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

Effective Date: August 24, 2001

Approval Date: 1

OMB #: 0938-0707 Exp. Date:

MODEL APPLICATION TEMPLATE FOR STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT STATE CHILDREN’S HEALTH INSURANCE PROGRAM

Preamble

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

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

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

Form CMS-R-211

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

Effective Date: August 24, 2001

Approval Date: 2

MODEL APPLICATION TEMPLATE FOR STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT STATE CHILDREN’S HEALTH INSURANCE PROGRAM

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

State/Territory:_South Dakota_ (Name of State/Territory)

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

James W. Ellenbecker________________________ (Signature of Governor, or designee, of State/Territory, Date Signed)

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

The following state officials are responsible for program administration and financial oversight (42 CFR 457.40(c)): Name: Damian L Prunty

Position/Title: Program Administrator Name: Larry Iversen

Position/Title: Assistant Program Administrator Name: Rick LaBrie

Position/Title: Program Manager

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0707. The time required to complete this information collection is estimated to average 160 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, N2-14-26, Baltimore, Maryland 21244.

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

Effective Date: August 24, 2001

Approval Date: 3 Section 1. General Description and Purpose of the State Child Health Plans and State Child Health Plan Requirements (Section 2101)

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

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

1.1.2. Providing expanded benefits under the State's Medicaid plan (Title XIX); OR

1.1.3. X A combination of both of the above.

Since July 1, 1998 South Dakota has provided SCHIP benefits to uninsured children by providing expanded eligibility under the State’s Medicaid plan. The original SCHIP plan included children age 6 through 18 from 100% to 133% of the Federal Poverty Level. The initial SCHIP program was approved on August 5, 1998, and a subsequent eligibility expansion with Medicaid occurred on April 1, 1999 that increased eligibility from 133% FPL to 140% FPL for children from birth to age 19 for both Medicaid and SCHIP program. South Dakota refers to its original SCHIP program, with subsequent expansion as M-SCHIP.

Subsequently, in July 2000, South Dakota added a State operated SCHIP program for targeted uninsured children from families with income levels higher than previously approved SCHIP eligibility levels. The new eligibility level, active outreach and beneficiary enrollment began on July 1, 2000. There was no corresponding amendment to the Medicaid State Plan submitted in conjunction with the SCHIP expansion at that time as Medicaid eligibility income levels remained unchanged. South Dakota refers to its separate child health program as CHIP-NM. Collectively, M- SCHIP and CHIP-NM are referred to throughout this document as SCHIP.

This State Plan Amendment does not seek to replace the approved SCHIP State Plan materials, but will add the appropriate information describing the additional requirements and assurances mandated as a result of the final SCHIP federal regulations. This State Plan Amendment will also update the existing pages of the current SCHIP State Plan. .

The Secretary of the Department of Social Services is the authorized State Official signing and submitting this State Plan Amendment. The Official responsible for program administration and financial oversight is Damian Prunty, Administrator, Office of Medical Services, South Dakota Department of Social Services, 700 Governors Drive, Pierre, South Dakota 57501 2291.

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

Effective Date: August 24, 2001

Approval Date: 4 1.2 Γ Please provide an assurance that expenditures for child health assistance will not be claimed prior to the time that the State has legislative authority to operate the State plan or plan amendment as approved by CMS. (42 CFR 457.40(d))

The State assures specific legislative authority to operate an expansion of the SCHIP program under Title XXI of the Social Security Act was granted by Act of the South Dakota Legislature and signed into law by the Governor of South Dakota.

The authority for M-SCHIP was granted by Act of the South Dakota Legislature and signed into law by the Governor of South Dakota, effective July 1, 1998. No expenditures for child health assistance were claimed for M-SCHIP prior to July 1, 1998.

The authority for CHIP-NM was granted by Act of the South Dakota Legislature and signed into law by the Governor of South Dakota, effective July 1, 2000. No expenditures for child health assistance were claimed for CHIP-NM prior to July 1, 2000.

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

With this State Plan submission the State assures that it will comply with all civil rights requirements including Title VI of the Civil Rights Act of 1964, Title II of the Americans with Disabilities Act of 1990, Section 504 of the Rehabilitation Act of 1973, and Age Discrimination Act of 1975, 45 CFR part 80, part 84, and part 91, and 28 CFR part 35.

1.4

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

Effective date: M-SCHIP became effective July 1, 1998 / CHIP-NM became effective July 1, 2000

Implementation date: M-SCHIP was implemented July 1, 1998 / CHIP-NM was implemented July 1, 2000

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

2.1. Describe the extent to which, and manner in which, children in the state including

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

Effective Date: August 24, 2001

Approval Date: 5 targeted low-income children and other classes of children, by income level and other relevant factors, such as race and ethnicity and geographic location, currently have creditable health coverage (as defined in 42 CFR 457.10). To the extent feasible, make a distinction between creditable coverage under public health insurance programs and public-private partnerships (See Section 10 for annual report requirements). (42 CFR 457.80(a))

South Dakota’s original SCHIP state plan provided a complete description of South Dakota’s population, estimates of the uninsured population and information on the populations served by the Medicaid program and IHS. Little has changed in the basic demographic profile of the State in the years that have elapsed. This SCHIP state plan amendment will recap the increases in enrollment in creditable health coverage and the corresponding reductions that have taken place in South Dakota since the 1998 SCHIP State Plan was implemented.

The following table shows the number of Medicaid and SCHIP eligible children from just prior to SCHIP implementation and for the last day of each quarter through March of 2002. . The number of Medicaid eligible children does not include children eligible in SSI categories.

Quarter Ending Medicaid Children SCHIP Children 06/30/1998 32,859 0 09/30/1998 34,290 903 12/31/1998 35,320 1,407 03/31/1999 36,435 1,710 06/30/1999 36,866 2,039 09/30/1999 37,158 2,488 12/31/1999 37,768 2,790 03/31/2000 39,195 3,179 06/30/2000 39,538 3,725 09/30/2000 39,887 4,681 12/31/2000 40,841 5,555 03/31/2001 42,550 6,277 06/30/2001 43,974 6,729 09/30/2001 44,658 7,171 12/31/2001 45,712 7,666 03/31/2002 46,805 7,972 Source: SD MMIS 1998,1999,2000,2001,2002

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

Effective Date: August 24, 2001

Approval Date: 6 Beginning July 1, 1998 eligibility levels for Medicaid and M-SCHIP were increased to include children ages 6 through 18 in families with incomes above 100% but not exceeding 133% of the FPL. Beginning April 1, 1999 the income eligibility levels for Medicaid and M-SCHIP increased from 133% to 140% of the FPL for children from birth through age 18. Beginning July 1, 2000, eligibility levels for SCHIP were increased and included children birth through age 18 from 141% to 200% of the FPL, with implementation of CHIP-NM.

Children from families with incomes in the expanded levels, who were uninsured and not otherwise eligible for Medicaid, received SCHIP coverage. All others who were eligible received Medicaid. The chart shows that the number of children with qualified coverage from Medicaid or SCHIP increased by 21,918 during the time period of SCHIP operation.

During this time period, 83% of the Medicaid enrolled children had no other health coverage when enrolled in the Medicaid program. All SCHIP enrolled children were, by definition, uninsured. Using this information the following table shows the number of uninsured children who received qualified coverage since SCHIP implementation.

Medicaid-SCHIP Enrollment of Uninsured Children Baseline Year Reporting Period Uninsured Medicaid SCHIP Total 1999 06/30/1998-09/30/1998 1,188 903 2,091 2000 10/01/1998-09/30/1999 2,381 1,585 3,966

2000 10/01/1999-09/30/2000 2,265 2,192 4,457 2001 10/01/2000-09/30/2001 3,960 2,490 6,450 2002 10/01/2001-03/31/2002 1,782 801 2,583 Totals

11,576 7,971 19,547 Source: MR63

The Census Bureau Current Population Survey reported 13,000 uninsured children under 200% of the FPL for South Dakota based upon its three year averages from 1996,1997 and 1998. South Dakota believes the CPS estimate was the best source of baseline data available for the number of uninsured children when SCHIP was implemented. The data in the preceding table indicates the actual enrollees into the Medicaid or SCHIP programs that were uninsured prior to enrollment. In 2001, South Dakota was one of nine states awarded a one-year Health Resources and Services Administration grant to develop a plan for expanding access to affordable health coverage to all state residents. The State contracted with The Lewin Group to collect and analyze information about the uninsured and underinsured in South Dakota. The Lewin Group concluded that South Dakota’s uninsured population for children under the age of 19 is considerably less than the CPS estimates. The Lewin Group estimates

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

Effective Date: August 24, 2001

Approval Date: 7 that 9,600 children under the age of 19 are uninsured in South Dakota as of the year 2000 . South Dakota believes that number to be further reduced, as evidenced by the preceding table for inclusion of enrollment of uninsured children in the years 2001 and 2002. South Dakota believes the enrollment of nearly 20,000 uninsured children into Medicaid or SCHIP, since implementation of SCHIP in July of 1998, has had a major impact on the number of uninsured children in South Dakota.

Minority enrollments have also increased significantly under the State’s SCHIP efforts. The most recent Statistical Enrollment Data System (March 2002) indicates that South Dakota had 1,839 American Indian children enrolled in the SCHIP program. This represents over 23% of the total number of children enrolled in the SCHIP program. Enrollment of American Indian children in Medicaid and SCHIP collectively, has grown by 44% from July 1, 1998 to March of 2002. It is the Department’s opinion that SCHIP efforts have been successful in increasing the number of American Indian children with creditable health coverage.

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

2.2.1. The steps the state is currently taking to identify and enroll all uncovered children who are eligible to participate in public health insurance programs (i.e. Medicaid and state-only child health insurance):

State efforts to enroll uninsured children prior to the implementation of the SCHIP program in South Dakota are documented in the original SCHIP plan. Medicaid was the primary public health insurance program at that time and the SCHIP program efforts built upon the existing Medicaid program. The key relationships with other DSS programs, Public Health, Education, Human Services and IHS will continue to be in place and are a vital part of SCHIP outreach efforts.

The enrollment of SCHIP eligible children is greatly enhanced by the widespread availability of Medicaid eligibility throughout the state. Coordinated delivery of multiple programs from the Department of Social Services using generalized co- located eligibility workers and automated information systems enhance the identification and enrollment of children into SCHIP and Medicaid. Access to program coverage is greatly assisted by the widespread availability of participating Medicaid providers throughout the state.

Established relationships with other public health programs operated by the State of South Dakota also provide numerous opportunities to identify and enroll children into Medicaid and SCHIP. Interagency agreements between the Departments of Health and Social Services establish referral mechanisms

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

Effective Date: August 24, 2001

Approval Date: 8 between the programs operated by the agencies. WIC, Community Health Services, Baby Care, MCH, Title V and Children’s Special Health Services programs are key referral sources for families seeking medical coverage for children. South Dakota’s Federally Qualified Health Centers, community and migrant health centers are very involved as sources of information about the State’s medical assistance programs to assist in identifying and enrolling uncovered children, in addition to serving as primary care providers.

Interagency agreements also exist with the Department of Education and the Department of Human Services to provide for the referral of children to the Department of Social Services for medical coverage. Individual school districts in the State also participate as direct services providers under Medicaid and therefore have incentives to identify and assist enrolling children in Medicaid and SCHIP programs.

Close collaboration between the Department of Social Services and the Indian Health Service to identify and enroll Medicaid and SCHIP eligible children is a key priority for both agencies. The Department of Social Services recognizes the critical importance of the IHS as a service provider in the Indian reservation areas of the State. The IHS as a provider and payer of services, relies very heavily upon third party funding for services they are responsible for, and therefore is a proven referral source for potentially eligible children.

The initial implementation of the SCHIP program provided a number of opportunities for improved outreach and a greater opportunity for outreach partners to participate in SCHIP outreach. Administrative changes were some of the most significant improvements made with the implementation of SCHIP. Notable among these administrative changes were the development of a new, shorter application form for Medicaid and SCHIP, dropping the requirement for face to face interviews, elimination of assets testing, reduced documentation requirements and direction for DSS eligibility staff to actively participate in program outreach.

The new application form for Medicaid low income children and SCHIP eligibility has been reduced to 3 pages from a form that had been over 30 pages in length. The new form, because of its size and simplicity has been widely distributed to outreach sites including other government agencies, schools, primary care and specialty health care providers, advocacy groups, tribal programs, and day care centers. In addition to the shortening of the form, and eliminating assets information the new form also has reduced documentation requirements as only earnings and childcare expenses need to be verified by the applicant family.

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

Effective Date: August 24, 2001

Approval Date: 9 The completed eligibility forms may be mailed or faxed to DSS eligibility offices without the need for a face to face interview. However, DSS caseworkers are available at DSS offices to assist with completing the applications if necessary. Workers at some outreach sites are also trained to assist with basic questions regarding Medicaid and SCHIP eligibility.

Redetermination for low income Medicaid and SCHIP has also been simplified. Redeterminations are conducted annually for eligible families and are initiated by DSS caseworkers that mail the redetermination materials to the families a month in advance. The redetermination materials do not require more information than the application process, and can be completed through the mail or fax.

Eligibility for individuals applying for Food Stamps, TANF, or other Medicaid programs is also simplified, as an additional application form is not required to obtain low income Medicaid or SCHIP coverage.

There is significant evidence to support the assertion that the changes to the application process have facilitated the identification and enrollment of uncovered children. Face value evidence exists in the growth in the number of uninsured children in Medicaid and SCHIP. Annual surveys conducted of the families of children enrolled in the Medicaid and SCHIP programs in 1998 and 1999 reported that 95% and 98% respectively, responded positively to the question on the ease of the application process.

Since the inception of the SCHIP program the State has used a number of approaches to conduct outreach to clients in addition to collaboration with other health or children’s programs. Included among the outreach approaches are direct mailings by the State to clients, the use of brochures and posters, client education sessions, an eligibility 800-telephone number, ads on public access television, paid radio announcements and public service announcements. Most effective among these efforts are the education sessions, direct mailings, and collaborations with other programs and the use of brochures. Least effective have been the radio and public access television ads.

Department of Social Services staff and collaborating agencies have conducted client outreach in many different settings. Included as some of the most effective settings for outreach are community health centers, health care provider locations, schools and adult education sites, Tribal agencies, social service agencies, local government offices, Headstart programs, and local charities. Many other locations such as laundries, fast food restaurants, libraries and senior centers have also been tried with less effectiveness.

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

Effective Date: August 24, 2001

Approval Date: 10 Surveys of SCHIP enrollees were conducted to assist in evaluating SCHIP implementation in South Dakota in both 1998 and in 1999. One of the items surveyed was outreach effectiveness. In the 1998 survey 76% of the respondents indicated that they had obtained information about the coverage program from the Department of Social Services. However, in comparison to the 1999 survey it appears the community based outreach efforts were increasing in effectiveness as only 55% of the respondents indicated the Department of Social Services was their source of information about SCHIP. Increasing in outreach effectiveness from 1998 to 1999 were community health nursing, health care providers and schools. Tribal health agencies also contributed effective outreach in both surveys.

American Indians are the largest minority population living in South Dakota. Approximately 7% of South Dakota’s population is American Indian, primarily residing on the 9 Indian Reservations within the States boundaries. For this reason specific outreach approaches have been considered for this population. Among the efforts specifically directed at American Indian persons are Consultation meetings held between the State and Tribal Government and Tribal Health officials. In addition, the Department has invited both Tribal Government and the IHS to be represented on the Medicaid Advisory Committee that assists in the monitoring of the Medicaid and SCHIP programs, and both entities are participating.

Some Tribal health departments have requested specific training of the their Community Health Representative staff in the SCHIP program and this training was provided by Department eligibility staff. One reservation even adapted the SCHIP radio ad to use in reaching the Indian population on their reservation.

Outreach brochures, posters and logos for SCHIP were designed with a culturally sensitive logo depicting children of varying ethnic backgrounds in an effort to convey that the program is intended for all races of children.

South Dakota has also had a successful applicant for the “South Dakota Covering Kids Initiative” through grant funding from the Robert Wood Johnson foundation for a three-year period of time from July 1, 2000 through June 30, 2003. The Community Healthcare Association of Sioux Falls, SD was the successful applicant. The South Dakota Covering Kids Initiative has four goals. They are: designing and conducting outreach programs to identify and enroll children in the Medicaid and SCHIP programs; continuing to simplify access to and completion of enrollment information and applications; assisting in coordinating coverage programs for low income, uninsured children; and designing programming specifically targeted to Native Americans and other special populations. The program will feature statewide initiatives to meet these goals and also pilot programs to address specific geographic areas and

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

Effective Date: August 24, 2001

Approval Date: 11 special populations.

The Community Healthcare Association of Sioux Falls does not contribute any funds to the State of South Dakota for the operation of the Covering Kids Initiative. This organization conducts their own outreach and targets Native American and other special populations in specific geographical areas of the state. This grant money is not being used to match any federal dollars for SCHIP.

2.2.2. The steps the state is currently taking to identify and enroll all uncovered children who are eligible to participate in health insurance programs that involve a public-private partnership:

When South Dakota implemented its SCHIP program in July of 1998, the South Dakota Caring Program for Children was a public-private partnership to make very limited services available to eligible children. The Program operated on an annual donation from Wellmark Blue Cross Blue Shield of South Dakota, administrative support from the South Dakota Department of Health, and private donations. The Caring Program did not provide qualified health care coverage, did not operate in all parts of South Dakota, and covered only a very limited number of children under 133% of FPL. No Caring for Children benefits would have ever been available to children expected to be served by the CHIP-NM program. The South Dakota Caring for Children Program ceased to exist in 1999, long before action by the state to implement a CHIP-NM program.

South Dakota counties continue to be required to provide medical services for persons in the State who are determined medically indigent. Eligibility is restricted to persons with very limited income and resources. Services are restricted to coverage of emergency hospital services only, with the exception of two counties, Minnehaha and Pennington which operate community health centers to make primary care clinic services available. As such, the County Indigent Program is not a health resource available to low income uninsured children with needs for full coverage of primary and preventive health care. All counties operate as the payer of last resort and provide referrals and assistance with Medicaid applications.

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

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

Effective Date: August 24, 2001

Approval Date: 12 The key programs providing creditable coverage for low-income children in South Dakota are the Medicaid and M-SCHIP programs that are jointly administered by the South Dakota Department of Social Services. The interagency agreements identified in Section 2.2.1 on page 8 serve as the referral procedures that the State uses to accomplish the coordination with Title V, WIC and MCH for both the Medicaid and SCHIP programs. The interagency agreements serve to assure the services provided under Title V, WIC, MCH, Title XIX and Title XXI are consistent with the needs of recipients and both the Department of Social Services and the Department of Health’s objectives and requirements to promote high quality health care and services.

There are no other State programs that provide creditable coverage for low-income children. The South Dakota Caring for Children program had existed as a private effort to provide very limited health coverage to low-income children, however operations under that program ceased in 1999. There are no other private programs that offer creditable coverage for low-income children in South Dakota.

The Indian Health Service continues as a provider of creditable coverage to Indian children. The IHS functions as a provider of services and also provides coverage for certain specialty services through their contract health program. Coordination with the IHS will continue in the same way as coordination with the Medicaid program. The IHS will be reimbursed for the direct services they provide to SCHIP children at the same rate of payment as the South Dakota Medicaid program. Since the IHS contract care program is the payer of last resort under Federal Regulations, the SCHIP program will be primary to IHS contract care. Benefit coordination will be accomplished by the IHS denying claims they receive and causing the claims to be submitted to the SCHIP program for payment just as currently happens with Medicaid. Payment for those services under the SCHIP program will be on the same basis as established for the Medicaid program.

The IHS also plays a very important role in the delivery of outreach services to facilitate the identification and enrollment of low-income children for Medicaid and SCHIP. This role will continue for potentially eligible SCHIP children using the established means to interface with the Department of Social Services medical assistance programs.

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

Effective Date: August 24, 2001

Approval Date: 13 There are no other public programs providing creditable coverage to low-income children. Children potentially eligible for other public programs will be referred to those programs for services in addition to those provided by Medicaid, M-SCHIP or CHIP-NM.

Children covered by Medicare will not be enrolled in SCHIP as they have creditable coverage.

Section 3. Methods of Delivery and Utilization Controls (Section 2102)(a)(4))

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

3.1. Describe the methods of delivery of the child health assistance using Title XXI funds to targeted low-income children. Include a description of the choice of financing and the methods for assuring delivery of the insurance products and delivery of health care services covered by such products to the enrollees, including any variations. (Section 2102)(a)(4) (42CFR 457.490(a))

South Dakota’s original implementation of SCHIP began in July of 1998 with the expansion of the State’s Medicaid program to include children age 6 through 18 from 100% to 133% of the Federal Poverty Level. Under this program expansion eligible children with insurance coverage were enrolled in Medicaid and uninsured children not otherwise eligible for Medicaid were enrolled in SCHIP. In April of 1999, SCHIP implementation via Medicaid expansion continued as the income level for eligibility was increased from 133% of the FPL to 140% for children from birth to age 19 for both the Medicaid and M-SCHIP programs. Again, insured children received Medicaid benefits, and targeted uninsured children received M-SCHIP.

South Dakota’s third effort under Title XXI to expand coverage to targeted uninsured children included the method of delivering child health assistance is through a state administered program. The State Administered program, called CHIP NM, is operated directly by the South Dakota Department of Social Services. Children to be covered under the CHIP-NM program are uninsured children from birth to age 19 in families with incomes above 140% of the FPL and not exceeding 200% of the FPL. As the single state agency for Medicaid the Department is jointly administering CHIP-NM with the Medicaid and M- SCHIP programs using DSS eligibility, outreach, benefit payment, reporting and management resources. General Funds have been appropriated by the South Dakota State Legislature to provide matching funds for Federal Title XXI funds.

Benefits delivered to targeted uninsured children under the CHIP-NM state administered program are identical to the benefits offered under the State’s Medicaid

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

Effective Date: August 24, 2001

Approval Date: 14 and M-SCHIP programs, including EPSDT benefits. Health care services are delivered using the existing delivery and payment systems including primary care case management and access to specialty health service providers, as approved under the State’s 1915(b) waiver under Medicaid. South Dakota will request the managed care waiver be incorporated into it’s Medicaid and SCHIP state plans. The State can assure that children receiving services under SCHIP will receive the same beneficiary protections as children receiving Medicaid coverage including grievances and appeals, privacy and confidentiality, respect and non-discrimination, access to emergency services, and an opportunity to participate in health care treatment decision and choice of providers. The State can also assure that it is providing SCHIP services in an effective and efficient manner by using Medicaid policies and procedures.

Children are considered uninsured if they do not qualify for Medicaid and have not had group health plan coverage in the three months immediately prior to application for the SCHIP program.

3.2. Describe the utilization controls under the child health assistance provided under the plan for targeted low-income children. Describe the systems designed to ensure that enrollees receiving health care services under the state plan receive only appropriate and medically necessary health care consistent with the benefit package described in the approved state plan. (Section 2102)(a)(4) (42CFR 457.490(b))

Services provided under SCHIP will share the utilization controls used by the Medicaid program to ensure that only health care services that are appropriate, medically necessary, and approved by the State are used. Children covered under SCHIP will be enrolled into a primary care case management system to ensure access to primary care and to provide monitoring and authorization for required specialty medical services. The primary care case management system used will be the PRIME program operated for Medicaid and SCHIP children in South Dakota, authorized by CMS under a 1915(b)(1) waiver. South Dakota will request the managed care waiver be incorporated into it’s Medicaid and SCHIP state plan.

The SCHIP program will also share the Medicaid SURS resources for post payment review of services provided to SCHIP children. Appropriateness and necessity for care are also monitored by the Department through a contract with the Professional Review Organization (PRO), also used by the Medicaid and Medicare programs in South Dakota. Pharmacy services for SCHIP will be dispensed via a Medicaid point of service computer system that provides prospective drug utilization review on each prescription filled. Additionally, specialized medical services requiring prior authorization under the Medicaid program will also require prior authorization under the SCHIP program.

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

Effective Date: August 24, 2001

Approval Date: 15

Section 4. Eligibility Standards and Methodology. (Section 2102(b))

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

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

4.1.1. X Geographic area served by the Plan: Statewide. 4.1.2. X Age: Birth to age 19 will be served. 4.1.3. X Income: Children from families with incomes over 140% FPL up to 200% FPL. The plan will use current Medicaid definitions of income, and allows deductions for child support paid and actual child care expenses for employment related daycare up to $500 per month for the family. In addition, the first $50 of current child and spousal support paid to the family unit, and earned income of children under 19 years old who are living with a caretaker, are also deducted. For children from families with incomes under 140% FPL, the additional income disregards are 20% of earned income and actual daycare costs associated with employment. 4.1.4. ∼ Resources (including any standards relating to spend downs and disposition of resources): 4.1.5. X Residency (so long as residency requirement is not based on length of time in state) : Children must be residents of the State of South Dakota and meet the citizenship and immigration status requirements applicable to Medicaid. 4.1.6. ∼ Disability Status (so long as any standard relating to disability status does not restrict eligibility): 4.1.7. X Access to or coverage under other health coverage: Children must not be eligible for Medicaid or covered under any other health insurance or group health plan. Children may not have had insurance coverage under a group health plan in the three months immediately prior to CHIP-NM application unless such coverage was dropped for good cause or access to care not available under the policy. 4.1.8. X Duration of eligibility: Eligibility is based on a month to month basis and is redetermined annually for all children. Eligibility may begin up to the first day of the third month prior to the application. Families are required to report all changes that may effect their eligibility, when the

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

Effective Date: August 24, 2001

Approval Date: 16 change occurs. 4.1.9. X Other standards (identify and describe): Families must cooperate with the Department to determine the actual or potential existence of third party coverage for medical expenses, and to establish initial or ongoing eligibility. The Department requires the social security numbers for individuals who are requesting assistance under the SCHIP Medicaid expansion option.

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

4.2.1. X These standards do not discriminate on the basis of diagnosis. 4.2.2. X Within a defined group of covered targeted low-income children, these standards do not cover children of higher income families without covering children with a lower family income. 4.2.3. X These standards do not deny eligibility based on a child having a pre- existing medical condition.

4.3. Describe the methods of establishing eligibility and continuing enrollment. (Section 2102)(b)(2)) (42CFR 457.350)

The SCHIP program follows the same eligibility process that is used by the Medicaid program for low-income children. . The process begins with potentially eligible individuals obtaining and completing an application form obtained from the Department of Social Services, or from any of the many local entities that are participating with outreach for the Medicaid and SCHIP programs. The short application form must be completed and signed by the head of household or parent of the children. The forms may then be mailed or delivered to the client’s local office from among the 41 Department of Social Services offices through out the State. Assistance in completing the forms is available from the Department of Social Services, including assistance for persons with Limited English Proficiency or disabilities.

Families applying for medical assistance, including the SCHIP program are provided with a pamphlet that explains SCHIP eligibility, the scope of covered services, and the limited cost sharing. The pamphlets are written in accurate, easy to understand language to assist families in making a decision to apply for medical assistance.

Information collected on the form includes identifying information of the parents of the children under age 19 requesting medical assistance, the children in the home who are under age 19, health insurance information for the persons requesting medical assistance, income information, child support payment information, and child care expense information. Verifications of income, childcare expenses paid so a person can work, and child support paid (unless paid to the child support enforcement office)

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

Effective Date: August 24, 2001

Approval Date: 17 must be included with the application. The application form also contains a simplified financial work sheet to assist potentially eligible persons make an estimate of their income, relative to the eligibility guidelines to assist them in making a decision to apply for benefits.

Department of Social Services caseworkers will make the eligibility determinations based on the information reported on the applications, other information available to the department, and Department regulations and policies. The Department will make decisions within 45 days of the receipt of the application with written notification of the result directly to the applicant parent or head of household.

Upon approval, families will be notified of the eligible children, receive an information packet including information on covered services, the primary care case management program, EPSDT benefits, and other important information. This information includes a description of the scope and duration of covered benefits, and access to emergency services. Clients are also notified of the need to choose a primary care provider and given a listing of the provider’s names and locations in their area. Clients are also notified of their rights to appeal and grievance processes, non-discrimination, and the confidentiality of client/patient information. SCHIP beneficiaries receive the same beneficiary information and protections as beneficiaries of the Medicaid program as both are delivered by the Department of Social Services.

Ongoing eligibility is monitored by requiring families to report changes that might affect their eligibility when they occur. The reporting procedures and forms for reporting changes under SCHIP are the same as those used for Medicaid.

Annual redeterminations are completed after 12 months of eligibility. The Department, during the 11th month of eligibility, initiates the redetermination process by mailing a redetermination packet to families. The information required and the redetermination process is very similar to the initial enrollment process. The redetermination process is completed prior to the end of the original eligibility period so families receive timely notice and there is no break in coverage if eligibility continues. Eligibility for Medicaid, and SCHIP will be reviewed during the redetermination process and the children enrolled in the appropriate coverage program. Children who had been eligible for SCHIP will have Medicaid eligibility reviewed at redetermination, and if Medicaid eligible, will be enrolled in the Medicaid program.

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

X Check here if this section does not apply to your state.

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

Effective Date: August 24, 2001

Approval Date: 18 4.4. Describe the procedures that assure that:

4.4.1. Through the screening procedures used at intake and follow-up eligibility determination, including any periodic redetermination, that only targeted low- income children who are ineligible for Medicaid or not covered under a group health plan or health insurance coverage (including access to a state health benefits plan) are furnished child health assistance under the state child health plan. (Sections 2102(b)(3)(A) and 2110(b)(2)(B)) (42 CFR 457.310(b) (42CFR 457.350(a)(1)) 457.80(c)(3))

The application form for SCHIP medical assistance in South Dakota also is used for the Medicaid program. Verifications of income and income deductions must be provided with the application. Information on the insurance status of individuals requesting assistance is required on the application form. Clients completing the form do not have a choice for a particular program of medical assistance. Department of Social Services caseworkers determine eligibility for each of the States’ medical assistance programs, Medicaid, M-SCHIP and CHIP-NM and make the decisions on which program is providing coverage.

Caseworkers use statewide procedures and a uniform, statewide eligibility database. Automated editing of intake data provides assistance to the caseworkers. The statewide database allows caseworkers to do follow up screening on applications to access eligibility information from other DSS programs, IEVS verifications, and an individual’s prior eligibility history. Insurance information including type of coverage, name and address of carrier, policy numbers and dates of coverage are part of the automated database maintained by the department for third party liability and eligibility purposes.

The caseworker will decide the appropriate category or program of coverage for the children depending on income and insurance status as follows: • Uninsured children birth to age 19 from families with incomes from over 140% to 200% of the FPL will receive CHIP-NM; • Uninsured children age 6 through 18 from families with incomes from over 100% of FPL to 140% of FPL will receive M-SCHIP; • Uninsured children under age 6 from families with incomes from over 133% to 140% of FPL will receive M-SCHIP;

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

Effective Date: August 24, 2001

Approval Date: 19 • Insured children, children age 6 through 18 from families with incomes below 100% of FPL, and children under age 6 from families with incomes below 133% of FPL will receive Medicaid. • Children otherwise eligible for Medicaid under other eligibility categories will receive Medicaid. • Children who are residents of public institutions will not be eligible for any coverage. • Income eligible children who are residents of Institutions for Mental Disease will receive Medicaid.

After making an eligibility decision, the caseworkers will enroll the eligible children in the appropriate program for health coverage. Children who are potentially eligible for Medicaid other than under low-income categories based on the information that has been submitted on the short form will not be approved for SCHIP. Denied applications will receive a notice that includes the reason for the denial, a notification of fair hearing, and a form to submit additional information to pursue Medicaid eligibility on another basis of eligibility.

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

Children found eligible for Medicaid are enrolled in the Medicaid program as described in 4.4.1.

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

Children found ineligible for Medicaid enrollment may be enrolled in M- SCHIP or CHIP-NM as described in 4.4.1. All Medical Assistance Programs are jointly administered by the Department of Social Services. A new application is not required if there is not break from Medicaid to SCHIP enrollment. 4.4.4 The insurance provided under the state child health plan does not substitute for coverage under group health plans. Check the appropriate box. (Section 2102)(b)(3)(C)) (42CFR 457.805) (42 CFR 457.810(a)-(c))

4.4.4.1. X Coverage provided to children in families at or below 200% FPL: describe the methods of monitoring substitution.

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

Effective Date: August 24, 2001

Approval Date: 20 SCHIP has specific measures to prevent the program from substituting for coverage under group health plans. The first measure is simply that persons covered by insurance providing hospital and medical services or HMO’s are not eligible for benefits under SCHIP. Another measure to prevent substitution is that children are ineligible if they have been covered by a group health plan in the 3 months immediately preceding the application for SCHIP. The Department has adopted a definition of group health plan that includes employers, self-employed plans, employee organizations, and self insured plans that provide health care directly or otherwise. There are exceptions to the 3-month rule when the parents providing the insurance die, become disabled, lose their jobs, or start new jobs without coverage. Exceptions will also be made if care is not accessible under the group plan, or group plan coverage costs more than 5% of the SCHIP family’s gross income.

