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

April 8, 2011

Darin Gordon, Director Bureau of TennCare Department of Finance and Administration 310 Great Circle Road Nashville, TN 37243

Re: Tennessee Title XIX State Plan Amendment, Transmittal #11-003

Dear Mr. Gordon:

We have reviewed the proposed amendment to the Tennessee Medicaid State Plan that was submitted March 3, 2011 under transmittal number 11-003. This State Plan Amendment addresses the list of incurred expenses that may be deducted for institutionalized persons as part of the post-eligibility treatment of income. Based on the information provided, we are now ready to approve the Tennessee Medicaid State Plan Amendment 11-003. This SPA was approved on April 7, 2011. The effective date for this amendment is March 1, 2011. We are also enclosing the approved HCFA-179 and plan pages.

If you have any questions or need any further assistance, please contact Rita Nimmons at (404) 562-7415.

Sincerely,

/s/

Jackie Glaze

Associate Regional Administrator

Division of Medicaid & Children's Health Operations

Enclosures

Revision: HCFA-PM-85-3 (BERC)

SUPPLEMENT 3 TO ATTACHMENT 2.6-A

Page 1

QMB NO.: 0938-0193

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

STATE: TENNESSEE

REASONABLE LIMITS ON AMOUNTS FOR NECESSARY MEDICAL OR REMEDIAL CARE NOT COVERED UNDER MEDICAID

____________________________________________________________________________________ ____________________________________________________________________________________

Methodology Used for Deduction of Incurred Expenses for Necessary Medical or Remedial Care for Institutionalized Persons in the Post-Eligibility Application of Income.

The following deductions will be made from the total income available for the cost of long-term nursing home care:

Payments for the following types of medical or remedial care recognized under state law, but not encompassed within the State’s Medicaid Plan or the TennCare Demonstration, subject to the following criteria.

1. Eyeglasses and necessary related services not covered under the State plan or the TennCare demonstration. Deductions can only be made for the following services and must be the least of the provider’s usual and customary charges, billed charges, or the Medicaid fee schedule.

(i) Examination and refraction

(ii) Frame

(iii) Lenses (bifocal)

(iv) Lenses (single)

2. Hearing aids and necessary related services. Deductions can only be made for the following services and must be the least of the provider’s usual and customary charges, billed charges, or the Medicaid fee schedule.

(i) Audiogram

(ii) Ear mold

(iii) Hearing aid

(iv) Batteries

(v) Hearing aid orientation

3. Dental services. Deductions can be made for routine and emergency dental services and in accordance with the Bureau of TennCare’s dental fee listing, whether such services are provided at a dental office, on-site at the long term care facility, or through a mobile dental services provider that contracts with the long-term care facility.

_____________________________________________________________________________________ TN No. 11-003 Approval Date:04-07-11

Effective Date 03/01/11 Supersedes TN No. 05-007

Revision: HCFA-PM-85-3 (BERC)

SUPPLEMENT 3 TO ATTACHMENT 2.6-A

Page 2

QMB NO.: 0938-0193

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

STATE: TENNESSEE

REASONABLE LIMITS ON AMOUNTS FOR NECESSARY MEDICAL OR REMEDIAL CARE NOT COVERED UNDER MEDICAID

____________________________________________________________________________________ ____________________________________________________________________________________

4. Deductions for any other medical service recognized under State law but not covered by Medicaid will be made at the least of the provider’s usual and customary charges, billed charges, or 80% of the Medicare fee schedule. Deductions will be allowed only for services that are determined by the state to be medically necessary for the particular individual on whose behalf the services are being requested.

Charges for nursing home days incurred as the result of bed-holds or therapeutic leave days that are in excess of the number of days covered under the Medicaid State Plan for the type of facility in question are not allowable deductions.

Medical expenses incurred more than three months prior to the month of application for Medicaid are disallowed as a deduction from patient liability. Allowable medical expenses incurred within three months prior to the month of application will be allowed as a deduction from patient liability. No deduction will be allowed for medical expenses that were incurred as the result of imposition of a transfer of assets penalty period.

_____________________________________________________________________________________

TN No. 11-003 Approval Date: 04-07-11 Effective Date 03/01/11 Supersedes TN No. 05-007

TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL

FOR: HEALTH CARE FINANCING ADMINISTRATION

1. TRANSMITTAL NUMBER: 11-003

2. STATE TENNESSEE

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

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

4, PROPOSED EFFECTIVE DATE March 1, 2011

5. TYPE OF PLAN MATERIAL (Check One):

(NEW STATE PLAN

AMENDMENT TO BE CONSIDERED AS NEW PLAN

X AMENDMENT

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

6. FEDERAL STATUTE/REGULATION CITATION: 42 CFR 435

7. FEDERAL BUDGET IMPACT: a. FFY 2011 $0 b. FFY 2012 $0

8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:

Supplement 3 to Attachment 2.6-A, pages 1 and 2.

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

Supplement 3 to Attachment 2.6-A, pages 1 and 2.

10. SUBJECT OF AMENDMENT:

Eligibility Conditions and Requirements — Reasonable Limits on Amounts for Necessary Medical or Remedial Care not Covered Under

Medicaid.

11, GOVERNOR’S REVIEW (Check One): X GOVERNOR’S OFFICE REPORTED NO COMMENT L] COMMENTS OF GOVERNOR’S OFFICE ENCLOSED

LJ NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL

CJ OTHER, AS SPECIFIED:

12. SIGN.

URE OF STATE AGENCY OFFICIAL: El

| 16. RETURN TO: Tennessee Department of Finance and Administration

13. TYPED NAME: Darin J. Gordon

Bureau of TennCare 310 Great Circle Road

14. TITLE: Director, Bureau of TennCare

Nashville, Tennessee 37243

15. DATE SUBMITTED:

Attention: George Woods

3 (2/1!

Table of Contents State/Territory Name: Tennessee State Plan Amendment (SPA) #:14-0001-MM3 This file contains the following documents in the order listed:

1) Approval Letter

2) Summary Form (with 179-like data)

3) Superseding Pages Notice (delete if not applicable) 4) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES

Centers for Medicare & Medicaid Services Atlanta Regional Office 61 Forsyth Street, Suite 4T20

Atlanta, Georgia 30303 CENTERS FOR MEDICARE & MEDICAID SERVICES

DIVISION OF MEDICAID & CHILDREN’S HEALTH OPERATIONS

April 25, 2014

Mr. Darin Gordon, Director Bureau of TennCare

310 Great Circle Road Nashville, TN 37243

Re: Tennessee State Plan Amendment 14-0001-MM3 Dear Mr. Gordon:

Enclosed is an approved copy of Tennessee’s state plan amendment (SPA) 14-0001-MM3, which was submitted to the Centers for Medicare & Medicaid Services (CMS) on March 24, 2014. SPA 14-0001 MM3 incorporates the MAGI-Based Income Methodologies into Tennessee’s state plan in accordance with the Affordable Care Act. This SPA was approved on April 23, 2014. The effective date of the SPA is January 1, 2014.

Enclosed is a copy of the new state plan pages to be incorporated within a separate section at the back of Tennessee’s approved state plan:

e S10, Page S10-1 and S10-2

In addition, enclosed is a summary of state plan pages which are superseded by SPA 14-0001-MM3, which should also be incorporated into a separate section in the front of the state plan:

e Superseding Pages of State Plan Material, 14-0001 MM3

Notwithstanding any other provisions of the Tennessee Medicaid state plan, the financial eligibility methodologies described in SPA TN-14 0001-MM3 will apply to all MAGI-based eligibility groups covered under Tennessee’s Medicaid state plan. The MAGI financial methodologies set forth in 42 CFR §435.603 apply to everyone except those individuals described at 42 CFR §435.603(j) for whom MAGI-based methods do not apply. This SPA supersedes the current financial eligibility provisions of the Medicaid state plan only with respect to the MAGI-based eligibility groups.

Darin Gordon Page 2

Congratulations to you and your staff for your hard work and strong collaboration. If you have any questions, please contact Kenni Howard at 404-562-7413 or Kenni.Howard@cms.hhs.gov.

Sincerely, /Is/I Jackie Glaze

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

Enclosures

Medicaid State Plan Eligibility: Summary Page (CMS 179)

State/Territory name: Tennessee

Transmittal Number:

Please enter the Transmittal Number (TN) in the format ST-YY-O000 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.

TN 14-000"

Proposed Effective Date

i

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

Federal Statute/Regulation Citation

| 42 CFR 43:

Federal Budget Impact

Federal Fiscal Year Amount

First Year 2014 $l 0.00 Second Year | 2015 $l 0.00

Subject of Amendment

Character Count: out of 2000

Implementation of MAG-based =|

Governor's Office Review

Governor's office reported no comment

Comments of Governor's office received

Describe:

No reply received within 45 days of submittal

Other, as specified

J alm] aa Signature of State Agency Official Submitted By:

Describe:

Susie Baird Last Revision Date: Apr 14, 2014

Submit Date: Mar 24, 2014

SUPERSEDING PAGES OF STATE PLAN MATERIAL

TRANSMITTAL NUMBER: 14-0001-MM3

STATE: Tennessee

PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:

S10 - MAGI Indome Methodology

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

Notwithstanding any other provisions of the Tennessee Medicaid State Plan, the financial eligibility methodologies described in State Plan Amendment 14-0001-MM3 will apply to all MAGI- based eligibility groups covered under Tennessee’s Medicaid State Plan. The MAGI financial methodologies set forth in 42 CFR § 435.603 apply to everyone except those individuals described at 42 CFR § 435.603(j) for whom MAGI-based methods do not apply. This State Plan Amendment supersedes the current financial eligibility provisions of the Medicaid State Plan only with respect to the MAGI-based eligibility groups.

CCMS Medicaid Eligibility

OMB Control Number 0938-1 14§ OMB Expiration date: 10/31'201<

MAGI-Based Income Methodologies.

1902(e)(14) 42 CFR 435.603

ml The state will apply Modified Adjusted Gross Income (MAGI)-based methodologies as described below, and consistent with 42 CFR 435.603.

in the case of determining ongoing eligibility for beneficiaries determined eligible for Medicaid on or before December 31, 2013, MAGI-based income methodologies will not be applied until March 31, 2014, or the next régularly-scheduled renewal of eligibility, whichever is later, if application of such methods results in a determination of ineligibility prior to such date.

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

| In determining family size for the eligibility determination of the other individuals in a household that includes a pregnant woman:

(@ The pregnant woman is counted just as herself.

C The pregnant woman is counted as herself, plus one.

| C The pregnant woman is counted as herself, plus the number of children she is expected to deliver. Financial eligibility is determined consistent with the foliowing 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 and family size for the remaining months of the current calendar year

In determining current monthly or projected annual household income, the state will use reasonable methods to: {J Include a prorated portion of a reasonably predictable increase in future income and/or family size. {[] Account for a reasonably predictable decrease in future income and/or family size.

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

In determining eligibility for Medicaid, an amount equivalent to 5 percentage points of the FPL for the applicable family size will be deducted from household income in accordance with 42 CFR 435.603(d).

Household income includes actually available cash support, exceeding nominal amounts, provided by the person claiming an individual described at §435.603(1)(2)(i) as a tax dependent. |

@ Yes (No |

TN No: 14-0001-MM3 Approval Date: 04-23-14 Effective Date 01/01/14 Tennessee $10-1

ccmMs Medicaid Eligibility

CORTE IC ECAR A Oa nat) ICES

i The age used for children with respect to 42 CFR 435.603(f)(3)(iv) is:

f

j

| Cc Age 19 @ Age 19. or in the case of full-time students, age 21

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this inforniation collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of

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

TN No: 14-0001-MM3 Approval Date: 04-23-14

Effective Date 01/01/14 Tennessee $10-2

Table of Contents

State/Territory Name: Tennessee State Plan Amendment (SPA) #:14-0002-MM6 This file contains the following documents in the order listed: 1) Approval Letter 2) Summary Form (with 179-like data) 3) Superseding Pages Notice 4) Approved SPA Pages

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

DIVISION OF MEDICAID & CHILDREN’S HEALTH OPERATIONS

June 20, 2014

Mr. Darin Gordon, Director Bureau of TennCare 310 Great Circle Road Nashville, TN 37243

Re: Tennessee State Plan Amendment 14-0002-MM6

Dear Mr. Gordon:

Enclosed is an approved copy of Tennessee’s state plan amendment (SPA) 14-0002-MM6, which was submitted to the Centers for Medicare & Medicaid Services (CMS) on March 24, 2014. SPA 14-0002-MM6 incorporates that the state affirms citizenship regulations, specifies reasonable opportunity options, and specifies policy options related to immigrant eligibility in accordance with the Affordable Care Act. This SPA was approved on June 20, 2014. The effective date of the SPA is January 1, 2014.

Enclosed is a copy of the new state plan pages to be incorporated within a separate section at the back of Tennessee’s approved state plan:

• S89 Non-Financial Eligibility- Citizenship and Non-Citizenship Eligibility

In addition, enclosed is a summary of state plan pages which are superseded by SPA 14-002- MM6, which should be incorporated into a separate section in the front of the state plan:

• Attachment 2.6-A, Page 2, item (3), paragraphs (a), (b) and (c), TN 98-2

Congratulation to you and your staff for your hard work and strong collaboration. If you have any questions, please contact Kenni Howard at 404-562-7413 or kenni.howard@cms.hhs.gov

Sincerely,

//s//

Jackie Glaze

Associate Regional Administrator

Division of Medicaid & Children’s Health Operations

Enclosures

Medicaid State Plan Eligibility: Summary Page (CMS 179)

State/Territory name: Tennessee

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.

TN 14-000:

Proposed Effective Date

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

Federal Statute/Regulation Citation

42 CFR 43!

Federal Budget Impact

Federal Fiscal Year Amount

First Year

2014 $ 0.00

Second Year

2015 | 0.00

Subject of Amendment

Character count out of 2000

Citizenship and roster)

lal —

Governor's Office Review

® Governor's office reported no comment

bd Comments of Governor's office received

= bat ie

® No reply received within 45 days of submittal

Describe:

® Other, as specified

4 bat re

Signature of State Agency Official

Describe:

Submitted By: Susie Baird Last Revision Date: Jun 19, 2014

Submit Date: Mar 24, 2014

SUPERSEDING PAGES OF STATE PLAN MATERIAL

TRANSMITTAL NUMBER: STATE:

14-0002 MM6 Tennessee

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

S89 Non-Financial Eligibility- Citizenship and Non-citizen Eligibility | Attachment 2.6-A: Page 2, Item (3), paragraphs (a) , (b), and (c), TN 98-2

cCCmMs Medicaid Eligibility

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

1902(a)(46)(B)

8 U.S.C. 1611, 1612, 1613, and 1641 1903(v)(2),(3) and (4)

42 CFR 435.4

42 CFR 435.406

42 CFR 435.956

Citizenship and Non-Citizen Eligibility

The state provides Medicaid to citizens and nationals of the United States and certain non-citizens consistent with requirements of 42 CFR 435.406, including during a reasonable opportunity period pending verification of their citizenship, national status or satisfactory immigration status.

[mM] The state provides Medicaid eligibility to otherwise eligible individuals:

{) Who are citizens or nationals of the United States; and

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

{m] Reconciliation Act (PRWORA) (8 U.S.C. §1641), or whose eligibility is required by section 402(b) of PRWORA (8 U.S.C. §1612(b)) and is not prohibited by section 403 of PRWORA (8 U.S.C. §1613); and

Who have declared themselves to be citizens or nationals of the United States, or an individual having satisfactory

a immigration status, during a reasonable opportunity period pending verification of their citizenship, nationality or satisfactory immigration status consistent with requirements of 1903(x), 1137(d), 1902(ee) of the SSA and 42 CFR 435.406, and 956.

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

The agency provides for an extension of the reasonable opportunity period if the individual is making a good faith effort to resolve any inconsistencies or obtain any necessary documentation, or the agency needs more time to complete the verification process.

C Yes @No

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

C Yes @No

The state provides Medicaid coverage to all Qualified Non-Citizens whose eligibility is not prohibited by section 403 of PRWORA (8 U.S.C. §1613).

C Yes @No Indicate which requirements apply:

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

C Yes @No TN 14-0002-MM6 Approval Date: 06-20-14 Effective Date: 01-01-14

Tennessee S89-1

AR FO OE A 4 aC AND EEC

CcCmMs Medicaid Eligibility

The state limits eligibility to 7 years for certain non-citizens. @ Yes CNo Check all that apply: [X] Non-citizens admitted to the U.S. as a refugee under section 207 of the INA KX] Non-citizens granted asylum under section 208 of the INA ] Non-citizens whose deportation is withheld under section 243(h) or 241(b)(3) of the INA

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

[X] Non-citizens admitted to the U.S. as Amerasian

The state elects the option to provide Medicaid coverage to otherwise eligible individuals under 21 and pregnant women, lawfully residing in the United States, as provided in section 1903(v)(4) of the Act.

C Yes @No

ia An individual is considered to be lawfully residing in the United States if he or she is lawfully present and otherwise meets the eligibility requirements in the state plan.

[M) An individual is considered to be lawfully present in the United States if he or she: 1. Is a qualified non-citizen as defined in 8 U.S.C. 1641(b) and (c);

2. Is a non-citizen in a valid nonimmigrant status, as defined in 8 U.S.C. | 101(a)(15) or otherwise under the immigration laws (as defined in 8 U.S.C. 1101(a)(17));

3. Is a non-citizen who has been paroled into the United States in accordance with 8 U.S.C. | 182(d)(5) for less than | year, except for an individual paroled for prosecution, for deferred inspection or pending removal proceedings;

4. Is a non-citizen who belongs to one of the following classes: [@) Granted temporary resident status in accordance with 8 U.S.C. 1160 or 1255a, respectively:

Granted Temporary Protected Status (TPS) in accordance with 8 U.S.C. §1254a, and individuals with pending a applications for TPS who have been granted employment authorization;

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

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

{@) Under Deferred Enforced Departure (DED) in accordance with a decision made by the President; {m) Granted Deferred Action status;

[®) Granted an administrative stay of removal under 8 CFR 241;

[m) Beneficiary of approved visa petition who has a pending application for adjustment of status;

5. Is an individual with a pending application for asylum under 8 U.S.C. 1158, or for withholding of removal under 8 U.S.C.1231, or under the Convention Against Torture who -

{@) Has been granted employment authorization; or TN 14-0002-MM6 Approval Date: 06-20-14 Effective Date: 01-01-14

Tennessee $89-2

cms Medicaid Eligibility

{m) Is under the age of 14 and has had an application pending for at least 180 days:

6._Has been granted withholding of removal under the Convention Against Torture:

7. Is a child who has a pending application for Special Immigrant Juvenile status as described in 8 U.S.C. | 101(a)(27)\(J);

8. Is lawfully present in American Samoa under the immigration laws of American Samoa; or

9. Is a victim of severe trafficking in persons, in accordance with the Victims of Traffi

cking and Violence Protection Act of 2000, Pub. L. 106-386, as amended (22 U.S.C. 7105(b));

10. Exception: An individual with deferred action under the Department of Homeland Security's deferred action for the childhood arrivals process, as described in the Secretary of Homeland Security's June 15, 2012 memorandum, shal! not be considered to be lawfully present with respect to any of the above categories in paragraphs (1) through (9) of this definition.

