICE ENCLOSED Ms. Singleton was designated by the Governor NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL to review and approve all State Plans 12. SIGNATURE OF STATE AGENCY OFFICIAL: /s/ 16. RETURN TO:

South Carolina Department of Health and Human Services Post Office Box 8206 Columbia, SC 29202-8206 13. TYPED NAME: Deirdra T. Singleton 14. TITLE: Acting Director 15. DATE SUBMITTED: September 21, 2017 FOR REGIONAL OFFICE USE ONLY 17. DATE RECEIVED: 09/21/17 18. DATE APPROVED: 11/20/19 PLAN APPROVED – ONE COPY ATTACHED 19. EFFECTIVE DATE OF APPROVED MATERIAL: 07/01/17 20. SIGNATURE OF REGIONAL OFFICIAL: /s/ 21. TYPED NAME: Davida R. Kimble 22. TITLE: Acting Deputy Director Division of Medicaid Field Operations South 23. REMARKS:

Attachment 4.19-B Page 3a.4

Injection Administration (96372) provided during a clinic setting will be reimbursed via the SC Medicaid Physician Fee schedule.

Effective for services provided on or after October 1, 2012, state owned governmental providers of community mental health clinic services will receive prospective payment rates based upon its 2010 fiscal year end Medicaid cost report. In order to trend the cost of each service to the initial payment period of October 1, 2012 through June 30 2013, the Medicaid Agency will employ the midpoint to midpoint methodology and the use of the CY 2010 Medicare Economic Index (1.2%). Effective for services provided on or after July 1, 2016, the SC Department of Mental Health providers of community mental health services will receive prospective payment rates based upon its 2015 fiscal year end Medicaid cost report. In order to trend the cost of each service to the payment period of July 1, 2016 through June 30, 2017, the Medicaid Agency will employ the midpoint to midpoint methodology and the use of the 3rd Quarter 2015 Global Insight Indexes of the CMS Medicare Economic index as well as the state of South Carolina cost of living increase provided to state employees effective July 1, 2016. State owned governmental providers of community mental health clinic services will be required to submit annual cost reports when certified public expenditures are used as the source of state matching funds.

Effective for services provided on and after July 1, 2017, the July 1, 2016 SCDMH clinic rates were increased by the calendar year 2017 Medicare Economic Index trend rate of 1.2%.

Interim Rates

Medicaid interim rates for mental health services in community mental health centers are established utilizing Medicare reasonable cost principles, as well as criteria outlined under 45 CFR Part 75 and 42 CFR Part 413. Costs reimbursable in the rates for mental health clinical services include but are not limited to: 1. Personnel costs – the salary and fringe benefit costs associated with direct line staff, meeting credentialing requirements, providing the services in the community mental health centers,

2. Clinical supervision – the salary and fringe benefit cost associated with the clinical supervision of these services,

3. Supplies – material and supply costs that are required for direct services to patients,

4. Training and travel – training and associated travel expenses that directly relate to maintaining certification, qualifications, or licensure required to render contracted mental health services but not to obtain their initial certification,

5. Indirect costs – Overhead/administrative costs incurred by mental health clinics and state agencies that are allocable to the individual mental health services via approved cost allocation methodologies as allowed under 45 CFR Part 75 and 42 CFR Part 413.

SC 17-0014 EFFECTIVE DATE: 07/01/17 RO APPROVAL: 11/20/19 SUPERSEDES: SC 16-0008

Table of Contents

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

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-26-12 Baltimore, Maryland 21244-1850

Financial Management Group

November 4, 2019

Joshua D. Baker, Director

Department of Health & Human Services

1801 Main Street

Columbia, SC 29201

RE: State Plan Amendment (SPA) 19-0010

Dear Mr. Baker:

We have reviewed the proposed amendment to Attachment 4.19-D of your Medicaid State plan submitted under transmittal number 19-0010. This amendment proposes to (1) rebase rates on the most recent cost report data; (2) require NFs to report costs associated with the operation of Medicaid certified beds only; (3) update the cost center standards based on the most recent cost reports; (4) apply a 2.7% inflation factor in the calculation of the payment rates; (5) revise the calculation of rates for NEMT; (6) replace the current modified FRV system with a updated FRV for capital related expenses; and (7) reimburse impacted NFs for Medicaid’s share of Hurricane Florence related evacuation costs due to mandatory evacuation.

We conducted our review of your submittal 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 have found that the proposed reimbursement methodology complies with applicable requirements and therefore have approved them with an effective date of October 1, 2019. We are enclosing the CMS-179 and the amended approved plan pages.

If you have any questions, please call Anna Dubois at (850) 878-0916.