The Department also requires that insurance information on the persons seeking medical assistance coverage be provided on the application for SCHIP as a measure to avoid substitution for group health coverage. The Department also requires that members of the SCHIP unit cooperate with the Department to determine the availability of coverage. Failure to cooperate may result in loss of eligibility for the unit.

The Department also maintains a database on persons with insurance coverage for persons applying for or receiving medical assistance from the Department under Medicaid, M-SCHIP or CHIP- NM. The database includes type of coverage, name and address of carrier, policy numbers, plan sponsor, premium payer, and dates of coverage. Information from this database is available to caseworkers to explore potential group health coverage. Caseworkers also have the opportunity to update the information on this database to keep the information up to date.

Targeted, low-income children belonging to employees of State government in South Dakota will not be eligible for SCHIP coverage since the State provides indirect assistance for the coverage of dependants in excess of the cost to cover the employee alone, regardless of the coverage choices made by the family. Children of employees of other government entities in South Dakota will have the coverage evaluated to ensure that there is no meaningful (exceeding $10.00 per month) employer contribution for group health coverage to dependent children.

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

Effective Date: August 24, 2001

Approval Date: 21

The Department will monitor whether or not coverage under SCHIP is substituting for coverage under group health plans by conducting survey random surveys. The surveys contain questions relating to insurance coverage, and specifically asks questions in order that ‘crowd out’ can be measured. In addition to the department’s random survey, the South Dakota Department of Health conducts a Behavioral Risk Factor Surveillance Survey (BRFSS), as described in Section 9.3, that asks specific questions regarding the dropping of private health insurance for public assistance programs. The responses of both surveys are computed, documented and are included in the SCHIP annual report to measure the affect of crowd- out.

The State also monitors the number of SCHIP applicants who are denied eligibility due to substituting coverage under group health plans within 3 months prior to application. Additionally, the State monitors the number of SCHIP applicants who are denied or closed due to existing health insurance. This information is captured in a reporting mechanism that is also included in the SCHIP annual report to measure whether recipients are trying to substitute private health insurance for public assistance.

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

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

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

The minimum period without coverage under a group health plan, including any allowable exceptions to the waiting period.

The minimum employer contribution.

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

Effective Date: August 24, 2001

Approval Date: 22 The cost-effectiveness determination.

4.4..5 Child health assistance is provided to targeted low-income children in the state who are American Indian and Alaska Native. (Section 2102)(b)(3)(D)) (42 CFR 457.125(a))

SCHIP is available to all targeted low-income Indian children in South Dakota regardless of tribal membership, enrollment, or affiliation. Inasmuch as the program is a statewide program, SCHIP is also made available to children living on Indian reservations within the State’s borders. Indian children not living on reservations are also potentially eligible for SCHIP coverage. The availability of services through the Indian Health Service is not considered insurance for the Medicaid, M-SCHIP or CHIP-NM program.

To help assure SCHIP is provided to Indian eligible children the Department has outreach efforts directed towards the Indian reservation areas of the state. The Indian Health Services currently plays and will continue to play a very important outreach role for targeted, low- income Indian children. Applications, enrollment assistance, and program information for SCHIP is available at IHS, Tribal, and Urban Indian Health locations in South Dakota.

SCHIP services will be provided to Indian children in the state eligible to receive services from the Indian Health Service as the Indian Health Service facilities and providers are enrolled as health care providers for the SCHIP program and eligible for reimbursement for services provided to SCHIP children. Tribal clinics and other providers are also eligible for reimbursement for covered services under SCHIP as are Urban Indian Health clinics.

Section 5. Outreach (Section 2102(c))

Describe the procedures used by the state to accomplish:

Outreach to families of children likely to be eligible for child health assistance or other public or private health coverage to inform them of the availability of the programs, and to assist them in enrolling their children in such a program: (Section 2102(c)(1)) (42CFR 457.90)

The CHIP-NM program built on the existing programs of coverage for low income,

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

Effective Date: August 24, 2001

Approval Date: 23 and low-income uninsured children, (Medicaid and M-SCHIP), to provide health coverage for additional uncovered children in South Dakota. Outreach for these programs in South Dakota was implemented with a strategy for statewide outreach coordination and a local outreach strategy. Statewide outreach was accomplished with the participation of other programs offered by the Department of Social Services, other State agencies and the Indian Health Service. Outreach at this level relied on interagency agreements to facilitate referrals and the use of automated systems for information sharing on potentially eligible children. Administrative reforms of the eligibility process, publicity materials and advertising were also part of this outreach.

Local coordination has been effectively done in communities and service areas of the State by Department of Social Services eligibility staff establishing connections with local resources to facilitate the identification and enrollment of children. Health care providers, schools, Tribal agencies, and many others have been very involved in distributing materials, providing applications and information, and assisting with enrollment.

Outreach for CHIP-NM program built on the successful outreach strategies already in place for the State’s medical assistance efforts. However, recognizing the differences in the income levels of the families targeted by CHIP-NM new efforts were made to supplement existing outreach, to help reach those potentially eligible for CHIP-NM. These additional outreach efforts began with a statewide training of Department of Social Services eligibility staff prior to the implementation of the program. New materials were developed for distribution and use around the state to prepare for the operation of the program including application forms, information sheets, brochures, and posters. Local Department of Social Services staff renewed connections with outreach partners to inform them of the new program and expanded eligibility levels. Medicaid and M-SCHIP providers were notified of the new program of coverage so they will be prepared to deliver health services.

The Department will also consider expanding the range of outreach partners to include entities not traditionally involved in outreach for publicly financed health care programs including the South Dakota Department of Labor, Job Service and other employment agencies, large and small employers and job training programs.

Section 6. Coverage Requirements for Children's Health Insurance (Section 2103)

∼

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

6.1. The state elects to provide the following forms of coverage to children:

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

Effective Date: August 24, 2001

Approval Date: 24 (Check all that apply.) (42CFR 457.410(a))

6.1.1. ∼ Benchmark coverage; (Section 2103(a)(1) and 42 CFR 457.420) 6.1.1.1. ∼ FEHBP-equivalent coverage; (Section 2103(b)(1)) (If checked, attach copy of the plan.) 6.1.1.2. ∼ State employee coverage; (Section 2103(b)(2)) (If checked, identify the plan and attach a copy of the benefits description.) 6.1.1.3. ∼ HMO with largest insured commercial enrollment (Section 2103(b)(3)) (If checked, identify the plan and attach a copy of the benefits description.)

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

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

6.1.4. X Secretary-Approved Coverage. (Section 2103(a)(4)) (42 CFR 457.450) 6.1.4.1. X Coverage the same as Medicaid State plan 6.1.4.2. Θ Comprehensive coverage for children under a Medicaid Section 1115 demonstration project

6.1.4.3. Θ Coverage that either includes the full EPSDT benefit or that the state has extended to the entire Medicaid population 6.1.4.4. Θ Coverage that includes benchmark coverage plus additional coverage 6.1.4.5. Θ Coverage that is the same as defined by Αexisting comprehensive state-based coverage≅

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

Effective Date: August 24, 2001

Approval Date: 25 6.1.4.6. Θ Coverage under a group health plan that is substantially equivalent to or greater than benchmark coverage through a benefit by benefit comparison (Please provide a sample of how the comparison will be done) 6.1.4.7. Θ Other (Describe)

6.2. The state elects to provide the following forms of coverage to children: (Check all that apply. If an item is checked, describe the coverage with respect to the amount, duration and scope of services covered, as well as any exclusions or limitations) (Section 2110(a)) (42CFR 457.490)

Services provided under SCHIP are identical to the benefits covered under the South Dakota Medicaid program for low-income children in amount, scope and duration. As such the benefits include all mandatory Medicaid services for the categorically needy and ESPDT benefits as well as all the optional services covered under the South Dakota Medicaid program.

Most medical services provided to children under South Dakota Medicaid are accessed through a primary care case management managed care system approved for Medicaid under a 1915(b) waiver. South Dakota will request the managed care waiver be incorporated into its Medicaid and SCHIP state plans. Children eligible for services under SCHIP will also be required to participate in the primary care case management system (PCCM). Under this program, a primary care physician (PCP) provides primary care services. Specialty services within the scope of the managed care program require a referral from the PCP. Emergency services, family planning services, and non-medical services (dental, chiropractic, optometry, podiatry, immunization and transportation), are exempt from all PCCM requirements. Non- waiver services are accessed directly by recipients. All services are reimbursed on a fee for service basis. There is no cost sharing for services provided to children under this plan.

Generally, all services provided under the Medicaid program must be “medically necessary”. SCHIP services must also meet the requirements of the definition of medically necessary used by Medicaid. Medically necessary services are those that: • are consistent with the recipient's symptoms, diagnosis, condition, or injury • are recognized as the prevailing standard and is consistent with generally accepted professional medical standards of the provider's peer group • are provided in response to a life-threatening condition; to treat pain, injury, illness, or infection; to treat a condition that could result in physical or mental disability; or to achieve a level of physical or mental function consistent with prevailing community standards for diagnosis or condition • are not furnished primarily for the convenience of the recipient or the provider

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

Effective Date: August 24, 2001

Approval Date: 26 • there is no other equally effective course of treatment available or suitable for the recipient requesting the service which is more conservative or substantially less costly.

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

Inpatient services include services provided in general acute care hospitals and specialty hospitals including rehabilitation, long term care, surgical specialty, psychiatric and children’s hospitals. Specialized units of acute care hospitals including neonatal intensive care, rehabilitation and psychiatric units are also covered. Inpatient hospital services are included as PCCM services requiring referrals. Psychiatric, Rehabilitation, and Long Term Care hospitals require prior authorization. Emergency psychiatric hospitalizations are authorized after admission. Inpatient surgeries that are normally performed in outpatient settings must be prior authorized. The Department monitors neonatal Intensive Care Services. There are no limitations on services provided.

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

Outpatient hospital services include laboratory services, X ray and other radiology services, emergency room services, medical supplies used during treatment at the facility, physical therapy, speech therapy, and occupational therapy when furnished or supervised by a licensed therapist and periodically reviewed by a physician, whole blood or packed red cells, drugs and biologicals which cannot be self- administered, dialysis treatments, services of hospital-based physicians, and outpatient surgical procedures. Outpatient hospital services are included as PCCM services. There are no limitations on services provided.

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

Physician services include medical and surgical services; services and supplies furnished incidental to the professional services of a physician; psychiatric services; drugs and biologicals administered in a physician's office which cannot be self-administered; routine physical examinations; routine visits to a facility, home and community-based provider, or home; and family planning services. Services provided by nurse practitioners, physician assistants, nurse midwifes, and certified registered nurse anesthetists within their scope of practice are also covered. Specialty services are included as PCCM services requiring referrals. There are no limitations on services provided.

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

Effective Date: August 24, 2001

Approval Date: 27

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

Surgical services covered in addition to those provided under hospital or physician services include those services provided in ambulatory surgical centers (ASC) to patients who do not require hospitalization. Services include nursing, technician, use of ASC facilities, drugs, biologicals, surgical supplies, equipment, diagnostic and therapeutic services directly related to the provision of surgical procedures. Surgery services are included as PCCM services. There are no limitations on services provided.

6.2.5. X Clinic services (including health center services) and other ambulatory health care services. (Section 2110(a)(5))

Clinic services include preventive, diagnostic, therapeutic, rehabilitative, or palliative items services provided by federally qualified health centers and rural health or services under the medical direction of a physician and provided at the clinic or center. Clinic and center services are included as PCCM services and clinics and centers are eligible to be primary care providers. Services are limited to two visits per day, if the second visit is due to illness or injury sustained after the first visit.

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

Prescription drug services include the following drugs, biologicals, and related items and services that are prescribed: • Legend eye preparations, vaginal therapeutics, otic pharmaceutical preparations, or inhalations for asthmatic conditions; • Antibiotic products which are known, either by sensitivity test or product information, to be the single item of choice for the diagnosis; • All other legend prescription drugs and biologicals, except for the items listed below. • Insulin; • Concentrated cryoprecipitate used in the home treatment of hemophilia; • Legend vitamins prescribed for the prenatal care of pregnant women; • Calcitriol if used for renal impairment and determined medically necessary by the prescriber; • Spacers, such as Aerochamber and InspirEase, and solutions that

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

Effective Date: August 24, 2001

Approval Date: 28 are medically necessary for the administration of legend drugs used for the delivery of respiratory or inhalation therapy; • Syringes and needles for the administration of medication covered under this chapter; • Urine and blood testing items for a diabetic, except for glucometers, which are covered as medical equipment; • Family planning items; and • Smoking cessation drugs.

Non-covered services include: • Non-legend prescription drugs and over-the-counter items and medical supplies except for those specifically listed above; • Medical supplies or delivery charges; • Legend oral vitamins except for legend vitamins prescribed for the prenatal care of pregnant women. • Items prescribed for weight control or appetite depressants;

• Agents to promote fertility or treat impotence; • Agents used for cosmetic purposes; • Hair growth products; • Items or drugs manufactured by a firm that has not signed a rebate agreement with the CMS; • Items which exceed a 34-day supply, except for family planning items and prenatal vitamins; • Services, procedures, or drugs which are considered experimental; • Drugs and biologicals which the federal government has determined to be less than effective. Prescription drug services are included as PCCM services, with the exception of family planning drugs and items. Azidothymidine is available only for persons diagnosed with HIV. Clozaril and growth hormones are prior authorized.

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

See 6.2.6.

6.2.8. X Laboratory and radiological services (Section 2110(a)(8))

Covered under 6.2.1, 6.2.2, 6.2.3, 6.2.4, 6.2.5 for diagnostic and treatment purposes. Coverage includes materials and services of technicians. Laboratory services are not included as PCCM services. There are no limitations on services provided.

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

Effective Date: August 24, 2001

Approval Date: 29

6.2.9. X Prenatal care and prepregnancy family services and supplies (Section 2110(a)(9))

Covered under 6.2.3, 6.2.5,6.2.6. Family planning and prenatal maternity care services are fully covered. Family planning services are exempt from PCCM requirements. There are no limitations on services provided.

6.2.10. X Inpatient mental health services, other than services described in 6.2.18., but including services furnished in a state-operated mental hospital and including residential or other 24-hour therapeutically planned structural services (Section 2110(a)(10))

Inpatient mental health services are provided in three different service settings. Psychiatric Inpatient Hospital services are covered under 6.2.1 and include psychiatric care in general acute care hospitals, psychiatric distinct part units, and free standing psychiatric hospitals, including a state operated adolescent psychiatric unit.

Inpatient psychiatric facility services are provided to children, with prior authorization. These services are exempt from PCCM requirements. There are no limitations on services provided.

Inpatient residential treatment services for children are covered in residential treatment facilities. Coverage is limited to the treatment services provided and does not include room and board costs. Services are prior authorized. There are no limitations on services provided.

6.2.11. X Outpatient mental health services, other than services described in 6.2.19, but including services furnished in a state-operated mental hospital and including community-based services (Section 2110(a)(11)

Outpatient mental health services are covered in 6.2.3 when provided by physicians.

• Outpatient mental health services are covered in community mental health centers and include the following services: • Evaluations completed by a psychiatrist; • Evaluations or testing completed by a psychologist; • Comprehensive evaluations completed utilizing the expertise of more than one mental health professional; • Therapy provided to an individual; • Therapy provided to groups of two or more individuals, not

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

Effective Date: August 24, 2001

Approval Date: 30 exceeding ten persons; • Therapy provided to a family unit; • Partial day care services for a duration of three to six hours a day, including various types of therapy elements; and • Consultation with a psychiatrist, psychologist, or other mental health professional or physician concerning the patient's diagnosis or plan of treatment. • Outpatient mental health services are also available from licensed psychologists, certified social workers in private independent practice, and licensed professional counselors-mental health. Services include psychiatric evaluation, diagnostic interviews, individual, group and family therapy, and psychological testing. Services are limited to the equivalent of 40 hours of individual therapy per 12 month period, unless additional services are prior authorized.

Outpatient mental health services are included as PCCM services, unless provided to a person diagnosed as chronically mentally ill.

6.2.12. X Durable medical equipment and other medically-related or remedial devices (such as prosthetic devices, implants, eyeglasses, hearing aids, dental devices, and adaptive devices) (Section 2110(a)(12))

Durable medical equipment is covered and includes devices and assistive technology including: • devices for persons confined to beds, including hospital beds, bed pans, urinals, commodes, trapeze, lifts, standers, and pressure reduction therapy devices if extensive pressure sores exist; • mobility devices including wheelchairs and accessories (seats, trays, cushions, and positioning devices), canes, crutches and walkers; • oxygen and respiratory equipment and supplies; • glucose monitoring equipment and supplies; • dialysis equipment; • apnea monitors; • infusion pumps; • hearing aids and augmentative communication devices;

Medical equipment is purchased or rented at the discretion of the Department and requires documented medical necessity. Some devices have specific coverage criteria and limitations. Disposable supplies used with the equipment are included in coverage.

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

Effective Date: August 24, 2001

Approval Date: 31

Prosthetic devices, except dental, are included for coverage, including braces, artificial limbs, artificial eyes, augmentative communication devices, items to replace all or part of an internal body organ, and the replacement of such devices required by a change in the patient's condition.

Eyeglasses and contact lenses are included in coverage and may be obtained from optical providers, physicians as described in 6.2.3, and optometrists along with professional services. Eyeglasses are limited to replacement after 15 months, unless significant vision changes have occurred.

Durable Medical Equipment and prosthetic devices are included in the PCCM program. Eyeglasses and services of vision professionals are not included in the PCCM program.

6.2.13. X Disposable medical supplies (Section 2110(a)(13))

Disposable medical supplies are covered when medically necessary under each of the forms of coverage in Section 6.2.

6.2.14. X Home and community-based health care services (See instructions) (Section 2110(a)(14))

Home and community based services are covered when medically necessary and ordered by a physician and provided by a home health agency or qualified professional. Home health services include medical supplies, skilled nursing services, home health aide services, physical therapy, speech therapy, occupational therapy, respiratory therapy when ventilator dependant, and medical social services. Individuals receiving these services must be unable to leave home without considerable effort. Services are of an intermittent nature, not more than once per day or 4 times per week. There is no limit on the number of visits a person may receive.

Extended home health aide services and private duty nursing services are covered when more than 3 consecutive hours of care are necessary. These services must be prior authorized.

Home based therapy services are also covered for children with mental disorders or who are seriously emotionally disturbed. A treatment plan must exist that documents the need for home based therapy services. Covered services include diagnostic assessment, individual therapy, family

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

Effective Date: August 24, 2001

Approval Date: 32 therapy, and collateral services. Services must be prior authorized. 6.2.15. X Nursing care services (See instructions) (Section 2110(a)(15))

Nursing care services are covered as described in 6.2.1, 6.2.2, 6.2.3, 6.2.4, 6.2.5 and 6.2.14.

6.2.16. X Abortion only if necessary to save the life of the mother or if the pregnancy is the result of an act of rape or incest (Section 2110(a)(16)

Coverage is the same as Medicaid coverage.

6.2.17. X Dental services (Section 2110(a)(17))

Dental services are covered including diagnostic services (oral examinations and x-rays), preventive services (prophylaxis, topical fluoride, and sealant), restorative services (amalgam restorations, resin restorations, and crowns to anterior teeth), endodontics, prosthodontics (complete and partial dentures, adjustments, and repairs).

Medical/Dental procedures are also covered including oral surgery for extraction, surgical extractions and tooth reimplantation, treatment of fractures, reduction of TMJ dysfunction, and periodontics. Medically necessary orthodontic procedures including diagnosis, minor treatment, interceptive orthodontic treatment and treatment of dentition are covered.

Dental exams, prophylaxis, and topical fluoride are limited to two services in a 12-month period, sealants are limited to once in a three year period. Orthodontic services in excess of $500 must be prior authorized.

All dental services are exempt from the PCCM program.

6.2.18. X Inpatient substance abuse treatment services and residential substance abuse treatment services (Section 2110(a)(18))

Inpatient treatment for substance abuse services are covered in certified facilities designed specifically for chemically dependent adolescents. Services are not included in the PCCM program, however, referrals from a physician or court are required. Services are prior authorized. Services are limited to 45 days in a 12 month period. Programs designed for substance abusing pregnant women are covered.

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

Effective Date: August 24, 2001

Approval Date: 33

6.2.19. X Outpatient substance abuse treatment services (Section 2110(a)(19))

Outpatient treatment for substance abuse services are covered in certified facilities designed specifically for chemically dependent adolescents. Programs designed for substance abusing pregnant women are covered. Services are not included in the PCCM program however, referrals from a physician or court are required. Services are prior authorized. Services are limited to 60 hours in a 12-month period.

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

Case management services are provided to all SCHIP children through the primary care case management program. Each program enrollee select or is assigned a primary care case management physician to provide the management and treatment of medical conditions and provide for referral for specialty care services. The primary care case manager can be either a physician (Family Practice, Internal Medicine, Pediatrics, OB-GYN, General Practice) or rural health clinic, federally qualified health center, or IHS facility. Services excluded from case management are emergency services, family planning, dental, podiatry, optometry, chiropractic, immunization, transportation and mental health services for chronically mentally ill clients.

Targeted case management services are available to severely and persistently mentally ill individuals at least 18 years of age when obtained from a certified case manager. The case managers provide face to face services including client identification and follow up, coordination of needs assessments, development of a case management plan, service mobilization, linkage and case monitoring. Services must include at least four units of service per month and non face to face services are limited on a monthly basis.

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

6.2.22. X Physical therapy, occupational therapy, and services for individuals with speech, hearing, and language disorders (Section 2110(a)(22))

Physical therapy, occupational therapy, and services for individuals with speech, hearing and language disorders are covered when provided under forms of coverage in 6.2.1, 6.2.2, 6.2.4, 6.2.5, and 6.2.14. The services are also available from individual providers

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

Effective Date: August 24, 2001

Approval Date: 34 within their scope of practice when referred by physicians and required to diagnose or treat a medical condition. These services may also be provided by school districts when medically necessary and identified as part of a child’s individual education program. The services are included in the PCCM program. There are no limitations on the services provided.

6.2.23. X Hospice care (Section 2110(a)(23))

Hospice benefits will follow the amount, duration and scope of coverage as identified in the State Medicaid manual.

6.2.24. X Any other medical, diagnostic, screening, preventive, restorative, remedial, therapeutic, or rehabilitative services. (See instructions) (Section 2110(a)(24))

Other medical services included in the plan are Chiropractic Services, Vision Services, Podiatry Services, Nutritional Services, Nursing Facility Services, Diabetes Self-management training programs, Vaccination Services and certain Organ Transplant Services.

Chiropractic services are limited to examinations and manual manipulations required to correct a subluxation of the spine. Services are outside of the PCCM program and limited to no more than one visit per day and thirty visits in a twelve-month period.

Vision services, in addition to the services of physicians in 6.2.3 include the services of optometrists. Covered services include examinations, removal of foreign bodies from the eye, vision screenings, and refractive services, eyeglasses and contact lenses. Services are outside of the PCCM program. Eyeglasses are limited to replacement after 15 months unless significant vision changes have occurred.

Podiatry services include the surgical and non-surgical diagnosis and treatment of conditions of the feet and lower extremities, excluding routine foot care. Services are outside of the PCCM program. There is no limit on the number of services provided.

Nutritional services are covered for children not able to obtain necessary nutrition through oral means. Enteral and perenteral nutrition are covered services. Perenteral nutrition services are prior authorized. Nutritional supplements are covered when physician ordered for conditions that exceed normal nutritional requirements.

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

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Nursing Facility services are covered when medically necessary and individuals meet level of care and financial eligibility criteria for long term care. Nursing facility services are prior authorized.

Immunization services include all recommended vaccinations and are covered under Section 6.2.6, prescription drugs.

Organ transplant services include Kidney, Cornea, Bone Marrow, Liver and Heart Transplants. All transplant services are covered only when all other medical and surgical treatments have been exhausted, patients are free from adverse factors and there is likelihood of success or survival. Transplants are limited to the transplantation of human organs. With the exception of kidney and cornea transplants, transplant procedures are prior authorized. 6.2.25. ∼ Premiums for private health care insurance coverage (Section 2110(a)(25))

6.2.26. X Medical transportation (Section 2110(a)(26))

Medical transportation includes medically necessary air ambulance, ground ambulance, wheelchair transportation and other medical transportation. Ambulance services are necessary when other forms of transportation may endanger a person’s life or health. Ground ambulance includes advanced life support and basic life support services and attendants. Air ambulance includes fixed wing emergency transportation, rotary emergency transportation, and medical air transportation. Air ambulance must be medically necessary because of time, distance and emergency. Wheelchair transportation includes transportation services to persons that are confined to wheelchairs or stretchers to and from medical services.

Other transportation services are available to assist persons obtain necessary medical services. These services include reimbursement for the use of private automobiles, meals and lodging, community transportation providers, tribal transportation providers and commercial carriers.

6.2.27. ∼ Enabling services (such as transportation, translation, and outreach services (See instructions) (Section 2110(a)(27)) 6.2.28. ∼ Any other health care services or items specified by the Secretary and not included under this section (Section 2110(a)(28))

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

Effective Date: August 24, 2001

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

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

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

Effective Date: August 24, 2001

Approval Date: 37 6.3.2. ∼ The state contracts with a group health plan or group health insurance coverage, or contracts with a group health plan to provide family coverage under a waiver (see Section 6.4.2. of the template). Pre- existing medical conditions are permitted to the extent allowed by HIPAA/ERISA (Section 2103(f)). Please describe: Previously 8.6

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

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

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

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

6.4.1.3. The coverage must be provided through the use of a community-based health delivery system, such as through contracts with health centers receiving funds under section 330 of the Public Health Service Act or with hospitals such as those that receive disproportionate share payment adjustments under section 1886(c)(5)(F) or 1923 of the Social Security Act. Describe the community based delivery system. (Section 2105(c)(2)(B)(iii)) (42CFR 457.1005(a)) 6.4.2. ∼ Purchase of Family Coverage. Describe the plan to purchase family coverage. Payment may be made to a state for the

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

Effective Date: August 24, 2001

Approval Date: 38 purpose of family coverage under a group health plan or health insurance coverage that includes coverage of targeted low- income children, if it demonstrates the following: (Section 2105(c)(3)) (42CFR 457.1010)

6.4.2.1. Purchase of family coverage is cost-effective relative to the amounts that the state would have paid to obtain comparable coverage only of the targeted low-income children involved; and (Describe the associated costs for purchasing the family coverage relative to the coverage for the low income children.) (Section 2105(c)(3)(A)) (42CFR 457.1010(a))

6.4.2.2. The state assures that the family coverage would not otherwise substitute for health insurance coverage that would be provided to such children but for the purchase of family coverage. (Section 2105(c)(3)(B)) (42CFR 457.1010(b))

6.4.2.3. The state assures that the coverage for the family otherwise meets title XXI requirements. (42CFR 457.1010(c))

Section 7. Quality and Appropriateness of Care

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

7.1. Describe the methods (including external and internal monitoring) used to assure the quality and appropriateness of care, particularly with respect to well-baby care, well- child care, and immunizations provided under the plan. (2102(a)(7)(A)) (42CFR 457.495(a))

The SCHIP program will use the methods that exist for the Medicaid program to assure quality and appropriateness of care since the programs will be jointly administered and delivered. There are numerous strategies that South Dakota uses under these programs to monitor quality and appropriateness of care including both external and internal sources.

The most comprehensive mechanism used by the State in the SCHIP program is the Primary Care Case Management system. Under this program each recipient of SCHIP selects a primary care physician or clinic (PCP) to provide primary care and authorize and manage all specialty medical care through a referral process. Under this program each PCP receives a monthly report of all the medical services used by each client enrolled with that PCP. In this way each PCP is able to provide case management services and monitor the appropriateness of services provided to enrollees.

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

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The state also monitors the performance of each PCP with regard to the number of clients enrolled with each PCP, the proportion of services provided directly or referred by each PCP, and the satisfaction of clients with PCPs via a complaint and disenrollment process used by recipients to change PCP’s. Case file reviews will be conducted on quality complaints. This program operates for Medicaid recipients under waiver authority from CMS. The waiver process provides for a biannual review of the program by CMS, and a number of focussed clinical studies to be completed each renewal period. Monitoring of this program by CMS has been ongoing since 1993, with the third and most recent renewal expiring September 30, 2002. . South Dakota will request the managed care waiver be incorporated into its Medicaid and SCHIP state plans. All of the quality and appropriateness monitoring available to Medicaid for the PCCM program will also be provided to the SCHIP program.

External reviews of medical, surgical and hospital services are conducted by the Professional Review Organization (PRO) in South Dakota. A large sample of services is selected for review each month on a variety of criteria, including specific diagnoses and random selections. Services provided to SCHIP clients will also be included in the sample selected for PRO review. The PRO reports to each provider and to the State the results of each review recommending approval, denial, changes or improvements to service delivery, action by the Medicaid program or referral to other entities for action.

Drug utilization review activities will also be made available to SCHIP clients through the pharmacy benefit management system used by the Department to provide prescription drug coverage. Each drug prescription is processed through a prospective drug use review protocol prior to authorizing a pharmacist to dispense a drug product. This point of service process checks for drug to drug interactions, contraindications, duplicate therapy, dosage, early refill, and days-supply edits to help assure appropriate and quality prescription drug services. The drug utilization review requirements are purchased from a national vendor and incorporated into the Department’s system. A licensed pharmacist employed by the Department oversees the operation of the DUR system.

The SCHIP program will also make use of the capabilities of the MMIS claims processing system to process and pay claims for SCHIP clients using the same procedures and rates as the Medicaid program. The MMIS claims systems has numerous edits, reports and capabilities to assist in assuring appropriate and quality services are delivered to SCHIP clients. The MMIS is the source for the Medicaid reporting of EPSDT screening services to CMS, and these reporting capabilities will be available to report on the SCHIP children also.

Surveillance and utilization review system (SURS) capabilities used by the Department to monitor Medicaid services will also be used to monitor the services

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

Effective Date: August 24, 2001

Approval Date: 40 obtained by SCHIP clients for fraud and abuse. This will provide the SCHIP program a capacity for the full investigation, referral to appropriate law enforcement, and reporting of sanctions as required. The SURS is the designated unit in the Department of Social Services for investigation of fraud, and collaboration with the South Dakota Attorney General’s office and U.S. Attorney. A toll free fraud reporting telephone number is also available to provide a convenient means to report fraud.

Surveys and quality assurance reports will also be used to monitor the quality and appropriateness of services provided the SCHIP clients. Client surveys have been an important part of the SCHIP annual reporting that has been completed by South Dakota for each year of the SCHIP program. . Specific questions are addressed to the families of SCHIP children asking about the quality and satisfaction that families have with the services provided. These surveys and the specific questions will continue under the Medicaid and SCHIP programs.

A number of quality assurance reports based on the HEDIS model have been completed for the SCHIP eligible children covered under South Dakota’s SCHIP program. These reports specifically address the key areas of immunization, well child and well baby. In addition to reports on those subjects reports have been completed on Dental, Optometry, Asthma, Substance Abuse, and Eating Disorders. Plans include repeating these measure to monitor progress and also to expand the number of measures under the HEDIS to be completed for the SCHIP children in South Dakota.

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

7.1.1. X Quality standards

The state will establish standards for the performance of PCP’s to meet for the well child screenings and immunization levels for children in the CHIP NM program.

7.1.2. X Performance measurement

The state will conduct HEDIS based measurement studies for immunization, dental, well child screenings, optometry, substance abuse and mental health services. 7.1.3. ∼ Information strategies 7.1.4. ∼ Quality improvement strategies

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

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

Effective Date: August 24, 2001

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7.2.1 Access to well-baby care, well-child care, well-adolescent care and childhood and adolescent immunizations. (Section 2102(a)(7)) (42CFR 457.495(a))

In addition to inclusion on the HCFA 416 report that measures utilization of EPSDT services, South Dakota, as part of its SCHIP general satisfaction survey of recipients routinely asks recipients access to care questions. The survey instrument specifically asks questions relating to well child care, immunizations, vision services, substance abuse and dental services. The surveys provide excellent feedback regarding recipients access to care.

Parents of SCHIP kids are routinely provided with educational materials relating to EPSDT services to inform them on the importance of preventive healthcare.

Access to quality primary and preventive health services will be measured by the number of new SCHIP children enrolled in medical assistance primary care case management system. Utilization based studies for immunization, dental, well child screenings, optometry, substance abuse and mental health services will be used to provide additional measurement of access to services. Further, additional measurements are collected in accordance with Section 9.3.7 of this state plan and are included in the SCHIP annual reports.

7.2.2 Access to covered services, including emergency services as defined in 42 CFR ∋457.10. (Section 2102(a)(7)) 42CFR 457.495(b))

SCHIP will use the same delivery system, provider network and covered services as the Medicaid program in South Dakota. One of the benefits of this arrangement is the excellent provider participation for all types of service providers in the State. Nearly all primary care and specialty physicians participate in the program, all inpatient and outpatient hospitals participate, nearly all pharmacies participate, and participation from allied health providers is also very good. Using the PCCM system for SCHIP facilitates access to primary care and the use of PCP’s to provide referrals for non- emergency specialty services enhances access to specialty services as referral arrangements with PCP’s are established and specialists are not accessed for primary care purposes.