(J Other

The state assures that it provides limited Medicaid services for treatment of an emergency medical condition, not related to an

organ transplant procedure, as defined in 1903(v)(3) of the SSA and implemented at 42 CFR 440.255, to the following individuals who meet all Medicaid eligibility requirements, except documentation of citizenship or satisfactory immigration status and/or present an SSN:

[M) Qualified non-citizens subject to the 5 year waiting period described in 8 U.S.C. 1613:

a Non-qualified non-citizens, unless covered as a lawfully residing child or pregnant woman by the state under the option in

accordance with 1903(v)(4) and implemented at 435.406(b).

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of

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

TN 14-0002-MM6 Approval Date: 06-20-14 Effective Date: 01-01-14 Tennessee S89-3

Table of Contents

State/Territory Name: Tennessee State Plan Amendment (SPA) #:14-0004-MM5 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages 4) Additional Attachments that are part of the state plan

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

DIVISION OF MEDICAID & CHILDREN’S HEALTH OPERATIONS

June 27, 2014

Mr. Darin Gordon, Director Bureau of TennCare 310 Great Circle Road Nashville, TN 37243

RE: TN 14-0004 MM5

Dear Mr. Gordon:

Enclosed is an approved copy of Tennessee’s state plan amendment (SPA) 14-0004-MM5, which was submitted to the Centers for Medicaid & Medicaid Services (CMS) on March 31, 2014. This SPA established the state’s residency requirements in accordance with the Affordable Care Act. This SPA was approved on June 26, 2014 with an effective date of January 1, 2014.

Enclosed is a copy of the new state plan pages and attachments to be incorporated with a separate section at the back of Tennessee’s approved state plan. In addition, a summary of the state plan pages which are superseded by SPA 14-0004-MM5 is enclosed.

CMS appreciates the significant amount of work your staff dedicated to preparing this state plan amendment. If you have any questions concerning this SPA, please contact Kenni Howard at (404) 562-7413 or by email at kenni.howard@cms.hhs.gov.

Sincerely,

//s//

Jackie Glaze

Associate Regional Administrator

Division of Medicaid & Children’s Health Operations

Enclosures

Medicaid State Plan Eligibility: Summary Page (CMS 179) State/Territory name: Tennessee

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.

TN 14-000¢

Proposed Effective Date

01/01/2014

[

(mm/dd/yyyy)

Federal Statute/Regulation Citation

| 42 CFR 43!

Federal Budget Impact

Federal Fiscal Year Amount

First Year | 2014 gl 0.00 Second Year | 2015 | 0.00

Subject of Amendment

Character count 1 out of 2000

In this submission, the State des |

—e

Governor's Office Review

E Governor's office reported no comment

c Comments of Governor's office received

5

c No reply received within 45 days of submittal

Describe:

Ec Other, as specified

+|

Signature of State Agency Official Submitted By:

Describe:

Susie Baird Last Revision Date: Jun 26, 2014

Submit Date: Mar 31, 2014

SUPERSEDING PAGES OF

STATE PLAN MATERIAL TRANSMITTAL NUMBER: STATE: 14-0004 MM5 Tennessee PAGE NUMBER OF THE PLAN SECTION OR PAGE NUMBER OF THE SUPERSEDED PLAN SECTION ATTACHMENT: OR ATTACHMENT (If Applicable): $88 Non-Financial Eligibility- State Residency Section 2: Page 13, Item 2.3, TN 87-12; Attachment 2.6-A: Page 3, TN 98-2

ccms Medicaid Eligibility

(Conn ee ASIEN BSED STEED

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

42 CFR 435.403

State Residency

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

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

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

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

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

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

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

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

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

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

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

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

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

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

[im] IV-E eligible children living in the state, or

TN-14-0004-MM5 Approval Date: 06-26-14 Tennessee $88-1

Effective Date: 01-01-14

ccms Medicaid Eligibility

(Conn ee ASIEN BSED STEED

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

42 CFR 435.403

State Residency

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

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

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

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

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

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

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

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

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

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

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

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

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

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

[im] IV-E eligible children living in the state, or

TN-14-0004-MM5 Approval Date: 06-26-14 Tennessee $88-1

Effective Date: 01-01-14

cCcoms Medicaid Eligibility

STARS FOR METRE ARTA SRRMECES

[i] Otherwise meet the requirements of 42 CFR 435.403.

TN-14-0004-MM5 Approval Date: 06-26-14 Effective Date: 01-01-14 Tennessee $88-2

ccm

SUNCLEA EOS USERS BAST ANS NETS

Medicaid Eligibility

@ Yes C No

[><] Alabama [X] Alaska

[xX] Arizona

[X] Arkansas [X] California XX] Colorado Connecticut [X] Delaware [IX] District of Columbia XX] Florida

[X] Georgia

DX] Hawaii

Idaho

Meet the criteria specified in an interstate agreement.

Illinois Indiana lowa

[X] Kansas Kentucky KX] Louisiana Maine Maryland Massachusetts Michigan &] Minnesota Mississippi Missouri

[lB] The state has interstate agreements with the following selected states:

Montana Nebraska

[IX] Nevada

New Hampshire New Jersey New Mexico (1 New York North Carolina North Dakota Ohio

IX] Oklahoma Oregon

Pennsylvania

Rhode Island South Carolina South Dakota (2) Tennessee Texas

Utah Vermont Virginia Washington West Virginia EX] Wisconsin

(1 Wyoming

iw The interstate agreement contains a procedure for providing Medicaid to individuals pending resolution of their residency

status and criteria for resolving disputed residency of individuals who (select all that apply): Are IV-E eligible

(D Are in the state only for the purpose of attending school

(1 Are out of the state only for the purpose of attending school

[7] Retain addresses in both states

[7] Other type of individual

The state has a policy related to individuals in the state only to attend school.

@ Yes C No

Provide a description of the policy:

Tennessee considers an applicant, aged 18-22 and a full time student in the state, to not be a resident of the state, if (1) neither parent lives in the state, (2) the student is claimed as a tax dependent by someone in another state, and (3) the student is applying on his or her own behalf.

|] Otherwise meet the criteria of resident, but who may be temporarily absent from the state. TN-14-0004-MM5 Approval Date: 06-26-14 Effective Date: 01-01-14 Tennessee $88-3

Medicaid Eligibility

OEE DO RERLENES BADE EEE

The state has a definition of temporary absence, including treatment of individuals who attend school in another state. @ Yes C No

Provide a description of the definition:

‘The State considers an individual who has established state residency to still be a state resident during a period of temporary absence which may include, but is not limited to, a temporary work assignment, hospitalization, mental health treatment or education purposes if the individual intends to return to the state when the reason for the temporary absence ends.

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 contro! number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data Tesources, 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.

Approval Date: 06-26-14 Effective Date: 01-01-14

S88-4

TN-14-0004-MM5 Tennessee

Table of Contents State/Territory Name: Tennessee State Plan Amendment (SPA) #: TN-14-0011-MM7 This file contains the following documents in the order listed: 1) Approval Letter 2) Summary Form 3) Approved SPA Pages TN NO.: 14-0011-MM7 Tennessee Approval Date 06/28/16 Effective Date 7/01/16

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Atlanta Regional Office 61 Forsyth Street, Suite 4T20 Atlanta, Georgia 30303 DIVISION OF MEDICAID & CHILDREN’S HEALTH OPERATIONS June 29, 2016 Darin Gordon, Director Bureau of TennCare 310 Great Circle Road Nashville, TN 37243 RE: Tennessee Title XIX State Plan Amendment, Transmittal S21 14-0011-MM 7 Dear Mr. Gordon: We have reviewed Tennessee State Plan Amendment 14-0011-MM7 which was submitted to the Atlanta Regional Office on July 15, 2014. This amendment establishes the process for Hospital Presumptive Eligibility (HPE). Based on the information provided, the Medicaid State Plan Amendment is approved on June 28, 2016. The effective date of this SPA is July 1, 2016. If you have any questions regarding this amendment, please contact Kenni Howard at (404) 562-7413 or via email at kenni.howard@cms.hhs.gov. Sincerely, //s// Jackie Glaze Associate Regional Administrator Division of Medicaid & Children’s Health Operations Enclosures TN NO.: 14-0011-MM7 Tennessee Approval Date 06/28/16 Effective Date 7/01/16

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Table of Contents

State/Territory Name: Tennessee State Plan Amendment (SPA) #:16-0001 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form 3) Approved SPA Pages

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

DIVISION OF MEDICAID & CHILDREN’S HEALTH OPERATIONS

March 22, 2016

Darin Gordon, Director Bureau of TennCare 310 Great Circle Road Nashville, TN 37243

RE: Tennessee Title XIX State Plan Amendment, Transmittal #16-0001

Dear Mr. Gordon:

We have reviewed Tennessee State Plan Amendment (SPA) 16-0001 which was submitted to the Atlanta Regional Office on January 19, 2016. This amendment requested a 12 month eligibility period for families under Transitional Medical Assistance, in accordance with section 1925 of the Social Security Act.

This SPA confirms that the state will offer a 12 month eligibility period rather than a 6 month eligibility period followed by a second 6-month eligibility period and is approved on March 22, 2016. The effective date of this SPA is January 1, 2016.

If you have any questions regarding this amendment, please contact Kenni Howard at (404) 562-7413 or via email at kenni.howard@cms.hhs.gov.

Sincerely,

//s//

Jackie Glaze

Associate Regional Administrator

Division of Medicaid & Children’s Health Operations

Enclosures

Approved with following change to block #6 as authorized by state on email dated 02/17/16. Block # 6 changed to read: 1902(a)(52), 1902(e)(1), and 1925 of the Act.

October 2009 OMB No.: 0938-1070 Revision: CMS-10283

SUPPLEMENT 12a TO ATTACHMENT 2.6-A STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: Tennessee

ELIGIBILITY UNDER SECTION 1925 OF THE ACT TRANSITIONAL MEDICAL ASSISTANCE

The State covers low-income families and children for Transitional Medical Assistance (TMA) under section 1925 of the Social Security Act (the Act). This coverage is provided for families who no longer qualify under section 1931 of the Act due to increased earned income, or working hours, from the caretaker relative’s employment, or due to the loss of a time-limited earned income disregard. (1902(a)(52), 1902(e)(1), and 1925 of the Act)

The amount, duration, and scope of services for this coverage are specified in Section 3.5 of this State plan.

For Medicaid eligibility to be extended through TMA, families must have been Medicaid eligible under section 1931 (months of retroactive eligibility may be used to meet this requirement):

__X__ During at least 3 of the 6 months immediately preceding the month in which the family became ineligible under section 1931.

_____ For fewer than 3 of the 6 previous months immediately preceding the month in which the family became ineligible under section 1931. Specify:

The State extends Medicaid eligibility under TMA for an initial period of:

_____ 6 months. For TMA eligibility to continue into a second 6-month extension period, the family must meet the reporting, technical, and income eligibility requirements specified at section 1925(b) of the Act.

___X_ 12 months. Section 1925(b) does not apply for a second 6-month extension period.

The State collects and reports participation information to the Department of Health and Human Services as required by section 1925(f) of the Act, in accordance with the format, timing, and frequency specified by the Secretary and makes such information publicly available.

TN No. __TN-16-0001__ Approval Date 03-22-16 Effective Date __1/1/2016____ Supersedes TN No. __NEW_

Table of Contents

State/Territory Name: Tennessee State Plan Amendment (SPA) #: 18-0004-MM2 This file contains the following documents in the order listed: 1) Approval Letter 2) Summary Form (with 179-like data) 3) Approved SPA Pages

6/11/2020 Medicaid State Plan Print View TN - Submission Package - TN2018MS0001O - (TN-18-0004) - Eligibility CMS-10434 OMB 0938-1188 Package Information Package ID TN2018MS0001O Program Name N/A SPA ID TN-18-0004 Version Number 4 Submitted By Aaron Butler Package Disposition Priority Code P2 Submission Type OŰcial State TN Region Atlanta, GA Package Status Approved Submission Date 10/15/2018 Approval Date 6/4/2020 1:52 PM EDT Related Actions

6/11/2020 Medicaid State Plan Print View DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Medicaid and CHIP Operations 601 East 12th Street, Room 355 Kansas City, MO 64106 Center for Medicaid & CHIP Services June 04, 2020 Stephen Smith Director Department of Finance & Administration 310 Great Circle Road Nashville, TN 37243 Re: Approval of State Plan Amendment TN-18-0004 Dear Stephen Smith: On October 15, 2018, the Centers for Medicare and Medicaid Services (CMS) received Tennessee State Plan Amendment (SPA) TN-18-0004 to include updates to the paper application, and the state’s election to use an alternative single, streamlined application developed by the state for individuals applying for coverage who may be eligible based on the applicable modiţed adjusted gross income standard.. We approve Tennessee State Plan Amendment (SPA) TN-18-0004 on June 04, 2020 with an eſective date(s) of October 22, 2018. Accompanying the approval of SPA 18-0004-MM2 is the enclosed companion letter regarding the need for Tennessee to make modiţcations to its online alternative single streamlined and paper applications. Tennessee will provide dates for completion of outstanding changes within 60 days of approval of this SPA, and will implement the revised online and paper applications addressing CMS concerns by the agreed-upon dates. Name Date Created TN 18-0004-MM2 Signed Companion Letter 6/3/2020 5:52 PM EDT If you have any questions regarding this amendment, please contact Tandra Hodges at Tandra.Hodges@cms.hhs.gov. Sincerely, James Scott Director, Division of Program Operations Center for Medicaid & CHIP Services RAI Policy Reference CMS is issuing this Request for Additional Information (RAI) pursuant to Section 1915(f) of the Social Security Act (added by P.L. 97-35). This request has the eſect of stopping the 90-day time period for CMS to act on the material. A new 90 day time frame will not begin until we receive your response to this request.Submission Package TN2018MS0001O Authority Eligibility State TN Agency Name Department of Finance & Administration Submission Date Oct 15, 2018 Priority Code P2 All Questions Question ID Reference CMS question to the State Policy/Regulation State Response

6/11/2020 Medicaid State Plan Print View Question ID Reference CMS question to the State Policy/Regulation State Response 1 States must identify AI/ANs who may be eligible for cost-sharing exemptions and deductions from MAGI income, as well as special enrollment periods and cost-sharing reductions for plans on the Marketplace. The state has indicated it will submit a change request to update the instructional text for the race question to say "Please tell us this person's race. You don't have to answer this question if you don't want to. This answer will not be used to make a decision about your coverage, but it is important if you are an American Indian or Alaskan Native and could mean you don't have copays." Please indicate whether TN intends to implement a future change to add a separate question on both the online and paper applications to ask about American Indian or Alaska Native status. This information is needed to ensure that individuals can properly identify themselves and potentially be exempt from cost sharing or eligible for special enrollment periods for Marketplace coverage. 42 CFR 447.56, 435.603e Yes, the State added a separate question to both the online and paper applications to ask about American Indian or Alaska Native status. This change was implemented on July 28, 2019. 2 States must identify AI/ANs who may be eligible for cost-sharing exemptions and deductions from MAGI income, as well as special enrollment periods and cost-sharing reductions for plans on the Marketplace. Please clarify whether applicants who indicate that they are American Indian/Alaska Native are asked about prior use of services or eligibility for the receipt of Indian Health Services for the purpose of Medicaid and CHIP cost sharing and whether they are asked about tribal income sources for purposes of appropriately calculating MAGI income for Medicaid/CHIP. 42 CFR 447.56 The State added a separate question to both the online and paper applications to ask about receipt of Indian Health Services. In addition, the State added "Tribal Income" as an income type for purposes of appropriately calculating MAGI income for Medicaid/CHIP. These changes were implemented on July 28, 2019. 3 Applicants may only be asked to provide information necessary to make an eligibility determination. Please clarify how the state intends to use information on the following living arrangements: a. At Home b. Correctional Facility c. Homeless/Homeless Shelter d. Hospital e. Home and Community Based Services f. Hospice Care g. Nursing Facility/ICF 42 CFR 435.907(e)(1) As the State has discussed with CMS in previous conversations, determining the applicant's living arrangement is necessary for the rules engine to determine eligibility for certain eligibility categories. For example, individuals with a living arrangement of "correctional facility" are not eligible in the parent/caretaker relative category. Selecting "nursing facility/ICF" or "HCBS" would prompt consideration for LTSS eligibility. Even if the applicant does not have a speciţc living arrangement that will impact their eligibility qualiţcation, they will still need an option to select in the drop down, so the State has provided a comprehensive list of options.