Sincerely,

/s/

Kristin Fan Director

cc: Anna Dubois Dan Yablochnikov

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB No. 0938-0193 TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES 1. TRANSMITTAL NUMBER 19-0010 2. STATE SC 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) TO: REGIONAL ADMINISTRATOR CENTERS FOR MEDICA RE & MEDICA ID SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES 4. PROPOSED EFFECTIV E DATE October 1, 2019 5. TYPE OF PLAN MATERIAL (Check One) NEW STATE PLAN AMENDMENT TO BE CONSIDERED AS NEW PLAN X AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate transmittal for each amendment)

6. FEDERAL STATUTE/REGULATION CITATION 42 CFR Subpart C (Part 447.250) 7. FEDERAL BUDGET IMPACT ($37.0 Million x 70.70%) a. FFY 2020 $26.2 Million b. FFY 2021 $Rates to be Rebased 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT

Attachment 4.19-D pages, 1, 2, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 26a, 26b, 26c, 26d (new page), 28, 28a, 28b, 28c (new page)

Removing pages 16a, 16b, 17a and 18a from Attachment 4.19-D due to language shift 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable) Attachment 4.19-D pages, 1, 2, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 26a, 26b, 26c, 28, 28a, 28b, 10. SUBJECT OF AMENDMENT

Nursing Facility Rate Update Effective October 1, 2019 and New Cost of Capital Reimbursement System Effective October 1, 2019

11. GOVERNOR’S REVIEW (Check One) GOVERNOR’S OFFICE REPORTED NO COMMENT OTHER, AS SPECIFIED COMMENTS OF GOVERNOR’S OFFICE ENCLOSED Mr. Baker w as designated by the NO REPLY RECEIV ED WITHIN 45 DAYS OF SUBMITTAL

Governor to review and approve all

State Plans.

12. SIGNATURE OF STATE AGENCY OFFICIAL 13. /s/ 16. RETURN TO

South Carolina Department of Health and Human Services Post Office Box 8206 Columbia, South Carolina 29202-8206 13. TYPED NAME Joshua D. Baker 14. TITLE Director 15. DATE SUBMITTED August 15, 2019 FOR REGIONAL OFFICE USE ONLY 17. DATE RECEIV ED 8/16/19 18. DATE APPROVED 11/4/19 PLAN APPROVED - ONE COPY ATTACHED 19. EFFECTIV E DATE OF APPROVED MATERIAL 10/1/19 20. SIGNATURE OF REGIONAL OFFICIAL /s/ 21. TYPED NAME Kristin Fan 22. TITLE Director, FMG 23. REMARKS FORM CMS-179 (07/92) Instructions on Back

ATTACHMENT 4.19-D Page 1 Revised 10/01/19

SC 19-0010 EFFECTIVE DATE: 10/01/19 RO APPROVED: 11/04/2019 SUPERSEDES: SC 12-013

PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE OF SOUTH CAROLINA

The Medicaid Agency Rate Setting Policies, Procedures and Methods for Nursing Facilities, Facilities for Individuals with Intellectual Disabilities (ICF/IID), and Long Term Care Institutions for Mental Diseases

I. Cost Finding and Uniform Cost Reports

A) Each nursing facility shall complete and file with the Medicaid Agency, Division of Long Term Care Reimbursements, an annual financial and statistical report supplied by the Medicaid Agency. Effective for the cost reporting period ending September 30, 2018, all nursing facilities will be required to submit their financial and statistical report using the new SENIORS (South Carolina Electronic Nursing Home Income/Expense Operating Report System) excel workbook software provided by the Medicaid Agency. Nursing facilities must report their operations from October 1 through September 30 on a fiscal year basis. Government owned and ICF/IID facilities may report their operations from July 1 through June 30. Hospital based facilities with fiscal year ends other than September 30 will be allowed effective with the 1990 cost reports to use their fiscal year end due to the reporting difficulties of nonconcurrent Medicare and Medicaid fiscal year ends. However, no additional inflation adjustment will be made.

Effective October 1, 2010, nursing facilities which have an annual Medicaid utilization of 3,000 days or less will not be required to file an annual financial and statistical report.

Nursing facilities which incur home office cost/management fees through a related organization are responsible for submitting a hard copy of an annual cost report detailing the cost of the related organization (home office) to the Medicaid Agency. The cost report period should be from October 1 to September 30. However, large chain operations which do business in other states may request a different cost reporting period for their home office cost report; however, no additional inflation adjustment will be made.

B) Nursing facilities are required to detail their cost for the entire reporting period or for period of participation in the plan, if less than the full cost reporting period. These costs are recorded by the facility on the basis of generally accepted accounting principles and the accrual method of accounting. The cash method of accounting is acceptable for public institutions.

ATTACHMENT 4.19-D Page 2 Revised 10/01/19

SC 19-0010 EFFECTIVE DATE: 10/01/19 RO APPROVED:11/04/2019 SUPERSEDES: SC 17-0016 C) Nursing facilities are required to list the cost of the various services provided under the plan in accordance with the Medicaid Agency's cost reporting format. However, facilities providing services not covered by the plan will be required to use a step down method of cost finding as described in 42 CFR 413.24(d)(1) to apportion cost between the services covered and the services not covered by the plan before listing the cost of the various services provided under the plan. Services not covered by the plan include, but are not limited to, non-certified Medicaid beds of a facility which participates in the Medicaid (XIX) Program.