The selected SCHIP program structure allows the maximum use of the available rural providers to enhance access to services in the rural areas of South Dakota. The Indian Health Service and Tribal services are key resources in the most under-served areas of the State. Each IHS service unit has participating PCP providers in the PCCM program. The SCHIP program is also structured so those eligible clients have maximum access to IHS programs without a referral from another PCP if the individuals have selected

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

Effective Date: August 24, 2001

Approval Date: 42 a non-IHS PCP. Tribal clinics are also eligible to be PCP providers as federally qualified health centers (FQHC’s). Rural areas outside of American Indian reservation are served by rural health clinics and federally qualified health centers that are also enrolled as PCP entities to enhance service availability. Favorable reimbursement mechanisms are in place for all of these provider types to ensure the availability of services.

Under the PCCM program the Department of Social Services carefully monitors the capacity of each participating PCP and presently averages about 85 enrollees per PCP entity, with very few PCP’s closed to new enrollees. PCP’s are limited to a maximum of 750 enrollees. County and sub-state areas are also monitored for PCP availability. Most PCCM participants select their own PCP’s and have free choice of providers for non-PCCM services. Time and distance standards ensure that PCCM enrollees do not have to travel more than 75 miles to their PCP. Routine monitoring of PCP performance also includes an analysis of PCP provided services versus referred services with the dual purpose of ensuring PCP’s are accessible and providing services to enrolled clients, and also not withholding appropriate referrals for specialty care.

The Department also carefully monitors the PCP changes and disenrollment reasons to assure that access to care issues are resolved. In addition, the Department randomly monitors PCP compliance with 24 hour per day, seven day per week requirement for PCP availability.

The SCHIP program uses the definition and procedure for accessing emergency services that applies to Medicaid that are consistent with Federal law.

Access and availability to services are presently monitored under Medicaid. This monitoring will also include SCHIP enrollees. Surveys of participants to measure access to services, waiting times, and satisfaction with service availability will continue to be completed with all Medicaid and SCHIP children.

7.2.3 Appropriate and timely procedures to monitor and treat enrollees with chronic, complex, or serious medical conditions, including access to an adequate number of visits to specialists experienced in treating the specific medical condition and access to out-of-network providers when the network is not adequate for the enrollee=s medical condition. (Section 2102(a)(7)) (42CFR 457.495(c))

Individuals with special healthcare needs are exempt from managed care requirements. As such, these individuals are not restricted under the SCHIP

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

Effective Date: August 24, 2001

Approval Date: 43 program. All SCHIP recipients have the same access to specialists as private pay individuals or individuals with private health insurance.

7.2.4 Decisions related to the prior authorization of health services are completed in accordance with state law or, in accordance with the medical needs of the patient, within 14 days after the receipt of a request for services. (Section 2102(a)(7)) (42CFR 457.495(d))

Decisions related to the prior authorization of health services are completed in accordance with the medical needs of the patient, within 14 days after the receipt of a request for services. The prior authorization policy is consistent with the prior authorizations under the South Dakota Medicaid Program. Oftentimes, the request for prior authorization does not contain sufficient documentation to make a determination. When that occurs, the physicians are contacted, additional documentation is requested, and the determination is made upon receipt of the additional documentation. The department maintains a database of prior authorizations, and monitoring of the determination within 14 days of receipt can be easily documented.

Section 8. Cost Sharing and Payment (Section 2103(e))

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

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

8.1.1. ∼ YES 8.1.2. X NO, skip to question 8.8.

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

8.2.1. Premiums:

8.2.2. Deductibles: 8.2.3. Coinsurance or copayments: 8.2.4. Other:

8.3. Describe how the public will be notified, including the public schedule, of this cost- sharing (including the cumulative maximum) and changes to these amounts and any differences based on income. (Section 2103(e)((1)(B)) (42CFR 457.505(b))

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

Effective Date: August 24, 2001

Approval Date: 44

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

8.4.1. ∼ Cost-sharing does not favor children from higher income families over lower income families. (Section 2103(e)(1)(B)) (42CFR 457.530) 8.4.2. ∼ No cost-sharing applies to well-baby and well-child care, including age-appropriate immunizations. (Section 2103(e)(2)) (42CFR 457.520) 8.4.3 Γ No additional cost-sharing applies to the costs of emergency medical services delivered outside the network. (Section 2103(e)(1)(A)) (42CFR 457.515(f))

8.5. Describe how the state will ensure that the annual aggregate cost-sharing for a family does not exceed 5 percent of such family's income for the length of the child's eligibility period in the State. Include a description of the procedures that do not primarily rely on a refund given by the state for overpayment by an enrollee: (Section 2103(e)(3)(B)) (42CFR 457.560(b) and 457.505(e))

8.6 Describe the procedures the state will use to ensure American Indian (as defined by the Indian Health Care Improvement Act of 1976) and Alaska Native children will be excluded from cost-sharing. (Section 2103(b)(3)(D)) (42CFR 457.535)

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

8.7.1 Please provide an assurance that the following disenrollment protections are being applied: Γ State has established a process that gives enrollees reasonable notice of and an opportunity to pay past due premiums, copayments, coinsurance, deductibles or similar fees prior to disenrollment. (42CFR 457.570(a)) Γ The disenrollment process affords the enrollee an opportunity to show that the enrollee's family income has declined prior to disenrollment for non payment of cost-sharing charges. (42CFR 457.570(b)) Γ In the instance mentioned above, that the state will facilitate enrolling the child in Medicaid or adjust the child's cost-sharing category as appropriate. (42CFR 457.570(b)) Γ The state provides the enrollee with an opportunity for an impartial review to address disenrollment from the program. (42CFR 457.570(c))

8.8 The state assures that it has made the following findings with respect to the payment

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

Effective Date: August 24, 2001

Approval Date: 45 aspects of its plan: (Section 2103(e))

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

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

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

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

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

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

Section 9. Strategic Objectives and Performance Goals and Plan Administration (Section 2107)

9.1. Describe strategic objectives for increasing the extent of creditable health coverage among targeted low-income children and other low-income children: (Section 2107(a)(2)) (42CFR 457.710(b)) South Dakota implemented CHIP-NM as an additional effort to address the objectives stated in the original M-SCHIP state plan. Those objectives are:

1. Achieve a measurable reduction in the number of uninsured children in South Dakota beginning July 1, 1998.

2. Improve access to quality primary and preventive health care services under Medicaid for approved SCHIP eligibles, new Medicaid eligibles, and previously non-enrolled children on July 1, 1998.

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3. Develop better measurement capabilities of health insurance coverage, and health care service availability and quality to children in South Dakota, beginning July 1, 1998.

Effective July 1, 2000 each objective will include the CHIP-NM program.

9.2. Specify one or more performance goals for each strategic objective identified: (Section 2107(a)(3)) (42CFR 457.710(c))

1. Achieve a measurable reduction in the number of uninsured children in South Dakota.

1.1 Implement CHIP-NM to provide coverage to an additional 2,400 targeted, uninsured children in families with incomes from 140% to 200% of the federal poverty level beginning July 1, 2000.

1.2 Continue to extend Medicaid to children age zero through eighteen at Medicaid eligibility levels in effect prior to July 1, 1998, and other low income children from 133% to 140% of the federal poverty level as amended effective April 1, 1999.

1.3 Continue to extend SCHIP benefits to targeted, uninsured, non-Medicaid eligible children age 6 through 18 in families with incomes from 100% to 133% of the federal poverty levels, and to targeted, uninsured, non Medicaid eligible children age 0 through 18 in families with incomes from 133% to 140% as amended effective April 1, 1999.

1.4 Continue to utilize a systematic approach to identify uninsured children with low incomes using Department data resources, partnerships with other public programs, and local involvement of interested parties including schools, providers, and others.

1.5 Expand the simplified medical assistance application process to include CHIP-NM the same as the Medicaid and M-SCHIP medical assistance programs.

2. Improve access to quality primary and preventive health care services for CHIP- NM eligible children.

2.1 Enroll 95% of all newly approved CHIP-NM children in the South Dakota medical assistance primary care case management program within 1 month of their enrollment, beginning July 1, 2000.

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2.2 Ensure each new CHIP-NM enrollee receives covered services, cost sharing and EPSDT information at the time that their eligibility is approved.

2.3 Include CHIP-NM eligible children in the quality measurement mechanisms that are used for Medicaid and M-SCHIP including measures of immunization, well child care, adolescent well care, satisfaction and other measures of health care quality. Measures will come from the HCFA 416 report, the Department of Health Immunization tracking system, and the evaluation process used in South Dakota’s PRIME managed care program operated under 1915(b) waiver authority. This evaluation process also uses client and provider surveys independent evaluations and clinical studies to report cost effectiveness and quality to CMS for waiver renewal purposes, and annual SCHIP reporting requirements. South Dakota will request the managed care waiver be incorporated into its Medicaid and SCHIP state plans.

3. Develop better measurement capabilities of health insurance coverage, health care service availability and quality to children in South Dakota.

3.1 Modify the Medicaid Management Information System to make CHIP-NM tracking and reporting capabilities available to measure enrollment, service, utilization, and overall program effectiveness. This enhancement will make all MARS and CMS reports available for CHIP-NM.

9.3. Describe how performance under the plan will be measured through objective, independently verifiable means and compared against performance goals in order to determine the state's performance, taking into account suggested performance indicators as specified below or other indicators the state develops: (Section 2107(a)(4)(A),(B)) (42CFR 457.710(d))

1. Achieve a measurable reduction in the number of uninsured children in South Dakota.

The success of this objective will be determined by the number of uninsured children in South Dakota who receive health insurance coverage as the result of the CHIP-NM State Plan amendment, M-SCHIP, or Medicaid coverage. Evidence of this reduction will come from South Dakota medical assistance enrollment figures, estimates provided by the United States Census Bureau and supported with survey data from the Behavioral Health Survey and other publications. (The South Dakota Behavioral Risk Factor Surveillance System (BRFSS) is designed to collect information on the health behaviors in the State.

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

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Approval Date: 48 The survey was initiated in 1987 by the South Dakota Department of Health with the assistance of the Centers for Disease Control and Prevention, and has been on-going since 1987. For the SCHIP Program in South Dakota, the BRFSS surveys South Dakotans to assist in measurements as to why a child is without health insurance, whether coverage such as Medicaid and SCHIP have been considered for those who respond that the child is uninsured, crowd out issues, etc. to determine effectiveness of outreach promotions.)

2. Improve access to quality primary and preventive health care services under Medicaid for CHIP-NM eligible children.

Access to quality primary and preventive health services will be measured by the number of new CHIP-NM children enrolled in medical assistance primary care case management system. Utilization based studies for immunization, dental, well child screenings, optometry, substance abuse and mental health services will be used to provide additional measurement of access to services.

3. Develop better measurement capabilities of health insurance coverage, and health care service availability and quality to children in South Dakota.

Adequate data is available for the completion of annual reports and evaluations for CHIP-NM as well as the original M-SCHIP program in compliance with Section 9.5 of this State Plan Amendment.

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

9.3.1. X The increase in the percentage of Medicaid-eligible children enrolled in Medicaid. 9.3.2. X The reduction in the percentage of uninsured children. 9.3.3. X The increase in the percentage of children with a usual source of care. 9.3.4. X The extent to which outcome measures show progress on one or more of the health problems identified by the state. 9.3.5. ∼ HEDIS Measurement Set relevant to children and adolescents younger than 19. 9.3.6. ∼ Other child appropriate measurement set. List or describe the set used. 9.3.7. X If not utilizing the entire HEDIS Measurement Set, specify which measures will be collected, such as: 9.3.7.1. X Immunizations – CPT range 90700 through 90749 9.3.7.2. X Well child care – SD EPSDT code W8630, CPT range 9981 through 99383 and 99391 through 99393

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

Effective Date: August 24, 2001

Approval Date: 49 9.3.7.3. X Adolescent well visits – CPT codes 99384 through 99394 9.3.7.4. X Satisfaction with care 9.3.7.5. X Mental health – CPT codes 90804 through 90899 9.3.7.6. X Dental care – Codes covering exams, x-rays, and certain treatments 9.3.7.7. X Other, please list: Optometric and Substance Abuse – Range of SD codes W7500 through W7507m W8500, W8600, W8601 and W8620 through W8624 9.3.8. X Performance measures for special targeted populations.

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

9.5. X The state assures it will comply with the annual assessment and evaluation required under Section 10. Briefly describe the state's plan for these annual assessments and reports. (Section 2107(b)(2)) (42CFR 457.750)

The South Dakota Department of Social Services will evaluate the operation and effectiveness of its State Children’s Health Insurance Program (SCHIP) on an ongoing basis and report the findings to CMS by January 1 of each year. A variety of data sources will be utilized to evaluate South Dakota’s program. These data sources will include, but will not be limited to, US Bureau of Census, South Dakota Department of Health, South Dakota Medical Assistance, and Indian Health Services. Annual reports will follow the format as specified by CMS.

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

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

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

9.8.1. X Section 1902(a)(4)(C) (relating to conflict of interest standards) 9.8.2. X Paragraphs (2), (16) and (17) of Section 1903(i) (relating to limitations on payment)

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

Effective Date: August 24, 2001

Approval Date: 50 9.8.3. X Section 1903(w) (relating to limitations on provider donations and taxes) 9.8.4. X Section 1132 (relating to periods within which claims must be filed)

9.9. Describe the process used by the state to accomplish involvement of the public in the design and implementation of the plan and the method for insuring ongoing public involvement. (Section 2107(c)) (42CFR 457.120(a) and (b))

The SCHIP program was initiated and authorized by specific action of the 1998 and 2000 South Dakota State Legislature which authorized the Department of Social Services to develop a program for low income uninsured children up to 200% of the Federal Poverty Level under the Federal Title XXI program.

Pursuant to this direction from the Legislature the Department of Social Services developed Administrative Rules for the administration and delivery of the SCHIP process. These rules were promulgated, heard, and implemented with the public process specified in the South Dakota Administrative Procedures Act. Public Notice was made in several newspapers and a Public Hearing was conducted to inform the public of the new program, eligibility, covered services, and other provisions of the SCHIP program.

Further public involvement was obtained by presentation of the SCHIP program to the Medical Advisory Committee, (meets semi-annually) and the Board of Social Services (meets quarterly) prior to implementation. The Medical Advisory Committee and the Board of Social Services are advisory groups that provide input into the design, implementation and operation of the Medical Assistance Program. (Titles XIX and XXI)

Inasmuch as the State Plan Amendment does not include a reduction in services or increase in cost sharing, but rather an expansion of services and coverage under the SCHIP program a public process is not required. However, with the public action of the South Dakota Legislature and the requirements of the Administrative Procedures Act, the Department has, in its judgement, allowed adequate public input in the design and implementation of SCHIP.

The Department recognizes that the SCHIP program does not differ significantly from the current delivery system and coverage under medical assistance programs in South Dakota, with the exception of expanded eligibility.

The Department will continue to actively solicit public involvement in the delivery of the Medical Assistance Program benefits under Titles XIX and XXI. The Department will ensure ongoing public involvement in the design and implementation of the SCHIP state plan through the processes described above.

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

Effective Date: August 24, 2001

Approval Date: 51

In addition, the Department continues it’s long-standing policy to provide for ongoing public involvement in the operation of the Medical Assistance Program. (Titles XIX and XXI) The Department has regular contacts with advocacy groups, and an open door policy to provide advocacy groups and individuals the opportunity to present input and feedback on the operation of the program. The Department meets with advocacy groups and individuals that request such a meeting.

9.9.1 Describe the process used by the state to ensure interaction with Indian Tribes and organizations in the state on the development and implementation of the procedures required in 42 CFR ∋457.125. (Section 2107(c)) (42CFR 457.120(c))

Consultation meetings have been held between the State and Tribal Government and Tribal Health officials. In addition, the Department has invited both Tribal Government and the IHS to be represented on the Medicaid Advisory Committee that assists in the monitoring of the Medicaid and SCHIP programs, and both entities are participating.

Some Tribal health departments have requested specific training of the their Community Health Representative staff in the SCHIP program and this training was provided by Department eligibility staff. One reservation even adapted the SCHIP radio ad to use in reaching the Indian population on their reservation.

Outreach brochures, posters and logos for SCHIP were designed with a culturally sensitive logo depicting children of varying ethnic backgrounds in an effort to convey that the program is intended for all races of children.

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

9.10. Provide a one year projected budget. A suggested financial form for the budget is attached. The budget must describe: (Section 2107(d)) (42CFR 457.140)

The following budget figures represent the estimated cost of serving the CHIP-NM, and M-SCHIP children for FFY 2000, FFY 2001, and FFY 2002. All of the funds used to operate the SCHIP programs by matching the federal funds have been allocated from the State’s General fund, as part of the General Appropriation bill. The State assures no general funds have been raised from impermissible provider taxes or donations, and that the State is in compliance with Section 1903 (w) of the Social Security Act. Three budget sheets are presented, one for the CHIP-NM, one for the existing M-SCHIP program, and the total for South Dakota SCHIP.

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

Effective Date: August 24, 2001

Approval Date: 52 A three year CHIP-NM budget is presented. FFY2000 budget amounts are estimated using three months of FFY 2000 from July to September of 2000. Estimates for FFY2001 and FFY2002 represent a full year of operation. This budget assumes 600 clients for FFY 2000, 2,400 clients for FFY 2001, and 2,700 for FFY 2002.

The CHIP-NM service budget is based upon funds appropriated by the South Dakota Legislature. This appropriation was based on an average cost of $991 per eligible child per year. Amounts were then allocated to service categories using utilization figures from currently eligible M-SCHIP children from July, 1999 through April, 2000. Administrative costs for CHIP-NM are calculated at 10% of the allowable service and administration costs. The percentages allocated to administrative categories reflect the best estimates of actual anticipated expenditures by the State.

Recognizing that South Dakota currently operates a M-SCHIP program, an updated 3 year budget for M-SCHIP is also presented for all of FFY 2000, FFY 2001, and FFY 2002. This budget is based on 3,839 clients for FFY 2000, 3,839 clients for FFY 2001, and 4,139 clients for FFY 2002. The average cost per client for FFY 2000 and FFY 2001 is $1,033 per child, per year based on actual costs from July-April of SFY 2000. Amounts have been allocated to service categories using utilization figures from the same time period. Administrative costs are estimated at 10% of the allowable expenditures for services and administration. These costs are based upon current state estimates of anticipated expenditures.

A total SCHIP budget for South Dakota for the three federal fiscal years is also presented. This budget is the sum of the anticipated expenditures for CHIP-NM and M-SCHIP in South Dakota.

CHIP-NM THREE YEAR BUDGET PROJECTION

Federal Fiscal Year Budget Estimates --- CHIP-NM FFY 2000 FFY 2001 FFY 2002 Medical Services Purchased

Physician $33,149 $530,383 $614,582 Inpatient Hospital $33,208 $531,335 $615,684 Outpatient Hospital $18,938 $303,008 $351,111 Prescription Drugs $17,288 $276,608 $320,519 Preventive Services (EPSDT)

Screening $580 $9,276 $10,748 Dental and Orthodontic $9,989 $159,828 $185,201 Optometric $6,035 $96,563 $111,892

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

Effective Date: August 24, 2001

Approval Date: 53 Treatment $23,353 $373,647 $432,963 Mental Health $4,787 $76,584 $88,742 All Other $1,323 $21,168 $24,529

Total Services $148,650 $2,378,400 $2,755,971

Administration

Personal Services $11,727 $187,629 $217,416 Outreach $2,147 $34,355 $39,808 Data Collection $1,487 $23,784 $27,560 Computer Services $1,156 $18,499 $21,435 Total Administration $16,517 $264,267 $306,219 Total Budget $165,167 $2,642,667 $3,062,190 Federal Share $128,995 $2,056,523 $2,331,858 State Share $36,172 $586,144 $730,332

M-SCHIP THREE YEAR BUDGET PROJECTION

Federal Fiscal Year Budget Estimates-- - M-SCHIP FFY 2000 FFY 2001 FFY 2002 Medical Services Purchased

Physician $746,133 $884,348 $982,069 Inpatient Hospital $747,471 $885,934 $983,830 Outpatient Hospital $426,266 $505,229 $561,056 Prescription Drugs $389,127 $461,209 $512,173 Preventive Services (EPSDT)

Screening $13,049 $15,466 $17,175 Dental and Orthodontic $224,844 $266,494 $295,942 Optometric $135,843 $161,007 $178,798 Treatment $525,639 $623,009 $691,852 Mental Health $107,738 $127,695 $141,805 All Other $29,778 $35,295 $39,195

Total Services $3,345,887 $3,965,687 $4,403,896

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

Effective Date: August 24, 2001

Approval Date: 54

Administration

Personal Services $263,953 $312,849 $347,418 Outreach $48,329 $57,282 $63,612 Data Collection $33,459 $39,657 $44,039 Computer Services $26,024 $30,844 $34,253 Total Administration $371,765 $440,632 $489,322 Total Budget $3,717,652 $4,406,319 $4,893,218 Federal Share $2,903,486 $3,428,997 $3,726,186 State Share $814,166 $977,322 $1,167,032

TOTAL SOUTH DAKOTA SCHIP THREE YEAR BUDGET PROJECTION

Federal Fiscal Year Budget Estimates - -- Total SCHIP FFY 2000 FFY 2001 FFY 2002 Medical Services Purchased

Physician $779,282 $1,414,731 $1,596,650 Inpatient Hospital $780,680 $1,417,269 $1,599,514 Outpatient Hospital $445,204 $808,237 $912,167 Prescription Drugs $406,415 $737,817 $832,693 Preventive Services (EPSDT)

Screening $13,629 $24,742 $27,923 Dental and Orthodontic $234,833 $426,323 $481,143 Optometric $141,878 $257,570 $290,691 Treatment $548,992 $996,656 $124,815 Mental Health $112,524 $204,280 $230,548 All Other $31,101 $56,462 $63,723

Total Services $3,494,537 $6,344,087 $7,159,867

Administration

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

Effective Date: August 24, 2001

Approval Date: 55 Personal Services $275,680 $500,478 $564,834 Outreach $50,477 91,637 $103,420 Data Collection $34,945 $63,441 $71,599 Computer Services $27,180 $49,343 $55,688 Total Administration $388,282 $704,899 $795,541 Total Budget $3,882,819 $7,048,986 $7,955,408 Federal Share $3,032,482 $5,485,521 $6,058,043 State Share $850,337 $1,563,465 $1,897,365

∃ Planned use of funds, including -- - Projected amount to be spent on health services; - Projected amount to be spent on administrative costs, such as outreach, child health initiatives, and evaluation; and - Assumptions on which the budget is based, including cost per child and expected enrollment. ∃ Projected sources of non-Federal plan expenditures, including any requirements for cost-sharing by enrollees.

Section 10. Annual Reports and Evaluations (Section 2108)

10.1. Annual Reports. The state assures that it will assess the operation of the state plan under this Title in each fiscal year, including: (Section 2108(a)(1),(2)) (42CFR 457.750) 10.1.1. X The progress made in reducing the number of uncovered low- income children and report to the Secretary by January 1 following the end of the fiscal year on the result of the assessment, and

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

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

Section 11. Program Integrity (Section 2101(a))

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

11.1 X The state assures that services are provided in an effective and efficient manner

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

Effective Date: August 24, 2001

Approval Date: 56 through free and open competition or through basing rates on other public and private rates that are actuarially sound. (Section 2101(a)) (42CFR 457.940(b))

11.2. The state assures, to the extent they apply, that the following provisions of the Social Security Act will apply under Title XXI, to the same extent they apply to a state under Title XIX: (Section 2107(e)) (42CFR 457.935(b)) The items below were moved from section 9.8. (Previously items 9.8.6. - 9.8.9) 11.2.1. X 42 CFR Part 455 Subpart B (relating to disclosure of information by providers and fiscal agents) 11.2.2. X Section 1124 (relating to disclosure of ownership and related information) 11.2.3. X Section 1126 (relating to disclosure of information about certain convicted individuals) 11.2.4. X Section 1128A (relating to civil monetary penalties) 11.2.5. X Section 1128B (relating to criminal penalties for certain additional charges) 11.2.6. X Section 1128E (relating to the National health care fraud and abuse data collection program)

Section 12. Applicant and enrollee protections (Sections 2101(a))

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

Eligibility and Enrollment Matters

12.1 Please describe the review process for eligibility and enrollment matters that complies with 42 CFR ∋457.1120.

Recipients of SCHIP have the same rights as recipients of the South Dakota Medicaid Program. The South Dakota Medical Assistance Program (T-19 & T-21) uses a program specific review process for eligibility and enrollment matters. The South Dakota Department of Social Services, Office of Administrative Hearings, is the impartial and external entity that conducts the administrative hearings to determine whether applications for assistance are correctly denied.

An applicant for public assistance whose application for assistance is denied may appeal the action or inaction as provided in Administrative Rules of South Dakota. Individual’s rights are printed on all applications of public assistance and on all formal notices issued by the Department of Social Services concerning action taken. Department workers explain to applicants their rights to a hearing at the time the application is submitted and informs the applicant or recipient of the right to a fair

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

Effective Date: August 24, 2001

Approval Date: 57 hearing at any time an action is taken affecting the rights or status of an application or recipient. Department workers also explain to applicants that they have the right to review all files relevant to their appeal, the right to appear in person at the time of the hearing, the right to be assisted at the hearing by a friend, relative, or lawyer at the applicant’s or recipient’s own cost, and the right to withdraw or abandon the hearing. Department workers explain to applicants that the request for hearing may be written or oral but that it has to be made within 30 days after the action complained of or 30 days after action should have been taken as provided by law or rule. The Department also provides an explanation of the circumstances under which eligibility may continue pending the review process. Applicants have the right to be present for all proceedings and the right to present evidence and testify at all proceedings. Applicants or recipients have the right to a written final decision within 90 days after the hearing request.

Health Services Matters

12.2 Please describe the review process for health services matters that complies with 42 CFR ∋457.1120.

Recipients of SCHIP have the same rights as recipients of the South Dakota Medicaid Program. The South Dakota Medical Assistance Program (T-19 & T-21) uses a program specific review process for eligibility and enrollment matters. The South Dakota Department of Social Services, Office of Administrative Hearings, is the impartial and external entity that conducts the administrative hearings to determine whether medical benefits are correctly denied.

A recipient of public assistance whose medical benefits are denied may appeal the action or inaction as provided in Administrative Rules of South Dakota. Individual’s rights are printed on all handbooks that are provided to the recipient. Recipients may appeal the denial by requesting a fair hearing at any time an action is taken affecting the benefits of a recipient. Department workers also explain to applicants that they have the right to appear in person at the time of the hearing, the right to be assisted at the hearing by a friend, relative, or lawyer at the applicant’s or recipient’s own cost, and the right to withdraw or abandon the hearing. Department workers explain to recipients that the request for hearing may be written or oral but that it has to be made within 30 days after the action complained of or 30 days after action should have been taken as provided by law or rule. Recipients have the right to review all files relevant to their appeal, the right to be present for all proceedings and the right to present evidence and testify at all proceedings. Recipients have the right to a written final decision within 90 days after the hearing request.

Recipients have the right to an expedited fair hearing upon presenting documentation to support that any delays under the standard time frame could jeopardize the

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

Effective Date: August 24, 2001

Approval Date: 58 individual’s life or health. In these situations, the Office of Administrative Hearings will schedule and conduct the review within 72 hours.

Premium Assistance Programs

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

SOUTH DAKOTA TITLE XXI PROGRAM FACT SHEET

Name of Plan: Children’s Health Insurance Program, Non- Medicaid (CHIP-NM) and Medicaid Children’s Health Insurance Program (M-CHIP)

Date State Plan Submitted: June 5, 1998 Date State Plan Approved:

August 25, 1998 Date State Plan Effective:

July 1, 1998

Date Amendment #1 Submitted: June 28, 1999 Date Amendment #1 Approved: October 28, 1999 Date Amendment #1 Effective: April 1, 1999

Date Amendment #2 Submitted: September 1, 2000 Date Amendment #2 Approved: November 30, 2000 Date Amendment #2 Effective: July 1, 2000

Date Amendment #3 Submitted: September 1, 2000 Date Amendment #3 Approved: December 27, 2000 Date Amendment #3 Effective: July 1, 2000

Date Amendment #4 Submitted: July 1, 2002 Date Amendment #4 Approved: September 19, 2002

Background

• On June 5, 1998, South Dakota submitted a SCHIP Medicaid expansion proposal (M-CHIP). South Dakota’s existing Medicaid program covered children ages 0-5 in families with incomes up to 133 percent of the Federal poverty level (FPL) and children ages 6-18 in families with incomes up to 100 percent of FPL.

• Through title XXI, the State expanded Medicaid eligibility to cover children ages 6 -18 in families with incomes between 100 percent and 133 percent of the FPL. This resulted in seamless coverage for all children in families with incomes below 133 percent of the FPL.

Amendments

• South Dakota submitted its first state plan amendment on June 28, 1999, to expand Medicaid eligibility to cover children through age 18 with family incomes up to 140 percent of the FPL.

• South Dakota submitted its second amendment on September 1, 2000, to eliminate cost sharing in M-CHIP for 18-year-olds. Page 1 of 4

• South Dakota submitted a third amendment on September 1, 2000, to establish a separate child health program called CHIP-NM (Children’s Health Insurance Program, Non-Medicaid) effective July 1, 2000. CHIP-NM covers uninsured children from birth to age 19 with family incomes above 140 percent of the FPL and not exceeding 200 percent of the FPL.

• South Dakota submitted its fourth amendment on July 1, 2002. This amendment updates and amends the SCHIP state plan to indicate the State’s compliance with the final SCHIP regulations.

Children Covered Under the Program

• The State reported that 14,584 SCHIP children and 11,254 M-CHIP children were ever enrolled during Federal fiscal year 2006.

Administration

• The Department of Social Services (DSS) is responsible for administering CHIP-NM as well as Medicaid and M-CHIP. Only DSS staff makes eligibility determinations.

Health Care Delivery System

• Most individuals enrolled in Medicaid participate in PRIME, a primary care case management system operated under a section 1915(b) waiver that has been in effect since 1993. Each participating individual must choose a primary care provider who, in turn, ensures 24-hour access, gives referrals for specialty services, and provides case management. Rural health clinics, Federally Qualified Health Centers (FQHCs) and Indian Health Service (IHS) clinics participate as primary care providers. Certain services (including emergency room, family planning, dental, vision, chiropractic, nursing facility and other specialized services) are covered on a fee-for-service basis.

• Health care services for CHIP-NM are delivered using the existing Medicaid program delivery and payment systems.

Benefit Package

• Medicaid PRIME waiver services include, but are not limited to the following: EPSDT, physician services, inpatient and outpatient hospital services, prescription drugs, mental health and other medical services. Other covered services, provided on a fee-for-service basis, include emergency room, family planning, dental, vision, chiropractic, nursing facility and other specialized services.

• The benefit package under CHIP-NM is the same as the SCHIP Medicaid expansion program package.

Page 2 of 4

Cost Sharing

• There is no cost sharing.

Coordination between SCHIP and Medicaid

• Both Medicaid and SCHIP programs utilize the same application and eligibility determination process, and are administered by the same agency (DSS). Measures adopted by the State to simplify the enrollment of children in both programs include the development of a three-page application, dropping the requirement for face-to- face interviews, eliminating the assets test, reducing documentation requirements and directing DSS staff to actively participate in program outreach.

Crowd Out Strategy

• An eligibility screening is completed to detect the presence of other insurance coverage. In the State’s separate child health program, children are ineligible if they have been covered by a group health plan in the 3 months immediately preceding the application.

• The State monitors the number of SCHIP applicants who are denied, and the number of SCHIP cases closed, due to existing health insurance. This information describes the extent to which recipients are trying to substitute private health insurance for public assistance and is reported in the SCHIP annual report.

Outreach Activities

• SCHIP outreach in South Dakota was built on the successful outreach strategies already in place for the State’s medical assistance efforts. Outreach in South Dakota includes both statewide and local outreach strategies.

• Statewide outreach strategies include the participation of other programs offered by DSS, other State agencies, and the Indian Health Service. Statewide outreach relies on interagency agreements to facilitate referrals and automated systems for information sharing on potentially eligible children.

• DSS eligibility staff has effectively coordinated local outreach in communities and service areas by establishing connections with local resources to facilitate the identification and enrollment of children. Health care providers, schools, Tribal agencies, and many others, distribute materials, provide applications and information, and assist with enrollment.

• DSS has outreach efforts directed towards the Indian reservation areas of the state to help assure that SCHIP is provided to eligible Indian children. The Indian Health Service currently plays and will continue to play an important role in outreach to targeted, low income Indian children. Applications, enrollment assistance, and Page 3 of 4

program information for SCHIP is available at IHS, Tribal, and Urban Indian Health locations in South Dakota.

• South Dakota’s joint Medicaid and SCHIP application has been widely distributed to outreach sites including other government agencies, schools, primary care and specialty health care providers, advocacy groups, tribal programs, and day care centers.