6/11/2020 Medicaid State Plan Print View Question ID Reference CMS question to the State Policy/Regulation State Response 4 The state must collect all information needed to conduct a MAGI determination. Please clarify how the state is collecting all appropriate information on household composition and relationships to determine MAGI eligibility under both tax ţler and non-ţler rules. For example, please indicate whether questions asked or logic is embedded to capture the following information: a. Does the individual plans to ţle a federal tax return or expect to be claimed as a tax dependent for the year in which coverage is sought? b. Does the individual not plan to ţle a federal tax return (or be claimed as a tax dependent) for the year in which coverage is sought? Please describe how the state will comply with 42 CFR 435.603, collecting appropriate information around tax ţling status and household composition for applicants and not collecting information of non-applicants. c. Whether applicant spouses living outside the household. Individuals included on the application who are claimed as a dependent by someone not in the household? Other individuals who may be eligible under non-ţler tax rules. 42 CFR 435.603 The State collects all appropriate information on household composition and relationships to determine MAGI eligibility. The online and paper applications include a question regarding if an individual plans to ţle a federal tax return or to be claimed as a tax dependent. The online and paper applications also contain a question regarding if the applicant intends to ţle a tax return jointly with a spouse. The online and paper applications also include a question regarding if the applicant will be claimed as a dependent by someone outside of the household. Based on the applicant's answers to the questions about tax ţling status, the State will determine if the individual should be evaluated for eligibility under ţler or non-ţler rules. 5 Applicants may only be asked to provide information necessary to make an eligibility determination. Please revise the application to ensure that only individuals who are seeking coverage are asked questions about citizenship and immigration status. 42 CFR 435.907(e)(1) The State has revised the online and paper applications to make the questions about citizenship and immigration status optional. These questions are not required for individuals who are not seeking coverage. This change was implemented on July 28, 2019. 6 The agency must provide Medicaid to otherwise eligible individuals described in 42 CFR 435.406. See additional regulatory citations for more detail. Please update the list of immigration statuses to include all qualiţed non- citizens (QNC) and lawfully present statuses. For reference, see: https://www.healthcare.gov /immigrants/lawfully- present-immigrants/ 42 CFR 435.406 (Medicaid and CHIP), and 45 CFR §155.2 (lawfully present non-citizen statuses for the Federally Facilitated Exhange). See full regulatory citation. The State has updated the online application to include the speciţed immigration statuses. This change was implemented July 28, 2019.

6/11/2020 Medicaid State Plan Print View Question ID Reference CMS question to the State Policy/Regulation State Response 7 The agency must provide Medicaid to Citizens and Nationals of the US, and to eligible non-citizens. The agency must also verify citizenship and satisfactory immigration status through electronic service established in accordance with 42 CFR 435.949. Please update the list of immigration documents to include the full list of available types. For reference, see: https://www.healthcare.gov /immigrants/documentatio n/: a. Notice of Action (I-797) b. Document indicating membership in a federally recognized Indian tribe or American Indian born in Canada c. Certiţcation from U.S. Department of Health and Human Services (HHS) OŰce of Refugee Resettlement (ORR) d. OŰce of Refugee Resettlement (ORR) eligibility letter (if under 18) e. Alien number (also called alien registration number or USCIS number) or I-94 number CMS recommends the list be revised to align with DHS list. 42 CFR 435.406, 42 CFR 435.956 The State has updated the online application to include the speciţed document types. This change was implemented on July 28, 2019. 8 States must provide Medicaid to eligible residents of the State, including residents who are absent from the State. The state has indicated that the question about enrollment in another state is used to determine appropriate enrollment date. Please note that an applicant’s enrollment in another state cannot be used as a condition of eligibility as long as the state has veriţed Tennessee residency. Please remove the questions from the paper and online applications related to enrollment in another state, or clarify how else this information is used for eligibility at application. 42 CFR 435.403 This question has been removed from the online and paper applications. This change was implemented on December 15, 2019.

6/11/2020 Medicaid State Plan Print View Question ID Reference CMS question to the State Policy/Regulation State Response 9 Applicants may only be asked to provide information necessary to make an eligibility determination. Per 42 CFR 435.907(e)(1), applicants may only be asked to provide information necessary to make an eligibility determination. For the single, streamlined application, questions may only be asked to determine eligibility on a MAGI basis unless an individual answers yes to one of the non-MAGI screening questions. Please clarify which questions in the application are used for determination of potential eligibility on a non-MAGI basis and how these questions screen for potential eligibility. For example, the “Additional Health Care Assistance Questions” section of the online application asks whether anyone in the household has resources. Please clarify whether this is used as a non-MAGI screening question or only of those who are potentially eligible on a non-MAGI basis. Please also conţrm that subsequent questions are only asked of applicants who indicate potential eligibility for Medicaid on a non-MAGI basis, based on responses to the initial screening questions. 42 CFR 435.907(e)(1) If the applicant answers aŰrmatively to one of the non-MAGI screening questions, then he will be asked to provide information about resources and answer any subsequent questions. If an applicant does not answer aŰrmatively to any of the non-MAGI screening questions, then he will not be asked to provide information about resources. 10 Applicants may only be asked to provide information necessary to make an eligibility determination. Speciţc questions around school enrollment status, beyond full-time student and age are not needed for MAGI eligibility. Please describe why these questions are needed in order to ensure compliance with 42 CFR 435.907(e)(1), which indicates that applicants may only be asked to provide information necessary to make an eligibility determination. Please clarify how information about past SSI beneţts is used for determining eligibility for Medicaid. 42 CFR 435.907(e)(1) The school enrollment status question is only asked of individuals under the age of 21. It is structured such that the state can capture both part- time and full-time enrollment statuses in one question. Part-time enrollment status is needed to determine eligibility for the Medically Needy eligibility category in Tennessee. The question about past receipt of SSI beneţts has been removed. This change was implemented on March 18, 2019.

6/11/2020 Medicaid State Plan Print View Question ID Reference CMS question to the State Policy/Regulation State Response 11 Applicants may only be asked to provide information necessary to make an eligibility determination. The state has indicated that several additional changes will be implemented through change requests. Please provide a timeline for these revisions. Changes to language related to the use of “family” vs. household in instructions related to Medicaid household composition. b. Changes to revise the current question, "Is this person a United States citizen?" to read "Is this person a United States citizen or national?" c. Addition of a new question asking, "Has this person received services or a referral from the Indian Health Services (IHS)?" if they select that this individual is an American Indian or Alaskan Native and answer Yes that they are a member of a federally recognized tribe. d. Updates to the online application to change the language for the minimum essential coverage question to match the healthcare.gov online application. It will say, "Does this health plan meet the minimum value standard?" e. Revisions to the paper application to remove questions related to resources. 42 CFR 435.907(e)(1) a. Additional instructions on who should be included on the application were added to the paper application on 12/15/2019. b. The change to revise the current question, "Is this person a United States citizen?" to read "Is this person a United States citizen or national?" was implemented on 3/15/2019. c. The addition of the question asking, "Has this person received services or a referral from the Indian Health Services (IHS)?" if they select that this individual is an American Indian or Alaskan Native and answer Yes that they are a member of a federally recognized tribe was implemented on 7/28/2019. d. Currently, the healthcare.gov/glossary uses the term "minimum essential coverage" and provides a deţnition for Minimum Essential Coverage. e. The paper application includes instructions for applicants to only answer questions related to resources if they are not a child, parent/caretaker of a minor child, or pregnant woman. The paper application states, "The next set of questions below ask about your family’s resources. You do not have to answer them if you think you might qualify as a pregnant woman, a child, or a caretaker of a minor child. If you choose not to answer, go to Step 4 to ţnish this application." 1 – 11 of 11 Submission Package was updated by the State in accordance with the response above Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | TN2018MS0001O | TN-18-0004 Package Header Package ID TN2018MS0001O Submission Type OŰcial Approval Date 6/4/2020 Superseded SPA ID N/A SPA ID TN-18-0004 Initial Submission Date 10/15/2018 Eſective Date N/A State Information Yes No

6/11/2020 Medicaid State Plan Print View State/Territory Name: Tennessee Medicaid Agency Name: Department of Finance & Administration Submission Component State Plan Amendment Medicaid CHIP

6/11/2020 Medicaid State Plan Print View Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | TN2018MS0001O | TN-18-0004 Package Header Package ID TN2018MS0001O Submission Type OŰcial Approval Date 6/4/2020 Superseded SPA ID N/A SPA ID TN-18-0004 Initial Submission Date 10/15/2018 Eſective Date N/A SPA ID and Eſective Date SPA ID TN-18-0004 Reviewable Unit Proposed Eſective Date Superseded SPA ID Application 10/22/2018 TN 14-0003

6/11/2020 Medicaid State Plan Print View Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | TN2018MS0001O | TN-18-0004 Package Header Package ID TN2018MS0001O Submission Type OŰcial Approval Date 6/4/2020 Superseded SPA ID N/A SPA ID TN-18-0004 Initial Submission Date 10/15/2018 Eſective Date N/A Executive Summary Summary Description Including Goals and Objectives In this SPA, the State indicates its election to use an alternative single, streamlined application developed by the State for individuals applying for coverage who may be eligible based on the applicable modiţed adjusted gross income standard. Federal Budget Impact and Statute/Regulation Citation Federal Budget Impact Federal Fiscal Year Amount First 2019 $0 Second 2020 $0 Federal Statute / Regulation Citation 42 CFR 435.907 Supporting documentation of budget impact is uploaded (optional). Name Date Created No items available

6/11/2020 Medicaid State Plan Print View Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | TN2018MS0001O | TN-18-0004 Package Header Package ID TN2018MS0001O Submission Type OŰcial Approval Date 6/4/2020 Superseded SPA ID N/A SPA ID TN-18-0004 Initial Submission Date 10/15/2018 Eſective Date N/A Governor's OŰce Review No comment Comments received No response within 45 days Other

6/11/2020 Medicaid State Plan Print View Submission - Public Comment MEDICAID | Medicaid State Plan | Eligibility | TN2018MS0001O | TN-18-0004 Package Header Package ID TN2018MS0001O Submission Type OŰcial Approval Date 6/4/2020 Superseded SPA ID N/A SPA ID TN-18-0004 Initial Submission Date 10/15/2018 Eſective Date N/A Indicate whether public comment was solicited with respect to this submission. Public notice was not federally required and comment was not solicited Public notice was not federally required, but comment was solicited Public notice was federally required and comment was solicited

6/11/2020 Medicaid State Plan Print View Submission - Tribal Input MEDICAID | Medicaid State Plan | Eligibility | TN2018MS0001O | TN-18-0004 Package Header Package ID TN2018MS0001O Submission Type OŰcial Approval Date 6/4/2020 Superseded SPA ID N/A SPA ID TN-18-0004 Initial Submission Date 10/15/2018 Eſective Date N/A One or more Indian health programs or Urban Indian Organizations furnish health care services in this state Yes No

6/11/2020 Medicaid State Plan Print View Medicaid State Plan Eligibility General Eligibility Requirements Application MEDICAID | Medicaid State Plan | Eligibility | TN2018MS0001O | TN-18-0004 Package Header Package ID TN2018MS0001O Submission Type OŰcial Approval Date 6/4/2020 Superseded SPA ID TN 14-0003 User-Entered SPA ID TN-18-0004 Initial Submission Date 10/15/2018 Eſective Date 10/22/2018 A. MAGI Paper Application The state uses the following paper application(s) for individuals applying for coverage based on the applicable modiţed adjusted gross income (MAGI) standard. Name Tennessee Paper Application The paper application(s) has been uploaded. Document Name Date Created TennCare Paper App 20200124 FINAL Eng 3/9/2020 8:10 AM EDT 1. The single, streamlined application for all insurance aſordability programs, developed by the Secretary in accordance with section 1413(b)(1)(A) of the Aſordable Care Act 2. One or more alternative single, streamlined applications developed by the state in accordance with section 1413(b)(1)(B) of the Aſordable Care Act and approved by the Secretary, which may be no more burdensome than the streamlined application developed by the Secretary 3. One or more alternative applications used to apply for multiple human service programs approved by the Secretary, provided that the agency makes readily available the single streamlined application used only for insurance aſordability programs to individuals seeking assistance only through such programs 4. Other alternative applications, provided that the agency makes readily available the single streamlined application used only for insurance aſordability programs to individuals seeking assistance only through such programs

6/11/2020 Medicaid State Plan Print View Application MEDICAID | Medicaid State Plan | Eligibility | TN2018MS0001O | TN-18-0004 Package Header Package ID TN2018MS0001O Submission Type OŰcial Approval Date 6/4/2020 Superseded SPA ID TN 14-0003 User-Entered SPA ID TN-18-0004 Initial Submission Date 10/15/2018 Eſective Date 10/22/2018 B. MAGI Online Application The state uses the following online application(s) for individuals applying for coverage based on the applicable MAGI standard. Name Tennessee Online Application Screenshots or other documentation of the online application(s) has been uploaded. Document Name Date Created Immigration Status Dropdown 3/9/2020 9:00 AM EDT TennCareConnect_FullApplicationScreenshots_Part08 3/9/2020 8:59 AM EDT TennCareConnect_FullApplicationScreenshots_Part07 3/9/2020 8:59 AM EDT TennCareConnect_FullApplicationScreenshots_Part06 3/9/2020 8:58 AM EDT TennCareConnect_FullApplicationScreenshots_Part05 3/9/2020 8:58 AM EDT 1 – 5 of 9 1. The single, streamlined application for all insurance aſordability programs, developed by the Secretary in accordance with section 1413(b)(1)(A) of the Aſordable Care Act 2. One or more alternative single, streamlined application developed by the state in accordance with section 1413(b)(1)(B) of the Aſordable Care Act and approved by the Secretary, which may be no more burdensome than the streamlined application developed by the Secretary 3. One or more alternative application used to apply for multiple human service programs approved by the Secretary, provided that the agency makes readily available the single application used only for insurance aſordability programs to individuals seeking assistance only through such programs 4. Other alternative applications, provided that the agency makes readily available the single streamlined application used only for insurance aſordability programs to individuals seeking assistance only through such programs

6/11/2020 Medicaid State Plan Print View Application MEDICAID | Medicaid State Plan | Eligibility | TN2018MS0001O | TN-18-0004 Package Header Package ID TN2018MS0001O Submission Type OŰcial Approval Date 6/4/2020 Superseded SPA ID TN 14-0003 User-Entered SPA ID TN-18-0004 Initial Submission Date 10/15/2018 Eſective Date 10/22/2018 C. Basis Other than MAGI - Paper Application The state uses the following paper application(s) for individuals applying for coverage on a basis other than the applicable MAGI standard: Name Tennessee Paper Application The paper application(s) has been uploaded. Document Name Date Created TennCare Paper App 20200124 FINAL Eng 3/9/2020 9:15 AM EDT 1. The single, streamlined application developed by the Secretary or one of the alternate forms developed by the state and approved by the Secretary, and supplemental forms to collect additional information needed to determine eligibility on such other basis, submitted to the Secretary 2. One or more applications designed speciţcally to determine eligibility on a basis other than the applicable MAGI standard which minimizes the burden on applicants, submitted to the Secretary 3. One or more applications used to apply for multiple human service programs 4. Other alternative applications

6/11/2020 Medicaid State Plan Print View Application MEDICAID | Medicaid State Plan | Eligibility | TN2018MS0001O | TN-18-0004 Package Header Package ID TN2018MS0001O Submission Type OŰcial Approval Date 6/4/2020 Superseded SPA ID TN 14-0003 User-Entered SPA ID TN-18-0004 Initial Submission Date 10/15/2018 Eſective Date 10/22/2018 D. Other than MAGI - Online Application The state uses the following online application(s) for individuals applying for coverage who may be eligible on a basis other than the applicable MAGI standard: Name Tennessee Online Application Screenshots or other documentation of the online application(s) has been uploaded. Document Name Date Created Immigration Status Dropdown 3/9/2020 2:52 PM EDT TennCareConnect_FullApplicationScreenshots_Part08 3/9/2020 2:52 PM EDT TennCareConnect_FullApplicationScreenshots_Part07 3/9/2020 2:51 PM EDT TennCareConnect_FullApplicationScreenshots_Part06 3/9/2020 2:51 PM EDT TennCareConnect_FullApplicationScreenshots_Part05 3/9/2020 2:50 PM EDT 1 – 5 of 9 1. The single, streamlined application developed by the Secretary or one of the alternate online forms developed by the state and approved by the Secretary, and supplemental online forms to collect additional information needed to determine eligibility on such other basis, submitted to the Secretary 2. One or more application designed speciţcally to determine eligibility on a basis other than the applicable MAGI standard which minimizes the burden on applicants, submitted to the Secretary 3. One or more application used to apply for multiple human service programs 4. Other alternative applications

6/11/2020 Medicaid State Plan Print View Application MEDICAID | Medicaid State Plan | Eligibility | TN2018MS0001O | TN-18-0004 Package Header Package ID TN2018MS0001O Submission Type OŰcial Approval Date 6/4/2020 Superseded SPA ID TN 14-0003 User-Entered SPA ID TN-18-0004 Initial Submission Date 10/15/2018 Eſective Date 10/22/2018 E. Additional Information (optional)

6/11/2020 Medicaid State Plan Print View PRA Disclosure Statement: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance OŰcer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. This view was generated on 6/11/2020 1:26 PM EDT

Table of Contents

State/Territory Name: Tennessee State Plan Amendment (SPA) #: 19-0001 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Atlanta Regional Office 61 Forsyth St., Suite 4T20 Atlanta, Georgia 30303-8909

DIVISION OF MEDICAID & CHILDREN’S HEALTH OPERATIONS

January 28, 2019

Gabe Roberts, Deputy Director Division of TennCare 310 Great Circle Road Nashville, TN 37243

Attention: Aaron Butler

Re: Tennessee State Plan Amendment, Transmittal # 19-0001

Dear Mr. Roberts:

We have reviewed the proposed amendment to the Tennessee State Plan, submitted under transmittal number MS 19-0001. The SPA was submitted to update the designated single state agency authorization for state plan amendments, effective January 19, 2019.

Based on the information provided, this amendment is approved on January 28, 2019. We are enclosing the approved form HCFA 179 and plan page. If you have any questions, please contact Tandra Hodges at 404-562-7409 or by email at Tandra.Hodges@cms.hhs.gov.