D) Nursing facilities are required to report cost on a Uniform Cost Report form provided by the Medicaid Agency. All Uniform Cost Reports must be filed with the Medicaid Agency no later than January 1. Failure to submit timely cost reports may result in a percent penalty fee. However, a thirty (30) day extension of the due date may be granted for good cause. Effective for the cost reporting period ending September 30, 2018, nursing facilities will be required to submit their financial and statistical report using the SENIORS excel workbook software. Hospital based/related nursing facility cost reports will be due no later than 30 calendar days after the due date of the hospital's Medicare cost report.

The financial and statistical report shall be certified by the operator of a proprietary medical facility, an officer of a voluntary medical facility, or the public official responsible for the operation of a public medical facility.

A new contract will not be executed until all cost reporting requirements are satisfied. Additionally, if such report properly executed has not been submitted by the required date, the Medicaid Agency shall withhold all funds, or any portion thereof to be determined by the Director, due the Provider until such report is properly submitted and a new contract executed.

ATTACHMENT 4.19-D Page 4 Revised 10/01/19

SC 19-0010 EFFECTIVE DATE: 10/01/19 RO APPROVED: 11/04/2019 SUPERSEDES: MA 99-012 a) Cost Subject to Standards: i) General Services: Nursing, Social Worker, and Activity Director and related cost. ii) Dietary iii) Laundry, Maintenance, and Housekeeping iv) Administration and Medical Records & Services b) Cost Not Subject to Standards: i) Utilities ii) Special Services iii) Medical Supplies and Oxygen iv) Property Taxes and Insurance - Building and Equipment v) Legal Fees c) Cost of Capital Reimbursement - Fair Rental Value (FRV) Payment System

Effective for dates of service beginning on or after October 1, 2019, the Medicaid Agency will reimburse South Carolina Medicaid contracting nursing facilities (NFs) for capital costs using a Fair Rental Value (FRV) methodology. The payment made under this methodology shall be the only payment made to reimburse providers for building and equipment in lieu of depreciation, interest expense, and lease costs. The only depreciation expense that will continue to be allowed relates to home office building and equipment expense as well as specialty vehicle depreciation expense as outlined in Attachment 4.19-D of the South Carolina Medicaid State Plan. Home office lease expense between unrelated parties will be considered to be allowed as an administrative expense.

(1) FRV Rate Year – Each NF shall receive a new prospective capital per diem rate effective October 1st of each year. The capital per diem rate shall be facility specific and determined each year using the data available from the Capital Data Surveys corresponding to the base year cost report period (i.e. FYE September 30th) used to establish the October 1st payment rates each year. Capital Data Surveys will be submitted annually in conjunction with the annual filing of the SC Medicaid Nursing Facility cost reports. FRV data elements that are not provider specific, including those published by RSMeans Construction Cost Data publication and the rental value rate as determined by the rolling three year average of the three most recently completed calendar years of 10 Year US Treasury Bond interest

ATTACHMENT 4.19-D Page 4 Revised 10/01/19

SC 19-0010 EFFECTIVE DATE: 10/01/19 RO APPROVED: 11/04/2019 SUPERSEDES: MA 99-012 rates, shall be determined annually and effective October 1st of each year.

ATTACHMENT 4.19-D Page 5 Revised 10/01/19

SC 19-0010 EFFECTIVE DATE: 10/01/19 RO APPROVED: 11/04/2019 SUPERSEDES: MA 99-012 (2) Calculation of FRV Capital Per Diem Rate – The new value construction cost per square foot shall be $256.61 prior to the Location Factor adjustment. After the application of the Location Factor adjustment, the adjusted new value construction cost per square foot shall be $215.55. For the FRV Capital Per Diem rate effective October 1, 2019 and annually thereafter, the adjusted new construction cost of $215.55 per square foot will be trended forward based on the historical cost index factor each October 1 st as published annually in the RSMeans Construction Cost Data publication (October 1 st, current year divided by October 1 st, previous year). The standard square footage minimum and maximums per age group per bed, the $7,000 addition per Medicaid certified bed for equipment, and the 7.50% land value to be added to the fixed capital replacement was established in partnership with the state’s nursing facility industry. The FRV Capital Per Diem rate is calculated as follows:

a) First, determine the square footage that will be used in the computation. The square footage that will be used will be the greater of the actual measured gross square footage or the square footage determined by multiplying the number of Medicaid certified beds by the minimum square footage amount per room of 275. However in no event can the square footage used in the payment calculation exceed the maximum square footage ceiling amount per age group multiplied by the number of Medicaid certified beds.

b) Next, to determine the New Building Value Cost, first multiply the square footage determined in step a) above by the January 1, 2018 new value construction cost per square foot of $256.61. To account for the Location Factor of each NF, apply the location factor as provided in the 2018 RSMeans Construction Cost Data publication against the amount calculated above. Location Factors are determined by the state in which the NF is located and the first three digits of the NF’s zip code. The Location Factors will be updated annually based upon the base year cost reporting period FYE date.

c) Next, to determine the Moveable Equipment Replacement Value, multiply the number of Medicaid certified beds for each NF by $7,000. Add this calculated amount to the New Building Value Cost as determined in step b) above to arrive at the Building and Equipment Replacement Value for each NF.