Financial Information

Total FFY 2007 SCHIP Allotment -$10,354,308 FFY 2007 Enhanced Federal Matching Rate: 74.04%

Date Last updated: April 26, 2007

Page 4 of 4

_____________________________________________________________________________

Table of Contents

State/Territory Name: South Dakota

State Plan Amendment (SPA) #: SD-13-0016

(In addition to the SPA noted above, this package contains other state plan amendment approvals)

This file contains the following documents in the order listed:

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

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

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services CM Ss 7500 Security Boulevard, Mail Stop: $2-26-12

CENTERS FOR MEDICARE & MEDICAID SERVICES.

Baltimore, Maryland 21244-1850

CENTER FOR MEDICAID & CHIP SERVICES

Children and Adults Health Programs Group

Ms. Nicki Bartel RN, RHIT NOV 18 2013 Nurse Consultant

South Dakota Department of Social Services

Division of Medical Services

700 Governors Drive

Pierre, SD 57501-2291

Dear Ms. Bartel:

I am pleased to inform you that your Title XXI Children’s Health Insurance Program (CHIP) state plan amendments (SPA) SD-13-0016, SD-13-0017 and SD-13-0019 submitted on September 20, 2013 and related to Modified Adjusted Gross Income (MAGI) Eligiblity have been approved with an effective date of January 1, 2014.

MAGI Eligiblity & Methods:

SPA number SD-13-0016, provides assurance on page CS15 that the state will apply methodologies based on MAGI for all separate CHIP covered groups; and using the approved MAGI conversion plan income thresholds, the state indicates on page CS7 that it will cover targeted low-income children. A copy of the approved CS15 is attached and should be incorporated within a separate subsection under Section 4.3 of the state’s approved CHIP state plan. A copy of the approved CS7 is attached and supersedes the current Age and Income Sections 4.1.2 and 4.1.3 of the current CHIP state plan.

Establish 2101(f) Group:

SPA number SD-13-0017 describes the state’s plan to provide coverage in its separate CHIP, as specified in the state’s submission of CS14: Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards. A copy of the approved state plan page (CS14) is attached, and should be incorporated within a separate subsection under Section 4.1 of South Dakota’s approved CHIP state plan.

Non-Financial Eligibility:

SPA number SD-13-0019 is approved to clarify the state’s non-financial eligibility policies on residency; citizenship; social security numbers; and substitution of coverage. Copies of the approved state plan pages are attached and these approved pages supersede sections of South Dakota’s current state plan as listed below:

Page 2 — Ms. Nicki Bartel

: c New State PlanPage === Impact on Current State Plan Section CSI7: ‘Non-Financial Eligibility — Residency” Section 4.1.5

CS18: Non-Financial Eligibility — Citizenship Section 4.1.0

CS19: Non-Financial Eligibility — Social Security Number | Section 4.1.9.1

CS20: Non-Financial Eligibility — Substitution of Section 4.4.4

Coverage

Your Title XXI project officer is Ms. Joyce Jordan. She is available to answer questions concerning these amendments and other CHIP-related issues. Ms. Jordan’s contact information is as follows:

Centers for Medicare & Medicaid Services Center for Medicaid & CHIP Services Mail Stop: $2-01-16

7500 Security Boulevard

Baltimore, MD 21244-1850

Telephone: (410) 786-3413

Facsimile: (410) 786-5882

E-mail: Joyce.Jordan@cms.hhs.gov

Please copy Mr. Richard Allen, Associate Regional Administrator (ARA) in our Denver Regional Office on all communications. Mr. Allen’s address is:

Centers for Medicare & Medicaid Services Denver Regional Office

Colorado State Bank Building

1600 Broadway, Suite# 700

Denver, CO 80202-4967

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

Sincerely,

Eliot Fishman Director

Enclosure cc: Richard Allen, ARA, CMS Region VIII, Denver

logged in as TONIABROWN(CMS CO Staff) read only mode application rev p01 Children's Health Insurance Program Eligibility SD.0334.R00.00 - Jan 01, 2014 Home Logout Finder Save Print Help Control Panel General Information File Management Tribal Input Summary State/Territory name: South Dakota State Funds: $ Federal Funds: $ Submitted By: Ann Schwartz Last Revision Date: Oct 23, 2013 Submit Date: Sep 20, 2013 Children's Health Insurance Program Eligibility: Summary Page Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. SD-13-0016 Type of SPA: MAGI Eligibility & Methods XXI Medicaid Expansion Establish 2101(f) Group Eligibility Processing Non-Financial Eligibility Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation 2102(b)(1)(B)(v) of the SSA and 42 CFR 457.310, 315 and 320; 2102(b)(1)(B)(v) of the SSA and Federal Budget Impact This SPA has a budget impact. Total budget impact: Subject of Amendment Please provide a brief summary of SPA changes. Character Count:113 out of 2000 This SPA sets MAGI income standards for all covered groups in South Dakota's Children's Health Insurance Program. Signature of State Agency Official Page 1 of 2 Children's Health Insurance Program Eligibility: CMS 179 04/16/2014 http://157.199.113.99/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

FAQs | Site Map | Contact | Medicaid.gov | CMS.gov Page 2 of 2 Children's Health Insurance Program Eligibility: CMS 179 04/16/2014 http://157.199.113.99/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

(CMS CHIP Eligibility

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

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

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

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

Must be under age 19.

Income Standards

Income standards are applied statewide.

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

Statewide Income Standards

Begin with lowest age range first.

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

From Age To Age Above (% FPL) Up to & including (% FPL)

19 182 204

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

Special Program for Children with Disabilities

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

PRA Disclosure Statement

SPA # SD-13-0016 Approval patO¥ i 8 2013 Effective Date: January 1, 2014 Page 1 of 2

CHIP Eligibility

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

V.20130709

NOV 18 2013

SPA # SD-13-0016 Approval Date: Effective Date: January 1, 2014 Page 2 of 2

CHIP Eligibility

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

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

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

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

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

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

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

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

by the person claiming an individual described at §435.603(f)(2)(i) as a tax dependent. ves

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

tenn Ee

PRA Disclosure Statement

NOV 1 8 2013

SPA # SD-13-0016 Approval Date: Effective Date: January 1, 2014

Page | of 2

CHIP Eligibility

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

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

SPA # SD-13-0016 Approval pateNOV i 8 2013 Effective Date: January 1, 2014

Page 2 of 2

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

igh

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

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

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

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

C

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

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

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

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

% FPL

The state will enroll children in a separate CHIP who are found to be ineligible for Medicaid based on MAGI but whose family income has not increased since the child’s last determination of Medicaid eligibility or who would have remained eligible for

* Medicaid (based on the 2013 Medicaid income standard) if the value of their 2013 disregards had been applied to the family income as determined by MAGI methodology.

C Other.

Describe the benefits provided to this population:

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

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

Describe premiums and cost sharing required of this population:

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

NOV 18 2013

SPA # SD-13-0017 Approval Date: Effective Date: January 1, 2014

Page 1 of 2

CHIP Eligibility

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

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

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

NOV 1 8 2013

SPA # SD-13-0017 Approval Date: Effective Date: January 1, 2014 Page 2 of 2

Cems. CHIP Eligibility

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

42 CFR 457,320

Residency

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

A child is considered to be a resident of the state under the following conditions:

rl A non-institutionalized child, if capable of indicating intent and who is emancipated or married, if the child is living in the state and:

1. Intends to reside in the state, including without a fixed address, or

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

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

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

rl An institutionalized child, who is not a ward of the state, if the state is the state of residence of the child's custodial parent or caretaker at the time of placement, or .

[ll A child who is a ward of the state regardless of where the child lives, or

ml A child physically located in the state when there is a dispute with one or more states as to the child's actual state of residence.

If the state covers pregnant women, a pregnant woman is considered to be a resident under the following conditions: {m] A non-institutionalized pregnant woman who is living in the state and: 1. Intends to reside in the state, including without a fixed address, or if incapable of indicating intent, is living in the state, or 2. Entered with a job commitment or seeking employment, whether or not currently employed.

rl An institutionalized pregnant woman placed in an out-of-state-institution, as defined in 42 CFR 435.1010, including foster care homes, by an agency of the state, or

ry An institutionalized pregnant woman residing in an in-state-institution, as defined in 42 CFR 435. 1010, whether or not the individual established residency in the state prior to entering the institution, or

cl A pregnant woman physically located in the state when there is a dispute with one or more states as to the pregnant woman's actual state of residence.

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

NOV 1 8 2013

SPA # SD-13-0019 Approval Date: Effective Date: January 1, 2014 Page | of 2

Cems. CHIP Eligibility

One or more interstate agreement(s). No }

A policy related to individuals in the state only for educational purposes. Yes

Provide a description of the policy:

‘An individual is not a South Dakota resident if s/he is in South Dakota temporarily to attend school (¢.g., college, boarding school, vocational school).

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

NOV 18 2013

SPA # SD-13-0019 Approval Date: Effective Date: January 1, 2014 Page 2 of 2

ccMs. CHIP Eligibility

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

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

Citizenship

The CHIP Agency provides CHIP eligibility to otherwise eligible citizens and nationals of the United States and certain non-citizens, including the time period during which they are provided with reasonable opportunity to submit verification of their citizenship, national status or satisfactory immigration status.

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

Who are citizens or nationals of the United States; or

Who are qualified non-citizens as defined in section 431 of the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) (8 U.S.C. $1641), or whose eligibility is required by section 402(b) of PRWORA (8 U.S.C. §1612(b)) and is not prohibited by section 403 of PRWORA (8 U.S.C. §1613); or

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

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

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

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

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

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

(@ Other date, as described:

The first day of the month in which the application containing the declaration of citizenship or immigration status was received.

The CHIP Agency elects the option to provide CHIP coverage to otherwise eligible children up to age 19, lawfully residing No in the United States, as provided in Section 2107(e)(1)(J) of the SSA (Section 214 of CHIPRA 2009, P.L. 111-3).

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

Income Pregnant Women. SPA # SD-13-0019 Approval Date NOV 1 8 a0t3 Effective Date: January 1, 26++

Page 1 of 2

‘No

CECMS CHIP Eligibility

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

NOV 18 2013

SPA # SD-13-0019 Approval Date : Effective Date: January 1, 2014 Page 2 of 2

Cems. CHIP Eligibility

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

42 CFR 457.340(b)

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

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

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

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

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

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

How the state will use the SSN.

The CHIP Agency provides assurance that it will verify each SSN furnished by an applicant or beneficiary with the Social Security Administration, not deny or delay services to an otherwise eligible applicant pending issuance or verification of the

Fa individual's SSN by the Social Security Administration and that the state's utilization of the SSNs is consistent with sections 205 and 1137 of the Social Security Act and the Privacy Act of 1974.

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

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

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

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

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

PRA Disclosure Statement

SPA # SD-13-0019 Approval NOV 18 2013

Effective Date : January 1, 2014 Page | of 2

CHIP Eligibility

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

NOV 18 2013

SPA # SD-13-0019 Approval Date: Effective Date : January 1, 2014 Page 2 of 2

CHIP Eligibility

OMB Control Number: 0938-1148 irati

457.310(b)(2) and (b)(3), 457.320(a)(9) and 2110(b)(1)(C) of the SSA

Substitution of Coverage

The CHIP Agency provides assurance that it has methods and policies in place to prevent the substitution of group health coverage or other commercial health insurance with public funded coverage. These policies include:

[Mi] Substitution of coverage prevention strategy:

Name of policy Description

A waiting period during which an individual is ineligible due to having dropped group health coverage.

How long is the waiting period?

© One month C Two months @ 90 days

© Other

[li] The state allows exemptions from the waiting period for the following reasons:

rT The premium paid by the family for coverage of the child under the group health plan exceeded 5 percent of household income.

The child’s parent is determined eligible for advance payment of the premium tax credit for enrollment in a QHP

fl] through the Marketplace because the ESI in which the family was enrolled is determined unaffordable in accordance with 26 CFR 1.36B—2(c)(3)(v).

[li] The cost of family coverage that includes the child exceeded 9.5 percent of the household income.

im The employer stopped offering coverage of dependents (or any coverage) under an employer-sponsored health insurance plan. :

ry] A change in employment, including involuntary separation, resulted in the child’s loss of employer-sponsored insurance (other than through full payment of the premium by the parent under COBRA).

[lM] The child has special health care needs.

[ll] The child lost coverage due to the death or divorce of a parent.

Does the state allow other exemptions in addition to those listed above? |No

NOV 18 2013

SPA # SD-13-0019 Approval Date: Effective Date: January 1, 2014 Page 1 of 2

CHIP Eligibility

[7] If the state covers pregnant women, the waiting period does not apply to pregnant women.

If the state elects to offer dental only supplemental coverage, the following assurances apply:

oO The other coverage exclusion does not apply to children who are otherwise eligible for dental only supplemental coverage as provided in section 2110(b)(5) of the SSA.

[[] The waiting period does not apply to children eligible for dental only supplemental coverage.

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 contro! number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance

Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. V.20130718

NOV 18 2013

SPA # SD-13-0019 Approval Date: Effective Date: January 1, 2014 Page 2 of 2

_____________________________________________________________________________

Table of Contents

State/Territory Name: South Dakota

State Plan Amendment (SPA) #: SD-13-0017

(In addition to the SPA noted above, this package contains other state plan amendment approvals)

This file contains the following documents in the order listed:

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

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

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services CM Ss 7500 Security Boulevard, Mail Stop: $2-26-12

CENTERS FOR MEDICARE & MEDICAID SERVICES.

Baltimore, Maryland 21244-1850

CENTER FOR MEDICAID & CHIP SERVICES

Children and Adults Health Programs Group

Ms. Nicki Bartel RN, RHIT NOV 18 2013 Nurse Consultant

South Dakota Department of Social Services

Division of Medical Services

700 Governors Drive

Pierre, SD 57501-2291

Dear Ms. Bartel:

I am pleased to inform you that your Title XXI Children’s Health Insurance Program (CHIP) state plan amendments (SPA) SD-13-0016, SD-13-0017 and SD-13-0019 submitted on September 20, 2013 and related to Modified Adjusted Gross Income (MAGI) Eligiblity have been approved with an effective date of January 1, 2014.

MAGI Eligiblity & Methods:

SPA number SD-13-0016, provides assurance on page CS15 that the state will apply methodologies based on MAGI for all separate CHIP covered groups; and using the approved MAGI conversion plan income thresholds, the state indicates on page CS7 that it will cover targeted low-income children. A copy of the approved CS15 is attached and should be incorporated within a separate subsection under Section 4.3 of the state’s approved CHIP state plan. A copy of the approved CS7 is attached and supersedes the current Age and Income Sections 4.1.2 and 4.1.3 of the current CHIP state plan.

Establish 2101(f) Group:

SPA number SD-13-0017 describes the state’s plan to provide coverage in its separate CHIP, as specified in the state’s submission of CS14: Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards. A copy of the approved state plan page (CS14) is attached, and should be incorporated within a separate subsection under Section 4.1 of South Dakota’s approved CHIP state plan.

Non-Financial Eligibility:

SPA number SD-13-0019 is approved to clarify the state’s non-financial eligibility policies on residency; citizenship; social security numbers; and substitution of coverage. Copies of the approved state plan pages are attached and these approved pages supersede sections of South Dakota’s current state plan as listed below:

Page 2 — Ms. Nicki Bartel

: c New State PlanPage === Impact on Current State Plan Section CSI7: ‘Non-Financial Eligibility — Residency” Section 4.1.5

CS18: Non-Financial Eligibility — Citizenship Section 4.1.0

CS19: Non-Financial Eligibility — Social Security Number | Section 4.1.9.1

CS20: Non-Financial Eligibility — Substitution of Section 4.4.4

Coverage

Your Title XXI project officer is Ms. Joyce Jordan. She is available to answer questions concerning these amendments and other CHIP-related issues. Ms. Jordan’s contact information is as follows:

Centers for Medicare & Medicaid Services Center for Medicaid & CHIP Services Mail Stop: $2-01-16

7500 Security Boulevard

Baltimore, MD 21244-1850

Telephone: (410) 786-3413

Facsimile: (410) 786-5882

E-mail: Joyce.Jordan@cms.hhs.gov

Please copy Mr. Richard Allen, Associate Regional Administrator (ARA) in our Denver Regional Office on all communications. Mr. Allen’s address is:

Centers for Medicare & Medicaid Services Denver Regional Office

Colorado State Bank Building

1600 Broadway, Suite# 700

Denver, CO 80202-4967

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

We look forward to continuing to work with you and your staff.

Sincerely,

not Fishman Director

Enclosure cc: Richard Allen, ARA, CMS Region VIII, Denver

logged in as TONIABROWN(CMS CO Staff) read only mode application rev p01 Children's Health Insurance Program Eligibility SD.0336.R00.00 - Jan 01, 2014 Home Logout Finder Save Print Help Control Panel General Information File Management Tribal Input Summary State/Territory name: South Dakota State Funds: $ Federal Funds: $ Submitted By: Ann Schwartz Last Revision Date: Sep 20, 2013 Submit Date: Sep 20, 2013 Children's Health Insurance Program Eligibility: Summary Page Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. SD-13-0017 Type of SPA: MAGI Eligibility & Methods XXI Medicaid Expansion Establish 2101(f) Group Eligibility Processing Non-Financial Eligibility Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation Section 2101(f) of the ACA and 42 CFR 457.310(d) Federal Budget Impact This SPA has a budget impact. Total budget impact: Subject of Amendment Please provide a brief summary of SPA changes. Character Count:130 out of 2000 This SPA establishes a new coverage group for children who lose Medicaid eligibility as a result of discontinuation of disregards. Signature of State Agency Official Page 1 of 2 Children's Health Insurance Program Eligibility: CMS 179 04/17/2014 http://157.199.113.99/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

FAQs | Site Map | Contact | Medicaid.gov | CMS.gov Page 2 of 2 Children's Health Insurance Program Eligibility: CMS 179 04/17/2014 http://157.199.113.99/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

(CMS CHIP Eligibility

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

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

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

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

Must be under age 19.

Income Standards

Income standards are applied statewide.

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

Statewide Income Standards

Begin with lowest age range first.

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

From Age To Age Above (% FPL) Up to & including (% FPL)

19 182 204

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

Special Program for Children with Disabilities

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

PRA Disclosure Statement

SPA # SD-13-0016 Approval patO¥ i 8 2013 Effective Date: January 1, 2014 Page 1 of 2

CHIP Eligibility

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

V.20130709

NOV 18 2013

SPA # SD-13-0016 Approval Date: Effective Date: January 1, 2014 Page 2 of 2

CHIP Eligibility

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

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

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

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

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

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

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

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

by the person claiming an individual described at §435.603(f)(2)(i) as a tax dependent. ves

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

tenn Ee

PRA Disclosure Statement

NOV 1 8 2013

SPA # SD-13-0016 Approval Date: Effective Date: January 1, 2014

Page | of 2

CHIP Eligibility

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

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

SPA # SD-13-0016 Approval pateNOV i 8 2013 Effective Date: January 1, 2014

Page 2 of 2

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

igh

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

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

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

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

C

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

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

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

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

% FPL

The state will enroll children in a separate CHIP who are found to be ineligible for Medicaid based on MAGI but whose family income has not increased since the child’s last determination of Medicaid eligibility or who would have remained eligible for

* Medicaid (based on the 2013 Medicaid income standard) if the value of their 2013 disregards had been applied to the family income as determined by MAGI methodology.

C Other.

Describe the benefits provided to this population:

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

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

Describe premiums and cost sharing required of this population:

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

NOV 18 2013

SPA # SD-13-0017 Approval Date: Effective Date: January 1, 2014

Page 1 of 2

CHIP Eligibility

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

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

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

NOV 1 8 2013

SPA # SD-13-0017 Approval Date: Effective Date: January 1, 2014 Page 2 of 2

Cems. CHIP Eligibility

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

42 CFR 457,320

Residency

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

A child is considered to be a resident of the state under the following conditions:

rl A non-institutionalized child, if capable of indicating intent and who is emancipated or married, if the child is living in the state and:

1. Intends to reside in the state, including without a fixed address, or

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

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

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

rl An institutionalized child, who is not a ward of the state, if the state is the state of residence of the child's custodial parent or caretaker at the time of placement, or .

[ll A child who is a ward of the state regardless of where the child lives, or

ml A child physically located in the state when there is a dispute with one or more states as to the child's actual state of residence.

If the state covers pregnant women, a pregnant woman is considered to be a resident under the following conditions: {m] A non-institutionalized pregnant woman who is living in the state and: 1. Intends to reside in the state, including without a fixed address, or if incapable of indicating intent, is living in the state, or 2. Entered with a job commitment or seeking employment, whether or not currently employed.

rl An institutionalized pregnant woman placed in an out-of-state-institution, as defined in 42 CFR 435.1010, including foster care homes, by an agency of the state, or

ry An institutionalized pregnant woman residing in an in-state-institution, as defined in 42 CFR 435. 1010, whether or not the individual established residency in the state prior to entering the institution, or

cl A pregnant woman physically located in the state when there is a dispute with one or more states as to the pregnant woman's actual state of residence.

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

NOV 1 8 2013

SPA # SD-13-0019 Approval Date: Effective Date: January 1, 2014 Page | of 2

Cems. CHIP Eligibility

One or more interstate agreement(s). No }

A policy related to individuals in the state only for educational purposes. Yes

Provide a description of the policy:

‘An individual is not a South Dakota resident if s/he is in South Dakota temporarily to attend school (¢.g., college, boarding school, vocational school).

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

NOV 18 2013

SPA # SD-13-0019 Approval Date: Effective Date: January 1, 2014 Page 2 of 2

ccMs. CHIP Eligibility

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

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

Citizenship

The CHIP Agency provides CHIP eligibility to otherwise eligible citizens and nationals of the United States and certain non-citizens, including the time period during which they are provided with reasonable opportunity to submit verification of their citizenship, national status or satisfactory immigration status.

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

Who are citizens or nationals of the United States; or

Who are qualified non-citizens as defined in section 431 of the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) (8 U.S.C. $1641), or whose eligibility is required by section 402(b) of PRWORA (8 U.S.C. §1612(b)) and is not prohibited by section 403 of PRWORA (8 U.S.C. §1613); or

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

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

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

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

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

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

(@ Other date, as described:

The first day of the month in which the application containing the declaration of citizenship or immigration status was received.

The CHIP Agency elects the option to provide CHIP coverage to otherwise eligible children up to age 19, lawfully residing No in the United States, as provided in Section 2107(e)(1)(J) of the SSA (Section 214 of CHIPRA 2009, P.L. 111-3).

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

Income Pregnant Women. SPA # SD-13-0019 Approval Date NOV 1 8 a0t3 Effective Date: January 1, 26++

Page 1 of 2

‘No

CECMS CHIP Eligibility

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

NOV 18 2013

SPA # SD-13-0019 Approval Date : Effective Date: January 1, 2014 Page 2 of 2

Cems. CHIP Eligibility

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

42 CFR 457.340(b)

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

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

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

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

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

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

How the state will use the SSN.

The CHIP Agency provides assurance that it will verify each SSN furnished by an applicant or beneficiary with the Social Security Administration, not deny or delay services to an otherwise eligible applicant pending issuance or verification of the

Fa individual's SSN by the Social Security Administration and that the state's utilization of the SSNs is consistent with sections 205 and 1137 of the Social Security Act and the Privacy Act of 1974.

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

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

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

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

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

PRA Disclosure Statement

SPA # SD-13-0019 Approval NOV 18 2013

Effective Date : January 1, 2014 Page | of 2

CHIP Eligibility

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

NOV 18 2013

SPA # SD-13-0019 Approval Date: Effective Date : January 1, 2014 Page 2 of 2

CHIP Eligibility

OMB Control Number: 0938-1148 irati

457.310(b)(2) and (b)(3), 457.320(a)(9) and 2110(b)(1)(C) of the SSA

Substitution of Coverage

The CHIP Agency provides assurance that it has methods and policies in place to prevent the substitution of group health coverage or other commercial health insurance with public funded coverage. These policies include:

[Mi] Substitution of coverage prevention strategy:

Name of policy Description

A waiting period during which an individual is ineligible due to having dropped group health coverage.

How long is the waiting period?

© One month C Two months @ 90 days

© Other

[li] The state allows exemptions from the waiting period for the following reasons:

rT The premium paid by the family for coverage of the child under the group health plan exceeded 5 percent of household income.

The child’s parent is determined eligible for advance payment of the premium tax credit for enrollment in a QHP

fl] through the Marketplace because the ESI in which the family was enrolled is determined unaffordable in accordance with 26 CFR 1.36B—2(c)(3)(v).

[li] The cost of family coverage that includes the child exceeded 9.5 percent of the household income.

im The employer stopped offering coverage of dependents (or any coverage) under an employer-sponsored health insurance plan. :

ry] A change in employment, including involuntary separation, resulted in the child’s loss of employer-sponsored insurance (other than through full payment of the premium by the parent under COBRA).

[lM] The child has special health care needs.

[ll] The child lost coverage due to the death or divorce of a parent.

Does the state allow other exemptions in addition to those listed above? |No

NOV 18 2013

SPA # SD-13-0019 Approval Date: Effective Date: January 1, 2014 Page 1 of 2

CHIP Eligibility

[7] If the state covers pregnant women, the waiting period does not apply to pregnant women.

If the state elects to offer dental only supplemental coverage, the following assurances apply:

oO The other coverage exclusion does not apply to children who are otherwise eligible for dental only supplemental coverage as provided in section 2110(b)(5) of the SSA.

[[] The waiting period does not apply to children eligible for dental only supplemental coverage.

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 contro! number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance

Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. V.20130718

NOV 18 2013

SPA # SD-13-0019 Approval Date: Effective Date: January 1, 2014 Page 2 of 2

_____________________________________________________________________________

Table of Contents

State/Territory Name: South Dakota

State Plan Amendment (SPA) #: SD-13-0018

This file contains the following documents in the order listed:

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

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

CMS

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop: S2-26-12

Baltimore, Maryland 21244-1850 CENTER FOR MEDICAID & CHIP SERVICES Children and Adults Health Programs Group

DEC 1 8 2013 Nicki Bartel RN, RHIT Nurse Consultant

South Dakota Department of Social Services Division of Medical Services

700 Governors Drive

Pierre, SD 57501-2291

Dear Ms. Bartel:

I am pleased to inform you that South Dakota’s Children’s Health Insurance Program (CHIP) State Plan Amendment (SPA) SD-13-0018, submitted on September 20, 2013, has been approved. This SPA incorporates the MAGI-based eligibility process requirements, including the single streamlined application, into South Dakota’s state plan in accordance with the Affordable Care Act. The effective date of this SPA is October 1, 2013.

The approval of SPA SD-13-0018 includes full approval of your state’s alternative single streamlined application used to apply for multiple human service programs. Until July 31, 2014, the state is using an interim alternative single streamlined online application with the addition of a supplemental form. By July 31, 2014 the state 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 new state plan pages and attachments to be incorporated within a separate section at the end of South Dakota’s approved state plan:

CS24 Attachment 1 - Economic Assistance Application (Application for Multiple Human Service Programs)

e Attachment 2 - South Dakota MAGI Medical Addendum

e Attachment 3 - Statement of Use with Respect to the Alternative Single, Streamlined Online Application

e Attachment 4 - Statement Related to Coordination of Eligibility and Enrollment

This approval and the attachments supercede the following sections of the current CHIP State Plan:

e Section 4.3: Single, Streamlined Application Screen and Enroll Process e Section 4.4: Renewals, Screening by Other Insurance Affordability Programs

CMS appreciates the significant amount of work your staff dedicated to preparing this State Plan Amendment. Your Title XXI project officer is Ms. Joyce Jordan. She is available to answer questions concerning this amendment and other CHIP-related issues. Ms. Jordan’s contact information is as follows:

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

7500 Security Blvd.

Baltimore, MD 21244-1850

Telephone: (410) 786-3413

Facsimile: (410) 786-5882

E-mail: Joyce.Jordan@cms.hhs.gov

Official communications regarding program matters should be sent simultaneously to Ms. Jordan and to Mr. Richard Allen, Associate Regional Administrator (ARA) in our Denver Regional Office. Mr. Allen’s address is:

Mr. Richard Allen

Office of the Regional Administrator 1600 Broadway, Suite 700

Denver, CO 80202-4367

If you have additional questions, please contact Linda Nablo, Director, Division of State Coverage Programs at (410) 786-5143.

We look forward to continuing to work with you and your staff.

Sincerely,

Eliot Fishman Director

ce: Mr. Richard Allen, ARA, CMS Region VIII, Denver

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

7500 Security Boulevard, Mail Stop: S2-26-12 Baltimore, Maryland 21244-1850

(CMS

CENTERS FOR MEDICARE & MEDICAID SERVICES. CENTER FOR MEDICAID & CHIP SERVICES:

Children and Adults Health Programs Group

Division of State Coverage Programs

Nicki Bartel RN, RHIT DEC 1 8 2013

Nurse Consultant

South Dakota Department of Social Services Division of Medical Services

700 Governors Drive

Pierre, SD 57501-2291

Dear Ms. Bartel:

This letter is being sent as a companion to Centers for Medicare & Medicaid Services (CMS) approval of South Dakota’s Children’s Health Insurance Program (CHIP) State Plan Amendment SD-13-0018, which was submitted to CMS on September 20, 2013. Our review of this submission included a review of the alternative single streamlined application used to apply for multiple human service programs.

Until July 31, 2014, the state is using an interim alternative single streamlined online application with the addition of a supplemental form. The application must be revised to meet the standards outlined in 42 CFR 435.907 and the guidance on alternative applications released by CMS on June 19, 2013.

Please submit a revised alternative single streamlined online application to CMS for review no

later than July 1, 2014 to ensure approval by July 31. 2014. For technical assistance with your application, please contact Victoria Collins at 410-786-2176 or Victoria.Collins@cms.hhs.gov.

Sincerel

nda Nablo Director, Division of State Coverage Programs

CC: Mr. Richard Allen, Region VII, Denver

logged in as TONIABROWN(CMS CO Staff) read only mode application rev p01 Children's Health Insurance Program Eligibility SD.0335.R00.00 - Jan 01, 2014 Home Logout Finder Save Validate Print Help Control Panel General Information File Management Tribal Input Summary State/Territory name: South Dakota State Funds: $ Federal Funds: $ Submitted By: Maraizu Onyenaka Last Revision Date: Apr 9, 2014 Submit Date: Sep 20, 2013 Children's Health Insurance Program Eligibility: Summary Page Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. SD-13-0018 Type of SPA: MAGI Eligibility & Methods XXI Medicaid Expansion Establish 2101(f) Group Eligibility Processing Non-Financial Eligibility Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation 2102(b)(3) & 2107(e)(1)(O) of the SSA and 42 CFR 457, subpart C Federal Budget Impact This SPA has a budget impact. Total budget impact: Subject of Amendment Please provide a brief summary of SPA changes. Character Count:260 out of 2000 These SPA pages detail South Dakota’s eligibility and enrollment process, including the application for Medical Assistance, the renewal process, and assurance that the state will coordinate eligibility and enrollment with the federally facilitated marketplace. Signature of State Agency Official Page 1 of 2 Children's Health Insurance Program Eligibility: CMS 179 11/02/2014 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01/pages/chp_179.jsp

FAQs | Site Map | Contact | Medicaid.gov | CMS.gov Page 2 of 2 Children's Health Insurance Program Eligibility: CMS 179 11/02/2014 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01/pages/chp_179.jsp

cms CHIP Eligibility

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

2102(b)(3) & 2107(e)(1)(O) of the SSA and 42 CFR 457, subpart C

The CHIP Agency meets all of the requirements of 42 CFR 457, subpart C for application processing, eligibility screening and enrollment.

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:

<7 The single, streamlined application 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 and approved by the Secretary in accordance with section 1413(b)(1)(B) of the Affordable Care Act.

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.

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 CFR 457.340(a), by telephone, via mail, in person and other commonly available electronic means. The agency accepts applications in the following other electronic means.

{[] Other electronic means:

Screen and Enroll Process

The CHIP Agency has coordinated eligibility and enrollment screening procedures in place that are applied at time of initial application, periodic redeterminations, and follow-up eligibility determinations. The procedures ensure that only targeted low-

income children are provided CHIP coverage and that enrollment is facilitated for applicants found to be potentially eligible for other insurance affordability programs.

Procedures include:

im Screening of application to identify all individuals eligible or potentially eligible for CHIP or other insurance affordability programs; and

ia Income eligibility test, with calculation of household income consistent with 42 CFR 457.315 for individuals identified as potentially eligible for Medicaid or other insurance affordability programs based on household income; and

SPA# SD-13-0018 Approval Date: DEL { g 2013 Effective Date: October 1, 2013

Page | of 2

cms. CHIP Eligibility

im Screening process for individuals who may qualify for Medicaid on a basis other than having household income at or below the applicable MAGI standard, based on information in the single streamlined application.