Sincerely,

//s//

Shantrina D. Roberts, MSN

Associate Regional Administrator

Division of Medicaid & Children’s Health Operations

Enclosures

TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES 1. TRANSMITTAL NUMBER: 19-0001 2. STATE TENNESSEE 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) TO: REGIONAL ADMINISTRATOR CENTERS FOR MEDICARE AND MEDICAID SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES 4. PROPOSED EFFECTIVE DATE January 19, 2019 5. TYPE OF PLAN MATERIAL (Check One): NEW STATE PLAN AMENDMENT TO BE CONSIDERED AS NEW PLAN X AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate Transmittal for each amendment) 6. FEDERAL STATUTE/REGULATION CITATION: 42 CFR 430.12(b) 7. FEDERAL BUDGET IMPACT: a. FFY 2019 $ 0 b. FFY 2020 $ 0 Section 7, page 89. 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable): Section 7, page 89. 10. SUBJECT OF AMENDMENT: General Provisions – State Governor’s Review. 11. GOVERNOR’S REVIEW (Check One): X GOVERNOR’S OFFICE REPORTED NO COMMENT OTHER, AS SPECIFIED: COMMENTS OF GOVERNOR’S OFFICE ENCLOSED NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL 12. SIGNATURE OF STATE AGENCY OFFICIAL: 16. RETURN TO: Tennessee Department of Finance and Administration Division of TennCare 310 Great Circle Road Nashville, Tennessee 37243 Attention: George Woods 13. TYPED NAME: John G. Roberts 14. TITLE: Director, Division of TennCare 15. DATE SUBMITTED: FOR REGIONAL OFFICE USE ONLY 17. DATE RECEIVED: 18. DATE APPROVED: PLAN APPROVED – ONE COPY ATTACHED 19. EFFECTIVE DATE OF APPROVED MATERIAL: 20. SIGNATURE OF REGIONAL OFFICIAL: 21. TYPED NAME: 22. TITLE: 23. REMARKS: 01/28/19 01/23/19 01/19/19 Shantrina D. Roberts Associate Regional Administrator Division of Medicaid & Children’s Health Operations //s// //s//

01/28/19

Table of Contents State/Territory Name: Tennessee State Plan Amendment (SPA) #: 19-0003-MM1 This file contains the following documents in the order listed: 1) Approval Letter 2) Summary Form (with 179-like data) 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Atlanta Regional Office 61 Forsyth Street, SW, Suite 4T20 Atlanta, Georgia 30303-8909 Division of Medicaid and Children's Health Operations December 19, 2019 Gabe Roberts Director Department of Finance & Administration 310 Great Circle Road Nashville, TN 37243 Re: Approval of State Plan Amendment TN-19-0003 Dear Gabe Roberts: On March 29, 2019, the Centers for Medicare and Medicaid Services (CMS) received Tennessee State Plan Amendment (SPA) TN-19-0003 to make changes to Hospital Presumptive Eligibility (HPE), modifications to Presumptive Eligibility (PE) for Pregnant Women, the Eligibility Process Reviewable Unit, and the state’s election to end the option to provide Presumptive Eligibility to children under age 1.. We approve Tennessee State Plan Amendment (SPA) TN-19-0003 on December 19, 2019 with an effective date(s) of March 18, 2019. In addition to submission of the Eligibility Process RU and removing the state plan option to provide PE to children under age 1, this amendment proposes to replace the paper PE application with an online application hospitals and qualified entities must use to make PE determinations, and removes the CHIP eligibility and enrollment Administrative Contractor as a qualified entity to make PE determinations for pregnant women. We note that the state has provided assurances that it provides HPE and PE coverage consistent with 435.1102(b)(2)(A) and (B), except when an individual does not submit a full Medicaid application during the PE period, in which case we understand the state provides an additional 5 days of PE coverage. This is due to the state’s eligibility system designed to ensure that all full Medicaid applications submitted during the PE period are registered prior to running a term batch and coverage is not erroneously terminated in such cases. Please note that accompanying the approval of SPA 19-0003 is the enclosed companion letter regarding the need for Tennessee to make modifications to its HPE and PE for Pregnant Women Online Application (online portal). Tennessee will provide dates for completion of outstanding changes within 60 days of approval of this SPA, and will implement a revised HPE and PE for Pregnant Women online application addressing CMS concerns by the dates listed in the companion letter. Name Date Created TN 19-0003 Companion Letter Exhibit A 12/19/2019 5:16 PM EST If you have any questions regarding this amendment, please contact Tandra Hodges at Tandra.Hodges@cms.hhs.gov. Sincerely, Davida R. Kimble Acting Deputy Director Division of Medicaid and Children's Health Operations RAI CMS is issuing this Request for Additional Information (RAI) pursuant to Section 1915(f) of the Social Security Act (added by P.L. 97 -35). This request has the effect of stopping the 90 -day time period for CMS to act on the material. A new 90 day time frame will not begin until we receive your response to this request. In accordance with our guidelines to all State Medicaid directors dated January 2, 2001, and subsequently reiterated in the August 16, 2018 Center for Medicaid and CHIP Services Informational Bulletin, if a response to a formal request for additional information from CMS is not received from the state within 90 days of issuance, CMS will initiate disapproval of the SPA or waiver action. In addition, because this amendment was submitted after January 2, 2001 and is effective after January 1, 2001, please be advised that we will defer federal financial participation (FFP) for state payments made in accordance with this amendment until it is approved. Upon approval, FFP will be available for the period beginning with the effective date through the date of approval. Page 2 of 36

Submission Package TN2019MS0003O Authority Eligibility State TN Agency Name Department of Finance & Administration Submission Date Mar 29, 2019 Priority Code P2 All Questions Question ID Reference CMS question to the State Policy/Regulation State Response 1 State agencies must have established mechanisms and procedures to provide to hospitals who make PE determinations with Medicaid eligibility information consistent with statute and regulations. Please explain how the state complies with the rules at 435.1102(b)(1)-(3) requiring the agency to have established mechanisms and procedures to provide hospitals electing to make PE determinations with Medicaid eligibility information, HPE determination approval and denial notices, and all other tools necessary to make PE determinations and implement HPE consistent with statute and regulations. 435.1102(b)(1)-(3) Tennessee has provided detailed responses to each requirement of 435.1102(b)(1)-(3). Detailed responses regarding how Tennesee has established mechanisms and procedures to provide hospitals electing to make PE determinations with Medicaid eligibility information are addressed in the responses to questions 2, 5, and 8. Detailed responses regarding the HPE approval and denial notices are addressed in the responses to questions 7 and 23. Detailed responses regarding all other tools necessary to make PE determinations and implement HPE consistent with statute and regulation are addressed in the responses to questions 2, 5, 13, 14, 15, 16, and 24. 2 State agencies must provide hospitals electing to make PE determinations with Medicaid eligibility information and all other tools necessary to make PE determinations and implement HPE consistent with statute and regulations. Please explain how the state trains hospitals participating in PE, and ensures that the hospitals have what they need to adequately train new providers on making presumptive eligibility determinations consistent with statute and regulations. 435.1102(b)(1)-(3) Hospitals received training on presumptive eligibility through webinars. Materials are provided to hospitals and posted to the state Medicaid agency's website to give new employees an explanation of presumptive eligibility. Training videos are currently being developed that will allow new hospital employees the opportunity to view training as a supplement to the existing materials. 3 For individuals determined to be presumptively eligible, if a Medicaid application is not filed by the last day of the following month, PE will end on the last day. In response to CMS comments, the state explained HPE/ PE coverage start and end dates consistent with 435.1102(b)(2)(A) and (B). However, the state explained that the state 435.1102(b)(2)(iv)(A) Individuals who receive services between 11/30- 12/5 will still be considered to be eligible. If a provider reviews existing systems to see if the individual is still eligible, the system will Page 3 of 36

Question ID Reference CMS question to the State Policy/Regulation State Response runs a batch to see if a full Medicaid application has been submitted after the end of the second month, and that the term date will actually be the 5th of the next month The state explained this gives the state a few days to ensure that all new applications are registered before running the term batch. The state provided the example of a PE application filed on 10/30 and coverage should end on 11/30 if no full application is submitted, since the state runs the batch to check for full applications on 12/5, the closure of the PE is actually on 12/5. Please explain based on the example above what happens if the individual receives services between 11/30 and 12/5 due to the PE case still being active in the state’s eligibility system. Will providers checking PE eligibility see an active PE case in the state’s eligibility system during that time period? Will payment for services provided during that time period be provided? display the individual as eligible. Payment for services provided during this time period will be provided. The batch operates in this fashion in order allow time for the eligibility to be transferred to the member's MCO. 4 For individuals determined to be presumptively eligible, if a Medicaid application is filed by the last day of the following month, PE will end on the day that a decision is made on the full Medicaid application. Please confirm that for individuals determined eligible for HPE or PE for PW who apply for full Medicaid during the PE period and are denied full Medicaid, the state’s eligibility system is able to end PE coverage on the date of the full Medicaid determination denial, even if it is mid- month. 435.1102(b)(2)(iv)(B) The State confirms that individuals who are eligible for HPE or PE, who subsequently apply for full Medicaid, and are denied full Medicaid are terminated upon the date of the full Medicaid denial, even if the denial occurs mid-month. 5 State agencies must provide hospitals electing to make PE determinations with Medicaid eligibility information and all other tools necessary to make PE determinations and implement HPE consistent with statute and regulations HPE Training Materials: Part 2 Slides 8 and 9-These slides references the Hospital PE cover sheet, Presumptive eligibility PDF, HPE affidavit for failure to submit form, HPE worksheet, HPE step-by-step instructional guide. Please provide 435.1102(b)(1)-(3) The Hospital PE Coversheet, Presumptive Elgiibility PDF, HPE Affidavit for failure to submit form, HPE Worksheet, and HPE Step-by-Step instructional guide are attached to this submission. Page 4 of 36

Question ID Reference CMS question to the State Policy/Regulation State Response CMS with copies of these materials. 6 Qualified entities make the H/PE determination. HPE Training Materials: Part 2 Slide 11-explain the purpose and process described for checking and correcting incorrect applications, and explain the Errata sheet submission process. Please explain the information providers obtain from “checking and correcting” HPE applications after the provider has made the HPE determination. 435.1102(a) Providers often will monitor HPE applications they submit to verify that the eligibility has been granted. If a provider notices that an individual's name or demographic information is incorrect, they will contact TennCare by emailing the errata sheet to TennCare noting the required update. If the provider notices that any other error has occurred in the HPE determination, they will contact TennCare to correct the HPE determination via email. This ensures the State will have correct information in its eligibility system. 7 The agency must establish procedures to ensure qualified entities provide notice in writing of the PE determination at the time the determination is made. HPE Training Materials: Part 2 Slide13-explains the state will send approved HPE beneficiaries the approval notice. Please explain if approved beneficiaries are provided with immediate notice of the HPE approvals, and explain how beneficiaries determined eligible for HPE can access coverage and services prior to receipt of the approval notice sent by the state agency. 435.1102(b)(2)(i) Hospitals are required to give HPE approved individuals a print out of the Application Summary notifying them of their approval for HPE. The Application Summary clearly states that they have been approved with the approval date and the date the coverage will end if a TennCare application is not submitted. An additional Approval notice is mailed to the PE Enrollee. If a hospital approves the HPE, the individual is encouraged to use the pharmacy services through the hospital that day, if they require a prescription. Providers are also able to view the individual's eligibility in a provider-facing online portal in two to three business days after the approval. 8 The agency must provide qualified entities with information and ensure presumptive eligibility determinations are made consistent with statute and regulations. The HPE RU and supporting materials do not explain non-citizen eligibility rules. Please explain how providers are trained on non- citizen eligibility rules. 435.1102(b)(1); 435.1102 (b)(3) Providers receive training regarding non-citizen eligibility rules in the HPE Step-by-Step Instructional guide. 9 Applicants may only be asked to provide HPE Online Application Screen Shots 435.907(e)(1) A change will be made to mark the Living Page 5 of 36

Question ID Reference CMS question to the State Policy/Regulation State Response information necessary to make an eligibility determination. The state provided an explanation of why it requests applicants for full Medicaid to select from the living arrangements dropdown list, but applicants for HPE should not be required to provide this information since it is not needed to make an HPE eligibility determination. Please mark this question as optional on the application, and provide a timeline for when this change will be made. Arrangement question as optional on the PE application. This change will occur with the 7.0 Release of the State's eligibility determination system, scheduled for December 2019. 10 Applicants may only be asked to provide information necessary to make an eligibility determination. HPE Online Application Screen Shots The state indicated in written responses that it will make a change in its system to only ask the citizenship and non- citizen status questions only of individuals applying for HPE, and that this question will not appear for non-applicant household members. Please provide a timeline of when this change will be made. 435.907(e)(1) The State has made this change. Citizenship and non-citizen status questions are now only asked of individuals applying for coverage. 11 Applicants may only be asked to provide information necessary to make an eligibility determination, and states may not require verification of the conditions for PE. HPE Online Application Screen Shots Because states must accept self-attestation of all factors of eligibility, the application should not have mandatory questions requesting an applicant, an applicant household member, or a non-applicant household member’s immigration document type or immigration document number. Please change these questions to indicate they are not required. 435.907(e)(1); 435.1102 (d)(2)(e) Tennessee has added an option in the drop down to select "Not Currently Available". If an applicant does not wish to provide immigration information or does not have it readily available, he can select this option and move forward with submitting his PE application. 12 The state has elected a reasonable estimate of MAGI-based income to determine household income. HPE Online Application Screen Shots The state has requested feedback on how to provide instructions explaining who to include in the HPE household. The instructions should be revised on the HPE 435.1102(a) The Hospital PE Online application will be updated to remove the language that suggests including “everyone” in the household. Additional language will be added to clarify who should be included in the household. This change Page 6 of 36

Question ID Reference CMS question to the State Policy/Regulation State Response application to explain that other relatives or friends should not be included in the HPE applicant’s household, even if they live with the applicant, since these individuals would not be considered part of the individual’s Medicaid household and should not be listed on the application. will be implemented in Release 7.0 of the State's eligibility determination system, currently scheduled for December 2019. 13 States may not require verification of the conditions for PE. Pregnancy Presumptive Eligibility Guide 2019 Page 7- the instructions state that an applicant must declare she is pregnant, and may be requested to present documentation of her pregnancy, but she is not required to do so. In addition to the requirement that self- attestation must be accepted for all factors of eligibility, states may not request documentation of pregnancy unless the state has information that is not reasonably compatible with such attestation. 42 CFR 435.956(e). Please remove the instructions stating that applicants may be requested to present documentation of her pregnancy for PE applications. 435.1102(d)(2)(ii) The State has updated its materials to reflect this suggestion. 14 The agency must provide qualified entities with information and ensure presumptive eligibility determinations are made consistent with statute and regulations. Pregnancy Presumptive Eligibility Guide 2019 Page 7 and 8-Ineligible non-citizen status- The instructions state that all LPRs who have been in that status less than 5 years are ineligible for PE and TennCare. This is inaccurate, as LPRs who adjusted from an immigration status that is exempt from the 5 year waiting period, such as refugees and asylees, are exempt from the 5 year waiting period. Please revise the instructions at page 7, and the instructions in the left column on page 8 to indicate that LPRs who adjusted from one of the 435.1102(b)(1) and (3) The State has updated its materials to reflect these suggestions. Page 7 of 36

Question ID Reference CMS question to the State Policy/Regulation State Response humanitarian statuses listed in the left hand column on page 8 are exempt from the five year waiting period. 15 The agency must provide qualified entities with information and ensure presumptive eligibility determinations are made consistent with statute and regulations. Pregnancy Presumptive Eligibility Guide 2019 Page 8- Abused Immigrants with a VAWA petition are qualified non-citizens, but they subject to the 5 year waiting period. Please revise the table to explain that individuals with an approved VAWA petition are eligible for Medicaid if they have been in that status for 5 years. 435.1102(b)(1) and (3) The State has updated its materials to reflect this suggestion. 16 The agency must provide hospitals with information needed to make eligibility determinations consistent with the statute and regulations. Pregnancy Presumptive Eligibility Guide 2019 Page 8- the instruction in the right column indicate that LPRs who have been in the US for less than 5 years are ineligible, but should be revised to say that LPRs who have been in that status for less than 5 year are ineligible 435.1102(b)(1) and (3) The State has updated its materials to reflect this suggestion. 17 Applicants may only be asked to provide information necessary to make an eligibility determination. Pregnancy Presumptive Eligibility Guide 2019 Page 15- Living arrangements is not needed to make a PE eligibility determination and should not be a required field. Please change this to an optional question. 42 CFR 435.907(e)(1) A change will be made to mark the Living Arrangement question as optional on the PE application. This change will occur with the 7.0 Release of the State's eligibility determination system, currently scheduled for December 2019. 18 Applicants may only be asked to provide information necessary to make an eligibility determination. Pregnancy Presumptive Eligibility Guide 2019 Page 16- The instructions say to complete the Individual Information screen for each household members. Questions on residency, citizenship, or pregnancy status should not appear for non-applicant household members. 435.907(e)(1) The State has modified the portal so that citizenship is no longer asked of anyone who was not applying. The State will implement a change so that residency will not be asked for anyone who is not applying; this change will be completed as part of the 7.0 release of the State's eligibility determination system, currently scheduled for December 2019. Pregnancy status is not asked of individuals who Page 8 of 36

Question ID Reference CMS question to the State Policy/Regulation State Response are not applying for presumptive eligibility. 19 Applicants may only be asked to provide information necessary to make an eligibility determination, and states may not require verification of the conditions for PE. Pregnancy Presumptive Eligibility Guide 2019 Page 15- Because states must accept self- attestation of all factors of eligibility, the application should not have mandatory questions requesting an applicant, an applicant household member, or a non-applicant household member’s immigration document type or immigration document number. Please change these questions to indicate they are not required. 435.907(e)(1); 435.1102 (d)(2)(e) Tennessee has added an option in the document type field to allow an applicant to select "Not Currently Available". If an applicant does not wish to provide immigration information or does not have it readily available, they can select this option and move forward with submitting their PE application 20 Applicants may only be asked to provide information necessary to make an eligibility determination. Pregnancy Presumptive Eligibility Guide 2019 Page21- The renewal of coverage question and request to renew coverage should not be a required field since it does not apply to PE. Please remove the asterisk or move this to the full Medicaid application flow. It is CMS’ understanding that the state has agreed to make a change to this section. Please explain how the state will correct this, and provide a timeline for when this will be done. 435.907(e)(1) The renewal of coverage question is not asked during the presumptive application process. It is only asked during the full Medicaid flow after an individual chooses to apply for full Medicaid. 21 Applicants may only be asked to provide information necessary to make an eligibility determination. Pregnancy Presumptive Eligibility Guide 2019 Page 21- The voter registration question should not be mandatory for PE applicants 435.907(e)(1) The voter registration question will be changed so that it is not mandatory. 22 The qualified entity that makes the PE determination based on a PE applicant’s attested information. Pregnancy Presumptive Eligibility Guide 2019 Page 22-Please explain the process for submitting and tracking the status of a PE “application.” Because it is the qualified entity that makes the PE 435.1102(a) The application tracking number is used by applicants and authorized representatives to check on the status of their application. Individuals can call TennCare and check on the status of their application by Page 9 of 36