ATTACHMENT 4.19-D Page 6 Revised 10/01/19

SC 19-0010 EFFECTIVE DATE: 10/01/19 RO APPROVED: 11/04/2019 SUPERSEDES: SC 17-0016 d) Next, to adjust for accumulated building and equipment depreciation expense, multiply the Fair Rental Value Age of each NF by an annual 2.00% depreciation rate. Then reduce the Building and Equipment Replacement Value determined in c) above by the calculated accumulated depreciation expense. The Fair Rental Value Age represents the weighted average age of the NF. Bed additions, replacements, and renovations may lower the weighted age of the NF. The maximum calculated age of a NF shall be 30 years; therefore NFs shall not be depreciated to an amount less than 40% (100 % minus (2.0% * 30 years)) of the Building and Equipment Replacement Value. There will be no recapture of depreciation in the event of a sale.

e) Next, to determine the Land Value of each NF, multiply the New Building Value Cost as described in step b) above by 7.50%.

f) Next, to determine the preliminary annual Fair Rental Gross amount of each NF, determine the Building, Equipment, and Land Depreciation Value by adding the amounts determined in steps d) and e) above. Multiply the summed amount by the rental factor of 7.50% to arrive at the Fair Rental Gross amount for each NF. The rental factor rate is based upon the rolling three year average of the yield of the three most recently completed calendar years of 10 Year US Treasury Bond (monthly frequency) interest rates, plus a risk factor of 3.00% with an imposed floor of 7.50% and a ceiling of 9.50%. The rental factor shall be determined annually and become effective October 1st of each year.

g) Next, income offset adjustments as defined in HIM- 15, section 202.2 will continue to be made, except that income adjustments will be limited to the Fair Rental Gross amount of the nursing facility, plus working capital and specialty vehicle interest, in lieu of actual interest expense.

h) To determine the final Fair Rental Value Gross amount for each NF two steps must occur. First, the preliminary annual Fair Rental Gross amount as determined in step f) above must be reduced by any qualifying income offset(s) or rental revenue offset(s). Next, this reduced amount will be divided by the

ATTACHMENT 4.19-D Page 7 Revised 10/01/19

SC 19-0010 EFFECTIVE DATE: 10/01/19 RO APPROVED: 11/04/2019 SUPERSEDES: SC 16-0006 greater of actual incurred total patient days or total patient days at 90.00% occupancy to arrive at a FRV Capital Per Diem rate. To account for vent unit and complex care patient days which are reimbursed under a separate Medicaid payment methodology, the FRV Capital Per Diem rate is multiplied by total incurred patient days (less complex care and vent days) to arrive at the final Fair Rental Value Gross amount to be used for Medicaid rate setting purposes.

(3) The initial age of each NF used in the FRV calculation was determined from the fiscal year ending September 30, 2018 Capital Data Survey, using each NF’s year of construction. The age may be reduced for replacements, renovations and/or additions which are recorded on the Capital Data Survey to be filed annually with the SC Medicaid Nursing Facility cost report. The age of the NF will be further adjusted each October 1st to make the NF one year older, up to the maximum of 30 years, and to reduce the age for those NFs that have completed and placed into service major renovation(s) or bed additions. If new beds are added, the new beds will be averaged in with the age of the original beds and the weighted average age for all beds will be used as the NF’s age. If a NF performed a major renovation/replacement project (defined as a project with capitalized cost equal to or greater than $500 per Medicaid certified bed), the cost of the renovation project completed as of September 30th will be used to determine the weighted average age of all beds for the NF. To compute the weighted average of the beds, determine a weighted average using the number of beds in the age group (value) as the weight. First, multiply each value by its weight. Second, add up the products of age multiplied by weight to get the total value. Third, add the weights together to get the total weight. Fourth, divide the total value by the total weights. The equivalent number of new beds from a renovation project will be determined by dividing the cost of the renovation/replacement project by the accumulated depreciation per bed of the NF’s existing beds immediately before the renovation project.

(4) In order to promote and ensure that the new capital funds are being used to update the capital assets (i.e. land, building, and equipment) of SC Medicaid contracting nursing facilities, the Medicaid Agency will employ the following compliance review:

ATTACHMENT 4.19-D Page 8 Revised 10/01/19

SC: 19-0010 EFFECTIVE DATE: 10/01/19 RO APPROVED: 11/04/2019 SUPERSEDES: SC 17-0016

i. Beginning Date of New Policy – October 1, 2019 using capitalized assets purchased prior to October 1, 2018.

ii. Annual Spending Test – There will be an annual spending test to determine if a provider spends the required amount on capital purchases to get credit the following year under the new FRV calculation. The threshold is $500 per Medicaid certified bed. For example, a 100-bed Medicaid certified facility must spend $50,000 (100 beds x $500) each fiscal year (i.e. October 1st – September 30th) for capital purchases to be recognized as an increase to the FRV calculation the following year.