The CHIP agency has entered into an arrangement with the Exchange to make eligibility determinations for advanced

premium tax credits in accordance with section 1943(b)(2) of the SSA. No

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 457.343:

[Mi] Once every 12 months.

rl 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 {i] information to complete the redetermination, it provides the individual with a pre-populated renewal form containing the information already available.

Screening by Other Insurance Affordability Programs

The CHIP Agency provides assurance that it has adopted procedures to accept and process electronic accounts of individuals screened as potentially eligible for CHIP by other insurance affordability programs in accordance with the requirements of 42

ra CFR 457.348(b) and to determine eligibility in accordance with 42 CFR 457.340 in the same manner as if the application had been submitted directly to, and processed by the state.

The CHIP Agency elects the option to accept CHIP eligibility decisions made by the Exchange or other agencies administering oO insurance affordability programs as provided in 42 CFR 457.348 and to furnish CHIP in accordance with requirements of 42

CFR 457.340 to the same extent and in the same manner as if the applicant had been determined by the state to be eligible for CHIP.

The CHIP Agency has entered into an agreement with agencies administering other insurance affordability programs to fulfill the im) requirements of 457.348(b) and will provide this agreement to the Secretary upon request.

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

V.20130709

SPA# SD-13-0018 Approval Date: DEC { 8 2013 Effective Date: October 1, 2013

Page 2 of 2

_____________________________________________________________________________

Table of Contents

State/Territory Name: South Dakota

State Plan Amendment (SPA) #: SD-13-0019

(In addition to the SPA noted above, this package contains other state plan amendment approvals)

This file contains the following documents in the order listed:

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

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

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services CM Ss 7500 Security Boulevard, Mail Stop: $2-26-12

CENTERS FOR MEDICARE & MEDICAID SERVICES.

Baltimore, Maryland 21244-1850

CENTER FOR MEDICAID & CHIP SERVICES

Children and Adults Health Programs Group

Ms. Nicki Bartel RN, RHIT NOV 18 2013 Nurse Consultant

South Dakota Department of Social Services

Division of Medical Services

700 Governors Drive

Pierre, SD 57501-2291

Dear Ms. Bartel:

I am pleased to inform you that your Title XXI Children’s Health Insurance Program (CHIP) state plan amendments (SPA) SD-13-0016, SD-13-0017 and SD-13-0019 submitted on September 20, 2013 and related to Modified Adjusted Gross Income (MAGI) Eligiblity have been approved with an effective date of January 1, 2014.

MAGI Eligiblity & Methods:

SPA number SD-13-0016, provides assurance on page CS15 that the state will apply methodologies based on MAGI for all separate CHIP covered groups; and using the approved MAGI conversion plan income thresholds, the state indicates on page CS7 that it will cover targeted low-income children. A copy of the approved CS15 is attached and should be incorporated within a separate subsection under Section 4.3 of the state’s approved CHIP state plan. A copy of the approved CS7 is attached and supersedes the current Age and Income Sections 4.1.2 and 4.1.3 of the current CHIP state plan.

Establish 2101(f) Group:

SPA number SD-13-0017 describes the state’s plan to provide coverage in its separate CHIP, as specified in the state’s submission of CS14: Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards. A copy of the approved state plan page (CS14) is attached, and should be incorporated within a separate subsection under Section 4.1 of South Dakota’s approved CHIP state plan.

Non-Financial Eligibility:

SPA number SD-13-0019 is approved to clarify the state’s non-financial eligibility policies on residency; citizenship; social security numbers; and substitution of coverage. Copies of the approved state plan pages are attached and these approved pages supersede sections of South Dakota’s current state plan as listed below:

Page 2 — Ms. Nicki Bartel

: c New State PlanPase ===. Impact on Current State Plan Section CSI7: ‘Non-Financial Eligibility — Residency” Section 4.1.5

CS18: Non-Financial Eligibility — Citizenship Section 4.1.0

CS19: Non-Financial Eligibility — Social Security Number | Section 4.1.9.1

CS20: Non-Financial Eligibility — Substitution of Section 4.4.4

Coverage

Your Title XXI project officer is Ms. Joyce Jordan. She is available to answer questions concerning these amendments and other CHIP-related issues. Ms. Jordan’s contact information is as follows:

Centers for Medicare & Medicaid Services Center for Medicaid & CHIP Services Mail Stop: $2-01-16

7500 Security Boulevard

Baltimore, MD 21244-1850

Telephone: (410) 786-3413

Facsimile: (410) 786-5882

E-mail: Joyce.Jordan@cms.hhs.gov

Please copy Mr. Richard Allen, Associate Regional Administrator (ARA) in our Denver Regional Office on all communications. Mr. Allen’s address is:

Centers for Medicare & Medicaid Services Denver Regional Office

Colorado State Bank Building

1600 Broadway, Suite# 700

Denver, CO 80202-4967

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

Sincerely,

Eliot Fishman Director

Enclosure cc: Richard Allen, ARA, CMS Region VIII, Denver

logged in as TONIABROWN(CMS CO Staff) read only mode application rev p01 Children's Health Insurance Program Eligibility SD.0337.R00.00 - Jan 01, 2014 Home Logout Finder Save Print Help Control Panel General Information File Management Tribal Input Summary State/Territory name: South Dakota State Funds: $ Federal Funds: $ Submitted By: Ann Schwartz Last Revision Date: Oct 23, 2013 Submit Date: Sep 20, 2013 Children's Health Insurance Program Eligibility: Summary Page Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. SD-13-0019 Type of SPA: MAGI Eligibility & Methods XXI Medicaid Expansion Establish 2101(f) Group Eligibility Processing Non-Financial Eligibility Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation 42 CFR 457.320; Sections 2105(c)(9) and 2107(e)(1)(J) of the SSA and 42 CFR 457.320(b)(6), ( Federal Budget Impact This SPA has a budget impact. Total budget impact: Subject of Amendment Please provide a brief summary of SPA changes. Character Count:319 out of 2000 This SPA contains South Dakota's assurances and policy decisions in regard to residency, citizenship, social security numbers, substitution of coverage, premium lock-outs, continuous eligibility, presumptive eligibility- children, and presumptive eligibility- pregnant women for the Children's Health Insurance P Signature of State Agency Official Page 1 of 2 Children's Health Insurance Program Eligibility: CMS 179 04/24/2014 http://157.199.113.99/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

FAQs | Site Map | Contact | Medicaid.gov | CMS.gov Page 2 of 2 Children's Health Insurance Program Eligibility: CMS 179 04/24/2014 http://157.199.113.99/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

(CMS CHIP Eligibility

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

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

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

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

Must be under age 19.

Income Standards

Income standards are applied statewide.

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

Statewide Income Standards

Begin with lowest age range first.

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

From Age To Age Above (% FPL) Up to & including (% FPL)

19 182 204

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

Special Program for Children with Disabilities

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

PRA Disclosure Statement

SPA # SD-13-0016 Approval patO¥ i 8 2013 Effective Date: January 1, 2014 Page 1 of 2

CHIP Eligibility

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

V.20130709

NOV 18 2013

SPA # SD-13-0016 Approval Date: Effective Date: January 1, 2014 Page 2 of 2

CHIP Eligibility

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

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

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

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

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

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

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

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

by the person claiming an individual described at §435.603(f)(2)(i) as a tax dependent. ves

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

tenn Ee

PRA Disclosure Statement

NOV 1 8 2013

SPA # SD-13-0016 Approval Date: Effective Date: January 1, 2014

Page | of 2

CHIP Eligibility

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

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

SPA # SD-13-0016 Approval pateNOV i 8 2013 Effective Date: January 1, 2014

Page 2 of 2

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

igh

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

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

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

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

C

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

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

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

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

% FPL

The state will enroll children in a separate CHIP who are found to be ineligible for Medicaid based on MAGI but whose family income has not increased since the child’s last determination of Medicaid eligibility or who would have remained eligible for

* Medicaid (based on the 2013 Medicaid income standard) if the value of their 2013 disregards had been applied to the family income as determined by MAGI methodology.

C Other.

Describe the benefits provided to this population:

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

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

Describe premiums and cost sharing required of this population:

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

NOV 18 2013

SPA # SD-13-0017 Approval Date: Effective Date: January 1, 2014

Page 1 of 2

CHIP Eligibility

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

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

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

NOV 1 8 2013

SPA # SD-13-0017 Approval Date: Effective Date: January 1, 2014 Page 2 of 2

Cems. CHIP Eligibility

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

42 CFR 457,320

Residency

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

A child is considered to be a resident of the state under the following conditions:

rl A non-institutionalized child, if capable of indicating intent and who is emancipated or married, if the child is living in the state and:

1. Intends to reside in the state, including without a fixed address, or

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

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

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

rl An institutionalized child, who is not a ward of the state, if the state is the state of residence of the child's custodial parent or caretaker at the time of placement, or .

[ll A child who is a ward of the state regardless of where the child lives, or

ml A child physically located in the state when there is a dispute with one or more states as to the child's actual state of residence.

If the state covers pregnant women, a pregnant woman is considered to be a resident under the following conditions: {m] A non-institutionalized pregnant woman who is living in the state and: 1. Intends to reside in the state, including without a fixed address, or if incapable of indicating intent, is living in the state, or 2. Entered with a job commitment or seeking employment, whether or not currently employed.

rl An institutionalized pregnant woman placed in an out-of-state-institution, as defined in 42 CFR 435.1010, including foster care homes, by an agency of the state, or

ry An institutionalized pregnant woman residing in an in-state-institution, as defined in 42 CFR 435. 1010, whether or not the individual established residency in the state prior to entering the institution, or

cl A pregnant woman physically located in the state when there is a dispute with one or more states as to the pregnant woman's actual state of residence.

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

NOV 1 8 2013

SPA # SD-13-0019 Approval Date: Effective Date: January 1, 2014 Page | of 2

Cems. CHIP Eligibility

One or more interstate agreement(s). No }

A policy related to individuals in the state only for educational purposes. Yes

Provide a description of the policy:

‘An individual is not a South Dakota resident if s/he is in South Dakota temporarily to attend school (¢.g., college, boarding school, vocational school).

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

NOV 18 2013

SPA # SD-13-0019 Approval Date: Effective Date: January 1, 2014 Page 2 of 2

ccMs. CHIP Eligibility

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

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

Citizenship

The CHIP Agency provides CHIP eligibility to otherwise eligible citizens and nationals of the United States and certain non-citizens, including the time period during which they are provided with reasonable opportunity to submit verification of their citizenship, national status or satisfactory immigration status.

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

Who are citizens or nationals of the United States; or

Who are qualified non-citizens as defined in section 431 of the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) (8 U.S.C. $1641), or whose eligibility is required by section 402(b) of PRWORA (8 U.S.C. §1612(b)) and is not prohibited by section 403 of PRWORA (8 U.S.C. §1613); or

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

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

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

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

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

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

(@ Other date, as described:

The first day of the month in which the application containing the declaration of citizenship or immigration status was received.

The CHIP Agency elects the option to provide CHIP coverage to otherwise eligible children up to age 19, lawfully residing No in the United States, as provided in Section 2107(e)(1)(J) of the SSA (Section 214 of CHIPRA 2009, P.L. 111-3).

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

Income Pregnant Women. SPA # SD-13-0019 Approval Date NOV 1 8 a0t3 Effective Date: January 1, 26++

Page 1 of 2

‘No

CECMS CHIP Eligibility

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

NOV 18 2013

SPA # SD-13-0019 Approval Date : Effective Date: January 1, 2014 Page 2 of 2

Cems. CHIP Eligibility

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

42 CFR 457.340(b)

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

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

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

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

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

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

How the state will use the SSN.

The CHIP Agency provides assurance that it will verify each SSN furnished by an applicant or beneficiary with the Social Security Administration, not deny or delay services to an otherwise eligible applicant pending issuance or verification of the

Fa individual's SSN by the Social Security Administration and that the state's utilization of the SSNs is consistent with sections 205 and 1137 of the Social Security Act and the Privacy Act of 1974.

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

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

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

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

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

PRA Disclosure Statement

SPA # SD-13-0019 Approval NOV 18 2013

Effective Date : January 1, 2014 Page | of 2

CHIP Eligibility

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

NOV 18 2013

SPA # SD-13-0019 Approval Date: Effective Date : January 1, 2014 Page 2 of 2

CHIP Eligibility

OMB Control Number: 0938-1148 irati

457.310(b)(2) and (b)(3), 457.320(a)(9) and 2110(b)(1)(C) of the SSA

Substitution of Coverage

The CHIP Agency provides assurance that it has methods and policies in place to prevent the substitution of group health coverage or other commercial health insurance with public funded coverage. These policies include:

[Mi] Substitution of coverage prevention strategy:

Name of policy Description

A waiting period during which an individual is ineligible due to having dropped group health coverage.

How long is the waiting period?

© One month C Two months @ 90 days

© Other

[li] The state allows exemptions from the waiting period for the following reasons:

rT The premium paid by the family for coverage of the child under the group health plan exceeded 5 percent of household income.

The child’s parent is determined eligible for advance payment of the premium tax credit for enrollment in a QHP

fl] through the Marketplace because the ESI in which the family was enrolled is determined unaffordable in accordance with 26 CFR 1.36B—2(c)(3)(v).

[li] The cost of family coverage that includes the child exceeded 9.5 percent of the household income.

im The employer stopped offering coverage of dependents (or any coverage) under an employer-sponsored health insurance plan. :

ry] A change in employment, including involuntary separation, resulted in the child’s loss of employer-sponsored insurance (other than through full payment of the premium by the parent under COBRA).

[lM] The child has special health care needs.

[ll] The child lost coverage due to the death or divorce of a parent.

Does the state allow other exemptions in addition to those listed above? |No

NOV 18 2013

SPA # SD-13-0019 Approval Date: Effective Date: January 1, 2014 Page 1 of 2

CHIP Eligibility

[7] If the state covers pregnant women, the waiting period does not apply to pregnant women.

If the state elects to offer dental only supplemental coverage, the following assurances apply:

oO The other coverage exclusion does not apply to children who are otherwise eligible for dental only supplemental coverage as provided in section 2110(b)(5) of the SSA.

[[] The waiting period does not apply to children eligible for dental only supplemental coverage.

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 contro! number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance

Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. V.20130718

NOV 18 2013

SPA # SD-13-0019 Approval Date: Effective Date: January 1, 2014 Page 2 of 2

_____________________________________________________________________________

Table of Contents

State/Territory Name: South Dakota

State Plan Amendment (SPA) #: SD-13-0020

This file contains the following documents in the order listed:

1) Approval Letter 2) SPA Summary Form 3) Approved SPA Pages

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

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop: S2-26-12

7" CENTERS FOR MEDICARE & MEDICAID SERVICES Baltimore, Maryland 21244-1850 CENTER FOR MEDICAID & CHIP SERVICES

Children and Adults Health Programs Group

Nicki Bartel RN, RHIT DEC 1.8 2013 Nurse Consultant

South Dakota Department of Social Services

Division of Medical Services

700 Governors Drive

Pierre, SD 57501-2291

Dear Ms. Bartel:

I am pleased to inform you that your Title XXI Children’s Health Insurance Program (CHIP) state plan amendment (SPA) SD-13-0020 submitted on October 22, 2013 and related to Modified Adjusted Gross Income (MAGI) Eligibility, has been approved with an effective date of January 1, 2014.

SPA number SD-13-0020 converts the state’s existing income eligibility standards to MAGI- equivalent standards, by age group, for children covered in its title XXI-funded Medicaid program. ‘A copy of the approved state plan page (CS3) is attached, and should be incorporated into the state’s approved CHIP state plan. This page supersedes the current Medicaid expansion Section (4.0) of the current CHIP state plan.

Your Title XXI project officer is Ms. Joyce Jordan. She is available to answer questions concerning these amendments and other CHIP-related issues. Ms. Jordan’s contact information is as follows:

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

7500 Security Boulevard

Baltimore, MD 21244-1850

Telephone: (410) 786-3413

Facsimile: (410) 786-5882

E-mail: Joyce.Jordan@cms.hhs.gov

Please copy Mr. Richard Allen, Associate Regional Administrator (ARA) in our Denver Regional Office on all communications. Mr. Allen’s address is:

Page 2 — Ms. Nicki Bartel

Centers for Medicare & Medicaid Services Denver Regional Office

Colorado State Bank Building

1600 Broadway, Suite# 700

Denver, Colorado 80202-4967

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

We look forward to continuing to work with you and your staff. Sincerely,

Eliot Fishman Director

Enclosure ce: Richard Allen, ARA, CMS Region VIII, Denver

logged in as TONIABROWN(CMS CO Staff) read only mode application rev p01 Children's Health Insurance Program Eligibility SD.0443.R00.00 - Jan 01, 2014 Home Logout Finder Save Print Help Control Panel General Information File Management Tribal Input Summary State/Territory name: South Dakota State Funds: $ Federal Funds: $ Submitted By: Ann Schwartz Last Revision Date: Oct 22, 2013 Submit Date: Oct 22, 2013 Children's Health Insurance Program Eligibility: Summary Page Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. SD-13-0020 Type of SPA: MAGI Eligibility & Methods XXI Medicaid Expansion Establish 2101(f) Group Eligibility Processing Non-Financial Eligibility Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation 42 CFR 457.320(a)(2) and (3) Federal Budget Impact This SPA has a budget impact. Total budget impact: Subject of Amendment Please provide a brief summary of SPA changes. Character Count:93 out of 2000 This SPA designates the income eligibility for children under the Medicaid Expansion Program. Signature of State Agency Official Page 1 of 2 Children's Health Insurance Program Eligibility: CMS 179 04/17/2014 http://157.199.113.99/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

FAQs | Site Map | Contact | Medicaid.gov | CMS.gov Page 2 of 2 Children's Health Insurance Program Eligibility: CMS 179 04/17/2014 http://157.199.113.99/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

December 18, 2013

_____________________________________________________________________________ Table of Contents State/Territory Name: South Dakota State Plan Amendment (SPA) #: SD-16-0006 This file contains the following documents in the order listed: 1) Approval Letter 2) State Plan Pages The complete title XXI state plan for South Dakota consists of the most recent state plan posted on Medicaid.gov under CHIP and State Plan Amendments. The link is provided below. Link to state title XXI state plans and amendments: http://medicaid.gov/Medicaid-CHIP-Program-Information/ By-Topics/Childrens-Health-Insurance-Program-CHIP/CHIP-State-Program-Information.html

DEPARTMENT OF HEALTH & HUMAN SERVICES

Centers for Medicare & Medicaid Services

7500 Security Boulevard, Mail Stop S2-01-16 < M Ss Baltimore, MD 21244-1850 CENTERS FOR MEDICARE & MEDICAID SERVICES

CENTER FOR MEDICAID & CHIP SERVICES Children and Adults Health Programs Group

DEC 1 5 2016

Nicki Bartel RN, RHIT

Nurse Consultant ©

South Dakota Department of Social Services Division of Medical Services

700 Governors Drive

Pierre, SD 57501-2291

Dear Ms. Bartel:

I am pleased to inform you that your title XXI Children’s Health Insurance Program (CHIP) state plan amendment (SPA), SD-16-0002, submitted on August 2, 2016, with additional information submitted on November 30, 2016, and SPAs SD-16-0006 and SD-16-0007, submitted on November 30, 2016, have been approved. These SPAs have an effective date of July 1, 2016, and implement an expansion of coverage to CHIP targeted low-income children from conception to birth.

South Dakota’s SPAs SD-16-0002 and SD-16-0006 allows the state to expand eligibility to include unborn children whose pregnant mothers are not otherwise eligible for Medicaid and whose family incomes are up to, and including 133 percent of the federal poverty level (FPL). Coverage will include pregnancy-related services, such as prenatal care for children from conception to birth. SPA SD-16-0007 specifies that this population will be excluded from the state’s 90-day waiting period. A copy of the approved CS9 is attached and incorporated into section 4.1.9 of the state’s current CHIP state plan. A copy of the approved CS20 state plan page is attached and supersedes section 4.4.4.1 of the current CHIP state plan.

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

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

7500 Security Boulevard

Baltimore, MD 21244-1850

Telephone: (410) 786-3413

Facsimile: (410) 786-5882

E-mail: Joyce.Jordan@cms.hhs.gov

Official communications regarding program matters should be sent simultaneously to Ms. Jordan and to Mr. Richard Allen, Associate Regional Administrator (ARA) in our Denver Regional Office. Mr. Allen’s address is:

/Anne Marie Costello/

CHIP Eligibility

State Name:{South Dakota OMB Control Number: 0938-1148 sD 0/31/2014

Transmittal Numbe! - 0002 Expiration date

42 CFR 457.10

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

From conception through birth.

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

Income Standards

Income standards are applied statewide. Yes

Are there any exceptions, e.g. populations in a county which may qualify under either a statewide income standard or a

county income standard? INo

Statewide Income Standard

The statewide income standard is: From zero up to }133 % FPL

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

[m] Exempted from requirement of verifying citizenship status.

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

DEC 1 5 206

SPA# SD-16-0002 Approval Date: Effective Date: July 1, 2016 Page 1 of 1

State Name:|South Dakota | OMB Control Number: 0938-1148 SD 0007

Transmittal Number:

Section 2102(b)(3)(C) of the SSA and 42 CFR 457.340(d)(3), 457.350(i), and 457.805

Substitution of Coverage

The CHIP Agency provides assurance that it has methods and policies in place to prevent the substitution of group health coverage or other commercial health insurance with public funded coverage. These policies include:

[m] Substitution of coverage prevention strategy:

Name of policy Description

ubstitution of Coverage Prevention | The CHIP Agency has specific methods and policies to prevent the Strategy program from substituting for coverage under group health plans. Persons covered by insurance providing hospital and medical services or HMO’s are not eligible for benefits under SCHIP. Additionally, children are ineligible if they have been covered by a group health plan in the 90 days immediately preceding the application for SCHIP. Exceptions to the waiting period are noted below. The Department has adopted a definition of "group health plan" that includes employers, self-employed plans, employee organizations, and self insured plans that provide health care directly or otherwise.

The Department also requires that insurance information on the persons seeking medical assistance coverage be provided on the application for SCHIP as a measure to avoid substitution for group health coverage. The Department also requires that members of the SCHIP unit cooperate with the Department to determine the availability of coverage. Failure to cooperate may result in loss of eligibility for the unit.

The Department also maintains a database on persons with insurance coverage for persons applying for or receiving medical assistance from the Departm ent under Medicaid, M-SCHIP or CHIP- NM. The database includes type of coverage, name and address of carrier, policy numbers, plan sponsor, premium payer, and dates of coverage. Information from this database is available to benefits specialists to explore potential group health coverage. Benefits specialists also have the opportunity to update the information on this database to keep the information up to date.

Targeted, low-income children belonging to employees of State government in South Dakota will not be eligible for SCHIP coverage since the State provides indirect assistance for the coverage of dependents in excess of the cost to cover the employee alone, regardless of the coverage choices made by the family.

DEC 1 5 2016 Page 1 of 3

SPA# SD-16-0007 Approval Date: Effective Date: July 1, 2016

CHIP Eligibility

A waiting period during which an individual is ineligible due to having dropped group health coverage. Yes

How long is the waiting period?

© One month © Two months @ 90 days

C Other

[H] The state allows exemptions from the waiting period for the following reasons:

rT The premium paid by the family for coverage of the child under the group health plan exceeded 5 percent of household income.

The child’s parent is determined eligible for advance payment of the premium tax credit for enrollment in a QHP [i] through the Marketplace because the ESI in which the family was enrolled is determined unaffordable in accordance with 26 CFR 1.36B-2(c)(3)(v).

[m] The cost of family coverage that includes the child exceeded 9.5 percent of the household income.

iw The employer stopped offering coverage of dependents (or any coverage) under an employer-sponsored health insurance plan.

wl A change in employment, including involuntary separation, resulted in the child’s loss of employer-sponsored insurance (other than through full payment of the premium by the parent under COBRA).

[m] The child has special health care needs.

[Mi] The child lost coverage due to the death or divorce of a parent.

Does the state allow other exemptions in addition to those listed above? |Yes

Describe

The state exempts unborn children from the waiting period.

rl Describe the processes the state employs to facilitate enrollment of CHIP-eligible children who have satisfied the waiting period.

When a child is subject to the waiting period due to having dropped group health coverage the benefits special ist will take appropriate steps to facilitate enrollment of CHIP-eligible children upon satisfaction of the waiting period. The case will be flagged by the benefits specialist for follow-up at conclusion of the waiting period. The waiting period and any items of significance will be noted in the case narration. The benefits specialist will follow-up prior to enrollment to inquire

whether anything of significance has changed during the waiting period. If eligible, the child will be enrolled when the waiting period has been satisfied.

Describe the processes the state employs to coordinate coverage of children subject to a waiting period with other [Ml] insurance affordability programs, including safeguards to prevent gaps in coverage for children transitioning from another insurance affordability program to CHIP after satisfying the waiting period.

When a child does not meet Medicaid eligibility criteria or any of the Federal or state exceptions to the waiting period, the state has a process in place to notify the family of the option to enroll the child in another insurance affordability program for the duration of the waiting period. The case will be flagged for follow up upon the expiration date of the waiting

DEC { 5 2016 Page 2 of 3

SPA# SD-16-0007 Approval Date: Effective Date: July 1, 2016

(CMS CHIP Eligibility

ARE TR AREIERDE BORAT

period, and the state will facilitate enrolment of the child into CHIP (if still eligible) to ensure there 1s no gap in coverage between the end date of coverage in another insurance affordability program (if applicable) and the effective date of CHIP coverage at the end of the waiting period.

The state provides assurance that:

It does not require a new application or the submission of information already provided by the family immediately preceding the waiting period for the purpose of enrolling CHIP-eligible children who have satisfied a waiting period.

For children subject to the waiting period, it will promptly transfer each individual’s electronic account to the applicable insurance affordability program and notify such program of the date on which the waiting period ends for each individual.

(7 If the state covers pregnant women, the waiting period does not apply to pregnant women.

If the state elects to offer dental only supplemental coverage, the following assurances apply:

oO The other coverage exclusion does not apply to children who are otherwise eligible for dental only supplemental coverage as provided in section 2110(b)(5) of the SSA.

(] The waiting period does not apply to children eligible for dental only supplemental coverage.

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

Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. V.20160722

DEC i 5 2016 Page 3 of 3

SPA# SD-16-0007 Approval Date: Effective Date: July 1, 2016

Model Application Template for the State Children's Health Insurance Program expansion of the State's Medicaid program to include children age 6 through 18 from 100% to 133% of the Federal Poverty Level. Under this program expansion eligible children with insurance coverage were enrolled in Medicaid and uninsured children not otherwise eligible for Medicaid were enrolled in SCHIP. In April of 1999, SCHIP implementation via Medicaid expansion continued as the income level for eligibility was increased from 133% of the FPL to 140%/or children from birth to age 19 for both the Medicaid and M-SCHIP programs. Again, insured children received Medicaid benefits, and targeted uninsured children received M-SCHIP. South Dakota's third effort under Title XXI to expand coverage to targeted uninsured children included the method of delivering child health assistance is through a state administered program. The State Administered program, called CHIP NM, is operated directly by the South Dakota Department of Social Services. Children to be covered under the CHIP-NM program are uninsured children/ram birth to age 19 in families with incomes above 140% of the FPL and not exceeding 200% of the FPL. 1;;/ji,ctive Jonuarv I. 201-1. the i11111/em<!nlatio11 Qf_ the a[fordohle care act reauircd stales to conFert !he estahlished income limits to -- ""'"""·-··----------·--"·-··-·-·-··-·""""'-···-·-l--·-·---"- . . --,- """"'"' __ .......... _ a Modified ,,/dfust Gross /11come (/1,/:/(;Ji equivalent. The ;\,J,-l(if eq11iruil'nts arc'" /i>llg11·s.: Al-·SC'f!ll' uninsured ehi!drrn 6 to 19 I I/% lo /8!% M-SCI Tl P uninsured children Oto 5 · I 47% to I 8 I% C!I/Nl'-N\1 uninsured children O lo /9 182% to 21N% E/[ect ive .!11/v 1. 20 / 6 South Dakota added coFerag',' o[_unborn_ch1Idren o{ [!.D::.,';!!Wllf women with incomes kum 0% FPL ond up /u and inc/udi111,; 133() __ !ͯ FPL__ m!Lot!J!"l"lfise eli<;[hlcli,r J\1pdic11id due to cilizemhiJ1DI.!Jl!.if.fillfc!.!:!i:LAs the single state agency for Medicaid the Department is jointly administering CHIP-NM with the Medicaid and M- SCHIP programs using DSS eligibility, outreach, benefit payment, reporting and management resources. General Funds have been appropriated by the South Dakota State Legislature to provide matchingfimds for Federal Title XX/funds. Benefits delivered to targeted uninsured children under the CHIP-NM state administered program are identical to the benefits offered under the State's Medicaid and M-SCHIP programs, including EPSDT benefits. Health care services are delivered using the existing delivery and payment systems including primary care case management and access to specialty health service providers, as approved under the State's 1915 (b) waiver under Medicaid. South Dakota will request the managed care waiver be incorporated into it's Medicaid and SCHIP state plans. The State can assure that children receiving services under SCHIP will receive the same beneficiary protections as children receiving Medicaid coverage including grievances and appeals, privacy and confidentiality, respect and non­ discrimination, access to emergency services, and an opportunity to participate in health care treatment decision and choice of providers. The State can also assure that it is providing SCHIP services in an effective and efficient manner by using Medicaid policies and procedures. Effective Date: August 24, 2001 15 Approval Date: December 15, 2016

Model Application Template for the State Children's Health Insurance Program Children are considered uninsured if they do not qualify for Medicaid and have not had group health plan coverage in the three months immediately prior to application for the SCHIP program. 3.2. Describe the utilization controls under the child health assistance provided under the plan for targeted low-income children. Describe the systems designed to ensure that enrollees receiving health care services under the state plan receive only appropriate and medically necessary health care consistent with the benefit package described in the approved state plan. (Section 2102)(a)(4) (42CFR457.490(b)) Services provided under SCHIP will share the utilization controls used by the Medicaid program to ensure that only health care services that are appropriate, medically necessary, and approved by the State are used. Children covered under SCHIP will be enrolled into a primary care case management system to ensure access to primary care and to provide monitoring and authorization for required specialty medical services. The primary care case management system used will be the PRIME program operated for Medicaid and SCHIP children in South Dakota, authorized by CMS under a 1915(b)(l) waiver. South Dakota will request the managed care waiver be incorporated into it's Medicaid and SCHIP state plan. The SCHIP program will also share the Medicaid SURS resources for post payment review of services provided to SCHIP children. Appropriateness and necessity/or care are also monitored by the Department through a contract with the Professional Review Organization (PRO), also used by the Medicaid and Medicare programs in South Dakota. Pharmacy services for SCHIP will be dispensed via a Medicaid point of service computer system that provides prospective drug utilization review on each prescription filled. Additionally, specialized medical services requiring prior authorization under the Medicaid program will also require prior authorization under the SCHJP program. Section 4. Eligibility Standards and Methodology. (Section 2102(b)) D Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state's Medicaid plan, and continue on to Section 5. 4.1. The following standards may be used to determine eligibility of targeted low­ income children for child health assistance under the plan. Please note whether any of the following standards are used and check all that apply. If applicable, describe the criteria that will be used to apply the standard. (Section 2102)(b)(l)(A)) (42CFR 457.305(a) and 457.320(a)) 4.1.1. X Geographic area served by the Plan: li+atewide.Sec SPi\ paQc CS7. for geographic area served bv the State Plan, 4.1.2. X Age: lJi;Ćh to age 19-witl be [;ervć+..SeeSJ>/\paL'e CS 7 forag,_ standards under the State Plan. Effective Date: August 24, 2001 16 Approval Date: December 15, 2016