Question ID Reference CMS question to the State Policy/Regulation State Response determination, explain what information this tracking feature provides. providing this number or their person information. 23 States must establish procedures to ensure qualified entities provide immediate notice of the PE determination in writing. Pregnancy Presumptive Eligibility Guide 2019 Page 23-the guide lacks instructions on providing immediate notice of the PE determination in writing, as is required in 435.1102(b)(2). Please describe the state’s procedures to ensure qualified entities provide immediate notice of PE determinations, and describe the state’s procedures of ensuring individuals determined eligible for PE can access coverage and services on the date of the PE approval, and provide CMS with copies of the PE approval and denial notices 435.1102(b)(2) PE applicants receive immediate notice of the PE determination in written form on the Application Summary. The Application Summary includes information on the individual's HPE approval or denial. If the individual is approved for PE, they will receive an additional PE Approval notice in the mail. 24 Notice and fair hearing rights do not apply to determinations of presumptive eligibility. Pregnancy Presumptive Eligibility Guide 2019 Page 25-provides information on eligibility appeals. Notice and fair hearing rights do not apply to determinations of presumptive eligibility. 435.1102(e). Please remove instructions on providing information on eligibility appeals and explain that this does not apply to PE determinations. 435.1102(e) The State has updated its materials based on this suggestion. 25 Applicants may only be asked to provide information necessary to make an eligibility determination. PE Application Screen Shots The following questions should not be asked on the PE application: “Date this person plans to return; immigration document type and alien number/immigration document number; pregnancy due date; and living arrangements. 435.907(e)(1) The referenced questions are optional on the PE Application. Below is why each question is needed on the screen: “Date this person plans to return”: This question is used to determine Tennessee Residence. If an individual is temporarily out of state, this question is used to determine the date they plan to return to the state. Individuals who are temporarily out of state are considered Page 10 of 36

Question ID Reference CMS question to the State Policy/Regulation State Response Tennessee residents. "Immigration Document Type and alien number/immigration document number": If this information is available, and if the individual chooses to provide it, then it facilitates the State's ability to verify the individual’s immigration information via SAVE or VLP when the full Medicaid application is submitted. This alleviates the burden on the applicant to provide proof later on when the full application is submitted. "Pregnancy Due Date": This field allows Tennessee to set the correct certification period for the individual upon approval for full Medicaid. This field is not required to be answered by the applicant. This field auto populates 10 months from the application date if this field is not answered. "Living Arrangement": This field will be optional on the screen. If the individual chooses not to answer this question it will be defaulted to “At Home” in the State's eligibility system. 26 Applicants may only be asked to provide information necessary to make an eligibility determination. The state has confirmed it will move the question “is this person applying for coverage” up in the application flow so it appears before the questions on pregnancy, citizenship and residency appear. Please provide a timeline for when this change will occur. 435.907(e)(1) The State has modified the portal so that citizenship is no longer asked of anyone who was not applying. The State will implement a change so that residency will not be asked for anyone who is not applying; this change will be completed as part of the 7.0 release of the State's eligibility determination system, currently scheduled for December 2019. Pregnancy status is not asked of individuals who are not applying for presumptive eligibility. 1 – 26 of 26 Page 11 of 36

Submission Package was updated by the State in accordance with the response above Yes No Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | TN2019MS0003O | TN-19-0003 Package Header Package ID TN2019MS0003O Submission Type Official Approval Date 12/19/2019 Superseded SPA ID N/A SPA ID TN-19-0003 Initial Submission Date 3/29/2019 Effective Date N/A State Information State/Territory Name: Tennessee Medicaid Agency Name: Department of Finance & Administration Submission Component State Plan Amendment Medicaid CHIP Page 12 of 36

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | TN2019MS0003O | TN-19-0003 Package Header Package ID TN2019MS0003O Submission Type Official Approval Date 12/19/2019 Superseded SPA ID N/A SPA ID TN-19-0003 Initial Submission Date 3/29/2019 Effective Date N/A SPA ID and Effective Date SPA ID TN-19-0003 Reviewable Unit Proposed Effective Date Superseded SPA ID Eligibility Process 3/18/2019 N/A Presumptive Eligibility 3/18/2019 N/A Presumptive Eligibility for Children under Age 19 3/18/2019 TN 14-0005 Presumptive Eligibility for Pregnant Women 3/18/2019 TN 16-0002 Presumptive Eligibility by Hospitals 3/18/2019 TN 14-0011 Page Number of the Superseded Plan Section or Attachment (If Applicable): Section 4, Page 79a, Item 4.33; Attachment 4.33-A Page 13 of 36

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | TN2019MS0003O | TN-19-0003 Package Header Package ID TN2019MS0003O Submission Type Official Approval Date 12/19/2019 Superseded SPA ID N/A SPA ID TN-19-0003 Initial Submission Date 3/29/2019 Effective Date N/A Executive Summary Summary Description Including Goals and Objectives This SPA ends the state's limited presumptive eligibility program for children younger than age 1. The SPA also makes adjustments to the state's hospital presumptive eligibility process and modifies the list of entities qualified to make presumptive eligibility determinations for pregnant women. Federal Budget Impact and Statute/Regulation Citation Federal Budget Impact Federal Fiscal Year Amount First 2019 $0 Second 2020 $0 Federal Statute / Regulation Citation 42 CFR Part 435, Subpart L Supporting documentation of budget impact is uploaded (optional). Name Date Created No items available Page 14 of 36

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | TN2019MS0003O | TN-19-0003 Package Header Package ID TN2019MS0003O Submission Type Official Approval Date 12/19/2019 Superseded SPA ID N/A SPA ID TN-19-0003 Initial Submission Date 3/29/2019 Effective Date N/A Governor's Office Review No comment Comments received No response within 45 days Other Page 15 of 36

Submission - Public Comment MEDICAID | Medicaid State Plan | Eligibility | TN2019MS0003O | TN-19-0003 Package Header Package ID TN2019MS0003O Submission Type Official Approval Date 12/19/2019 Superseded SPA ID N/A SPA ID TN-19-0003 Initial Submission Date 3/29/2019 Effective Date N/A Indicate whether public comment was solicited with respect to this submission. Public notice was not federally required and comment was not solicited Public notice was not federally required, but comment was solicited Public notice was federally required and comment was solicited Page 16 of 36 /23/2019

Submission - Tribal Input MEDICAID | Medicaid State Plan | Eligibility | TN2019MS0003O | TN-19-0003 Package Header Package ID TN2019MS0003O Submission Type Official Approval Date 12/19/2019 Superseded SPA ID N/A SPA ID TN-19-0003 Initial Submission Date 3/29/2019 Effective Date N/A One or more Indian Health Programs or Urban Indian Organizations furnish health care services in this state Yes No Page 17 of 36 Medicaid State Plan Print View

Medicaid State Plan Eligibility General Eligibility Requirements Eligibility Process MEDICAID | Medicaid State Plan | Eligibility | TN2019MS0003O | TN-19-0003 Package Header Package ID TN2019MS0003O Submission Type Official Approval Date 12/19/2019 Superseded SPA ID N/A User-Entered SPA ID TN-19-0003 Initial Submission Date 3/29/2019 Effective Date 3/18/2019 The state meets all the requirements of 42 CFR 435, Subpart J for processing applications, determining, verifying and renewing eligibility, and furnishing Medicaid. A. Submission of Application  1. The agency's procedures permit an individual, or authorized person acting on behalf of the individual, to submit an application via the internet website described in 42 CFR 435.1200(f), by telephone, via mail, and in person. These modes of submission are available to all individuals applying for coverage, including those who may be eligible based on the applicable Modified Adjusted Gross Income (MAGI) standard and those who may be eligible on a basis other than MAGI. 2. The agency also accepts applications by other electronic means: Yes No  3. The agency ensures that any application or supplemental form is accessible to persons who are limited English proficient and persons who have disabilities, consistent with 42 CFR 435.905(b). Page 18 of 36

Eligibility Process MEDICAID | Medicaid State Plan | Eligibility | TN2019MS0003O | TN-19-0003 Package Header Package ID TN2019MS0003O Submission Type Official Approval Date 12/19/2019 Superseded SPA ID N/A User-Entered SPA ID TN-19-0003 Initial Submission Date 3/29/2019 Effective Date 3/18/2019 B. Establishment of Outstation Locations  The agency has procedures to take applications, assist applicants and perform initial processing of applications for the eligibility groups listed below at locations other than those used for the receipt and processing of applications for the title IV-A program, including Federally-qualified health centers and disproportionate share hospitals: 1. Parents and Other Caretaker Relatives, 2. Pregnant Women, and 3. Infants and Children under Age 19. C. MAGI Renewals  Redeterminations of eligibility for individuals whose financial eligibility is based on the applicable MAGI standard are performed as follows, consistent with 42 CFR 435.916: 1. Once every 12 months 2. Without requiring an in-person interview 3. Without requiring information from the individual if the agency is able to determine eligibility based on reliable information contained in the individual's account or other more current information available to the agency 4. If the agency cannot determine eligibility solely on the basis of the information available to it, or otherwise needs additional information to complete the redetermination, the agency: a. Provides the individual with a pre-populated renewal form containing the information available to the agency (including information gathered from electronic data sources). b. Provides the individual with a reasonable period of time from the date of the prepopulated renewal form to respond and provide any necessary information. The time period used by the state is: i. 30 days ii. More than 30 days The number of days is: 40 c. Permits an individual, or authorized person acting on behalf of the individual, to submit the renewal form via the internet website described in 42 CFR 435.1200(f) (d), by telephone, via mail, and in person. d. Verifies information provided by the beneficiary in accordance with 42 CFR 435.925 through 435.956 e. Reconsiders eligibility, without requiring a new application, for individuals who are terminated for failure to submit the renewal form or necessary information if the individual subsequently submits the renewal form. For this purpose, the renewal form is accepted within the time period after the termination date selected below: i. 90 days ii. More than 90 days. Page 19 of 36 Medicaid State Plan Print View

Eligibility Process MEDICAID | Medicaid State Plan | Eligibility | TN2019MS0003O | TN-19-0003 Package Header Package ID TN2019MS0003O Submission Type Official Approval Date 12/19/2019 Superseded SPA ID N/A User-Entered SPA ID TN-19-0003 Initial Submission Date 3/29/2019 Effective Date 3/18/2019 D. Renewals on a Basis Other than MAGI  Redeterminations of eligibility for individuals whose financial eligibility is not based on the MAGI standard are performed as follows, consistent with 42 CFR 435.916: 1. Frequency:  a. Once every 12 months b. Once every 6 months c. Other, more frequent than once every 12 months 2. Without requiring information from the individual, if the agency is able to determine eligibility based on reliable information contained in the individual's account or other more current information available to the agency. 3. If the agency cannot determine eligibility solely on the basis of the information available to it, or otherwise needs additional information to complete the redetermination, the agency:  a. Provides the individual with a renewal form i. The renewal form is pre-populated with information available to the agency (including information gathered from electronic data sources). Yes No ii. As part of this process, the agency: (1) Provides the individual with a reasonable period of time from the date of the renewal form to respond and provide any necessary information. The time period used by the state is: (a) 30 days (b) More than 30 days The number of days is: 40 (2) Permits an individual, or authorized person acting on behalf of the individual, to submit the renewal form using the following methods:  (a) Via the internet website described in 42 CFR 435.1200(f)  (b) By telephone  (c) Via mail  (d) In person  (e) By other means Description: By fax (3) Verifies information provided by the beneficiary in accordance with 42 CFR 435.925 through 435.956 (4) Reconsiders eligibility, without requiring a new application, for individuals who are terminated for failure to submit the renewal form or necessary information if the individual subsequently submits the renewal form. For this purpose, the renewal form is accepted within the time period after the termination date selected below: Yes No Page 20 of 36

(a) 90 days (b) Other b. Utilizes an alternative process to redetermine eligibility. Page 21 of 36 Medicaid State Plan Print View

Eligibility Process MEDICAID | Medicaid State Plan | Eligibility | TN2019MS0003O | TN-19-0003 Package Header Package ID TN2019MS0003O Submission Type Official Approval Date 12/19/2019 Superseded SPA ID N/A User-Entered SPA ID TN-19-0003 Initial Submission Date 3/29/2019 Effective Date 3/18/2019 E. Determination of Ineligibility  1. Prior to making a determination of ineligibility, the agency considers all bases of eligibility, consistent with 42 CFR 435.911  2. For individuals determined ineligible for Medicaid, the agency determines potential eligibility for other insurance affordability programs and complies with the procedures set forth in 42 CFR 435.1200(e) F. Assistance with Application and Renewal  The agency provides assistance to any individual seeking help with the application or renewal process in person, over the telephone, and online, and in a manner that is accessible to individuals with disabilities and those who are limited English proficient, consistent with 42 CFR 435.905(b) Page 22 of 36

Eligibility Process MEDICAID | Medicaid State Plan | Eligibility | TN2019MS0003O | TN-19-0003 Package Header Package ID TN2019MS0003O Submission Type Official Approval Date 12/19/2019 Superseded SPA ID N/A User-Entered SPA ID TN-19-0003 Initial Submission Date 3/29/2019 Effective Date 3/18/2019 G. Notices  1. The agency provides individuals with a choice to receive notices and information in an electronic format or by regular mail, in accordance with 42 CFR 435.918.  2. The agency provides applicants with timely and accurate notice of any approval or disapproval of Medicaid eligibility, which includes, but is not limited to: the basis and effective date of eligibility, the circumstances and procedures for reporting a change that may impact eligibility, the level of benefits and services approved, any applicable premiums or cost sharing, appeal rights, and if applicable, the amount of medical expenses which must be incurred to establish eligibility.  3. The agency makes notices, as well as cards evidencing eligibility for medical assistance, available to an individual who does not reside in a permanent dwelling or does not have a fixed home or mailing address. Notices and cards are made available through the following method(s) If an individual does not have a residence address, they can enter a mailing address, such as a PO box, or can choose to receive materials electronically. If an individual is homeless, they are not required to provide a residence address. The mailing address they can enter can be the shelter where they sometimes reside, their local DHS office, or any place where they could access mail. If they have no way to access mail, then the address that will be input for them will be the TennCare address.  4. The agency provides beneficiaries with timely and adequate notice of proposed adverse action to terminate, discontinue, or suspend their eligibility or to reduce or discontinue services they may receive under Medicaid, and sends corresponding notice(s) to the individual at least 10 days prior to the action’s effective date, as described in 42 CFR 431.211.  5. All notices provided by the agency are written in plain language. To ensure that notices are clear and undertstandable to consumer, the agency:  a. Utilizes an in-house readability and plain language review process b. Contracts with an outside entity to complete a readability and plain language review c. Other Page 23 of 36

Eligibility Process MEDICAID | Medicaid State Plan | Eligibility | TN2019MS0003O | TN-19-0003 Package Header Package ID TN2019MS0003O Submission Type Official Approval Date 12/19/2019 Superseded SPA ID N/A User-Entered SPA ID TN-19-0003 Initial Submission Date 3/29/2019 Effective Date 3/18/2019 H. Authorized Representatives  1. The agency permits applicants and beneficiaries to designate an individual or organization to act responsibly on their behalf in assisting with individuals' application and renewal of eligibility and other ongoing communications with the agency.  2. The agency requires that, as a condition of serving as an authorized representative, a provider or staff member or volunteer of an organization affirms that he or she will adhere to the regulations in 42 CFR 431, subpart F and at 45 CFR 155.260(f) (relating to confidentiality of information), §447.10 of this chapter (relating to the prohibition against reassignment of provider claims as appropriate for a facility or an organization acting on the facility's behalf), as well as other relevant State and Federal laws concerning conflicts of interest and confidentiality of information.  3.Designations of authorized representatives are accepted through all of the modalities described in 42 CFR 435.907(a) and are permitted at application and at other times. The agency accepts electronic, including telephonically recorded, signatures and handwritten signatures transmitted by facsimile or other electronic transmission. I. Coordination of Eligibility and Enrollment  The state meets all the requirements of 42 CFR 435, Subpart M relative to coordination of eligibility and enrollment between Medicaid, CHIP, Exchanges and other insurance affordability programs. The single state agency has entered into agreements with the Exchange and with other agencies administering insurance affordability programs. J. Additional Information (optional) Page 24 of 36

Medicaid State Plan Eligibility Eligibility and Enrollment Processes Presumptive Eligibility MEDICAID | Medicaid State Plan | Eligibility | TN2019MS0003O | TN-19-0003 Package Header Package ID TN2019MS0003O Submission Type Official Approval Date 12/19/2019 Superseded SPA ID N/A User-Entered SPA ID TN-19-0003 Initial Submission Date 3/29/2019 Effective Date 3/18/2019 The state provides Medicaid services to individuals during a presumptive eligibility period following a determination by a qualified entity. Presumptive eligibility covered in the state plan includes: Eligibility Groups Eligibility Group Name Covered In State Plan Include RU In Package ? Included in Another Submission Package Source Type ? Presumptive Eligibility for Children under Age 19 CONVERTED Parents and Other Caretaker Relatives - Presumptive Eligibility NEW Presumptive Eligibility for Pregnant Women APPROVED Adult Group - Presumptive Eligibility NEW Individuals above 133% FPL under Age 65 - Presumptive Eligibility NEW Individuals Eligible for Family Planning Services - Presumptive Eligibility NEW Former Foster Care Children - Presumptive Eligibility NEW Individuals Needing Treatment for Breast or Cervical Cancer - Presumptive Eligibility NEW Hospitals Eligibility Group Name Covered In State Plan Include RU In Package ? Included in Another Submission Package Source Type ? Presumptive Eligibility by Hospitals APPROVED     Page 25 of 36

Presumptive Eligibility MEDICAID | Medicaid State Plan | Eligibility | TN2019MS0003O | TN-19-0003 Package Header Package ID TN2019MS0003O Submission Type Official Approval Date 12/19/2019 Superseded SPA ID N/A User-Entered SPA ID TN-19-0003 Initial Submission Date 3/29/2019 Effective Date 3/18/2019 Eligibility Groups Deselected from Coverage The following eligibility groups were previously covered in the source approved version of the state plan and deselected from coverage as part of this submission package: • Presumptive Eligibility for Children under Age 19 Page 26 of 36