(1) If a facility is undergoing a renovation under a signed construction contract within the compliance measurement in determining compliance with the period, the cost of the project per the construction contract can be included in determining compliance with the expenditure threshold.

(2) Compliance with the $500 per bed threshold is determined based upon the cost of assets capitalized during the compliance measurement period utilizing the facility’s current capitalization policies. A facility cannot change those policies for purposes of meeting the expenditure threshold.

(3) If a facility’s actual capitalized expenditures are more than quadruple the threshold for the measurement period, the facility is exempt from the expenditure requirement for the subsequent measurement period.

iii. Penalty for Non-Compliance with Spending Test – In the event a nursing facility’s age is greater than five years and they do not spend the annual threshold amount as explained above, there will be a ten percent (10%) penalty applied to the capital per diem in

ATTACHMENT 4.19-D Page 9 Revised 10/01/19

SC: 19-0010 EFFECTIVE DATE: 10/01/19 RO APPROVED: 11/04/2019 SUPERSEDES: SC 16-0006 effect prior to the penalty rate period that will be imposed on the next Medicaid rate cycle. This test must be met at least once over a two year period beginning with the October 1, 2022 Medicaid rate cycle (which will be based upon capital spending incurred during the October 1, 2019 thru September 30, 2021 cost reporting period).

iv. Medicaid Rate Years Beginning October 1, 2020 and October 1, 2021 – The penalty for non- compliance of the annual spending test will not be in effect during these two years.

v. Penalty Exemption for Total New Facility Construction or Total Replacement Facility Construction – A newly constructed building or total replacement facility will not be subject to the non-compliance spending test for the first five years of operation.

vi. Verification by DHHS of Annual Capital Spending - In order to document compliance with FRV spending requirements and support capital related costs claimed on the Medicaid Cost Report each year, facilities will be required to submit invoices/documentation to DHHS when filing their cost reports. These invoices will be reviewed and approved by the agency during the rate setting process.

d) Lease and Sales

The South Carolina Department of Health and Human Services will treat any new lease or sale of a facility executed after December 15, 1981, as a related party transaction. Therefore, in the event of a sale after December 15, 1981, the provider's capital related cost will be limited to the lower of the sales price or the historical cost of the prior owner. In the event of a lease executed after December 15, 1981, the provider's capital related cost will be limited to the lower of the lease cost or the historical cost of the owner (lessor). The historical costs of the prior owner would include:

ATTACHMENT 4.19-D Page 10 Revised 10/01/19

SC: 19-0010 EFFECTIVE DATE: 10/01/19 RO APPROVED: 11/04/2019 SUPERSEDES: SC 16-0006

a) Depreciation expense of the prior owner.

b) Interest expense which will be limited to the prior owner's expense.

c) Prior owner's equity in the facility.

However, in the event of a sale or lease on and after October 1, 2019, the provider's (new owner) capital related cost will be limited to the cost of capital reimbursement received by the prior owner (i.e., cost of capital payment for the new owner will be the same as the old owner). No revaluation of assets will be recognized by the South Carolina Medicaid Program as a result of a sale. No recapture of depreciation will be necessary from the prior owner unless the prior owner used accelerated depreciation in excess of the allowable straight line depreciation, or depreciation was overstated over the allowable straight line depreciation because of the application of a shorter useful life in calculating the depreciation.

II. Auditing

A) All cost reports will be desk reviewed by the Medicaid Agency. The Provider will be notified of the desk review exceptions and the provider has the right to respond within fifteen (15) days.

B) All cost reports are subject to on-site audit. Any overpayments determined as a result of on-site audits will be collected after issuing the final audit report and accounted for on the CMS-64 report no later than the second quarter following the quarter in which the final audit report is issued. The provider has the right to appeal the final audit decision through the appeal process. The appeal decision will be binding upon the SCDHHS.

III. Payment Determination

The rate cycle will be October 1 through September 30 and will be recomputed every twelve (12) months, utilizing the cost reports submitted in accordance with Section I, Cost Finding and Uniform Cost Reports, of the Plan.

ATTACHMENT 4.19-D Page 11 Revised 10/01/19

SC: 19-0010 EFFECTIVE DATE: 10/01/19 RO APPROVED: 11/04/2019 SUPERSEDES: SC 16-0006

A. REIMBURSEMENT METHODOLOGY TO BE USED IN THE CALCULATION OF THE MEDICAID REIMBURSEMENT RATES

A prospective rate shall be established for each nursing facility separately based on the facility's cost report, and upon the standard costs which are developed in accordance with the methodology described below. In the event that audit adjustments are made to cost reports in accordance with Title XIX and Title XVIII Program rules, regulations, policies and procedures, the rate of payment will be established so as to be consistent with the facility's cost as audited. In the event that such adjustment is made subsequent to the date that a facility was paid an incorrect rate based on unaudited costs, the facility will be liable to repay to the South Carolina Department of Health and Human Services the difference between the audited rate and the interim rate for the contract period. In a case in which an audited rate exceeds the interim rate, the South Carolina Department of Health and Human Services will be liable to repay the facility the difference between the audited rate and the interim rate for the contract periods beginning on or after October 1, 1994.