Model Application Template for the State Children's Health Insurance Program 4.1.3. X Income: f+H.klrefl-frt->1t1-+an1i-!tes-w+lh-iflcttmes-,wt,r-!40'V.,-FP-lc-t1fl· lf1-ll)(1o/,-F-lllԠ-!:J.t<:,-pHltl--\o\'1I-I-H-!'Bfl t Med iea-i<.Hk./+1ti{t*4H-s-+,r +11€,etH1c>s-tHW-a!lews-de4-hllt,-lf,S··H'tf-dti+d-sttppofl- pa+a-aHcl-ac•tual €-ltiltl-earc-c-><-pew.;es-for-cmploy1n1c'Ht-H,'1Af£d-da-y0are-up--to--H;'.\4\).1)01•­ m o nth for the family. In uddition, the firnt $50 of eurrent child r!Afi­ ԡ,al support paid to the fomily unit and caR-K.'-tH-fl€Bl11&H1:. children under 19 yeaL; old who are living with n careta+(er. ore aJ.w deducted. !'or chih.lren from familie,; with income.;Ԣ .J-.44!!4,-FJ2-h-.--t1te-a4JitiHtta-!,joooHH:,-lti,1°cԣ;--a1'6-2()%.o.l'..,;a Rtetl-· t-ac,<,HHe .. ,a.n,d .. ·ae-ll+a-J-. daytHre .. eHsts .. ,asso{; . i-atetl-\v-i-th .. e . n,--,ԤH-H:!Fl+;-___:_(;_·- 4.1.4. D 4.1.5. X 4.1.6. D 4.1.7. X 4.1.8. X 4.1.9. X S PA __ pagic_CS3 and CS7 forinc<1mc st,rndards L111,lcr. the State l'l,1n, Resources (including any standards relating to spend downs and disposition of resources): Residency (so long as residency requirement is not based on length of time in state): _Sec SPApa!.!C" CS 17 and CS 18 l(,r rcsidcncv requirements.Children muJt-f>f:'-fec;idents-efihe Stnte ef Seuth Dakota and meet the citi;·c1d1ip and imrnigratffifl-6lalL"IH­ requiremenb applicable to Medicnid. Disability Status (so long as any standard relating to disability status does not restrict eligibility): Access to or coverage under other health coverage: Children must not be eligible for Medicaid or covered under any other health insurance or group health plan. Children may not have had insurance coverage under a group health plan in the three months immediately prior to CHIP-NM application unless such coverage was dropped for good cause or access to care not available under the policy. Duration of eligibility: Eligibility is based on a month to month basis and is redetermined annually for all children. Eligibility may begin up to the first day of the third month prior to the application. Families are required to report all changes that may effect their eligibility, when the change occurs. Other standards (identify and describe): Families must cooperate with the Department to determine the actual or potential existence of third party coverage for medical expenses, and to establish initial or ongoing eligibility. The Departntefltrc,iui,ԥԦ,---+al S<l€tHt7+l{Jffi ["el'5-f<w-iHEliv-i,lu-aJs-who t: re rcctuestiAg-afe'iNattee­ under the SCHIP 1',•ledirnid ext:>flla,;iora option. !"he stale provides coverage for unhorn_childrcn in houseJ1olds with income up to and including 133% FPL whose mothers arc 1101 otherwise eligible for Medicaid. The unborn child or children arc counted as if'born and living with the mother in determining family group size. See SPA page CS 19 fo1: additional standards_,_ Effective Date: August 24, 2001 17 Approval Date: December 15, 2016

Model Application Template for the State Children's Health Insurance Program function consistent with prevailing community standards for diagnosis or condition • are not furnished primarily for the convenience of the recipient or the provider • there is no other equally effective course of treatment available or suitable for the recipient requesting the service which is more conservative or substantially less costly. Covered Services fi)I· Unhorn Children Sowh Dakora proPides coverag-e /i!r unbom children in households with income U/L lo_and including.)33% FPF whose mothers are 1101 otlwrwise eligj_blejjJ1· Medicaid due_w citi::enship sta/us. Unhom childrcn receive_ coveNJgethal i.1·dwsame as weg-mmcv related services pi'Ol'ided through the Medicaid Sime /'Ian [iir u11insurcd pregnan( womerL. .All coverage listedjn section 6Ь_2 on!v OJ)j)lies lo nrf.:s.l1((}}CJ'._ related serl'ices. Bene/ifs lo u11i>om children arc delirered through rhe 1·w11,;__ delivl!rV and utili::atio11 co11/rol svs1ems. S,Эyfh f)ak.Q[ilJ{Sc?S /.I bundl<yJ /WV/11§_1]/ 111e1hodoi<JRt:li11· f)l"(!l!fLIJ.!L.liQЮQQЯ\:c.!trJu.1_r_ andde!iverv and 12ostpartum visits,.]he hundledJ>!J.Yment i.а_biLfr_d 01:,J./w dq/et2L hi1·1h 0[1he lw/JJ· so the 11ostpart11111 visit is prepaid !(the swte is unable to use o. bundled t1av11w111 fi,r (/JIV ri:ason. 1he .1·enices are paid /i!e-(i,r,servi<;L <;_lfij' /eye! FFP is availahle fi,r all services provided cfe11_-ing t(бc.Pl:('!;l.'fil!LCYJJ/Jl!J.i!!: the Imm/led 1wvmen/. No Cl/IP level FF!' is available fi1r 11011-hum/led non­ cme1вgJ}_fl<;V services pro1;h/ed during the_posnwrtum P.f.J)JHL 6.2.1. X 6.2.2. X Inpatient services (Section 2110(a)(l)) Inpatient services include services provided in general acute care hospitals and specialty hospitals including rehabilitation, long term care, surgical specialty, psychiatric and children's hospitals. Specialized units of acute care hospitals including neonatal intensive care, rehabilitation and psychiatric units are also covered. Inpatient hospital services are included as PCCM services requiring referrals. Psychiatric, Rehabilitation, and Long Term Care hospitals require prior authorization. Emergency psychiatric hospitalizations are authorized after admission. Inpatient surgeries that are normally performed in outpatient settings must be prior authorized. The Department monitors neonatal Intensive Care Services. There are no limitations on services provided. Outpatient services (Section 2110(a)(2)) Outpatient hospital services include laboratory services, X ray and other Effective Date: August 24, 200 I 27 Approval Date: December 15, 2016

Model Application Template for the State Children's Health Insurance Program 6.2.13.X 6.2.14. X 6.2.15. X Prosthetic devices, except dental, are included.for coverage, including braces, artificial limbs, artificial eyes, augmentative communication devices, items to replace all or part of an internal body organ, and the replacement of such devices required by a change in the patient's condition. Eyeglasses and contact lenses are included in coverage and may be obtained from optical providers, physicians as described in 6.2.3, and optometrists along with professional services. Eyeglasses are limited to replacement after 15 months, unless significant vision changes have occurred. Not applicable to the unborn. Durable Medical Equipment and prosthetic devices are included in the PCCM program. Eyeglasses and services of vision professionals are not included in the PCCM program. Disposable medical supplies (Section 21 IO(a)(l3)) Disposable medical supplies are covered when medically necessary under each of the forms of coverage in Section 6.2. Home and community-based health care services (See instructions) (Section 21 IO(a)(l4)) Home and community based services are covered when medically necessary and ordered by a physician and provided by a home health agency or qualified professional. Home health services include medical supplies, skilled nursing services, home health aide services, physical therapy, speech therapy, occupational therapy, respiratory therapy when ventilator dependent, and medical social services. Individuals receiving these services must be unable to leave home without considerable effort. Services are of an intermittent nature, not more than once per day or 4 times per week. There is no limit on the number of visits a person may receive. Extended home health aide services and private duty nursing services are covered when more than 3 consecutive hours of care are necessary. These services must be prior authorized. Home based therapy services are also covered.for children with mental disorders or who are seriously emotionally disturbed. A treatment plan must exist that documents the need for home based therapy services. Covered services include diagnostic assessment, individual therapy, family therapy, and collateral services. Services must be prior authorized. Nursing care services (See instructions) (Section 2110(a)(l5)) Effective Date: August 24, 200 I 32 Approval Date: December 15, 2016

Model Application Template for the State Children's Health Insurance Program database of prior authorizations, and monitoring of the determination within 14 days of receipt can be easily documented. Section 8. Cost Sharing and Payment (Section 2!03(e)) D Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state's Medicaid plan, and continue on to Section 9. 8.1. ls cost-sharing imposed on any of the children covered under the plan? (42CFR 457.505) 8.1.1. D 8.1.2. X YES NO, skip to question 8.8. 8.2. Describe the amount of cost-sharing, any sliding scale based on income, the group or groups of enrollees that may be subject to the charge and the service for which the charge is imposed or time period for the charge, as appropriate. (Section 2!03(e)(l)(A)) (42CFR 457.505(a), 457.510(b) &(c), 457.515(a)&(c)) 8.2.1. Premiums: 8.2.2. Deductibles: 8.2.3. Coinsurance or copayments: 8.2.4. Other: Unborn children arc excluded from cost-sharing requirements. 8.3. Describe how the public will be notified, including the public schedule, of this cost- sharing (including the cumulative maximum) and changes to these amounts and any differences based on income. (Section 2I03(e)((l)(B)) (42CFR 457.505(b)) 8.4. The state assures that it has made the following findings with respect to the cost sharing in its plan: (Section 2103(e)) 8.4.1. D Cost-sharing does not favor children from higher income families over lower income families. (Section 2!03(e)(l)(B)) (42CFR 457.530) 8.4.2. 0No cost-sharing applies to well-baby and well-child care, including age-appropriate immunizations. (Section 2103(e)(2)) (42CFR 457.520) 8.4.3 D No additional cost-sharing applies to the costs of emergency medical services delivered outside the network. (Section 2!03(e)(l)(A))(42CFR 457.515(1)) 8.5. Describe how the state will ensure that the annual aggregate cost-sharing for a family does not exceed 5 percent of such family's income for the length of the child's eligibility period in the State. Include a description of the procedures that do not primarily rely on a refund given by the state for overpayment by an enrollee: (Section 2!03(e)(3)(B)) (42CFR 457.560(b) and 457.505(e)) Effective Date: August 24, 200 I 43 Approval Date: December 15, 2O16

_____________________________________________________________________________ Table of Contents State/Territory Name: South Dakota State Plan Amendment (SPA) #: SD-17-0009 This file contains the following documents in the order listed: 1) Approval Letter 2) Approved CHIP State Plan 3) Supporting Documentation The complete title XXI state plan for South Dakota consists of the most recent state plan posted on Medicaid.gov under CHIP and State Plan Amendments. The link is provided below. The following approved templates are in addition to, or replace sections of the state’s posted current state plan. The attached approval letter(s) explain how these templates fit into that state plan. Link to state title XXI state plans and amendments: http://medicaid.gov/Medicaid-CHIP-Program-Information/By- Topics/Childrens-Health-Insurance-Program-CHIP/CHIP-State-Program-Information.html

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop 32-01-16 Baltimore, MD 21244-1850 Children and cuts crNrtRs roß MtDtcARE & MED|CAIO SERV|CTS CENTEN ÍON MEDICAID & CHIP SIRVICES Pro!trams APR 0 2 20'.t0 William Snyder Director, Medical Services Division of Medical Services South Dakota Department of Social Services 700 Governors Drive Pierre, SD 57501-2291 Dear Mr. Snyder: I am pleased to inform you that your title XXI Children's Health Insurance program (CHIp) state plan amendment, SD-I7-0009, submitted on December29,2017,has been approved. SD-I7- 0009 implements mental health parity requirements in section 2103(c)(6) of the Social Security Act (the Act) consistent with regulations at 42 CFR 457.496 to ensure that treatment limitations and financial requirements applied to mental health and substance use disorder benefits are no more restrictive than those applied to medical/surgical benefits. This SPA has an effective date of October 1,2017. Section 2103(c)(6)(B) of the Act, as implemented through regulations at 42 CFR 457.496(b), provides that if CHIP coverage includes Early, Periodic Screening, Diagnostic and Treatment (EPSDT) as defined in section 1905(r) of the Act and provided in accordance with section 1902(a)(a3) of the Act, the state plan will be deemed to satisfy parity requirements. South Dakota has provided the necessary assurances and supporting documentation that EPSDT is covered under South Dakota's CHIP program and provided in accordance with sections 1905(r) and 1902(aX43) of the Act. This approval relates only to benefits provided under the CHIP state plan; Medicaid benefits will be analyzed separately. Your title XXI project officer is Ms. Joyce Jordan. She is available to answer questions concerning this amendment and other CHlP-related issues. Ms. Jordan's contact information is as follows: Centers for Medicare & Medicaid Services Center for Medicaid and CHIP Services Mail Stop: S2-01-16 7500 Security Boulevard Baltimore, MD 21244-1 850 Telephone: (41 0) 786-3413 E-mail : Jo)rce..lordan@cms.hhs. gov

Page2 - Mr. William Snyder Offrcial communications regarding program matters should be sent simultaneously to Ms. Jordan and to Mr. Richard Allen, Associate Regional Administrator (ARA) in our Denver Regional Office. Mr. Allen's address is: Centers for Medicare & Medicaid Services 196l Stout Street Room 08-148 Denver, Colorado 80294 If you have additional questions, please contact Ms. Amy Lutzky, Director, Division of State Coverage Programs at (410) 786-0721. We look forward to continuing to work with you and your staff, Sincerely, Marie Costello Director cc: Mr. Richard Allen, ARA, CMS Region VIII, Denver / Anne Marie Costello /

Model Application Template for the State Children's Health Insurance Program Effective Date: August 24, 2001 1 Approval Date:

OMB #: 0938-0707 Exp. Date:

MODEL APPLICATION TEMPLATE FOR STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT STATE CHILDREN’S HEALTH INSURANCE PROGRAM

Preamble

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

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

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

Form CMS-R-211

Model Application Template for the State Children's Health Insurance Program Effective Date: August 24, 2001 2 Approval Date:

MODEL APPLICATION TEMPLATE FOR STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT STATE CHILDREN’S HEALTH INSURANCE PROGRAM

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

State/Territory:_South Dakota_ (Name of State/Territory)

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

James W. Ellenbecker

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

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

The following state officials are responsible for program administration and financial oversight (42 CFR 457.40(c)): Name: Damian L Prunty Position/Title: Program Administrator Name: Larry Iversen Position/Title: Assistant Program Administrator Name: Rick LaBrie Position/Title: Program Manager

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0707. The time required to complete this information collection is estimated to average 160 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, N2-14-26, Baltimore, Maryland 21244.

Model Application Template for the State Children's Health Insurance Program Effective Date: August 24, 2001 3 Approval Date:

Section 1. General Description and Purpose of the State Child Health Plans and State Child Health Plan Requirements (Section 2101)

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

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

1.1.2. Providing expanded benefits under the State's Medicaid plan (Title XIX); OR

1.1.3. A combination of both of the above.

Since July 1, 1998 South Dakota has provided SCHIP benefits to uninsured children by providing expanded eligibility under the State’s Medicaid plan. The original SCHIP plan included children age 6 through 18 from 100% to 133% of the Federal Poverty Level (FPL). The initial SCHIP program was approved on August 5, 1998, and a subsequent eligibility expansion with Medicaid occurred on April 1, 1999 that increased eligibility from 133% FPL to 140% FPL for children from birth to age 19 for both Medicaid and SCHIP program. South Dakota refers to its original SCHIP program, with subsequent expansion as M-SCHIP.

Subsequently, in July 2000, South Dakota added a State operated SCHIP program for targeted uninsured children from families with income levels higher than previously approved SCHIP eligibility levels. The new eligibility level, active outreach and beneficiary enrollment began on July 1, 2000. There was no corresponding amendment to the Medicaid State Plan submitted in conjunction with the SCHIP expansion at that time as Medicaid eligibility income levels remained unchanged. South Dakota refers to its separate child health program as CHIP-NM. Collectively, M- SCHIP and CHIP-NM are referred to throughout this document as SCHIP.

This State Plan Amendment does not seek to replace the approved SCHIP State Plan materials, but will add the appropriate information describing the additional requirements and assurances mandated as a result of the final SCHIP federal regulations. This State Plan Amendment will also update the existing pages of the current SCHIP State Plan.

The Secretary of the Department of Social Services is the authorized State Official signing and submitting this State Plan Amendment. The Official responsible for program administration and financial oversight is Damian Prunty, Administrator, Office of Medical Services, South Dakota Department of Social Services, 700 Governors Drive, Pierre, South Dakota 57501 2291.

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1.2

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

The State assures specific legislative authority to operate an expansion of the SCHIP program under Title XXI of the Social Security Act was granted by Act of the South Dakota Legislature and signed into law by the Governor of South Dakota.

The authority for M-SCHIP was granted by Act of the South Dakota Legislature and signed into law by the Governor of South Dakota, effective July 1, 1998. No expenditures for child health assistance were claimed for M-SCHIP prior to July 1, 1998.

The authority for CHIP-NM was granted by Act of the South Dakota Legislature and signed into law by the Governor of South Dakota, effective July 1, 2000. No expenditures for child health assistance were claimed for CHIP-NM prior to July 1, 2000.

1.3

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

With this State Plan submission the State assures that it will comply with all civil rights requirements including Title VI of the Civil Rights Act of 1964, Title II of the Americans with Disabilities Act of 1990, Section 504 of the Rehabilitation Act of 1973, and Age Discrimination Act of 1975, 45 CFR part 80, part 84, and part 91, and 28 CFR part 35.

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

Effective date: M-SCHIP became effective July 1, 1998 / CHIP-NM became effective July 1, 2000

Implementation date: M-SCHIP was implemented July 1, 1998 / CHIP-NM was implemented July 1, 2000

SPA# SD-16-0002: This state plan amendment establishes coverage for unborn children from conception to birth when the mother is not eligible for Medicaid. Effective Date: July 1, 2016

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SPA# SD-16-0006: This state plan amendment provides proposed program specifics to the state’s CHIP state plan for unborn children from conception to birth. Effective Date: July 1, 2016

SPA# SD-16-0007: This state plan amendment updates the state’s exemptions from its waiting period to include coverage for unborn children. Effective Date: July 1, 2016

SPA# SD-17-0009: This state plan amendment clarifies that the Mental Health Parity and Addiction Equity Act requirements are satisfied through the EPSDT benefit. Effective Date: October 1, 2017

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

Superseding Pages of MAGI CHIP State Plan Material

Transmittal Number SPA Group PDF # Description Superseded Plan Section(s) SD-13-0016

Approval Date: 11/18/13 Effective/Implementation Date: January 1, 2014 MAGI Eligibility & Methods CS7

CS15 Eligibility – Targeted Low Income Children

MAGI-Based Income Methodologies Superseded sections 4.1.1, 4.1.2, and 4.1.3

Incorporated in section 4.3.2

SD-13-0020

Approval Date: 12/18/13 Effective/Implementation Date: January 1, 2014 XXI Medicaid Expansion CS3 Eligibility for Medicaid Expansion Program Superseded section 4.1.3 SD-13-0017

Approval Date: 11/18/13 Effective/Implementation Date: January 1, 2014 Establish 2101(f) Group CS14 Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards Incorporated in section 4.1.10 SD-13-0018

Approval Date: 12/18/13 Effective/Implementation Date: October 1, 2013 Eligibility Processing CS24 Eligibility Process Superseded the sections 4.3, 4.4.1, 4.4.2, and 4.4.3 SD-13-0019

Approval Date: 11/18/13 Effective/Implementation Date: January 1, 2014 Non-Financial Eligibility CS17

CS18

CS19

CS20

Non-Financial Eligibility – Residency

Non-Financial Eligibility – Citizenship

Non-Financial Eligibility – Social Security Number

Non-Financial Eligibility – Substitution of Coverage Superseded section 4.1.5

Superseded section 4.1.5

Superseded section 4.1.9

Superseded part of section 4.4.4.1

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

Transmittal Number SPA Group PDF # Description Superseded Plan Section(s) SD-14-008

Approval Date: 09/22/14 Effective Date: January 1, 2014 XXI Medicaid Expansion CS3

Eligibility for Medicaid Expansion Program Supersedes the current Medicaid expansion section 4.0 SD-16-0002

Approval Date: 12/15/16 Effective Date: July 1, 2016 MAGI Eligibility & Methods CS9 Eligibility - Coverage from Conception to Birth Incorporated into the current section 4.1.9 SD-16-0007

Approval Date: 12/15/16 Effective Date: July 1, 2016 Non-Financial Eligibility CS20 Non-Financial Eligibility – Substitution of Coverage Supersedes the current section 4.4.4.1

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Section 2. General Background and Description of State Approach to Child Health Coverage and Coordination (Section 2102 (a)(1)-(3)) and (Section 2105)(c)(7)(A)-(B)) 2.1. Describe the extent to which, and manner in which, children in the state including targeted low-income children and other classes of children, by income level and other relevant factors, such as race and ethnicity and geographic location, currently have creditable health coverage (as defined in 42 CFR 457.10). To the extent feasible, make a distinction between creditable coverage under public health insurance programs and public-private partnerships (See Section 10 for annual report requirements). (42 CFR 457.80(a))

South Dakota’s original SCHIP state plan provided a complete description of South Dakota’s population, estimates of the uninsured population and information on the populations served by the Medicaid program and IHS. Little has changed in the basic demographic profile of the State in the years that have elapsed. This SCHIP state plan amendment will recap the increases in enrollment in creditable health coverage and the corresponding reductions that have taken place in South Dakota since the 1998 SCHIP State Plan was implemented.

The following table shows the number of Medicaid and SCHIP eligible children from just prior to SCHIP implementation and for the last day of each quarter through March of 2002. The number of Medicaid eligible children does not include children eligible in SSI categories.

Quarter Ending Medicaid Children SCHIP Children 06/30/1998 32,859 0 09/30/1998 34,290 903 12/31/1998 35,320 1,407 03/31/1999 36,435 1,710 06/30/1999 36,866 2,039 09/30/1999 37,158 2,488 12/31/1999 37,768 2,790 03/31/2000 39,195 3,179 06/30/2000 39,538 3,725 09/30/2000 39,887 4,681 12/31/2000 40,841 5,555 03/31/2001 42,550 6,277 06/30/2001 43,974 6,729 09/30/2001 44,658 7,171 12/31/2001 45,712 7,666 03/31/2002 46,805 7,972 Source: SD MMIS 1998,1999,2000,2001,2002

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Beginning July 1, 1998 eligibility levels for Medicaid and M-SCHIP were increased to include children ages 6 through 18 in families with incomes above 100% but not exceeding 133% of the FPL. Beginning April 1, 1999 the income eligibility levels for Medicaid and M-SCHIP increased from 133% to 140% of the FPL for children from birth through age 18. Beginning July 1, 2000, eligibility levels for SCHIP were increased and included children birth through age 18 from 141% to 200% of the FPL, with implementation of CHIP-NM.

Children from families with incomes in the expanded levels, who were uninsured and not otherwise eligible for Medicaid, received SCHIP coverage. All others who were eligible received Medicaid. The chart shows that the number of children with qualified coverage from Medicaid or SCHIP increased by 21,918 during the time period of SCHIP operation.

During this time period, 83% of the Medicaid enrolled children had no other health coverage when enrolled in the Medicaid program. All SCHIP enrolled children were, by definition, uninsured. Using this information the following table shows the number of uninsured children who received qualified coverage since SCHIP implementation.

Medicaid-SCHIP Enrollment of Uninsured Children Baseline Year Reporting Period Uninsured Medicaid SCHIP Total 1999 06/30/1998-09/30/1998 1,188 903 2,091 2000 10/01/1998-09/30/1999 2,381 1,585 3,966

2000 10/01/1999-09/30/2000 2,265 2,192 4,457 2001 10/01/2000-09/30/2001 3,960 2,490 6,450 2002 10/01/2001-03/31/2002 1,782 801 2,583 Totals

11,576 7,971 19,547 Source: MR63

The Census Bureau Current Population Survey reported 13,000 uninsured children under 200% of the FPL for South Dakota based upon its three year averages from 1996, 1997 and 1998. South Dakota believes the CPS estimate was the best source of baseline data available for the number of uninsured children when SCHIP was implemented. The data in the preceding table indicates the actual enrollees into the Medicaid or SCHIP programs that were uninsured prior to enrollment. In 2001, South Dakota was one of nine states awarded a one- year Health Resources and Services Administration grant to develop a plan for expanding access to affordable health coverage to all state residents. The State contracted with The Lewin Group to collect and analyze information about the uninsured and underinsured in South Dakota. The Lewin Group concluded that South Dakota’s uninsured population for children under the age of 19 is considerably less than the CPS estimates. The Lewin Group estimates that 9,600 children under the age of 19 are uninsured in South Dakota as of the year 2000. South Dakota believes that number to be further reduced, as evidenced by the preceding table for inclusion of enrollment of uninsured children in the years 2001 and 2002. South Dakota believes the enrollment of nearly 20,000 uninsured children into Medicaid or SCHIP, since implementation of SCHIP in July of 1998, has had a major impact on the number of

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uninsured children in South Dakota.

Minority enrollments have also increased significantly under the State’s SCHIP efforts. The most recent Statistical Enrollment Data System (March 2002) indicates that South Dakota had 1,839 American Indian children enrolled in the SCHIP program. This represents over 23% of the total number of children enrolled in the SCHIP program. Enrollment of American Indian children in Medicaid and SCHIP collectively, has grown by 44% from July 1, 1998 to March of 2002. It is the Department’s opinion that SCHIP efforts have been successful in increasing the number of American Indian children with creditable health coverage.

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

2.2.1. The steps the state is currently taking to identify and enroll all uncovered children who are eligible to participate in public health insurance programs (i.e. Medicaid and state-only child health insurance):

State efforts to enroll uninsured children prior to the implementation of the SCHIP program in South Dakota are documented in the original SCHIP plan. Medicaid was the primary public health insurance program at that time and the SCHIP program efforts built upon the existing Medicaid program. The key relationships with other DSS programs, Public Health, Education, Human Services and IHS will continue to be in place and are a vital part of SCHIP outreach efforts.

The enrollment of SCHIP eligible children is greatly enhanced by the widespread availability of Medicaid eligibility throughout the state. Coordinated delivery of multiple programs from the Department of Social Services using generalized co- located eligibility workers and automated information systems enhance the identification and enrollment of children into SCHIP and Medicaid. Access to program coverage is greatly assisted by the widespread availability of participating Medicaid providers throughout the state. Established relationships with other public health programs operated by the State of South Dakota also provide numerous opportunities to identify and enroll children into Medicaid and SCHIP. Interagency agreements between the Departments of Health and Social Services establish referral mechanisms between the programs operated by the agencies. WIC, Community Health Services, Baby Care, MCH, Title V and Children’s Special Health Services programs are key referral sources for families seeking medical coverage for children. South Dakota’s Federally Qualified Health Centers, community and migrant health centers are very involved as sources of information about the State’s medical assistance programs to assist in identifying and enrolling uncovered children, in addition to serving as primary care providers.

Interagency agreements also exist with the Department of Education and the

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Department of Human Services to provide for the referral of children to the Department of Social Services for medical coverage. Individual school districts in the State also participate as direct services providers under Medicaid and therefore have incentives to identify and assist enrolling children in Medicaid and SCHIP programs.

Close collaboration between the Department of Social Services and the Indian Health Service to identify and enroll Medicaid and SCHIP eligible children is a key priority for both agencies. The Department of Social Services recognizes the critical importance of the IHS as a service provider in the Indian reservation areas of the State. The IHS as a provider and payer of services, relies very heavily upon third party funding for services they are responsible for, and therefore is a proven referral source for potentially eligible children.

The initial implementation of the SCHIP program provided a number of opportunities for improved outreach and a greater opportunity for outreach partners to participate in SCHIP outreach. Administrative changes were some of the most significant improvements made with the implementation of SCHIP. Notable among these administrative changes were the development of a new, shorter application form for Medicaid and SCHIP, dropping the requirement for face to face interviews, elimination of assets testing, reduced documentation requirements and direction for DSS eligibility staff to actively participate in program outreach.

The new application form for Medicaid low income children and SCHIP eligibility has been reduced to 3 pages from a form that had been over 30 pages in length. The new form, because of its size and simplicity has been widely distributed to outreach sites including other government agencies, schools, primary care and specialty health care providers, advocacy groups, tribal programs, and day care centers. In addition to the shortening of the form, and eliminating assets information the new form also has reduced documentation requirements as only earnings and childcare expenses need to be verified by the applicant family. The completed eligibility forms may be mailed or faxed to DSS eligibility offices without the need for a face to face interview. However, DSS caseworkers are available at DSS offices to assist with completing the applications if necessary. Workers at some outreach sites are also trained to assist with basic questions regarding Medicaid and SCHIP eligibility.

Redetermination for low income Medicaid and SCHIP has also been simplified. Redeterminations are conducted annually for eligible families and are initiated by DSS caseworkers that mail the redetermination materials to the families a month in advance. The redetermination materials do not require more information than the application process, and can be completed through the mail or fax.

Eligibility for individuals applying for Food Stamps, TANF, or other Medicaid

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programs is also simplified, as an additional application form is not required to obtain low income Medicaid or SCHIP coverage.

There is significant evidence to support the assertion that the changes to the application process have facilitated the identification and enrollment of uncovered children. Face value evidence exists in the growth in the number of uninsured children in Medicaid and SCHIP. Annual surveys conducted of the families of children enrolled in the Medicaid and SCHIP programs in 1998 and 1999 reported that 95% and 98% respectively, responded positively to the question on the ease of the application process.

Since the inception of the SCHIP program the State has used a number of approaches to conduct outreach to clients in addition to collaboration with other health or children’s programs. Included among the outreach approaches are direct mailings by the State to clients, the use of brochures and posters, client education sessions, an eligibility 800-telephone number, ads on public access television, paid radio announcements and public service announcements. Most effective among these efforts are the education sessions, direct mailings, and collaborations with other programs and the use of brochures. Least effective have been the radio and public access television ads.

Department of Social Services staff and collaborating agencies have conducted client outreach in many different settings. Included as some of the most effective settings for outreach are community health centers, health care provider locations, schools and adult education sites, Tribal agencies, social service agencies, local government offices, Headstart programs, and local charities. Many other locations such as laundries, fast food restaurants, libraries and senior centers have also been tried with less effectiveness. Surveys of SCHIP enrollees were conducted to assist in evaluating SCHIP implementation in South Dakota in both 1998 and in 1999. One of the items surveyed was outreach effectiveness. In the 1998 survey 76% of the respondents indicated that they had obtained information about the coverage program from the Department of Social Services. However, in comparison to the 1999 survey it appears the community based outreach efforts were increasing in effectiveness as only 55% of the respondents indicated the Department of Social Services was their source of information about SCHIP. Increasing in outreach effectiveness from 1998 to 1999 were community health nursing, health care providers and schools. Tribal health agencies also contributed effective outreach in both surveys.

American Indians are the largest minority population living in South Dakota. Approximately 7% of South Dakota’s population is American Indian, primarily residing on the 9 Indian Reservations within the States boundaries. For this reason specific outreach approaches have been considered for this population. Among the efforts specifically directed at American Indian persons are Consultation meetings held between the State and Tribal Government and Tribal Health officials. In addition, the Department has invited both Tribal Government and the IHS to be

Effective Date: August 24, 2001 13 Approval Date: Model Application Template for the State Children's Health Insurance Program

represented on the Medicaid Advisory Committee that assists in the monitoring of the Medicaid and SCHIP programs, and both entities are participating.

Some Tribal health departments have requested specific training of the their Community Health Representative staff in the SCHIP program and this training was provided by Department eligibility staff. One reservation even adapted the SCHIP radio ad to use in reaching the Indian population on their reservation.

Outreach brochures, posters and logos for SCHIP were designed with a culturally sensitive logo depicting children of varying ethnic backgrounds in an effort to convey that the program is intended for all races of children.

South Dakota has also had a successful applicant for the “South Dakota Covering Kids Initiative” through grant funding from the Robert Wood Johnson foundation for a three-year period of time from July 1, 2000 through June 30, 2003. The Community Healthcare Association of Sioux Falls, SD was the successful applicant. The South Dakota Covering Kids Initiative has four goals. They are: designing and conducting outreach programs to identify and enroll children in the Medicaid and SCHIP programs; continuing to simplify access to and completion of enrollment information and applications; assisting in coordinating coverage programs for low income, uninsured children; and designing programming specifically targeted to Native Americans and other special populations. The program will feature statewide initiatives to meet these goals and also pilot programs to address specific geographic areas and special populations.

The Community Healthcare Association of Sioux Falls does not contribute any funds to the State of South Dakota for the operation of the Covering Kids Initiative. This organization conducts their own outreach and targets Native American and other special populations in specific geographical areas of the state. This grant money is not being used to match any federal dollars for SCHIP.

2.2.2. The steps the state is currently taking to identify and enroll all uncovered children who are eligible to participate in health insurance programs that involve a public-private partnership:

When South Dakota implemented its SCHIP program in July of 1998, the South Dakota Caring Program for Children was a public-private partnership to make very limited services available to eligible children. The Program operated on an annual donation from Wellmark Blue Cross Blue Shield of South Dakota, administrative support from the South Dakota Department of Health, and private donations. The Caring Program did not provide qualified health care coverage, did not operate in all parts of South Dakota, and covered only a very limited number of children under 133% of FPL. No Caring for Children benefits would have ever been available to children expected to be served by the CHIP-NM

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program. The South Dakota Caring for Children Program ceased to exist in 1999, long before action by the state to implement a CHIP-NM program.

South Dakota counties continue to be required to provide medical services for persons in the State who are determined medically indigent. Eligibility is restricted to persons with very limited income and resources. Services are restricted to coverage of emergency hospital services only, with the exception of two counties, Minnehaha and Pennington which operate community health centers to make primary care clinic services available. As such, the County Indigent Program is not a health resource available to low income uninsured children with needs for full coverage of primary and preventive health care. All counties operate as the payer of last resort and provide referrals and assistance with Medicaid applications.

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

The key programs providing creditable coverage for low-income children in South Dakota are the Medicaid and M-SCHIP programs that are jointly administered by the South Dakota Department of Social Services. The interagency agreements identified in Section 2.2.1 on page 8 serve as the referral procedures that the State uses to accomplish the coordination with Title V, WIC and MCH for both the Medicaid and SCHIP programs. The interagency agreements serve to assure the services provided under Title V, WIC, MCH, Title XIX and Title XXI are consistent with the needs of recipients and both the Department of Social Services and the Department of Health’s objectives and requirements to promote high quality health care and services.