Medicaid State Plan Eligibility Presumptive Eligibility Presumptive Eligibility for Children under Age 19 MEDICAID | Medicaid State Plan | Eligibility | TN2019MS0003O | TN-19-0003 The state provides Medicaid coverage to children when determined presumptively eligible by a qualified entity. Package Header Package ID TN2019MS0003O Submission Type Official Approval Date 12/19/2019 Superseded SPA ID TN 14-0005 User-Entered SPA ID TN-19-0003 Initial Submission Date 3/29/2019 Effective Date 3/18/2019 Group No Longer Covered Covered Through 3/17/2019 Terminated As Of 3/18/2019 Page 27 of 36

Medicaid State Plan Eligibility Presumptive Eligibility Presumptive Eligibility for Pregnant Women MEDICAID | Medicaid State Plan | Eligibility | TN2019MS0003O | TN-19-0003 Package Header Package ID TN2019MS0003O Submission Type Official Approval Date 12/19/2019 Superseded SPA ID TN 16-0002 System-Derived SPA ID TN-19-0003 Initial Submission Date 3/29/2019 Effective Date 3/18/2019 The state covers ambulatory prenatal care for individuals qualifying as pregnant women under 42 CFR 435.116 when determined presumptively eligible by a qualified entity. A. Presumptive Eligibility Period 1. The presumptive period begins on the date the determination is made. 2. The end date of the presumptive period is the earlier of: a. The date the eligibility determination for regular Medicaid is made, if an application for Medicaid is filed by the last day of the month following the month in which the determination of presumptive eligibility is made; or b. The last day of the month following the month in which the determination of presumptive eligibility is made, if no application for Medicaid is filed by that date. 3. There may be no more than one period of presumptive eligibility per pregnancy. B. Application for Presumptive Eligibility  1. The state uses a standardized screening process for determining presumptive eligibility. 2. The state uses a single application form for Medicaid and presumptive eligibility, approved by CMS. A copy of the single streamlined application with questions necessary for a PE determination highlighted or denoted is included. 3. The state uses a separate application form for presumptive eligibility, approved by CMS. A copy of the application form is included.  4. The state uses an online portal or electronic screening tool for presumptive eligibility approved by CMS. Screenshots of the tool included. Name Date Created PP_Screenshots_PEOnly_121 82019 12/19/2019 9:56 AM EST C. Presumptive Eligibility Determination The presumptive eligibility determination is based on the following factors: 1. The woman must be pregnant. 2. Household income must not exceed the applicable income standard at 42 CFR 435.116. a. A reasonable estimate of MAGI-based income is used to determine household income. b. Gross income is used to determine household size.  3. State residency  4. Citizenship, status as a national, or satisfactory immigration status Page 28 of 36

Presumptive Eligibility for Pregnant Women MEDICAID | Medicaid State Plan | Eligibility | TN2019MS0003O | TN-19-0003 Package Header Package ID TN2019MS0003O Submission Type Official Approval Date 12/19/2019 Superseded SPA ID TN 16-0002 System-Derived SPA ID TN-19-0003 Initial Submission Date 3/29/2019 Effective Date 3/18/2019 D. Qualified Entities 1. The state uses qualified entities, as defined in section 1920A of the Act, to determine eligibility presumptively for this eligibility group. A qualified entity is an entity that is determined by the agency to be capable of making presumptive eligibility determinations based on an individual’s household income and other requirements. 2. The following qualified entities are used to determine presumptive eligibility for this eligibility group:  Other entity the agency determines is capable of making presumptive eligibility determinations Name of entity Description Selected FQHCs Selected FQHCs in high volume areas County health departments Offices of the Department of Health located in each of Tennessee's 95 counties  3. The state assures that it has communicated the requirements for qualified entities, at 1920A(b)(3) of the Act, and has provided adequate training to the entities and organizations involved. 4. A copy of the training materials has been uploaded for review during the submission process. Name Date Created PE Desk Guide 121719 12/17/2019 12:56 PM EST Page 29 of 36

Presumptive Eligibility for Pregnant Women MEDICAID | Medicaid State Plan | Eligibility | TN2019MS0003O | TN-19-0003 Package Header Package ID TN2019MS0003O Submission Type Official Approval Date 12/19/2019 Superseded SPA ID TN 16-0002 System-Derived SPA ID TN-19-0003 Initial Submission Date 3/29/2019 Effective Date 3/18/2019 E. Additional Information (optional) Page 30 of 36

Medicaid State Plan Eligibility Presumptive Eligibility Presumptive Eligibility by Hospitals MEDICAID | Medicaid State Plan | Eligibility | TN2019MS0003O | TN-19-0003 Package Header Package ID TN2019MS0003O Submission Type Official Approval Date 12/19/2019 Superseded SPA ID TN 14-0011 System-Derived SPA ID TN-19-0003 Initial Submission Date 3/29/2019 Effective Date 3/18/2019  The state provides an assurance that it has policies and procedures in place to enable qualified hospitals to determine presumptive eligibility under 42 CFR 435.1110, and the state is providing Medicaid coverage for individuals determined presumptively eligible under this provision.  The state attests that presumptive eligibility by hospitals is administered in accordance with the following provisions: A. Qualifications of Hospitals A qualified hospital is a hospital that: 1. Participates as a provider under the state plan or a Medicaid 1115 Demonstration, notifies the Medicaid agency of its election to make presumptive eligibility determinations and agrees to make presumptive eligibility determinations consistent with state policies and procedures. 2. Has not been disqualified by the Medicaid agency for failure to make presumptive eligibility determinations in accordance with applicable state policies and procedures or for failure to meet any standards that may have been established by the Medicaid agency. 3. Assists individuals in completing and submitting the full application and understanding any documentation requirements. Yes No Page 31 of 36

Presumptive Eligibility by Hospitals MEDICAID | Medicaid State Plan | Eligibility | TN2019MS0003O | TN-19-0003 Package Header Package ID TN2019MS0003O Submission Type Official Approval Date 12/19/2019 Superseded SPA ID TN 14-0011 System-Derived SPA ID TN-19-0003 Initial Submission Date 3/29/2019 Effective Date 3/18/2019 B. Eligibility Groups or Populations Included The eligibility groups or populations for which hospitals determine eligibility presumptively are: 1. Pregnant Women 2. Infants and Children under Age 19 3. Parents and Other Caretaker Relatives 4. Adult Group, if covered by the state 5. Individuals above 133% FPL under Age 65, if covered by the state 6. Individuals Eligible for Family Planning Services, if covered by the state 7. Former Foster Care Children 8. Certain Individuals Needing Treatment for Breast or Cervical Cancer, if covered by the state The state limits qualified hospitals for this group to providers who conduct screenings for breast and cervical cancer under the state’s Centers for Disease Control and Prevention’s National Breast and Cervical Cancer Early Detection Program. Yes No 9. Other Medicaid state plan eligibility groups: 10. Demonstration populations covered under section 1115 Page 32 of 36

Presumptive Eligibility by Hospitals MEDICAID | Medicaid State Plan | Eligibility | TN2019MS0003O | TN-19-0003 Package Header Package ID TN2019MS0003O Submission Type Official Approval Date 12/19/2019 Superseded SPA ID TN 14-0011 System-Derived SPA ID TN-19-0003 Initial Submission Date 3/29/2019 Effective Date 3/18/2019 C. Standards for Participating Hospitals The state establishes reasonable standards for qualified hospitals making presumptive eligibility determinations. Yes No  The state has a standard requiring that a percentage of individuals who are determined presumptively eligible submit a regular application, as described at 42 CFR 435.907, before the end of the presumptive eligibility period. Percentage of individuals submitting a regular application: 99.00%  The state has a standard requiring that a percentage of individuals who are determined presumptively eligible be determined eligible for Medicaid based on the submission of an application before the end of the presumptive eligibility period. Percentage of individuals found eligible for Medicaid 97.00% D. Presumptive Eligibility Period 1. The presumptive period begins on the date the determination is made. 2. The end date of the presumptive period is the earlier of: • The date the eligibility determination for regular Medicaid is made, if an application for Medicaid is filed by the last day of the month following the month in which the determination of presumptive eligibility is made; or • The last day of the month following the month in which the determination of presumptive eligibility is made, if no application for Medicaid is filed by that date. 3. Periods of presumptive eligibility are limited as follows: a. No more than one period within a calendar year. b. No more than one period within two calendar years. c. No more than one period within a six-month period, starting with the effective date of the initial presumptive eligibility period. d. No more than one period within a twelve-month period, starting with the effective date of the initial presumptive eligibility period. e. Other reasonable limitation: Page 33 of 36

Presumptive Eligibility by Hospitals MEDICAID | Medicaid State Plan | Eligibility | TN2019MS0003O | TN-19-0003 Package Header Package ID TN2019MS0003O Submission Type Official Approval Date 12/19/2019 Superseded SPA ID TN 14-0011 System-Derived SPA ID TN-19-0003 Initial Submission Date 3/29/2019 Effective Date 3/18/2019 E. Application for Presumptive Eligibility  1. The state uses a standardized screening process for determining presumptive eligibility. 2. The state uses a single application form for Medicaid and presumptive eligibility, approved by CMS. A copy of the single streamlined application with questions necessary for a PE determination highlighted or denoted is included. 3. The state uses a separate paper application form for presumptive eligibility, approved by CMS. A copy of the application form is included.  4. The state uses an online portal or electronic screening tool for presumptive eligibility approved by CMS. Screenshots of the tool included. Name Date Created PP_Screenshots_PEOnly_121 82019 12/19/2019 9:58 AM EST F. Presumptive Eligibility Determination The presumptive eligibility determination is based on the following factors: 1. The individual’s categorical or non-financial eligibility for the group for which the individual’s presumptive eligibility is being determined (e.g., based on age, pregnancy status, status as a parent/caretaker relative, disability, or other requirements specified in the Medicaid state plan or a Medicaid 1115 demonstration for that group) 2. Household income must not exceed the applicable income standard for the group for which the individual's presumptive eligibility is being determined, if an income standard is applicable for this group. a. A reasonable estimate of MAGI-based income is used to determine household income. b. Gross income is used to determine household size. c. Other income methodology  3. State residency  4. Citizenship, status as a national, or satisfactory immigration status Page 34 of 36

Presumptive Eligibility by Hospitals MEDICAID | Medicaid State Plan | Eligibility | TN2019MS0003O | TN-19-0003 Package Header Package ID TN2019MS0003O Submission Type Official Approval Date 12/19/2019 Superseded SPA ID TN 14-0011 System-Derived SPA ID TN-19-0003 Initial Submission Date 3/29/2019 Effective Date 3/18/2019 G. Qualified Entity Requirements  1. The state assures that it has communicated the requirements for qualified hospitals, and has provided adequate training to the hospitals. 2. A copy of the training materials has been uploaded for review during the submission process. Name Date Created Hospital PE Training Presentation 12.13.19 12/17/2019 12:47 PM EST HPE Step-By-Step Instructional Guide v13 12/17/2019 12:48 PM EST HPE FAQ v.16 12/17/2019 12:48 PM EST Hospital PE Worksheet v06 12/17/2019 12:50 PM EST H. Additional Information (optional) Participating hospitals shall ensure no less than 99% of individuals approved for PE actually completed and submitted the full application for ongoing TennCare eligibility. Applicants who choose not to apply for full coverage will not count against the 99% application standard. No less than 93% of all applicants made presumptively eligible shall be found eligible for full Medicaid benefits in year 1, with the required approval proportion increasing to 95% and 97% in years 2 and 3, respectively. Thus, a hospital faces termination of HPE privileges if greater than 7% of the applicants they made presumptively eligible in year 1 were not in fact Medicaid eligible after determination based on a regular Medicaid application. Page 35 of 36

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Table of Contents

State/Territory Name: Tennessee State Plan Amendment (SPA) #: 20-0001 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form 3) Approved SPA Pages

DEPARTMENT OF HEALTH &HUMAN SERVICES Centers for Medicare & Medicaid Services 601 East 12th Street Room 355 Kansas City, Missouri 64106

Medicaid and CHIP Operations

March 23, 2020

Mr. Stephen M. Smith Director, Division of TennCare Attention: Aaron Butler 310 Great Circle Road Nashville, Tennessee 37243

Re: Tennessee State Plan Amendment, Transmittal # 20-0001

Dear Mr. Smith:

We have reviewed the proposed amendment to the Tennessee State Plan, submitted under transmittal number TN 20-0001. The SPA was submitted to update the State Governor Review regarding who is authorized to submit SPAs on behalf of the Tennessee, effective March 3, 2020.

Based on the information provided, this amendment is approved on March 23, 2020. We are enclosing the approved form HCFA 179 and plan page. If you have any questions, please contact Tandra Hodges at 404-562-7409 or by email at Tandra.Hodges@cms.hhs.gov.

If you have any additional questions or need further assistance, please contact Tandra Hodges at (404) 562-7409 or Tandra.Hodges@cms.hhs.gov.

Sincerely,

/s/

James Scott Director Division of Program Operations

Enclosures

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED HEALTH CARE FINANCING ADMINISTRATION OMB NO. 0938-0193 FORM HCFA-179 (07-92) TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL

FOR: HEALTH CARE FINANCING ADMINISTRATION 1. TRANSMITTAL NUMBER: 20-0001 2. STATE Tennessee 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) TO: REGIONAL ADMINISTRATOR HEALTH CARE FINANCING ADMINISTRATION DEPARTMENT OF HEALTH AND HUMAN SERVICES 4. PROPOSED EFFECTIVE DATE

5. TYPE OF PLAN MATERIAL (Check One):

NEW STATE PLAN AMENDMENT TO BE CONSIDERED AS NEW PLAN X AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate Transmittal for each amendment) 6. FEDERAL STATUTE/REGULATION CITATION: 42CFR 430.12(b) 7. FEDERAL BUDGET IMPACT: a. FFY $ b. FFY $ 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:

Section 7, page 89 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable): Section 7, page 89 10. SUBJECT OF AMENDMENT: General Provisions – State Governor’s Reviews

11. GOVERNOR’S REVIEW (Check One):

GOVERNOR’S OFFICE REPORTED NO COMMENT OTHER, AS SPECIFIED:

COMMENTS OF GOVERNOR’S OFFICE ENCLOSED

NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL 12. SIGNATURE OF STATE AGENCY OFFICIAL: /s/ 16. RETURN TO: Tennessee Department of Finance and Administration Division of TennCare 310 Great Circle Road Nashville, Tennessee 37243

13. TYPED NAME: Stephen Smith 14. TITLE: Director, Division of TennCare 15. DATE SUBMITTED: 03/13/20 FOR REGIONAL OFFICE USE ONLY 17. DATE RECEIVED: 03/13/20 18. DATE APPROVED: 03/23/20 PLAN APPROVED – ONE COPY ATTACHED 19. EFFECTIVE DATE OF APPROVED MATERIAL: 03/03/20 20. SIGNATURE OF REGIONAL OFFICIAL: /s/ 21. TYPED NAME: James Scott

22. TITLE: Director, Division of Program Operations

23. REMARKS:

89

Revision: HCFA-PM-91-4 AUGUST 1991 (BPD) 0MB No. 0938-

State/Territory: TENNESSEE

Citation 7.4 State Governor's Review

42 CFR 430.12(b) The Medicaid agency will provide opportunity for the Office of the Governor to review State plan amendments, long-range program planning projections, and other periodic reports thereon, excluding periodic statistical, budget and fiscal reports. Any comments made will be transmitted to the Center for Medicare and Medicaid Services with such documents.

X Not applicable. The Governor-

X Does not wish to review any plan material.

Wishes to review only the plan materials specified in the enclosed document.

I hereby certify that I am authorized to submit this plan on behalf of

TENNESSEE DEPARTMENT OF FINANCE AND ADMINISTRATION

(Designated Single State Agency)

Date:

_______/s/_______________ (Signature)

Director. Division ofTennCare (Title)

TN No. TN-20-0001 Supersedes TN No. TN-19-0001 Approval Date 03/13/2020 Effective 3/3/2020

Table of Contents State/Territory Name: Tennessee State Plan Amendment (SPA) #: 2-000 This file contains the following documents in the order listed: 1) Approval Letter 2) Summary Form (with 179-like data) 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 601 E. 12th St., Room 355 Kansas City, Missouri 64106 Medicaid and CHIP Operations Group 0D\, 2021 6WHSKHQ6PLWK 'LUHFWRU'LYLVLRQRI7HQQ&DUH $WWHQWLRQ *HRUJH:RRGV *UHDW&LUFOH5RDG 1DVKYLOOH, 71  Re: 7HQQHVVHH State Plan Amendment 21-000 Dear Mr. 6PLWK: :HUHYLHZHG\RXUSURSRVHG0HGLFDLG6WDWH3ODQ$PHQGPHQW71ZKLFKZDV VXEPLWWHGWRWKH&HQWHUVIRU0HGLFDUH 0HGLFDLG6HUYLFHV &06 RQ0DUFKThis DPHQGPHQWSURSRVHVWRLPSOHPHQWWKH  O 6WDWH3ODQ2SWLRQWKDWSURYLGHV0HGLFDLG $VVLVWDQFHIRUHOLJLEOHLQGLYLGXDOVZKRDUHSDWLHQWVLQHOLJLEOHLQVWLWXWLRQVIRUPHQWDOGLVHDVHV

,0' LQDFFRUGDQFHZLWK6HFWLRQRI3XEOLF/DZ &06DSSURYHG 71 21-000 on 0D\ , 2021ZLWKDQ effective date of0DUFK, 2021. If you have any TXHVWLRQVUHJDUGLQJWKLVDPHQGPHQW, please contact William Pak at (404) 562-7407 orYLDHPDLODWWilliam.Pak@cms.hhs.gov. Sincerely, James G. Scott, Director Division of Program Operations Medicaid and CHIP Operations Group

TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES 1. TRANSMITTAL NUMBER: 21-0002 2. STATE TENNESSEE 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) TO: REGIONAL ADMINISTRATOR CENTERS FOR MEDICARE AND MEDICAID SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES 4. PROPOSED EFFECTIVE DATE March 1, 2021 5. TYPE OF PLAN MATERIAL (Check One): NEW STATE PLAN AMENDMENT TO BE CONSIDERED AS NEW PLAN X AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate Transmittal for each amendment) 6. FEDERAL STATUTE/REGULATION CITATION: § 1915(1) of the Social Security Act 7. FEDERAL BUDGET IMPACT: a. FFY 2021 $0 b. FFY 2022 $0 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: Supplement 4 to Attachment 3.1-A, pages 1 – 3. Attachment 3.1-A, Item 27, page 12. 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable): New pages. 10. SUBJECT OF AMENDMENT: Add SSA § 1915(1) State Plan Option for reimbursement of state plan substance use disorder services delivered in an IMD setting. 11. GOVERNOR’S REVIEW (Check One): X GOVERNOR’S OFFICE REPORTED NO COMMENT OTHER, AS SPECIFIED: COMMENTS OF GOVERNOR’S OFFICE ENCLOSED NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL 12. SIGNATURE OF STATE AGENCY OFFICIAL: 16. RETURN TO: Tennessee Department of Finance and Administration Division of TennCare 310 Great Circle Road Nashville, Tennessee 37243 Attention: George Woods 13. TYPED NAME: Stephen Smith 14. TITLE: Director, Division of TennCare 15. DATE SUBMITTED: March 1, 2021 FOR REGIONAL OFFICE USE ONLY 17. DATE RECEIVED:0DUFK 18. DATE APPROVED:0D\ PLAN APPROVED – ONE COPY ATTACHED 19. EFFECTIVE DATE OF APPROVED MATERIAL: 20. SIGNATURE OF REGIONAL OFFICIAL: 21. TYPED NAME:-DPHV*6FRWW 22. TITLE:'32'LYLVLRQ'LUHFWRU 23. REMARKS: FORM HCFA-179 (07-92) 0DUFK

Supplement 4 to Attachment 3.1-A Page 1 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE: TENNESSEE _____________________________________________________________________________________ _____________________________________________________________________________________ 1915(l) State Plan Option To Provide Medical Assistance For Eligible Individuals Who Are Patients In Eligible Institutions for Mental Diseases General assurances ܈Services provided under 1915(l) are covered under the Medicaid state plan. ܈Coverage is available for a maximum of 30 days per 12-month period per eligible individual from the date an eligible individual is first admitted to an eligible IMD. Eligibility for Services ܈Medicaid beneficiaries age 21 through 64 who have at least one substance use disorder and reside in an eligible institution for mental diseases (IMD) primarily to receive withdrawal management or substance use disorder treatment services. Eligible IMDs ܈The state provides assurance that providers follow reliable evidence-based practices and offer at least two forms of medication-assisted treatment onsite, including one antagonist and one partial agonist for opioid use disorder, in accordance with 1915(l)(7)(C). Please briefly describe how the state assures the provision of evidence-based practices, including medication-assisted treatment, in IMDs: The state assures that IMDs follow reliable evidence-based practices and offer two forms of MAT on-site (one antagonist and one partial agonist). The state partners with managed care organizations for monitoring of standards for evidence- based practices, and for ensuring that all IMDs offer two forms of MAT on-site. The state Medicaid agency and the state’s substance use disorder agency (the licensing agency for these facilities) work collaboratively to ensure adequate education and communication with IMDs about these requirements. ___________________________________________________________________________________ TN No. 21-0002 Supersedes Approval Date  Effective Date 03/01/21 TN No. New

Supplement 4 to Attachment 3.1-A Page 2 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE: TENNESSEE _____________________________________________________________________________________ _____________________________________________________________________________________ Evidence-based Clinical Screening ܈The state provides assurance that eligible individuals receive an appropriate evidence-based clinical screening prior to receiving services in an eligible IMD, including initial and periodic reassessments to determine the appropriate level of care, length of stay, and setting for each individual. Please briefly describe the assessment process or processes the state will use to obtain information to determine the appropriate level of care, length of stay, and treatment setting: Prior authorization is required for SUD treatment services in IMDs, which involves a review of the provider’s request for services, including a comprehensive diagnostic assessment prior to admission. All substance use disorder treatment services in Tennessee are delivered through a managed care service delivery system. The state requires that its contracted MCOs have in place, and follow, written policies and procedures for processing requests for initial and continuing authorizations of services and have in effect mechanisms to ensure consistent application of review criteria for authorization decisions. Network providers (including IMDs) are also required to follow evidence-based Level of Care Guidelines established or adopted by the MCOs, which are used to ensure correct placement aligned with ASAM criteria. Comprehensive Continuum of Care ܈In accordance with section 1915(l)(4)(C), the states provides assurance that SUD treatment and withdrawal management services are covered under the state plan consistent with the following levels of care: ܈Early intervention ܈Outpatient services ܈Intensive outpatient services ܈Partial hospitalization ____________________________________________________________________________________ TN No. 21-0002 Supersedes Approval Date  Effective Date 03/01/21 TN No. New

Supplement 4 to Attachment 3.1-A Page 3 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE: TENNESSEE _____________________________________________________________________________________ Please select at least two of the following residential and inpatient levels of care: ܆Clinically managed low-intensity residential services ܈Clinically managed, population specific, high-intensity residential services for adults ܈Clinically managed, medium-intensity residential services for adolescents ܈Clinically managed, high-intensity residential services for adults ܈Medically monitored, high-intensity inpatient services for adolescents ܈Medically monitored, intensive inpatient services withdrawal management for adults ܈Medically managed intensive inpatient services. Care Transitions ܈The state provides assurance that placement of beneficiaries in an IMD will allow for their successful transition to the community, considering such factors as proximity to an individual’s support network (e.g., family members, employment, counseling and other services near an individual’s place of residence) in accordance with 1915(l)(4)(D)(i). Please briefly describe the state’s transition process that will ensure a beneficiary’s successful transition to the community: As part of the utilization review process for continued stay criteria, ongoing discharge planning is required. The state requires that all enrollees discharged from all Residential Treatment Facilities (including IMDs) be evaluated for mental health and substance abuse services as medically necessary and provided with appropriate behavioral health follow-up services. Step-down outpatient services post discharge includes Opioid Use Disorder Medication Assisted Treatment Program, Intensive Outpatient Treatment, and Peer Recovery Services. These services include counseling and care coordination. ___________________________________________________________________________________ TN No. 21-0002 Supersedes Approval Date  Effective Date 03/01/21 TN No. New

Supplement 4 to Attachment 3.1-A Page 4 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE: TENNESSEE _____________________________________________________________________________________ _____________________________________________________________________________________ ܈The state provides assurance that eligible IMDs either provide services at lower levels of clinical intensity or establish relationships with Medicaid-enrolled providers offering services at lower levels of care pursuant to 1915(l)(4)(D)(ii). Please briefly describe how the state assures that IMDs either provide services at lower levels of clinical intensity or establishes relationships with Medicaid-enrolled providers offering services at lower levels of care: The state requires that all enrollees discharged from all Residential Treatment Facilities (including IMDs) be evaluated for mental health and substance abuse services as medically necessary and provided with appropriate behavioral health follow-up services. IMDs may also coordinate discharge planning with MCOs, especially for the medically complex beneficiaries. The MCOs also monitor discharge plans and provide coordination of care. The state provides access to a robust provider network that furnishes Medication Assisted Treatment in the community. ______________________________________________________________________________ TN No. 21-0002 Supersedes Approval Date  Effective Date 03/01/21 TN No. New

Attachment 3.1-B Page 12 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE: TENNESSEE AMOUNT, DURATION, AND SCOPE OF SERVICES PROVIDED MEDICALLY NEEDY GROUP (S): Children Under 21, Pregnant Women. _____________________________________________________________________________________ _____________________________________________________________________________________ 27. 1915(l) state plan option to provide medical assistance for eligible individuals who are patients in eligible institutions for mental diseases (IMD), provided as defined, described and limited in Supplement 4 to Attachment 3.1-A. ___________________________________________________________________________________ TN No. 21-0002 Supersedes Approval Date  Effective Date 03/01/21 TN No. New

 



  
 




   

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Table of Contents State/Territory Name: Tennessee State Plan Amendment (SPA) #: 21-0010 This file contains the following documents in the order listed: 1) Approval Letter 2) Summary Form (with 179-like data) 3) Approved SPA Pages

Records Submission Packages • View All TN - Submission Package - TN2020MS0002O - (TN-21-0010) - Eligibility Summary Reviewable Units Versions News Related Actions DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services CAHPG/DMEP 601 E. 12th Street, Room 335 Kansas City, MO 64106 Correspondence Log Center for Medicaid & CHIP Services March 23, 2022 Stephen Smith Director Division of TennCare 310 Great Circle Road Nashville, TN 37243 Re: Approval of State Plan Amendment TN-21-0010 Dear Stephen Smith, Analyst Notes Review Assessment Report Approval Letter Transaction Logs CtMEIIS Fo« MlDICARt & MfOf0\10 SUIVICF5 On December 29, 2021, the Centers for Medicare and Medicaid Services (CMS) received Tennessee State Plan Amendment (SPA) TN-21-0010 which proposed to add a new resource disregard to the eligibility determinations of multiple eligibility groups. TN 21-0010 proposes that, to the extent the state may not adjust the patient liability of an individual receiving Medicaid coverage for certain long-term services and supports during the COVID 19-based public health emergency, the resources such an enrollee accrues as a result will be disregarded as countable resources. We approve Tennessee State Plan Amendment (SPA) TN-21-001 O with an effective date(s) of October 01, 2021. If you have any quest ions regarding this amendment. please contact Tandra Hodges at Tandra.Hodges@cms.hhs.gov Sincerely, Director, Division of Program Operations Center for Medicaid & CHIP Services _J

Records / Submission Packages - View All TN - Submission Package - TN2020MS0002O - (TN-21-0010) - Eligibility Summary Reviewable Units Versions Correspondence Log Analyst Notes Review Assessment Report Approval Letter Transaction Logs News Related Actions CMS-10434 OMB 0938-1188 Package Information Package ID TN2020MS0002O Program Name N/A SPA ID TN-21-0010 Version Number 3 Submitted By Aaron Butler Package Disposition Priority Code P2 Submission Type Official State TN Region Atlanta, GA Package Status Approved Submission Date 12/29/2021 Approval Date 3/23/2022 12:48 PM EDT e

Submission - Summary MEDICAID I Medicaid State Plan I Eligibility I TN2020MS0002O I TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/ 23/2022 Superseded SPA ID N/A State Information State/Territory Name: Tennessee Submission Component O State Plan Amendment SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date NIA Medicaid Agency Name: Department of Finance & Administration 0 Medicaid O CHIP

Submission - Summary MEDICAID I Medicaid State Plan I Eligibility I TN2020MS0002O I TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID N/A SPA ID and Effective Date SPA ID TN-21-0010 Reviewable Unit Eligibility Determinations of Individuals Age 6S or Older or Who Have Blindness or a Disability MAGI-Based Methodologies Non-MAGI Methodologies AFDC Income Standards Medically Needy Income Level Handling of Excess Income (Spenddown) Medically Needy Resource Level Mandatory Eligibility Groups Infants and Children under Age 19 Parents and Other Caretaker Relatives Pregnant Women Deemed Newborns Children with Title IV-E Adoption Assistance, Foster Care or Guardianship Care Former Foster care Children Transitional Medical Assistance Extended Medicaid due to Spousal Support Collections 551 Beneficiaries Closed Eligibility Groups Individuals Deemed To Be Receiving 551 Working Individuals under 1619(b) Qualified Medicare Beneficiaries Qualified Disabled and Working Individuals Specified Low Income Medicare Beneficiaries Qualifying Individuals Optional Eligibility Groups Children with Non-lV-E Adoption Assistance Proposed Effective Date 10/1/2021 10/1/2021 10/1/2021 10/1/2021 10/1/2021 10/1/2021 10/1/2021 10/1/2021 10/1/2021 10/1/2021 10/1/2021 10/1/2021 10/1/2021 10/1/2021 10/1/2021 10/1/2021 10/1/2021 10/1/2021 10/1/2021 10/1/2021 10/1/2021 10/1/2021 10/1/2021 10/1/2021 10/1/2021 10/1/2021 SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date N/ A Superseded SPA ID NEW TN 14-0001 TN 92-7; TN 92-24 TN 14-000S TN 99-7 TN92-7 TN92-7 NEW TN 14-000S TN 14-000S TN 16-0002 TN92-23 TN92-6 TN 14-0005 TN 16-0001 TN92-6 TN 92-23; TN 92-6 TN 92-6 TN 92-6; TN 92-20 TN 92-6 TN 10-001 TN 10-001 TN 10-001 TN 10-001 NEW TN 14-0005

Reviewable Unit Proposed Effective Date Superseded SPA ID Individuals Needing Treatment for Breast or 10/1/2021 TN2002-3 Cervical cancer Individuals Eligible for Cash Except for 10/1/2021 TN 94-1 Institutionalization Individuals Receiving Home and Community- 10/1/2021 TN 11-014 Based Waiver Services under Institutional Rules Individuals in Institutions Eligible under a Special 10/1/2021 TN92-6 Income Level PACE Participants 10/1/2021 TN 11-014 Medically Needy Pregnant Women 10/1/2021 TN 92-6 Medically Needy Children under Age 18 10/1/2021 TN92-6 Medically Needy Reasonable Classifications of 10/1/2021 TN92-6 Individuals under Age 21 Page Number of the Superseded Plan Section or Attachment (If Applicable): Attachment 2.2-A. pages 1 through 23a, Item B.20 on page 23b, and pages 24 through 26. Notwithstanding any other provisions of the Medicaid State Plan, MAGI and non-MAGI financial eligibility methodologies will be applied as described in SPA TN 21-0010.

Submission - Summary MEDICAID I Medicaid State Plan I Eligibility I TN2020MS0002O I TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID N/A Executive Summary SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date N/ A Summary Description Including SPA TN 21-0010 adjusts the state's patient liability policies by disregarding resources that an enrollee accrues as a result of Goals and Objectives the state"s inability to adjust patient liability amounts during the COVID-19 public health emergency for a period of 12 months following the end of the emergency. SPA TN 21-001 O establishes an income disregard for individuals receiving HCBS waiver services under institutional rules. Federal Budget Impact and Statute/Regulation Citation Federal Budget Impact First Second Federal Fiscal Year 2022 2023 Federal Statute I Regulation Citation 42 CFR43S Amount $0 $0 Supporting documentation of budget impact is uploaded {optional). Name Date Created No items available

Submission - Summary MEDICAID I Medicaid State Plan I Eligibility I TN2020MS0002O I TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID N/A Governor's Office Review 0 Nocomment 0 Comments received 0 No response within 45 days Q Other SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date NIA

Medicaid State Plan Eligibility Income/Resource Methodologies Eligibility Determinations of Individuals Age 65 or Older or Who Have Blindness or a Disability MEDICAID I Medicaid State Plan I Eligibility I TN2020MS0002O I TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 Approval Date 3/23/2022 Superseded SPA ID NEW User-Entered A. Eligibility Determinations of Individuals Who Are Age 65 or Older or Who Have Blindness or a Disability Eligibility determinations of individuals who are age 65 or older or who have blindness or a disability are based on one of the following; O 1. SSA Eligibility Determination State (1634 State) The state has an agreement under section 16 4 of the ocial ecurity Act for the ocial ecurity Administration to determine Medicaid eligibility of I beneficiaries For all other individuals who seek Medicaid eligibility on the basis of being age 65 or older or having blindness or a disability. the state requires a separate Medicaid application and determines financial eligibility based on SSI income and resource methodologies. O 2. State Eligibility Determination (SSI Criteria State) The state requires all individuals who seek Medicaid eligibility on the basis of being age 65 or older or having blindness or a disability. including SSI beneficiaries. to file a separate Medicaid application. and determines financial eligibility based on SSI income and resource methodologies. O 3. State Eligibility Determination (209(b) State) The state requires all individuals who seek Medicaid eligibility on the basis of being age 65 or older or having blindness or a disability including s I beneficiaries to file a separate Medicaid application and determines financial eligibility using income and resource methodologies more restrictive than SSI. B. Additional information (optional)

Medicaid State Plan Eligibility MAGI Based Methodologies MEDICAID I Medicaid State Plan I Eligibility I TN2020MS0002O I TN-21-0010 Package Header Package ID TN2020MS0002O ubmission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 14-0001 System-Derived SPA ID TN-21-0010 Initial ubmission Date 1 / 9/ o 1 Effective Date 10/1/2021 The state will apply Modified Adjusted Gross Income (MAGl)-based methodologies as described below. and consistent with 42 CFR 43S.603. A. Household Composition 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 0 a. The pregnant woman is counted just as herself. 0 b The pregnant woman is counted as herself plus one O c. The pregnant woman is counted as herself. plus the number of children she is expected to deliver. 3. In establishing household composition under the rules for non-filers set forth at 42 CFR 435.603(1)(3). the state elects the following age for children: Oa Age 19 O b. Age 19. or in the case of full-time students. age 21

MAGI Based Methodologies MEDICAID I Medicaid State Plan I Eligibility I TN2020MS0002O I TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 14-0001 System-Derived B. Household Income Financial eligibility is determined consistent with the following provisions: SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 1. When determining eligibility for new applicants, financial eligibility is based on current monthly income and family size. 2. When determining eligibility for current beneficiaries, financial eligibility is based on: 0 a. Current monthly household income and family size 0 b. Projected annual household income and family size for the remaining months of the current calendar year. 3. In determining current monthly or projected annual household income, the state considers reasonably predictable changes in income: 0 Yes 0 No 4. MAGI-based income is calculated using the financial methodologies defined in section 36B(d)(2)(B) of the Internal Revenue Code, except as described at 42 CFR 435.603(e), and without regard to whether an individual expects to file taxes. 5. Except as provided at 42 CFR 435.603(d)(2) through (d)(4), household income is the sum of the MAGI-based income of every individual included in the individual's household. 6. In determining the eligibility of an individual using MAGI-based income, the state must subtract an amount equivalent to 5 percentage points of the federal poverty level for the applicable family size only to determine the eligibility of an individual for medical assistance under the eligibility group with the highest income standard using MAGI-based methodologies in the applicable Title of the Act, but not to determine eligibility for a particular eligibility group. 7. 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. O Yes 0 No The state uses a specific nominal amount and frequency. O Yes 0 No a. The amount of the nominal amount is: S30.00 b. Frequency of the nominal amount: C i.Weekly 0 ii. Bi-weekly 0 iii. Monthly 0 iv. Quarterly O v. Yearly c. Explanation: optional

MAGI Based Methodologies MEDICAID | Medicaid State Plan | Eligibility | TN2020MS0002O | TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 14-0001 System-Derived SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 C. Resource Test There is no resource test applied to eligibility groups that use MAGI-based methodologies. D. Additional Information (optional)

Medicaid State Plan Eligibility Income/Resource Methodologies Non-MAGI Methodologies MEDICAID I Medicaid State Plan I Eligibility I TN2020MS0002O I TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 92-7; TN 92-24 User-Entered SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 The state will apply the methodologies as described below, and consistent with 42 CFR 435.601, 435.602, and 435 831. A. Basic Financial Methodology 1. The state applies the income and resource methodologies of the SSI program when determining eligibility for a population based on age (65 or older) or having blindness or a disability, with the exceptions described below in B. through G. 2. The state applies the financial methodologies of either the SSI program or the AFDC program in effect as of July 16. 1996 (whichever is most closely related) when determining eligibility for a population based on age (as a child), pregnancy, or status as a caretaker relative, with the exceptions described below in B. through G. B. Use of Less Restrictive Methodologies 1. The state elects to apply income and/or resources methodologies that are less restrictive than those used under the cash assistance programs, in accordance with 42 CFR 435.601(d). 0 Yes 0 No 2. The less restrictive income and resource methodologies are described on the RU for each applicable eligibility group.