Effective October 1, 2010, nursing facilities which do not incur an annual Medicaid utilization in excess of 3,000 patient days will receive a prospective payment rate which will represent the weighted average industry rate at the beginning of each rate cycle. This rate will not be subject to change as a result of any field audit, but will be subject to change based on the lower of cost or charges test to ensure compliance with the state plan.

Minimum occupancy levels of 90% are currently being utilized for Medicaid rate setting purposes. For clarification purposes, nursing facility beds that are taken off-line due to renovation/construction issues relating to unsafe building conditions and considered unusable to meet the SC Department of Health and Environmental Control survey and certification guidelines will be temporarily excluded from the minimum occupancy computation for Medicaid rate setting purposes. Effective on and after October 1, 2013, Medicaid rates for nursing facilities located in counties where the county occupancy rate is less than 85% based upon the FYE September 30 cost report information will be established using the following policy:

• The SCDHHS will waive the 90% minimum occupancy requirement used for rate setting purposes for those nursing facilities located in counties whose occupancy is less than 85%. However, standards will remain at the 90% minimum occupancy level. • The SCDHHS will calculate the affected nursing facilities’ Medicaid reimbursement rate based upon the greater of the nursing facility’s actual occupancy or the average of the county where the nursing facility is located. However, the SCDHHS will not participate in establishing payment rates using an occupancy rate of less than eighty-five percent (85%).

ATTACHMENT 4.19-D Page 12 Revised 10/01/19

SC 19-0010 EFFECTIVE DATE: 10/01/19 RO APPROVED: 11/04/2019 SUPERSEDES: MA 05-008

PROVIDER NAME: 0 PROVIDER NUMBER: 0 REPORTING PERIOD: 10/01/17 through 09/30/18 DATE EFF. 10/01/19

MAXIMUM BED DAYS: 0 PATIENT DAYS USED: 0 PATIENT DAYS INCURRED: 0 TOTAL PROVIDER BEDS: 0 ACTUAL OCCUPANCY %: 0.00% % SKILLED 0.000 PATIENT DAYS @ 90.00% 0 COMPUTATION OF REIMBURSEMENT RATE - PERCENT SKILLED METHODOLOGY PROFIT TOTAL COST COMPUTED INCENTIVE ALLOW COST STANDARD RATE COSTS SUBJECT TO STANDARDS: GENERAL SERVICE 0.00 0.00 DIETARY 0.00 0.00 LAUNDRY/HOUSEKEEPING/MAINT. 0.00 0.00 SUBTOTAL 0.00 0.00 0.00 0.00 ADMIN & MED REC 0.00 0.00 0.00 0.00 SUBTOTAL 0.00 0.00 0.00 0.00 COSTS NOT SUBJECT TO STANDARDS: UTILITIES 0.00 0.00 SPECIAL SERVICES 0.00 0.00 MEDICAL SUPPLIES AND OXYGEN 0.00 0.00 TAXES AND INSURANCE 0.00 0.00 LEGAL COST 0.00 0.00 SUBTOTAL 0.00 0.00 GRAND TOTAL 0.00 0.00 INFLATION FACTOR 2.70% 0.00 COST OF CAPITAL 0.00 PROFIT INCENTIVE (MAX 3.5% OF ALLOWABLE COST) 3.50% 0.00 COST INCENTIVE - FOR GENERAL SERVICE, DIETARY, LHM 0.00 EFFECT OF CAP ON COST/PROFIT INCENTIVES $1.75 0.00 SUBTOTAL 0.00 NON-EMERGENCY MEDICAL TRANSPORTATION (NEMT) ADD-ON 0.00 BUDGET NEUTRALITY ADJUSTMENT 0.0000% 0.00 REIMBURSEMENT RATE 0.00

ATTACHMENT 4.19-D Page 13 Revised 10/01/19

SC 19-0010 EFFECTIVE DATE: 10/01/19 RO APPROVED: 11/04/2019 SUPERSEDES: 16-0006

Effective October 1, 1995, for the purpose of establishing all cost center standards, the facilities are grouped according to bed size. The bed groupings are: 0 Through 60 Beds 61 Through 99 Beds 100 Plus Beds

B. General Services cost center standards will be computed using private and non-state owned governmental free standing and hospital based nursing facilities. All other cost center standards will be computed using private for profit free standing nursing facilities.