There are no other State programs that provide creditable coverage for low- income children. The South Dakota Caring for Children program had existed as a private effort to provide very limited health coverage to low-income children, however operations under that program ceased in 1999. There are no other private programs that offer creditable coverage for low-income children in South Dakota.

The Indian Health Service continues as a provider of creditable coverage to Indian children. The IHS functions as a provider of services and also provides coverage for certain specialty services through their contract health program. Coordination with the IHS will continue in the same way as coordination with the Medicaid program. The IHS will be reimbursed for the direct services they provide to SCHIP children at the same rate of payment as the South Dakota

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Medicaid program. Since the IHS contract care program is the payer of last resort under Federal Regulations, the SCHIP program will be primary to IHS contract care. Benefit coordination will be accomplished by the IHS denying claims they receive and causing the claims to be submitted to the SCHIP program for payment just as currently happens with Medicaid. Payment for those services under the SCHIP program will be on the same basis as established for the Medicaid program.

The IHS also plays a very important role in the delivery of outreach services to facilitate the identification and enrollment of low-income children for Medicaid and SCHIP. This role will continue for potentially eligible SCHIP children using the established means to interface with the Department of Social Services medical assistance programs. There are no other public programs providing creditable coverage to low-income children. Children potentially eligible for other public programs will be referred to those programs for services in addition to those provided by Medicaid, M- SCHIP or CHIP-NM.

Children covered by Medicare will not be enrolled in SCHIP as they have creditable coverage.

Section 3. Methods of Delivery and Utilization Controls (Section 2102)(a)(4))

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

3.1. Describe the methods of delivery of the child health assistance using Title XXI funds to targeted low-income children. Include a description of the choice of financing and the methods for assuring delivery of the insurance products and delivery of health care services covered by such products to the enrollees, including any variations. (Section 2102)(a)(4) (42CFR 457.490(a))

South Dakota’s original implementation of SCHIP began in July of 1998 with the expansion of the State’s Medicaid program to include children age 6 through 18 from 100% to 133% of the Federal Poverty Level. Under this program expansion eligible children with insurance coverage were enrolled in Medicaid and uninsured children not otherwise eligible for Medicaid were enrolled in SCHIP. In April of 1999, SCHIP implementation via Medicaid expansion continued as the income level for eligibility was increased from 133% of the FPL to 140% for children from birth to age 19 for both the Medicaid and M-SCHIP programs. Again, insured children received Medicaid benefits, and targeted uninsured children received M-SCHIP.

South Dakota’s third effort under Title XXI to expand coverage to targeted uninsured children included the method of delivering child health assistance is through a state administered program. The State Administered program, called

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CHIP NM, is operated directly by the South Dakota Department of Social Services. Children to be covered under the CHIP-NM program are uninsured children from birth to age 19 in families with incomes above 140% of the FPL and not exceeding 200% of the FPL. Effective January 1, 2014, the implementation of the affordable care act required states to convert the established income limits to a Modified Adjust Gross Income (MAGI) equivalent. The MAGI equivalents are as follows:

M-SCHIP uninsured children 6 to 19 – 111% to 181% M-SCHIP uninsured children 0 to 5 – 147% to 181% CHINP-NM uninsured children 0 to 19 – 182% to 204%

Effective July 1, 2016 South Dakota added coverage of unborn children of pregnant women with incomes from 0% FPL and up to and including 133% FPL not otherwise eligible for Medicaid due to citizenship requirements. As the single state agency for Medicaid the Department is jointly administering CHIP-NM with the Medicaid and M- SCHIP programs using DSS eligibility, outreach, benefit payment, reporting and management resources. General Funds have been appropriated by the South Dakota State Legislature to provide matching funds for Federal Title XXI funds.

Benefits delivered to targeted uninsured children under the CHIP-NM state administered program are identical to the benefits offered under the State’s Medicaid and M-SCHIP programs, including EPSDT benefits. Health care services are delivered using the existing delivery and payment systems including primary care case management and access to specialty health service providers, as approved under the State’s 1915(b) waiver under Medicaid. South Dakota will request the managed care waiver be incorporated into it’s Medicaid and SCHIP state plans. The State can assure that children receiving services under SCHIP will receive the same beneficiary protections as children receiving Medicaid coverage including grievances and appeals, privacy and confidentiality, respect and non- discrimination, access to emergency services, and an opportunity to participate in health care treatment decision and choice of providers. The State can also assure that it is providing SCHIP services in an effective and efficient manner by using Medicaid policies and procedures.

Children are considered uninsured if they do not qualify for Medicaid and have not had group health plan coverage in the three months immediately prior to application for the SCHIP program.

3.2. Describe the utilization controls under the child health assistance provided under the plan for targeted low-income children. Describe the systems designed to ensure that enrollees receiving health care services under the state plan receive only appropriate and medically necessary health care consistent with the benefit package described in the approved state plan. (Section 2102)(a)(4) (42CFR 457.490(b))

Services provided under SCHIP will share the utilization controls used by the Medicaid program to ensure that only health care services that are appropriate, medically necessary, and approved by the State are used. Children covered under SCHIP will be enrolled into a primary care case management system to ensure access to primary care and to provide monitoring and authorization for required specialty medical services.

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The primary care case management system used will be the PRIME program operated for Medicaid and SCHIP children in South Dakota, authorized by CMS under a 1915(b)(1) waiver. South Dakota will request the managed care waiver be incorporated into it’s Medicaid and SCHIP state plan.

The SCHIP program will also share the Medicaid SURS resources for post payment review of services provided to SCHIP children. Appropriateness and necessity for care are also monitored by the Department through a contract with the Professional Review Organization (PRO), also used by the Medicaid and Medicare programs in South Dakota. Pharmacy services for SCHIP will be dispensed via a Medicaid point of service computer system that provides prospective drug utilization review on each prescription filled. Additionally, specialized medical services requiring prior authorization under the Medicaid program will also require prior authorization under the SCHIP program.

Section 4. Eligibility Standards and Methodology. (Section 2102(b))

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

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

4.1.1.

Geographic area served by the Plan: See SPA page CS7 for geographic area served by the State Plan. 4.1.2.

Age: See SPA page CS7 for age standards under the State Plan. 4.1.3.

Income: See SPA page CS3 and CS7 for income standards under the State Plan. 4.1.4.

Resources (including any standards relating to spend downs and disposition of resources): 4.1.5.

Residency (so long as residency requirement is not based on length of time in state): See SPA pages CS17 and CS18 for residency requirements. 4.1.6.

Disability Status (so long as any standard relating to disability status does not restrict eligibility): 4.1.7.

Access to or coverage under other health coverage: Children must not be eligible for Medicaid or covered under any other health insurance or group health plan. Children may not have had insurance coverage under a group health plan in the three months immediately prior to CHIP-NM application unless such coverage was dropped for good cause or access to care not available under the policy.

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4.1.8.

Duration of eligibility: Eligibility is based on a month to month basis and is redetermined annually for all children. Eligibility may begin up to the first day of the third month prior to the application. Families are required to report all changes that may effect their eligibility, when the change occurs. 4.1.9.

Other standards (identify and describe): Families must cooperate with the Department to determine the actual or potential existence of third party coverage for medical expenses, and to establish initial or ongoing eligibility.

The state provides coverage for unborn children in households with income up to and including 133% FPL whose mothers are not otherwise eligible for Medicaid. The unborn child or children are counted as if born and living with the mother in determining family group size. See SPA page CS19 for additional standards.

4.1.10

Children ineligible for Medicaid as a result of the elimination of income disregards: See SPA page CS14 for this information.

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

4.2.1.

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

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

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

4.3. Describe the methods of establishing eligibility and continuing enrollment. (Section 2102)(b)(2)) (42CFR 457.350)

See SPA page CS24 for eligibility process for the State Plan.

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

Check here if this section does not apply to your state.

4.3.2 MAGI-based income methodologies: See SPA page CS15 for MAGI-based income methodologies. 4.4. Describe the procedures that assure that:

4.4.1. Through the screening procedures used at intake and follow-up eligibility determination, including any periodic redetermination, that only targeted low-

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income children who are ineligible for Medicaid or not covered under a group health plan or health insurance coverage (including access to a state health benefits plan) are furnished child health assistance under the state child health plan. (Sections 2102(b)(3)(A) and 2110(b)(2)(B)) (42 CFR 457.310(b) (42CFR 457.350(a)(1)) 457.80(c)(3))

See SPA page CS24 for screening and redetermination processes. 4.4.2. The Medicaid application and enrollment process is initiated and facilitated for children found through the screening to be potentially eligible for medical assistance under the state Medicaid plan under Title XIX. (Section 2102)(b)(3)(B)) (42CFR 457.350(a)(2))

See SPA page CS24 for procedures in place.

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

See SPA page CS24 for this information.

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

4.4.4.1.

Coverage provided to children in families at or below 200% FPL: describe the methods of monitoring substitution. See SPA page CS20 for information regarding substitution of coverage.

4.4.4.2.

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

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

4.4.4.4.

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

The minimum period without coverage under a group health plan, including any allowable exceptions to the waiting period.

The minimum employer contribution.

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The cost-effectiveness determination.

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

SCHIP is available to all targeted low-income Indian children in South Dakota regardless of tribal membership, enrollment, or affiliation. Inasmuch as the program is a statewide program, SCHIP is also made available to children living on Indian reservations within the State’s borders. Indian children not living on reservations are also potentially eligible for SCHIP coverage. The availability of services through the Indian Health Service is not considered insurance for the Medicaid, M-SCHIP or CHIP-NM program.

To help assure SCHIP is provided to Indian eligible children the Department has outreach efforts directed towards the Indian reservation areas of the state. The Indian Health Services currently plays and will continue to play a very important outreach role for targeted, low- income Indian children. Applications, enrollment assistance, and program information for SCHIP is available at IHS, Tribal, and Urban Indian Health locations in South Dakota.

SCHIP services will be provided to Indian children in the state eligible to receive services from the Indian Health Service as the Indian Health Service facilities and providers are enrolled as health care providers for the SCHIP program and eligible for reimbursement for services provided to SCHIP children. Tribal clinics and other providers are also eligible for reimbursement for covered services under SCHIP as are Urban Indian Health clinics. Section 5. Outreach (Section 2102(c))

Describe the procedures used by the state to accomplish:

Outreach to families of children likely to be eligible for child health assistance or other public or private health coverage to inform them of the availability of the programs, and to assist them in enrolling their children in such a program: (Section 2102(c)(1)) (42CFR 457.90)

The CHIP-NM program built on the existing programs of coverage for low income, and low- income uninsured children, (Medicaid and M-SCHIP), to provide health coverage for additional uncovered children in South Dakota. Outreach for these programs in South Dakota was implemented with a strategy for statewide outreach coordination and a local outreach strategy. Statewide outreach was accomplished with the participation of other programs offered by the Department of Social Services, other State agencies and the Indian Health Service. Outreach at this level relied on interagency agreements to facilitate referrals and the use of automated systems for information sharing on potentially eligible children. Administrative reforms of the eligibility process, publicity materials and advertising were also part of this outreach.

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Local coordination has been effectively done in communities and service areas of the State by Department of Social Services eligibility staff establishing connections with local resources to facilitate the identification and enrollment of children. Health care providers, schools, Tribal agencies, and many others have been very involved in distributing materials, providing applications and information, and assisting with enrollment.

Outreach for CHIP-NM program built on the successful outreach strategies already in place for the State’s medical assistance efforts. However, recognizing the differences in the income levels of the families targeted by CHIP-NM new efforts were made to supplement existing outreach, to help reach those potentially eligible for CHIP-NM. These additional outreach efforts began with a statewide training of Department of Social Services eligibility staff prior to the implementation of the program. New materials were developed for distribution and use around the state to prepare for the operation of the program including application forms, information sheets, brochures, and posters. Local Department of Social Services staff renewed connections with outreach partners to inform them of the new program and expanded eligibility levels. Medicaid and M-SCHIP providers were notified of the new program of coverage so they will be prepared to deliver health services.

The Department will also consider expanding the range of outreach partners to include entities not traditionally involved in outreach for publicly financed health care programs including the South Dakota Department of Labor, Job Service and other employment agencies, large and small employers and job training programs.

Section 6. Coverage Requirements for Children's Health Insurance (Section 2103)

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

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

6.1.1.

Benchmark coverage; (Section 2103(a)(1) and 42 CFR 457.420) 6.1.1.1.

FEHBP-equivalent coverage; (Section 2103(b)(1)) (If checked, attach copy of the plan.) 6.1.1.2.

State employee coverage; (Section 2103(b)(2)) (If checked, identify the plan and attach a copy of the benefits description.) 6.1.1.3.

HMO with largest insured commercial enrollment (Section 2103(b)(3)) (If checked, identify the plan and attach a copy of the benefits description.) 6.1.2.

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

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6.1.3.

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

6.1.4.

Secretary-Approved Coverage. (Section 2103(a)(4)) (42 CFR 457.450) 6.1.4.1.

Coverage of all benefits that are provided to children that is the same as the benefits provided under the Medicaid State plan, including Early Periodic Screening, Diagnostic, and Treatment (EPSDT). 6.1.4.2.

Comprehensive coverage for children under a Medicaid Section 1115 demonstration project 6.1.4.3.

Coverage that either includes the full EPSDT benefit or that the state has extended to the entire Medicaid population 6.1.4.4.

Coverage that includes benchmark coverage plus additional coverage 6.1.4.5.

Coverage that is the same as defined by Αexisting comprehensive state-based coverage 6.1.4.6.

Coverage under a group health plan that is substantially equivalent to or greater than benchmark coverage through a benefit by benefit comparison (Please provide a sample of how the comparison will be done) 6.1.4.7.

Other (Describe) 6.2. The state elects to provide the following forms of coverage to children: (Check all that apply. If an item is checked, describe the coverage with respect to the amount, duration and scope of services covered, as well as any exclusions or limitations) (Section 2110(a)) (42CFR 457.490)

Services provided under SCHIP are identical to the benefits covered under the South Dakota Medicaid program for low-income children in amount, scope and duration. As such the benefits include all mandatory Medicaid services for the categorically needy and ESPDT benefits as well as all the optional services covered under the South Dakota Medicaid program.

Most medical services provided to children under South Dakota Medicaid are accessed through a primary care case management managed care system. South Dakota will request the managed care waiver be incorporated into its Medicaid and SCHIP state plans. Children eligible for services under SCHIP will also be required to participate in the primary care case management system (PCCM). Under this program, a primary care physician (PCP) provides primary care services. Specialty

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services within the scope of the managed care program require a referral from the PCP. Emergency services, family planning services, and non-medical services (dental, chiropractic, optometry, podiatry, immunization and transportation), are exempt from all PCCM requirements. Non- waiver services are accessed directly by recipients. All services are reimbursed on a fee for service basis. There is no cost sharing for services provided to children under this plan.

Generally, all services provided under the Medicaid program must be “medically necessary”. SCHIP services must also meet the requirements of the definition of medically necessary used by Medicaid. Medically necessary services are those that: • are consistent with the recipient's symptoms, diagnosis, condition, or injury • are recognized as the prevailing standard and is consistent with generally accepted professional medical standards of the provider's peer group • are provided in response to a life-threatening condition; to treat pain, injury, illness, or infection; to treat a condition that could result in physical or mental disability; or to achieve a level of physical or mental function consistent with prevailing community standards for diagnosis or condition • are not furnished primarily for the convenience of the recipient or the provider • there is no other equally effective course of treatment available or suitable for the recipient requesting the service which is more conservative or substantially less costly.

Covered Services for Unborn Children

South Dakota provides coverage for unborn children in households with income up to and including 133% FPL whose mothers are not otherwise eligible for Medicaid due to citizenship status. Unborn children receive coverage that is the same as EPSDT services provided through the Medicaid State Plan. Coverage includes pregnancy related services provided through the Medicaid State Plan for uninsured pregnant women. Benefits to unborn children are delivered through the same delivery and utilization control systems.

South Dakota uses a bundled payment methodology for prenatal services, labor and delivery, and postpartum visits. The bundled payment is billed on the date of birth of the baby so the postpartum visit is prepaid. If the state is unable to use a bundled payment for any reason, the services are paid fee-for-service.

CHIP level FFP is available for all services provided during the pregnancy and for the bundled payment. No CHIP level FFP is available for non-bundled non- emergency services provided during the postpartum period.

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6.2.1.

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

Inpatient services include services provided in general acute care hospitals and specialty hospitals including rehabilitation, long term care, surgical specialty, psychiatric and children’s hospitals. Specialized units of acute care hospitals including neonatal intensive care, rehabilitation and psychiatric units are also covered. Inpatient hospital services are included as PCCM services requiring referrals. Psychiatric, Rehabilitation, and Long Term Care hospitals require prior authorization. Emergency psychiatric hospitalizations are authorized after admission. Inpatient surgeries that are normally performed in outpatient settings must be prior authorized. The Department monitors neonatal Intensive Care Services. There are no limitations on services provided.

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

Outpatient hospital services include laboratory services, X ray and other radiology services, emergency room services, medical supplies used during treatment at the facility, physical therapy, speech therapy, and occupational therapy when furnished or supervised by a licensed therapist and periodically reviewed by a physician, whole blood or packed red cells, drugs and biologicals which cannot be self- administered, dialysis treatments, services of hospital-based physicians, and outpatient surgical procedures. Outpatient hospital services are included as PCCM services. There are no limitations on services provided.

6.2.3.

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

Physician services include medical and surgical services; services and supplies furnished incidental to the professional services of a physician; psychiatric services; drugs and biologicals administered in a physician's office which cannot be self-administered; routine physical examinations; routine visits to a facility, home and community-based provider, or home; and family planning services. Services provided by nurse practitioners, physician assistants, nurse midwifes, and certified registered nurse anesthetists within their scope of practice are also covered. Specialty services are included as PCCM services requiring referrals. There are no limitations on services provided.

6.2.4.

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

Surgical services covered in addition to those provided under hospital or physician services include those services provided in ambulatory surgical centers (ASC) to patients who do not require hospitalization. Services include nursing, technician, use of ASC facilities, drugs,

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biologicals, surgical supplies, equipment, diagnostic and therapeutic services directly related to the provision of surgical procedures. Surgery services are included as PCCM services. There are no limitations on services provided.

6.2.5.

Clinic services (including health center services) and other ambulatory health care services. (Section 2110(a)(5))

Clinic services include preventive, diagnostic, therapeutic, rehabilitative, or palliative items services provided by federally qualified health centers and rural health or services under the medical direction of a physician and provided at the clinic or center. Clinic and center services are included as PCCM services and clinics and centers are eligible to be primary care providers. Services are limited to two visits per day, if the second visit is due to illness or injury sustained after the first visit.

6.2.6.

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

Prescription drug services include the following drugs, biologicals, and related items and services that are prescribed: • Legend eye preparations, vaginal therapeutics, otic pharmaceutical preparations, or inhalations for asthmatic conditions; • Antibiotic products which are known, either by sensitivity test or product information, to be the single item of choice for the diagnosis; • All other legend prescription drugs and biologicals, except for the items listed below. • Insulin; • Concentrated cryoprecipitate used in the home treatment of hemophilia; • Legend vitamins prescribed for the prenatal care of pregnant women; • Calcitriol if used for renal impairment and determined medically necessary by the prescriber; • Spacers, such as Aerochamber and InspirEase, and solutions that

Non-covered services include: • Non-legend prescription drugs and over-the-counter items and medical supplies except for those specifically listed above; • Medical supplies or delivery charges; • Legend oral vitamins except for legend vitamins prescribed for the prenatal care of pregnant women. • Items prescribed for weight control or appetite depressants; • Agents to promote fertility or treat impotence; • Agents used for cosmetic purposes;

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• Hair growth products; • Items or drugs manufactured by a firm that has not signed a rebate agreement with the CMS; • Items which exceed a 34-day supply, except for family planning items and prenatal vitamins; • Services, procedures, or drugs which are considered experimental; • Drugs and biologicals which the federal government has determined to be less than effective. Prescription drug services are included as PCCM services, with the exception of family planning drugs and items. Azidothymidine is available only for persons diagnosed with HIV. Clozaril and growth hormones are prior authorized.

6.2.7.

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

See 6.2.6.

6.2.8.

Laboratory and radiological services (Section 2110(a)(8))

Covered under 6.2.1, 6.2.2, 6.2.3, 6.2.4, 6.2.5 for diagnostic and treatment purposes. Coverage includes materials and services of technicians. Laboratory services are not included as PCCM services. There are no limitations on services provided.

6.2.9.

Prenatal care and prepregnancy family services and supplies (Section 2110(a)(9))

Covered under 6.2.3, 6.2.5, 6.2.6. Family planning and prenatal maternity care services are fully covered. Family planning services are exempt from PCCM requirements. There are no limitations on services provided.

6.2.10.

Inpatient mental health services, other than services described in 6.2.18., but including services furnished in a state-operated mental hospital and including residential or other 24-hour therapeutically planned structural services (Section 2110(a)(10))

Inpatient mental health services are provided in three different service settings. Psychiatric Inpatient Hospital services are covered under 6.2.1 and include psychiatric care in general acute care hospitals, psychiatric distinct part units, and free standing psychiatric hospitals, including a state operated adolescent psychiatric unit.

Inpatient psychiatric facility services are provided to children, with prior authorization. These services are exempt from PCCM requirements. There are no limitations on services provided.

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Inpatient residential treatment services for children are covered in residential treatment facilities. Coverage is limited to the treatment services provided and does not include room and board costs. Services are prior authorized. There are no limitations on services provided.

6.2.11.

Outpatient mental health services, other than services described in 6.2.19, but including services furnished in a state-operated mental hospital and including community-based services (Section 2110(a)(11)

Outpatient mental health services are covered in 6.2.3 when provided by physicians.

• Outpatient mental health services are covered in community mental health centers and include the following services: • Evaluations completed by a psychiatrist; • Evaluations or testing completed by a psychologist; • Comprehensive evaluations completed utilizing the expertise of more than one mental health professional; • Therapy provided to an individual; • Therapy provided to groups of two or more individuals, not exceeding ten persons; • Therapy provided to a family unit; • Partial day care services for a duration of three to six hours a day, including various types of therapy elements; and • Consultation with a psychiatrist, psychologist, or other mental health professional or physician concerning the patient's diagnosis or plan of treatment. • Outpatient mental health services are also available from licensed psychologists, certified social workers in private independent practice, and licensed professional counselors-mental health. Services include psychiatric evaluation, diagnostic interviews, individual, group and family therapy, and psychological testing. Services are limited to the equivalent of 40 hours of individual therapy per 12 month period, unless additional services are prior authorized.

Outpatient mental health services are included as PCCM services, unless provided to a person diagnosed as chronically mentally ill.

6.2.12.

Durable medical equipment and other medically-related or remedial devices (such as prosthetic devices, implants, eyeglasses, hearing aids, dental devices, and adaptive devices) (Section 2110(a)(12))

Durable medical equipment is covered and includes devices and assistive technology including:

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• devices for persons confined to beds, including hospital beds, bed pans, urinals, commodes, trapeze, lifts, standers, and pressure reduction therapy devices if extensive pressure sores exist; • mobility devices including wheelchairs and accessories (seats, trays, cushions, and positioning devices), canes, crutches and walkers; • oxygen and respiratory equipment and supplies; • glucose monitoring equipment and supplies; • dialysis equipment; • apnea monitors; • infusion pumps; • hearing aids and augmentative communication devices;

Medical equipment is purchased or rented at the discretion of the Department and requires documented medical necessity. Some devices have specific coverage criteria and limitations. Disposable supplies used with the equipment are included in coverage.

Prosthetic devices, except dental, are included for coverage, including braces, artificial limbs, artificial eyes, augmentative communication devices, items to replace all or part of an internal body organ, and the replacement of such devices required by a change in the patient's condition.

Eyeglasses and contact lenses are included in coverage and may be obtained from optical providers, physicians as described in 6.2.3, and optometrists along with professional services. Eyeglasses are limited to replacement after 15 months, unless significant vision changes have occurred. Not applicable to the unborn.

Durable Medical Equipment and prosthetic devices are included in the PCCM program. Eyeglasses and services of vision professionals are not included in the PCCM program.

6.2.13.

Disposable medical supplies (Section 2110(a)(13))

Disposable medical supplies are covered when medically necessary under each of the forms of coverage in Section 6.2.

6.2.14.

Home and community-based health care services (See instructions) (Section 2110(a)(14))

Home and community based services are covered when medically necessary and ordered by a physician and provided by a home health agency or qualified professional. Home health services include medical supplies, skilled nursing services, home health aide services, physical therapy, speech therapy, occupational therapy, respiratory therapy when

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ventilator dependent, and medical social services.

Individuals receiving these services must be unable to leave home without considerable effort. Services are of an intermittent nature, not more than once per day or 4 times per week. There is no limit on the number of visits a person may receive.

Extended home health aide services and private duty nursing services are covered when more than 3 consecutive hours of care are necessary. These services must be prior authorized.

Home based therapy services are also covered for children with mental disorders or who are seriously emotionally disturbed. A treatment plan must exist that documents the need for home based therapy services. Covered services include diagnostic assessment, individual therapy, family therapy, and collateral services. Services must be prior authorized.

6.2.15.

Nursing care services (See instructions) (Section 2110(a)(15))

Nursing care services are covered as described in 6.2.1, 6.2.2, 6.2.3, 6.2.4, 6.2.5 and 6.2.14.

6.2.16.

Abortion only if necessary to save the life of the mother or if the pregnancy is the result of an act of rape or incest (Section 2110(a)(16) Coverage is the same as Medicaid coverage.

6.2.17.

Dental services (Section 2110(a)(17))

Dental services are covered including diagnostic services (oral examinations and x-rays), preventive services (prophylaxis, topical fluoride, and sealant), restorative services (amalgam restorations, resin restorations, and crowns to anterior teeth), endodontics, prosthodontics (complete and partial dentures, adjustments, and repairs).

Medical/Dental procedures are also covered including oral surgery for extraction, surgical extractions and tooth reimplantation, treatment of fractures, reduction of TMJ dysfunction, and periodontics. Medically necessary orthodontic procedures including diagnosis, minor treatment, interceptive orthodontic treatment and treatment of dentition are covered.

Dental exams, prophylaxis, and topical fluoride are limited to two services in a 12-month period, sealants are limited to once in a three year period. Orthodontic services in excess of $500 must be prior authorized.

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All dental services are exempt from the PCCM program.

6.2.18.

Vision screenings and services (Section 2110(a)(24))

Vision screenings and services, in addition to the services of physicians in 6.2.3 include the services of optometrists. Covered services include examinations, removal of foreign bodies from the eye, vision screenings, and refractive services, eyeglasses and contact lenses. Services are outside of the PCCM program. Eyeglasses are limited to replacement after 15 months unless significant vision changes have occurred.

6.2.19.

Hearing screenings and services (Section 2110(a)(24))

Hearing screenings and services are limited to services provided by a physician as described in 6.2.3 or a clinical audiologist if the recipient has a referral from a physician or other licensed practitioner and the services are necessary to diagnose or treat a medical problem.

6.2.20.

Inpatient substance abuse treatment services and residential substance abuse treatment services (Section 2110(a)(18))

Inpatient treatment for substance abuse services are covered in certified facilities designed specifically for chemically dependent adolescents. Services are not included in the PCCM program, however, referrals from a physician are required. Services are prior authorized. Programs designed for substance abusing pregnant women are covered.

6.2.21.

Outpatient substance abuse treatment services (Section 2110(a)(19))

Outpatient treatment for substance abuse services are covered in certified facilities designed specifically for chemically dependent adolescents. Programs designed for substance abusing pregnant women are covered. Services are not included in the PCCM program however, referrals from a physician or court are required. Services are prior authorized.

6.2.22.

Case management services (Section 2110(a)(20))

Case management services are provided to all SCHIP children through the primary care case management program. Each program enrollee select or is assigned a primary care case management physician to provide the management and treatment of medical conditions and provide for referral for specialty care services. The primary care case manager can be either a physician (Family Practice, Internal Medicine, Pediatrics, OB-GYN, General Practice) or rural health clinic, federally qualified health center,

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or IHS facility. Services excluded from case management are emergency services, family planning, dental, podiatry, optometry, chiropractic, immunization, transportation and mental health services for chronically mentally ill clients.

Targeted case management services are available to severely and persistently mentally ill individuals at least 18 years of age when obtained from a certified case manager. The case managers provide face to face services including client identification and follow up, coordination of needs assessments, development of a case management plan, service mobilization, linkage and case monitoring. Services must include at least four units of service per month and non face to face services are limited on a monthly basis. 6.2.23.

Care coordination services (Section 2110(a)(21)) 6.2.24.

Physical therapy, occupational therapy, and services for individuals with speech, hearing, and language disorders (Section 2110(a)(22))

Physical therapy, occupational therapy, and services for individuals with speech, hearing and language disorders are covered when provided under forms of coverage in 6.2.1, 6.2.2, 6.2.4, 6.2.5, and 6.2.14. The services are also available from individual providers within their scope of practice when referred by physicians and required to diagnose or treat a medical condition. These services may also be provided by school districts when medically necessary and identified as part of a child’s individual education program. The services are included in the PCCM program. There are no limitations on the services provided.

6.2.25.

Hospice care (Section 2110(a)(23)) Hospice benefits will follow the amount, duration and scope of coverage as identified in the State Medicaid manual.

6.2.26.

EPSDT consistent with requirements of sections 1905(r) and 1902(a)(43) of the Act

Any Medicaid eligible child under 21 years of age, pursuant to Section 1905(r)(5) of the Act, has access to necessary health care, diagnostic services, treatment and other measures described in Section 1905(a) to correct or ameliorate defects and physical and mental illnesses and conditions discovered by the screening services whether or not such services are covered under this State plan.

Payment will also be allowed under EPSDT for the following medically necessary services:

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1. Nutrition items, prior authorization required for total parenteral nutrition. 2. Orthodontic services, prior authorization required. 3. Private duty nursing services, prior authorization required.

Payment will also be made for any medically necessary services provided to children less than 21 years of age in excess of service limitations applicable to adult Medicaid recipients.

6.2.27.

Any other medical, diagnostic, screening, preventive, restorative, remedial, therapeutic, or rehabilitative services. (See instructions) (Section 2110(a)(24))

Other medical services included in the plan are Chiropractic Services, Podiatry Services, Nutritional Services, Nursing Facility Services, Diabetes Self-management training programs, Vaccination Services and certain Organ Transplant Services.

Chiropractic services are limited to examinations and manual manipulations required to correct a subluxation of the spine. Services are outside of the PCCM program and limited to no more than one visit per day and thirty visits in a twelve-month period.

Podiatry services include the surgical and non-surgical diagnosis and treatment of conditions of the feet and lower extremities, excluding routine foot care. Services are outside of the PCCM program. There is no limit on the number of services provided.

Nutritional services are covered for children not able to obtain necessary nutrition through oral means. Enteral and perenteral nutrition are covered services. Perenteral nutrition services are prior authorized. Nutritional supplements are covered when physician ordered for conditions that exceed normal nutritional requirements.

Nursing Facility services are covered when medically necessary and individuals meet level of care and financial eligibility criteria for long term care. Nursing facility services are prior authorized.

Immunization services include all recommended vaccinations and are covered under Section 6.2.6, prescription drugs.

Organ transplant services include Kidney, Cornea, Bone Marrow, Liver and Heart Transplants. All transplant services are covered only when all other medical and surgical treatments have been exhausted, patients are free from adverse factors and there is likelihood of success or survival. Transplants are limited to the transplantation of human organs. With the exception of kidney and cornea transplants, transplant procedures are

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prior authorized.

6.2.28. Premiums for private health care insurance coverage (Section 2110(a)(25)) 6.2.29.

Medical transportation (Section 2110(a)(26))

Medical transportation includes medically necessary air ambulance, ground ambulance, wheelchair transportation and other medical transportation. Ambulance services are necessary when other forms of transportation may endanger a person’s life or health. Ground ambulance includes advanced life support and basic life support services and attendants. Air ambulance includes fixed wing emergency transportation, rotary emergency transportation, and medical air transportation. Air ambulance must be medically necessary because of time, distance and emergency. Wheelchair transportation includes transportation services to persons that are confined to wheelchairs or stretchers to and from medical services.

Other transportation services are available to assist persons obtain necessary medical services. These services include reimbursement for the use of private automobiles, meals and lodging, community transportation providers, tribal transportation providers and commercial carriers.

6.2.30.

Enabling services (such as transportation, translation, and outreach services (Section 2110(a)(27))

6.2.31.

Any other health care services or items specified by the Secretary and not included under this section (Section 2110(a)(28))

6.2- MHPAEA Section 2103(c)(6)(A) of the Social Security Act requires that, to the extent that it provides both medical/surgical benefits and mental health or substance use disorder benefits, a State child health plan ensures that financial requirements and treatment limitations applicable to mental health and substance use disorder benefits comply with the mental health parity requirements of section 2705(a) of the Public Health Service Act in the same manner that such requirements apply to a group health plan. If the state child health plan provides for delivery of services through a managed care arrangement, this requirement applies to both the state and managed care plans. These requirements are also applicable to any additional benefits provided voluntarily to the child health plan population by managed care entities and will be considered as part of CMS’s contract review process at 42 CFR 457.1201(l).