A BRIEF DESCRIPTION ON THE CALCULATION OF ALL THE STANDARDS IS AS FOLLOWS:

1. General Services:

a. Accumulate all allowable cost for the General Services cost center (Nursing & Restorative) for all facilities in each bed size.

b. Determine total patient days by multiplying total beds for all facilities in each group by (365 x 90%).

c. Calculate the mean cost per patient day by dividing total cost in (a) by total patient days in (b).

d. Calculate the standard by multiplying the mean by 105%.

e. The establishment of the General Services standard for all nursing facilities (excluding state owned facilities) will be based on the average of the percentage of Medicaid Level A patients/total Medicaid patients served. Rates effective on or after October 1, 2000 will be computed annually using nursing facility utilization (including nursing facility days paid under the Hospice Benefit) by patient acuity based upon the preceding July 1 through June 30 data period. Effective October 1, 2003, co-insurance days for dual eligibles are excluded from the computation. Effective December 31, 2011, nursing facility providers will no longer be allowed to appeal its acuity level (i.e. percent skilled) payment adjustment determination for any current or future year payment rates. The General Services standard for each separate facility will be determined in relation to the percent of Level A Medicaid patients served, i.e., the base standard determination in (d.) above will be decreased as the percent of Level A Medicaid patients is decreased and increased as the percent of Level A Medicaid patients is increased.

ATTACHMENT 4.19-D Page 14 Revised 10/01/19

SC 19-0010 EFFECTIVE DATE: 10/01/19 RO APPROVED: 11/04/2019 SUPERSEDES: SC 18-0005 2. Dietary; Laundry, Maintenance and Housekeeping; Administration and Medical Records & Services: The standard for each of these three cost categories is calculated as follows:

a. Accumulate all allowable cost for each cost center for all facilities in each bed size. b. Total patient days are determined by taking maximum bed days available from each bed group, subtracting complex care days associated with each bed group, and multiplying the net amount by 90%. c. Calculate the mean cost per patient day by dividing total cost in (a) by total patient days in (b). d. Calculate the standard by multiplying the mean by 105%.

C. Rate Computation

Rates will be computed using the attached rate computation sheet (see page 12) as follows:

1. For each facility, determine allowable cost for the following categories:

COST SUBJECT TO STANDARDS:

General Services Dietary Laundry, Maintenance and Housekeeping Administration and Medical Records & Services

COST NOT SUBJECT TO STANDARDS:

Utilities Special Services Medical Supplies Property Taxes and Insurance Coverage - Building and Equipment Legal Fees

2. Calculate actual allowable cost per day based on the cost reports for each category by dividing allowable cost by actual days. If the facility has less than 90% occupancy, actual days will be adjusted to reflect 90% occupancy.

3. For cost subject to standards, the lower of cost determined in step 2 or the cost standard will be allowed in determining the facility's rates. Effective October 1, 1997, the General Services, Dietary, and Laundry, Housekeeping, and Maintenance cost centers are combined. Therefore, compare the sum of the allowable cost of these three cost centers to the sum of these three cost standards.

ATTACHMENT 4.19-D Page 15 Revised 10/01/19

SC 19-0010 EFFECTIVE DATE: 10/01/19 RO APPROVED: 11/04/2019 SUPERSEDES: SC 17-0016

4. For costs not subject to standards, the cost determined in step 2 will be allowed in determining the facility's rate.

5. Accumulate per diem costs determined in steps 3 and 4.

6. Inflate the cost in step 5 by multiplying the cost in step 5, by the inflation factor. The maximum inflation factor that can be used will be that provided by the State of South Carolina Revenue and Fiscal Affairs Office and is determined as follows:

a. Proxy indices for each of the eleven major expenditure components of nursing homes, (salaries, food, medical supplies, etc.) during the third quarter of 2019 were weighted by the expenditure weights of the long term care facilities. These eleven weighted indices are summed to one total proxy index for the third quarter of 2019.

b. Proxy indices are estimated for each of the eleven major expenditure components of nursing homes, (salaries, food, medical supplies, etc.), during the third quarter of 2020 and then weighted by the same expenditure weights as in step a. These weighted proxy indices were summed to one total proxy index for the third quarter of 2020.

c. The percent change in the total proxy index during the third quarter of 2019 (as calculated in step a), to the total proxy index in the third quarter of 2020 (as calculated in step b), was 2.70%. Effective October 1, 2019 the inflation factor used was 2.70%.

ATTACHMENT 4.19-D Page 16 Revised 10/01/19

SC 19-0010 EFFECTIVE DATE: 10/01/19 RO APPROVED: 11/04/2019 SUPERSEDES: SC 18-0005

7. The per patient day cost of capital will be calculated by dividing capital cost as determined under I.(F)(c) of this plan by actual patient days. However, if the facility has less than 90% occupancy, actual days will be adjusted to reflect 90% occupancy.

8. Cost Incentive - General Services, Dietary, and Laundry, Housekeeping, and Maintenance

If the facility's actual allowable costs for these three cost centers are below the sum of these three allowable cost standards, the facility will be eligible for a cost incentive of an amount equal to the difference between the sum of the standards and the sum of the facility's actual costs, up to 7% of the sum of the standards.

9. Profit will be allowed if the provider's allowable cost is lower than the standard as follows:

a. Administration and Medical Records & Services - 100% of difference with no limitation.

Ceiling on profit will be limited to 3 1/2% of the sum of the provider's allowable cost determined in step 2. The sum of the cost incentive and the profit cannot exceed $1.75 per patient day.

ATTACHMENT 4.19-D Page 17 Revised 10/01/19

SC 19-0010 EFFECTIVE DATE: 10/01/19 RO APPROVED: 11/04/2019 SUPERSEDES: SC 18-0005

10. Effective for services provided on or after October 1, 2019, the Medicaid Agency will determine the facility specific Non- Emergency Medical Transportation (NEMT) Add-On as follows: • For nursing facilities that were not capped by the NEMT transport trip criteria developed by the agency to adjust for significant acuity and utilization shifts observed in the type of NEMT transports among some of the participants residing in the nursing facility and employed in the determination of the October 1, 2018 NEMT add-ons, each facility’s October 1, 2019 NEMT add-on will be determined based upon nine months of allowable Medicaid reimbursable NEMT costs incurred from January 1, 2018 through September 30, 2018 divided by the number of incurred and paid January 1, 2018 through September 30, 2018 Medicaid patient days obtained from the agency’s SAS reporting system.

• For nursing facilities that were capped by the NEMT transport trip criteria developed by the agency to adjust for significant acuity and utilization shifts observed in the type of NEMT transports among some of the participants residing in the nursing facility and employed in the determination of the October 1, 2018 NEMT add-ons, each facility’s October 1, 2019 NEMT add-on will be determined based upon the lower of the NEMT add-on determined October 1, 2018 or nine months of allowable Medicaid reimbursable NEMT costs incurred from January 1, 2018 through September 30, 2018 divided by the number of incurred and paid January 1, 2018 through September 30, 2018 Medicaid patient days obtained from the agency’s SAS reporting system.

11. The Medicaid reimbursement rate will be the total of costs accumulated in step 5, inflation, cost of capital, cost incentive/profit, and NEMT Add-On per diem.

ATTACHMENT 4.19-D Page 18 Revised 10/01/19

SC 19-0010 EFFECTIVE DATE: 10/01/19 RO APPROVED: 11/04/2019 SUPERSEDES: SC 18-0008

D. Payment for Hospital-based and Non-profit Facilities

Hospital-based and non-profit facilities will be paid in accordance with Sections III A, B, and C.

E. Payment determination for a new facility, replacement facility, change of ownership through a purchase of fixed assets, change of ownership through a lease of fixed assets, when a facility changes its bed capacity by more than fifty percent (50%), or when temporary management is assigned by the state agency to run a facility.

1. Payment determination for a new facility or a facility that changes its bed capacity by more than fifty percent (50%):

The following methodology shall be utilized to determine the rate to be paid to a new facility or a facility that changes its bed capacity by more than fifty percent (50%):

Based on a six (6) month's projected budget of allowable costs covering the first six months of the Provider's operation under the Medicaid program, the Medicaid agency will set an interim rate to cover the first six (6) months of operation or through the last day of the sixth (6th) full calendar month of operation. The same rate setting methodology previously described will be applied to the provider's allowable costs in determining the rate except that all standards to be used will

ATTACHMENT 4.19-D Page 19 Revised 10/01/19

SC 19-0010 EFFECTIVE DATE: 10/01/19 RO APPROVED: 11/04/2019 SUPERSEDES: SC 16-0006 be one hundred twenty percent (120%) of the standards for the size of facility to adjust for lower initial occupancy. The one hundred twenty percent (120%) adjustment is determined by considering the average eighty percent (80%) occupancy for the first six (6) months of operation of a new facility versus the minimum of ninety percent (90%) occupancy required for all facilities that have been in operation for more than six (6) months. Within ninety (90) days after the end of the first full six (6) calendar months of operation, the provider will submit to the Medicaid Agency a Uniform Financial and Statistical report covering the period through the first full six (6) calendar months of operation. However, a thirty (30) day extension of the due date of the cost report may be granted for good cause. To request an extension, a written request should be submitted to the Division of Long Term Care Reimbursements prior to the cost report due date.

This report will be used to determine allowable reimbursement of the provider for the initial rate cycle. A new prospective rate, based upon the Uniform Financial and Statistical Report, will be determined using the methodology as previously stated in Section III C of this plan except for the following methodology:

a) Payment for the first six months will be retrospectively adjusted to actual costs not to exceed 120% of the standards and actual occupancy.

b) No inflation adjustment will be made to the first six (6) months cost. c) Effective on the first (1st) day of the seventh (7th) month of operation through the September 30 rate, the per diem costs effective July 1, 1994 will be adjusted to reflect the higher of:

1. Actual occupancy of the provider at the last month of the initial cost report; or