6.2.1- MHPAEA Before completing a parity analysis, the State must determine whether each covered benefit is a medical/surgical, mental health, or substance use disorder benefit based on a standard that is consistent with state and federal law and generally recognized independent standards of medical practice. (42 CFR 457.496(f)(1)(i))

6.2.1.1- MHPAEA Please choose the standard(s) the state uses to determine whether a

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covered benefit is a medical/surgical benefit, mental health benefit, or substance use disorder benefit. The most current version of the standard elected must be used. If different standards are used for different benefit types, please specify the benefit type(s) to which each standard is applied. If “Other” is selected, please provide a description of that standard.

International Classification of Disease (ICD) Diagnostic and Statistical Manual of Mental Disorders (DSM) State guidelines (Describe: ) Other (Describe: ) 6.2.1.2- MHPAEA Does the State provide mental health and/or substance use disorder benefits?

Yes No

6.2.2- MHPAEA Section 2103(c)(6)(B) of the Social Security Act (the Act) provides that to the extent a State child health plan includes coverage of early and periodic screening, diagnostic, and treatment services (EPSDT) defined in section 1905(r) of the Act and provided in accordance with section 1902(a)(43) of the Act, the plan shall be deemed to satisfy the parity requirements of section 2103(c)(6)(A) of the Act.

6.2.2.1- MHPAEA Does the State child health plan provide coverage of EPSDT? The State must provide for coverage of EPSDT benefits, consistent with Medicaid statutory requirements, as indicated in section 6.2.26 of the State child health plan in order to answer “yes.”

Yes No 6.2.2.2- MHPAEA EPSDT benefits are provided to the following:

All children covered under the State child health plan. A subset of children covered under the State child health plan. Please describe the different populations (if applicable) covered under the State child health plan that are provided EPSDT benefits consistent with Medicaid statutory requirements. 6.2.2.3- MHPAEA To be deemed compliant with the MHPAEA parity requirements, States

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must provide EPSDT in accordance with sections 1902(a)(43) and 1905(r) of the Act (42 CFR 457.496(b)). The State assures each of the following for children eligible for EPSDT under the separate State child health plan:

All screening services, including screenings for mental health and substance use disorder conditions, are provided at intervals that align with a periodicity schedule that meets reasonable standards of medical or dental practice as well as when medically necessary to determine the existence of suspected illness or conditions. (Section 1905(r))

All diagnostic services described in 1905(a) of the Act are provided as needed to diagnose suspected conditions or illnesses discovered through screening services, whether or not those services are covered under the Medicaid state plan. (Section 1905(r))

All items and services described in section 1905(a) of the Act are provided when needed to correct or ameliorate a defect or any physical or mental illnesses and conditions discovered by the screening services, whether or not such services are covered under the Medicaid State plan. (Section 1905(r)(5))

Treatment limitations applied to services provided under the EPSDT benefit are not limited based on a monetary cap or budgetary constraints and may be exceeded as medically necessary to correct or ameliorate a medical or physical condition or illness. (Section 1905(r)(5))

Non-quantitative treatment limitations, such as definitions of medical necessity or criteria for medical necessity, are applied in an individualized manner that does not preclude coverage of any items or services necessary to correct or ameliorate any medical or physical condition or illness. (Section 1905(r)(5))

EPSDT benefits are not excluded on the basis of any condition, disorder, or diagnosis. (Section 1905(r)(5))

The provision of all requested EPSDT screening services, as well as any corrective treatments needed based on those screening services, are provided or arranged for as necessary. (Section 1902(a)(43))

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All families with children eligible for the EPSDT benefit under the separate State child health plan are provided information and informed about the full range of services available to them. (Section 1902(a)(43)(A)) 6.2.3- MHPAEA In order to conduct the parity analysis, the State must place all medical/surgical and mental health and substance use disorder benefits covered under the State child health plan into one of four classifications: Inpatient, outpatient, emergency care, and prescription drugs. (42 CFR 457.496(d)(2)(ii); 42 CFR 457.496(d)(3)(ii)(B))

6.2.3.1 MHPAEA Please describe below the standard(s) used to place covered benefits into one of the four classifications.

6.2.3.1.1 MHPAEA The State assures that:

The State has classified all benefits covered under the State plan into one of the four classifications. The same reasonable standards are used for determining the classification for a mental health or substance use disorder benefit as are used for determining the classification of medical/surgical benefits. 6.2.3.1.2- MHPAEA Does the State use sub-classifications to distinguish between office visits and other outpatient services?

Yes No

6.2.3.1.2.1- MHPAEA If the State uses sub-classifications to distinguish between outpatient office visits and other outpatient services, the State assures the following:

The sub-classifications are only used to distinguish office visits from other outpatient items and services, and are not used to distinguish between similar services on other bases (ex: generalist vs. specialist visits). 6.2.3.2 MHPAEA The State assures that:

Mental health/ substance use disorder benefits are provided in all classifications in which medical/surgical benefits are provided under the State child health plan. Annual and Aggregate Lifetime Dollar Limits

6.2.4- MHPAEA A State that provides both medical/surgical benefits and mental health and/or substance use disorder benefits must comply with parity requirements related to annual and aggregate

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lifetime dollar limits for benefits covered under the State child health plan. (42 CFR 457.496(c))

6.2.4.1- MHPAEA Please indicate whether the State applies an aggregate lifetime dollar limit and/or an annual dollar limit on any mental health or substance abuse disorder benefits covered under the State child health plan.

Aggregate lifetime dollar limit is applied Aggregate annual dollar limit is applied No dollar limit is applied 6.2.4.2- MHPAEA Are there any medical/surgical benefits covered under the State child health plan that have either an aggregate lifetime dollar limit or an annual dollar limit? If yes, please specify what type of limits apply.

Yes (Type(s) of limit: ) No 6.2.4.3 – MHPAEA. States applying an aggregate lifetime or annual dollar limit on medical/surgical benefits and mental health or substance use disorder benefits must determine whether the portion of the medical/surgical benefits to which the limit applies is less than one- third, at least one-third but less than two-thirds, or at least two-thirds of all medical/surgical benefits covered under the State plan (42 CFR 457.496(c)). The portion of medical/surgical benefits subject to the limit is based on the dollar amount expected to be paid for all medical/surgical benefits under the State plan for the State plan year or portion of the plan year after a change in benefits that affects the applicability of the aggregate lifetime or annual dollar limits. (42 CFR 457.496(c)(3))

The State assures that it has developed a reasonable methodology to calculate the portion of covered medical/surgical benefits which are subject to the aggregate lifetime and/or annual dollar limit, as applicable. 6.2.4.3.1- MHPAEA Please indicate the portion of the total costs for medical and surgical benefits covered under the State plan which are subject to a lifetime dollar limit:

Less than 1/3 At least 1/3 and less than 2/3 At least 2/3

6.2.4.3.2- MHPAEA Please indicate the portion of the total costs for medical and surgical benefits covered under the State plan which are subject to an annual dollar

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limit:

Less than 1/3 At least 1/3 and less than 2/3 At least 2/3 6.2.4.3.2.1- MHPAEA If the State applies an aggregate lifetime or annual dollar limit to at least 1/3 and less than 2/3 of all medical/surgical benefits, the State assures the following (42 CFR 457.496(c)(4)(i)(B)); (42 CFR 457.496(c)(4)(ii)):

The State applies an aggregate lifetime or annual dollar limit on mental health or substance use disorder benefits that is no more restrictive than an average limit calculated for medical/surgical benefits. 6.2.4.3.2.2- MHPAEA If at least 2/3 of all medical/surgical benefits are subject to an annual or lifetime limit, the State assures either of the following (42 CFR 457.496(c)(2)(i)); (42 CFR 457.496(c)(2)(ii)):

The aggregate lifetime or annual dollar limit is applied to both medical/surgical benefits and mental health and substance use disorder benefits in a manner that does not distinguish between medical/surgical benefits and mental health and substance use disorder benefits; or The aggregate lifetime or annual dollar limit placed on mental health and substance use disorder benefits is no more restrictive than the aggregate lifetime or annual dollar limit on medical/surgical benefits. Quantitative Treatment Limitations

6.2.5- MHPAEA Does the State apply quantitative treatment limitations (QTLs) on any mental health or substance use disorder benefits in any classification of benefits? If yes, specify the classification(s) of benefits in which the State applies one or more QTLs on any mental health or substance use disorder benefits.

Yes (Specify: ) No 6.2.5.1- MHPAEA Does the State apply any type of QTL on any medical/surgical benefits?

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Yes No 6.2.5.2- MHPAEA Within each classification of benefits in which the State applies a type of QTL on any mental health or substance use disorder benefits, the State must determine the portion of medical and surgical benefits in the classification which are subject to the limitation. More specifically, the State must determine the ratio of (a) the dollar amount of all payments expected to be paid under the State plan for medical and surgical benefits within a classification which are subject to the type of quantitative treatment limitation for the plan year (or portion of the plan year after a mid-year change affecting the applicability of a type of quantitative treatment limitation to any medical/surgical benefits in the class) to (b) the dollar amount expected to be paid for all medical and surgical benefits within the classification for the plan year. For purposes of this paragraph, all payments expected to be paid under the State plan includes payments expected to be made directly by the State and payments which are expected to be made by MCEs contracting with the State. (42 CFR 457.496(d)(3)(i)(C))

The State assures it has applied a reasonable methodology to determine the dollar amounts used in the ratio described above for each classification within which the State applies QTLs to mental health or substance use disorder benefits. (42 CFR 457.496(d)(3)(i)(E)) 6.2.5.3- MHPAEA For each type of QTL applied to any mental health or substance use disorder benefits within a given classification, does the State apply the same type of QTL to “substantially all” (defined as at least two-thirds) of the medical/surgical benefits within the same classification? (42 CFR 457.496(d)(3)(i)(A))

Yes No 6.2.5.3.1- MHPAEA For each type of QTL applied to mental health or substance use disorder benefits, the State must determine the predominant level of that type which is applied to medical/surgical benefits in the classification. The “predominant level” of a type of QTL in a classification is the level (or least restrictive of a combination of levels) that applies to more than one-half of the medical/surgical benefits in that classification, as described in 42 CFR 457.496(d)(3)(i)(B). The portion of medical/surgical benefits in a classification to which a given level of a QTL type is applied is based on the dollar amount of payments expected to be paid for medical/surgical benefits subject to that level as compared to all medical/surgical benefits in the classification, as described in 42 CFR 457.496(d)(3)(i)(C). For each type of quantitative treatment limitation applied to mental health or substance use disorder benefits, the State assures:

The same reasonable methodology applied in determining the dollar amounts used to determine whether substantially all medical/surgical benefits

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within a classification are subject to a type of quantitative treatment limitation also is applied in determining the dollar amounts used to determine the predominant level of a type of quantitative treatment limitation applied to medical/surgical benefits within a classification. (42 CFR 457.496(d)(3)(i)(E)) The level of each type of quantitative treatment limitation applied by the State to mental health or substance use disorder benefits in any classification is no more restrictive than the predominant level of that type which is applied by the State to medical/surgical benefits within the same classification. (42 CFR 457.496(d)(2)(i)) Non-Quantitative Treatment Limitations

6.2.6- MHPAEA The State may utilize non-quantitative treatment limitations (NQTLs) for mental health or substance use disorder benefits, but the State must ensure that those NQTLs comply with all the mental health parity requirements. (42 CFR 457.496(d)(4)); (42 CFR 457.496(d)(5)) 6.2.6.1 – MHPAEA If the State imposes any NQTLs, complete this subsection. If the State does not impose NQTLs, please go to Section 6.2.7-MHPAEA.

The State assures that the processes, strategies, evidentiary standards or other factors used in the application of any NQTL to mental health or substance use disorder benefits are no more stringent than the processes, strategies, evidentiary standards or other factors used in the application of NQTLs to medical/surgical benefits within the same classification. 6.2.6.2 – MHPAEA The State or MCE contracting with the State must comply with parity if they provide coverage of medical or surgical benefits furnished by out-of-network providers.

6.2.6.2.1- MHPAEA Does the State or MCE contracting with the State provide

coverage of medical or surgical benefits provided by out-of-network providers?

Yes No 6.2.6.2.2- MHPAEA If yes, the State must provide access to out-of-network providers for mental health or substance use disorder benefits. Please assure the following:

The State attests that when determining access to out-of-network providers within a benefit classification, the processes, strategies, evidentiary standards, or other factors used to determine access to those providers for mental health/ substance use disorder benefits are comparable to and applied no more stringently than the processes, strategies, evidentiary standards or other factors

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used to determine access for out- of-network providers for medical/surgical benefits. Availability of Plan Information 6.2.7- MHPAEA The State must provide beneficiaries, potential enrollees, and providers with information related to medical necessity criteria and denials of payment or reimbursement for mental health or substance use disorder services (42 CFR 457.496(e)) in addition to existing notice requirements at 42 CFR 457.1180.

6.2.7.1- MHPAEA Medical necessity criteria determinations must be made available to any current or potential enrollee or contracting provider, upon request. The state attests that the following entities provide this information:

State Managed Care entities Both Other

6.2.7.2- MHPAEA Reason for any denial for reimbursement or payment for

mental health or substance use disorder benefits must be made available to the

enrollee by the health plan or the State. The state attests that the following

entities provide denial information:

State Managed Care entities Both

Other

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

6.3.1.

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

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

6.4 Additional Purchase Options. If the state wishes to provide services under the plan

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through cost effective alternatives or the purchase of family coverage, it must request the appropriate option. To be approved, the state must address the following: (Section 2105(c)(2) and(3)) (42 CFR 457.1005 and 457.1010)

6.4.1.

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

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

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

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

6.4.2.

Purchase of Family Coverage. Describe the plan to purchase family coverage. Payment may be made to a state for the purpose of family coverage under a group health plan or health insurance coverage that includes coverage of targeted low- income children, if it demonstrates the following: (Section 2105(c)(3)) (42CFR 457.1010)

6.4.2.1. Purchase of family coverage is cost-effective relative to the amounts that the state would have paid to obtain comparable coverage only of the targeted low-income children involved; and (Describe the associated costs for purchasing the

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family coverage relative to the coverage for the low income children.) (Section 2105(c)(3)(A)) (42CFR 457.1010(a))

6.4.2.2. The state assures that the family coverage would not otherwise substitute for health insurance coverage that would be provided to such children but for the purchase of family coverage. (Section 2105(c)(3)(B)) (42CFR 457.1010(b))

6.4.2.3. The state assures that the coverage for the family otherwise meets title XXI requirements. (42CFR 457.1010(c))

Section 7. Quality and Appropriateness of Care

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

7.1. Describe the methods (including external and internal monitoring) used to assure the quality and appropriateness of care, particularly with respect to well-baby care, well- child care, and immunizations provided under the plan. (2102(a)(7)(A)) (42CFR 457.495(a))

The SCHIP program will use the methods that exist for the Medicaid program to assure quality and appropriateness of care since the programs will be jointly administered and delivered. There are numerous strategies that South Dakota uses under these programs to monitor quality and appropriateness of care including both external and internal sources.

The most comprehensive mechanism used by the State in the SCHIP program is the Primary Care Case Management system. Under this program each recipient of SCHIP selects a primary care physician or clinic (PCP) to provide primary care and authorize and manage all specialty medical care through a referral process. Under this program each PCP receives a monthly report of all the medical services used by each client enrolled with that PCP. In this way each PCP is able to provide case management services and monitor the appropriateness of services provided to enrollees.

The state also monitors the performance of each PCP with regard to the number of clients enrolled with each PCP, the proportion of services provided directly or referred by each PCP, and the satisfaction of clients with PCPs via a complaint and disenrollment process used by recipients to change PCP’s. Case file reviews will be conducted on quality complaints. This program operates for Medicaid recipients under waiver authority from CMS. The waiver process provides for a biannual review of the program by CMS, and a number of focused clinical studies to be completed each renewal period. Monitoring of this program by CMS has been ongoing since 1993, with the third and most recent renewal expiring September 30,

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2002. South Dakota will request the managed care waiver be incorporated into its Medicaid and SCHIP state plans. All of the quality and appropriateness monitoring available to Medicaid for the PCCM program will also be provided to the SCHIP program.

External reviews of medical, surgical and hospital services are conducted by the Professional Review Organization (PRO) in South Dakota. A large sample of services is selected for review each month on a variety of criteria, including specific diagnoses and random selections. Services provided to SCHIP clients will also be included in the sample selected for PRO review. The PRO reports to each provider and to the State the results of each review recommending approval, denial, changes or improvements to service delivery, action by the Medicaid program or referral to other entities for action.

Drug utilization review activities will also be made available to SCHIP clients through the pharmacy benefit management system used by the Department to provide prescription drug coverage. Each drug prescription is processed through a prospective drug use review protocol prior to authorizing a pharmacist to dispense a drug product. This point of service process checks for drug to drug interactions, contraindications, duplicate therapy, dosage, early refill, and days-supply edits to help assure appropriate and quality prescription drug services. The drug utilization review requirements are purchased from a national vendor and incorporated into the Department’s system. A licensed pharmacist employed by the Department oversees the operation of the DUR system.

The SCHIP program will also make use of the capabilities of the MMIS claims processing system to process and pay claims for SCHIP clients using the same procedures and rates as the Medicaid program. The MMIS claims systems has numerous edits, reports and capabilities to assist in assuring appropriate and quality services are delivered to SCHIP clients. The MMIS is the source for the Medicaid reporting of EPSDT screening services to CMS, and these reporting capabilities will be available to report on the SCHIP children also.

Surveillance and utilization review system (SURS) capabilities used by the Department to monitor Medicaid services will also be used to monitor the services obtained by SCHIP clients for fraud and abuse. This will provide the SCHIP program a capacity for the full investigation, referral to appropriate law enforcement, and reporting of sanctions as required. The SURS is the designated unit in the Department of Social Services for investigation of fraud, and collaboration with the South Dakota Attorney General’s office and U.S. Attorney. A toll free fraud reporting telephone number is also available to provide a convenient means to report fraud. Surveys and quality assurance reports will also be used to monitor the quality and appropriateness of services provided the SCHIP clients. Client surveys have been an important part of the SCHIP annual reporting that has been completed by South Dakota for each year of the SCHIP program. . Specific questions are addressed to the families of SCHIP children asking about the

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quality and satisfaction that families have with the services provided. These surveys and the specific questions will continue under the Medicaid and SCHIP programs.

A number of quality assurance reports based on the HEDIS model have been completed for the SCHIP eligible children covered under South Dakota’s SCHIP program. These reports specifically address the key areas of immunization, well child and well baby. In addition to reports on those subjects reports have been completed on Dental, Optometry, Asthma, Substance Abuse, and Eating Disorders. Plans include repeating these measure to monitor progress and also to expand the number of measures under the HEDIS to be completed for the SCHIP children in South Dakota.

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

7.1.1.

Quality standards

The state will establish standards for the performance of PCP’s to meet for the well child screenings and immunization levels for children in the CHIP NM program.

7.1.2.

Performance measurement

The state will conduct HEDIS based measurement studies for immunization, dental, well child screenings, optometry, substance abuse and mental health services.

7.1.3.

Information strategies

7.1.4.

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

7.2.1 Access to well-baby care, well-child care, well-adolescent care and childhood and adolescent immunizations. (Section 2102(a)(7)) (42CFR 457.495(a)) In addition to inclusion on the HCFA 416 report that measures utilization of EPSDT services, South Dakota, as part of its SCHIP general satisfaction survey of recipients routinely asks recipients access to care questions. The survey instrument specifically asks questions relating to well child care, immunizations, vision services, substance abuse and dental services. The surveys provide excellent feedback regarding recipients access to care. Parents of SCHIP kids are routinely provided with educational materials relating to EPSDT services to inform them on the importance of preventive healthcare.

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Access to quality primary and preventive health services will be measured by the number of new SCHIP children enrolled in medical assistance primary care case management system. Utilization based studies for immunization, dental, well child screenings, optometry, substance abuse and mental health services will be used to provide additional measurement of access to services. Further, additional measurements are collected in accordance with Section 9.3.7 of this state plan and are included in the SCHIP annual reports.

7.2.2 Access to covered services, including emergency services as defined in 42 CFR 457.10. (Section 2102(a)(7)) 42CFR 457.495(b)) SCHIP will use the same delivery system, provider network and covered services as the Medicaid program in South Dakota. One of the benefits of this arrangement is the excellent provider participation for all types of service providers in the State. Nearly all primary care and specialty physicians participate in the program, all inpatient and outpatient hospitals participate, nearly all pharmacies participate, and participation from allied health providers is also very good. Using the PCCM system for SCHIP facilitates access to primary care and the use of PCP’s to provide referrals for non- emergency specialty services enhances access to specialty services as referral arrangements with PCP’s are established and specialists are not accessed for primary care purposes.

The selected SCHIP program structure allows the maximum use of the available rural providers to enhance access to services in the rural areas of South Dakota. The Indian Health Service and Tribal services are key resources in the most under-served areas of the State. Each IHS service unit has participating PCP providers in the PCCM program. The SCHIP program is also structured so those eligible clients have maximum access to IHS programs without a referral from another PCP if the individuals have selected a non-IHS PCP. Tribal clinics are

also eligible to be PCP providers as federally qualified health centers (FQHC’s). Rural areas outside of American Indian reservation are served by rural health clinics and federally qualified health centers that are also enrolled as PCP entities to enhance service availability. Favorable reimbursement mechanisms are in place for all of these provider types to ensure the availability of services.

Under the PCCM program the Department of Social Services carefully monitors the capacity of each participating PCP and presently averages about 85 enrollees per PCP entity, with very few PCP’s closed to new enrollees. PCP’s are limited to a maximum of 750 enrollees. County and sub-state areas are also monitored for PCP availability. Most PCCM participants select their own PCP’s and have free choice of providers for non-PCCM services. Time and distance standards ensure that PCCM enrollees do not have to travel more than 75 miles to their PCP. Routine monitoring of PCP performance also includes an analysis of PCP provided services versus referred services with the dual purpose of ensuring PCP’s are accessible and providing services to enrolled clients, and

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also not withholding appropriate referrals for specialty care.

The Department also carefully monitors the PCP changes and disenrollment reasons to assure that access to care issues are resolved. In addition, the Department randomly monitors PCP compliance with 24 hour per day, seven day per week requirement for PCP availability.

The SCHIP program uses the definition and procedure for accessing emergency services that applies to Medicaid that are consistent with Federal law.

Access and availability to services are presently monitored under Medicaid. This monitoring will also include SCHIP enrollees. Surveys of participants to measure access to services, waiting times, and satisfaction with service availability will continue to be completed with all Medicaid and SCHIP children.

7.2.3 Appropriate and timely procedures to monitor and treat enrollees with chronic, complex, or serious medical conditions, including access to an adequate number of visits to specialists experienced in treating the specific medical condition and access to out-of-network providers when the network is not adequate for the enrollee's medical condition. (Section 2102(a)(7)) (42CFR 457.495(c))

Individuals with special healthcare needs are exempt from managed care requirements. As such, these individuals are not restricted under the SCHIP program. All SCHIP recipients have the same access to specialists as private pay individuals or individuals with private health insurance.

7.2.4 Decisions related to the prior authorization of health services are completed in accordance with state law or, in accordance with the medical needs of the patient, within 14 days after the receipt of a request for services. (Section 2102(a)(7)) (42CFR 457.495(d))

Decisions related to the prior authorization of health services are completed in accordance with the medical needs of the patient, within 14 days after the receipt of a request for services. The prior authorization policy is consistent with the prior authorizations under the South Dakota Medicaid Program. Oftentimes, the request for prior authorization does not contain sufficient documentation to make a determination. When that occurs, the physicians are contacted, additional documentation is requested, and the determination is made upon receipt of the additional documentation. The department maintains a database of prior authorizations, and monitoring of the determination within 14 days of receipt can be easily documented.

Section 8. Cost Sharing and Payment (Section 2103(e))

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

Effective Date: August 24, 2001 48 Approval Date: Model Application Template for the State Children's Health Insurance Program

to Section 9.

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

8.1.1.

YES 8.1.2.

NO, skip to question 8.8.

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

8.2.1. Premiums: 8.2.2. Deductibles: 8.2.3. Coinsurance or copayments: 8.2.4. Other: Unborn children are excluded from cost-sharing requirements.

8.3. Describe how the public will be notified, including the public schedule, of this cost- sharing (including the cumulative maximum) and changes to these amounts and any differences based on income. (Section 2103(e)((1)(B)) (42CFR 457.505(b)) 8.4. The state assures that it has made the following findings with respect to the cost sharing in its plan: (Section 2103(e))

8.4.1. Cost-sharing does not favor children from higher income families over lower income families. (Section 2103(e)(1)(B)) (42CFR 457.530) 8.4.2. No cost-sharing applies to well-baby and well-child care, including age-appropriate immunizations. (Section 2103(e)(2)) (42CFR 457.520)

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

8.5. Describe how the state will ensure that the annual aggregate cost-sharing for a family does not exceed 5 percent of such family's income for the length of the child's eligibility period in the State. Include a description of the procedures that do not primarily rely on a refund given by the state for overpayment by an enrollee: (Section 2103(e)(3)(B)) (42CFR 457.560(b) and 457.505(e))

8.6 Describe the procedures the state will use to ensure American Indian (as defined by the Indian Health Care Improvement Act of 1976) and Alaska Native children will be excluded from cost-sharing. (Section 2103(b)(3)(D)) (42CFR 457.535)

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

Effective Date: August 24, 2001 49 Approval Date: Model Application Template for the State Children's Health Insurance Program

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

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

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

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

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

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

8.8.1.

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

8.8.2.

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

8.8.3.

No funds under this title will be used for coverage if a private insurer would have been obligated to provide such assistance except for a provision limiting this obligation because the child is eligible under

this title. (Section 2105(c)(6)(A)) (42CFR 457.626(a)(1))

8.8.4.

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

8.8.5.

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

8.8.6.

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

Effective Date: August 24, 2001 50 Approval Date: Model Application Template for the State Children's Health Insurance Program

Section 9. Strategic Objectives and Performance Goals and Plan Administration (Section 2107)

9.1. Describe strategic objectives for increasing the extent of creditable health coverage among targeted low-income children and other low-income children: (Section 2107(a)(2)) (42CFR 457.710(b))

South Dakota implemented CHIP-NM as an additional effort to address the objectives stated in the original M-SCHIP state plan. Those objectives are:

1. Achieve a measurable reduction in the number of uninsured children in South Dakota beginning July 1, 1998.

2. Improve access to quality primary and preventive health care services under Medicaid for approved SCHIP eligibles, new Medicaid eligibles, and previously non-enrolled children on July 1, 1998.

3. Develop better measurement capabilities of health insurance coverage, and health care service availability and quality to children in South Dakota, beginning July 1, 1998.

Effective July 1, 2000 each objective will include the CHIP-NM program.

9.2. Specify one or more performance goals for each strategic objective identified: (Section 2107(a)(3)) (42CFR 457.710(c))

1. Achieve a measurable reduction in the number of uninsured children in South Dakota.

1.1 Implement CHIP-NM to provide coverage to an additional 2,400 targeted, uninsured children in families with incomes from 140% to 200% of the federal poverty level beginning July 1, 2000.

1.2 Continue to extend Medicaid to children age zero through eighteen at Medicaid eligibility levels in effect prior to July 1, 1998, and other low income children from 133% to 140% of the federal poverty level as amended effective April 1, 1999.

1.3 Continue to extend SCHIP benefits to targeted, uninsured, non-Medicaid eligible children age 6 through 18 in families with incomes from 100% to 133% of the federal poverty levels, and to targeted, uninsured, non Medicaid eligible children age 0 through 18 in families with incomes from 133% to 140% as amended effective April 1, 1999.

1.4 Continue to utilize a systematic approach to identify uninsured children with low incomes using Department data resources, partnerships with other public programs, and local involvement of interested parties including schools,

Effective Date: August 24, 2001 51 Approval Date: Model Application Template for the State Children's Health Insurance Program

providers, and others.

1.5 Expand the simplified medical assistance application process to include CHIP-NM the same as the Medicaid and M-SCHIP medical assistance programs.

2. Improve access to quality primary and preventive health care services for CHIP- NM eligible children.

2.1 Enroll 95% of all newly approved CHIP-NM children in the South Dakota medical assistance primary care case management program within 1 month of their enrollment, beginning July 1, 2000.

2.2 Ensure each new CHIP-NM enrollee receives covered services, cost sharing and EPSDT information at the time that their eligibility is approved.

2.3 Include CHIP-NM eligible children in the quality measurement mechanisms that are used for Medicaid and M-SCHIP including measures of immunization, well child care, adolescent well care, satisfaction and other measures of health care quality. Measures will come from the HCFA 416 report, the Department of Health Immunization tracking system, and the evaluation process used in South Dakota’s PRIME managed care program operated under 1915(b) waiver authority. This evaluation process also uses client and provider surveys independent evaluations and clinical studies to report cost effectiveness and quality to CMS for waiver renewal purposes, and annual SCHIP reporting requirements. South Dakota will request the managed care waiver be incorporated into its Medicaid and SCHIP state plans.

3. Develop better measurement capabilities of health insurance coverage, health care service availability and quality to children in South Dakota.

3.1 Modify the Medicaid Management Information System to make CHIP-NM tracking and reporting capabilities available to measure enrollment, service, utilization, and overall program effectiveness. This enhancement will make all MARS and CMS reports available for CHIP-NM.

9.3. Describe how performance under the plan will be measured through objective, independently verifiable means and compared against performance goals in order to determine the state's performance, taking into account suggested performance indicators as specified below or other indicators the state develops: (Section 2107(a)(4)(A),(B)) (42CFR 457.710(d))

1. Achieve a measurable reduction in the number of uninsured children in South Dakota.

The success of this objective will be determined by the number of uninsured children in South Dakota who receive health insurance coverage as the result of the CHIP-

Effective Date: August 24, 2001 52 Approval Date: Model Application Template for the State Children's Health Insurance Program

NM State Plan amendment, M-SCHIP, or Medicaid coverage. Evidence of this reduction will come from South Dakota medical assistance enrollment figures, estimates provided by the United States Census Bureau and supported with survey data from the Behavioral Health Survey and other publications. (The South Dakota Behavioral Risk Factor Surveillance System (BRFSS) is designed to collect information on the health behaviors in the State.

The survey was initiated in 1987 by the South Dakota Department of Health with the assistance of the Centers for Disease Control and Prevention, and has been on-going since 1987. For the SCHIP Program in South Dakota, the BRFSS surveys South Dakotans to assist in measurements as to why a child is without health insurance, whether coverage such as Medicaid and SCHIP have been considered for those who respond that the child is uninsured, crowd out issues, etc. to determine effectiveness of outreach promotions.)

2. Improve access to quality primary and preventive health care services under Medicaid for CHIP-NM eligible children.

Access to quality primary and preventive health services will be measured by the number of new CHIP-NM children enrolled in medical assistance primary care case management system. Utilization based studies for immunization, dental, well child screenings, optometry, substance abuse and mental health services will be used to provide additional measurement of access to services.

3. Develop better measurement capabilities of health insurance coverage, and health care service availability and quality to children in South Dakota.

Adequate data is available for the completion of annual reports and evaluations for CHIP-NM as well as the original M-SCHIP program in compliance with Section 9.5 of this State Plan Amendment.

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

9.3.1.

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

The reduction in the percentage of uninsured children. 9.3.3.

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

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

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

Other child appropriate measurement set. List or describe the set used. 9.3.7.

If not utilizing the entire HEDIS Measurement Set, specify which measures will be collected, such as:

Effective Date: August 24, 2001 53 Approval Date: Model Application Template for the State Children's Health Insurance Program

9.3.7.1.

Immunizations – CPT range 90700 through 90749 9.3.7.2.

Well child care – SD EPSDT code W8630, CPT range 9981 through 99383 and 99391 through 99393 9.3.7.3.

Adolescent well visits – CPT codes 99384 through 99394 9.3.7.4.

Satisfaction with care 9.3.7.5.

Mental health – CPT codes 90804 through 90899 9.3.7.6.

Dental care – Codes covering exams, x-rays, and certain treatments 9.3.7.7. Other, please list: Optometric and Substance Abuse – Range of SD codes W7500 through W7507m W8500, W8600, W8601 and W8620 through W8624 9.3.8.

Performance measures for special targeted populations.

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

9.5. The state assures it will comply with the annual assessment and evaluation required under Section 10. Briefly describe the state's plan for these annual assessments and reports. (Section 2107(b)(2)) (42CFR 457.750)

The South Dakota Department of Social Services will evaluate the operation and effectiveness of its State Children’s Health Insurance Program (SCHIP) on an ongoing basis and report the findings to CMS by January 1 of each year. A variety of data sources will be utilized to evaluate South Dakota’s program. These data sources will include, but will not be limited to, US Bureau of Census, South Dakota Department of Health, South Dakota Medical Assistance, and Indian Health Services. Annual reports will follow the format as specified by CMS.

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