Non-MAGI Methodologies MEDICAID I Medicaid State Plan I Eligibility I TN2020MS0002O I TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 92-7; TN 92-24 User-Entered C. Financial Responsibility of Relatives SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 1. In determining financial eligibility for an individual. the state does not include income and resources from anyone other than the individual's spouse. and for individuals under age 21 or who have blindness or disability. the individual's parent. a.The state includes the income and resources of a spouse or parent only when they are living with the individual in the same household. except as follows: i. In the case of spouses who are age 65 or older or who have blindness or disability and who share the same room in a Medicaid institution. the state: 0 (1) Considers these couples either as living together or as living separately for the purpose of counting income and resources. whichever is more advantageous to the couple. O (2) Considers these couples as living separately for the purpose of counting income and resources. ii. Where applicable. the state determines income and resource eligibility consistent with the spousal impoverishment rules of section 1924 of the Act as described in the Resource Assessment and Eligibility reviewable unit. b. In the case of individuals under age 21 for whom AFDC is the most closely related cash assistance program. the income and resources of parents and spouses are included only if the individual would have been considered a dependent under the state's approved AFDC state plan in effect as of July 16. 1996.

Non-MAGI Methodologies MEDICAID I Medicaid State Plan I Eligibility I TN2020MS0002O I TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 92-7; TN 92-24 User-Entered D. Family Size SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 1. The family size of an individual for whom the SSI income and resource methodologies are used (as described in section A) includes the persons identified below: a. The individual applying, or b. If the individual lives together with his or her spouse, the individual applying and the spouse, or c. If the individual lives together with his or her parent(s) and the individual is under 21 or has blindness or a disability, the individual applying and the parent(s). 2. The family size of an individual for whom the AFDC income and resource methodologies are used (as described in section A.), includes the persons who would have been included in the family under the state's July 16, 1996 AFDC state plan, except where the state has elected to use the MAGI-like methodologies (as described in section E). 3. The state defines family size for one or more of the following FPL eligibility groups to include others beyond those identified in D.1. and D.2. 0 Yes O No

Non-MAGI Methodologies MEDICAID I Medicaid State Plan I Eligibility I TN2020MS0002O I TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 92-7; TN 92-24 User-Entered E. Use of MAGI-like Methodologies SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 1. The state uses MAGI-like methodologies for one or more populations for whom the most closely related cash assistance program would be the AFDC program in effectasofJuly 16, 1996. O Yes O No

Non-MAGI Methodologies MEDICAID | Medicaid State Plan | Eligibility | TN2020MS0002O | TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 92-7; TN 92-24 User-Entered SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 F. Countable Income Deductions for the Medically Needy In determining countable income for individuals who are age 65 or older or who have blindness or a disability, the state deducts: 1. Amounts that would be deducted in determining eligibility under SSI. 2. The highest amounts that would be deducted in determining eligibility for optional state supplements if these supplements are paid to all individuals who are receiving SSI or would be eligible for SSI except for their income.

Non-MAGI Methodologies MEDICAID | Medicaid State Plan | Eligibility | TN2020MS0002O | TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 92-7; TN 92-24 User-Entered SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 G. Additional Information (optional)

Medicaid State Plan Eligibility AFDC Income Standards MEDICAID I Medicaid State Plan I Eligibility I TN2020MS0002O I TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 14-0005 System-Derived SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 A. MAGI-equivalent AFDC Payment Standard in Effect As of May 1, 1988 Statewide standard The statewide standard is: Household size 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 The state uses an additional incremental amount for larger household sizes. Q Yes O No The dollar amounts increase automatically each year Q Yes 0 No Standard $104.00 $153.00 $198.00 $240.00 $281.00 $324.00 $367.00 $410.00 $453.00 $495.00 $539.00 $580.00 $623.00 $666.00 $709.00 $752.00 $793.00 $836.00 $879.00 $921.00

AFDC Income Standards MEDICAID I Medicaid State Plan I Eligibility I TN2020MS0002O I TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 14-0005 System-Derived B. AFDC Payment Standard in Effect As of July 16, 1996 Statewide standard The statewide standard is: Household size 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 The state uses an additional incremental amount for larger household sizes. Q Yes O No The dollar amounts increase automatically each year Q Yes 0 No Standard $95.00 $142.00 $185.00 $226.00 $264.00 $305.00 $345.00 $386.00 $425.00 $467.00 $508.00 $549.00 $589.00 $630.00 $670.00 $711.00 $750.00 $790.00 $831.00 $871.00 SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021

AFDC Income Standards MEDICAID I Medicaid State Plan I Eligibility I TN2020MS0002O I TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 14-0005 System-Derived SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 C. MAGI-equivalent AFDC Payment Standard in Effect As of July 16, 1996 Statewide standard The statewide standard is: Household size 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 The state uses an additional incremental amount for larger household sizes. Q Yes O No The dollar amounts increase automatically each year Q Yes 0 No Standard $1 19.00 $174.00 $225.00 $274.00 $321.00 $370.00 $418.00 $467.00 $515.00 $565.00 $614.00 $663.00 $712.00 $761.00 $809.00 $858.00 $905.00 $954.00 $1003.00 $1051.00

AFDC Income Standards MEDICAID | Medicaid State Plan | Eligibility | TN2020MS0002O | TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 14-0005 System-Derived SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 D. AFDC Need Standard in Effect As of July 16, 1996

AFDC Income Standards MEDICAID | Medicaid State Plan | Eligibility | TN2020MS0002O | TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 14-0005 System-Derived SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 E. AFDC Payment Standard in Effect As of July 16, 1996, increased by no more than the percentage increase in the Consumer Price Index for urban consumers (CPI-U) since such date.

AFDC Income Standards MEDICAID | Medicaid State Plan | Eligibility | TN2020MS0002O | TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 14-0005 System-Derived SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 F. MAGI-equivalent AFDC Payment Standard in Effect As of July 16, 1996, increased by no more than the percentage increase in the Consumer Price Index for urban consumers (CPI-U) since such date.

AFDC Income Standards MEDICAID I Medicaid State Plan I Eligibility I TN2020MS0002O I TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 14-0005 System-Derived G. TANF payment standard Statewide standard The statewide standard is: Household size 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 The state uses an additional incremental amount for larger household sizes. Q Yes O No The dollar amounts increase automatically each year Q Yes 0 No Standard $696.00 $896.00 $1066.00 $1211.00 $1335.00 $1441.00 $1534.00 $1617.00 $1691.00 $1760.00 $1824.00 $1885.00 $1944.00 $2001.00 $2055.00 $2107.00 $2155.00 $2197.00 $2232.00 $2257.00 SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021

AFDC Income Standards MEDICAID I Medicaid State Plan I Eligibility I TN2020MS0002O I TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 14-0005 System-Derived H. MAGI-equivalent TANF payment standard Statewide standard The statewide standard is: Household size 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 The state uses an additional incremental amount for larger household sizes. Q Yes O No The dollar amounts increase automatically each year Q Yes 0 No Standard $1018.00 $1329.00 $1611.00 $1867.00 $2102.00 $2320.00 $2524.00 $2718.00 $2903.00 $3084.00 $3259.00 $3431.00 $3601.00 $3770.00 $3935.00 $4098.00 $4257.00 $4411.00 $4557.00 $4693.00 SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021

AFDC Income Standards MEDICAID | Medicaid State Plan | Eligibility | TN2020MS0002O | TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 14-0005 System-Derived SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 I. Additional Information (optional)

Medicaid State Plan Eligibility Income/Resource Standards Medically Needy Income Level MEDICAID I Medicaid State Plan I Eligibility I TN2020MS0002O I TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 99-7 User-Entered A. Income Level Used 1. The state employs a single income level for the medically neecly. SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 2. The income level varies based on differences between shelter costs in urban and rural areas. e ves O No 3.Thelevelused i~ Household size 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Standard $241.00 $258.00 $317.00 $325.00 $392.00 $408.00 $467.00 $517.00 $567.00 $625.00 $683.00 $733.00 $792.00 $842.00 $900.00 $950.00 $1000.00 $1058.00 $1 108.00 $1 167.00 The state uses an additional incremental amount for larger household sizes. Q Yes O No The dollar amounts increase automatically each year Q Yes 0 No

Medically Needy Income Level MEDICAID | Medicaid State Plan | Eligibility | TN2020MS0002O | TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 99-7 User-Entered SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 B. Basis for Income Level 1. Minimum Income Level The minimum income level for this eligibility group is the lower of the state’s July 1996 AFDC payment standard or the state’s income standard for the Parents and Other Caretaker Relatives eligibility group. 2. Maximum Income Level The maximum income level for this eligibility group is 133 1/3 percent of the higher of the state's 1996 AFDC payment standard or the state's income standard for the Parents and Other Caretaker Relatives eligibility group.

Medically Needy Income Level MEDICAID | Medicaid State Plan | Eligibility | TN2020MS0002O | TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official Approval Date / / 0 uperseded PA ID TN 99 7 User-Entered SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/ 0 1 C. Additional Information (optional)

Medicaid State Plan Eligibility Income/Resource Standards Handling of Excess Income (Spenddown) MEDICAID I Medicaid State Plan I Eligibility I TN2020MS0002O I TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official Approval Date I I o uperseded PA ID TN 9 7 User-Entered SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1 I o 1 If countable income exceeds the income standard, the state must deduct from income medical expenses incurred by the individual or family or financially responsible relatives that are not subject to payment by a third party, in accordance with 42 CFR 435.831 and 42 CFR 435.121. A. Budget Periods Income in excess of the appropriate income standard is considered available for payment of medical or remedial care expenses in budget periods that do not exceed six months 1 In determining income eligibility countable income is reduced by the amount of incurred medical or remedial care expenses during the budget period specified below: O a. One budget period of: O i. 6months O ii months 0 iii. 4 months O iv. 3 months Q v.2 months O vi. 1 month O b. More than one budget period, as described below: The state includes part or all of the retroactive period in the budget period 0 Yes 0 No

Handling of Excess Income (Spenddown) MEDICAID I Medicaid State Plan I Eligibility I TN2020MS0002O I TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/ 23/ 2022 Superseded SPA ID TN 92-7 User-Entered SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/ 2021 B. Types of Eligible Expenses 1. In determining incurred expenses to be deducted from income, the state includes: a. Medicare. Medicaid, and other health insurance premiums and enrollment fees. b. Cost sharing, including copayments, coinsurance, and deductibles, imposed by Medicare. Medicaid or other health insurance. c. Expenses for necessary medical and remedial services recognized by state law but not included in the state plan. d. Expenses for necessary medical and remedial services included in the state plan, including those that exceed limitations on the amount duration, and scope of services. 2. The state also includes medical institutional expenses projected to the end of the budget period at the Medicaid reimbursement rate. 0 Yes 0 No 3. Incurred expenses subject to payment by a third party are not deducted unless the third party is a public program (other than Medicaid) of a state and the program is financed by the state.

Handling of Excess Income (Spenddown) MEDICAID I Medicaid State Plan I Eligibility I TN2020MS0002O I TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/ 23/ 2022 Superseded SPA ID TN 92-7 User-Entered C. Timeframe of Deduction of Expenses In determining incurred expenses to be deducted from income. the state deducts: SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/ 2021 1. For retroactive budget periods and a budget period that includes both retroactive and prospective budget the state deducts: a. Eligible expenses incurred during the budget period. whether paid or unpaid. b. Payments made during the budget period on eligible expenses incurred at any time prior to the budget period. if not previously deducted in establishing eligibility. c. Unpaid eligible expenses, which have not been deducted previously in establishing eligibility, and were incurred: 2. For prospective budget period(s). the state deducts: O i. At any time prior to the budget period. O ii. Prior to the third month before the month of application. but no earlier than: 0 iii. No earlier than the third month before the month of application. a. Eligible expenses incurred during the budget period. whether paid or unpaid. b. Payments made during the budget period on eligible expenses incurred at any time prior to the budget period. if not previously deducted in establishing eligibility. c. Unpaid eligible expenses that are carried over from the prior budget period and have not been deducted previously in establishing eligibility.

Handling of Excess Income (Spenddown) MEDICAID I Medicaid State Plan I Eligibility I TN2020MS0002O I TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 92-7 User-Entered D. Order of Deduction of Expenses Incurred medical or remedial care expenses are deducted in the following order: O 1. By the type of service. in the following order. SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 a. Premiums. deductibles. coinsurance and co-payments. b. Expenses for necessary medical or remedial care services that are recognized under state law but not included in the State Plan. c. Expenses for necessary medical or remedial care services that are included in the state Plan that exceed agency limitations on amount duration, or scope of services. d. Expenses for necessary medical or remedial care services that are included in the state Plan that are within the agency limitations on amount duration, or scope of services. O 2. In chronological order by the date of the service. or the date cost sharing payments are due. O 3. In chronological order by the date the bill is submitted to the state by the individual.

Handling of Excess Income (Spenddown) MEDICAID I Medicaid State Plan I Eligibility I TN2020MS0002O I TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/ 23/ 2022 Superseded SPA ID TN 92-7 User-Entered E. Reasonable Limitations The state sets reasonable limits on the amount to be deducted for expenses. O Yes 0 No SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/ 2021

Handling of Excess Income (Spenddown) MEDICAID I Medicaid State Plan I Eligibility I TN2020MS0002O I TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/ 23/ 2022 Superseded SPA ID TN 92-7 User-Entered F. Spenddown Payments Made by Individuals The state permits individuals to pay-in their spenddown liability. O Yes 0 No SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/ 2021

Handling of Excess Income (Spenddown) MEDICAID | Medicaid State Plan | Eligibility | TN2020MS0002O | TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 92-7 User-Entered SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 G. Additional Information (optional)

Medicaid State Plan Eligibility Income/Resource Standards Medically Needy Resource Level MEDICAID | Medicaid State Plan | Eligibility | TN2020MS0002O | TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 92-7 User-Entered SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 A. Medically Needy Resource Level Structure 1. The state employs a single resource level for the medically needy. 2. The resource level is equal to or higher than the lowest resource standard used under the most closely related cash assistance program.

Medically Needy Resource Level MEDICAID I Medicaid State Plan I Eligibility I TN2020MS0002O I TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 92-7 User-Entered B. Resource Level Used The level used is: Household size 2 3 4 5 6 7 8 9 10 Standard $2000.00 $3000.00 $3100.00 $3200.00 $3300.00 $3400.00 $3500.00 $3600.00 $3700.00 $3800.00 SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 The state uses an additional incremental amount for larger household sizes. 0 Yes Q No Incremental Amount: $100.00

Medically Needy Resource Level MEDICAID | Medicaid State Plan | Eligibility | TN2020MS0002O | TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 92-7 User-Entered SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 C. Additional Information (optional)

Medicaid State Plan Eligibility Mandatory Eligibility Groups MEDICAID I Medicaid State Plan I Eligibility I TN2020MS0002O I TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID NEW User-Entered Mandatory Coverage SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 A. The state provides Medicaid to mandatory groups of individuals. The mandatory groups covered are: Families and Adults Eligibility Group Name Covered In State Plan Include RU In Package Included in Another 9 Submission Package Infants and Children ~ 0 under Age 19 Parents and Other ~ 0 Caretaker Relatives Pregnant Women ~ • Deemed Newborns ~ 0 Children with Title IV-E Adoption Assistance, ~ 0 Foster Care or Guardianship care Former Foster care ~ @ @ 0 Children Transitional Medical ~ @ @ 0 Assistance Extended Medicaid due ~ to Spousal Support 0 Collections Aged, Blind and Disabled Eligibility Group Name Covered In State Plan Include RU In Package Included in Another 9 Submission Package SSI Beneficiaries ~ @ 0 Closed Eligibility ~ @ 0 Groups Individuals Deemed To ~ 0 Be Receiving SSI Working Individuals ~ 0 under 1619(b) Qualified Medicare ~ 0 Beneficiaries Qualified Disabled and ~ 0 Working Individuals Source Type 9 APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED Source Type 9 APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED

Eligibility Group Name Covered In State Plan Include RU In Package Included in Another Source Type 9 9 Submission Package Specified Low Income ~ @ @ 0 APPROVED Medicare Beneficiaries Qualifying Individuals ~ @ @ 0 APPROVED

Mandatory Eligibility Groups MEDICAID I Medicaid State Plan I Eligibility I TN2020MS0002O I TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID NEW User-Entered B. The state elects the Adult Group, described at 42 CFR 435.119. 0 Yes 0 No c. Additional Information (optional) Eligibility Groups Deselected from Coverage SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 The following eligibility groups were previously covered in the source approved version of the state plan and deselected from coverage as part of this submission package: • N/A

Medicaid State Plan Eligibility Eligibility Groups - Mandatory Coverage Infants and Children under Age 19 MEDICAID | Medicaid State Plan | Eligibility | TN2020MS0002O | TN-21-0010 Infants and children under age 19 with household income at or below standards established by the state based on age group. Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 14-0005 System-Derived SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 The state covers the mandatory infants and children under age 19 group in accordance with the following provisions: A. Characteristics Children qualifying under this eligibility group must meet the following criteria: 1. Are under age 19

2. Have household income at or below the standard established by the state. B. Financial Methodologies MAGI-based methodologies are used in calculating household income. Please refer as necessary to MAGI-Based Methodologies, completed by the state. C. Income Standards Used 1. The amount of the income standard for infants under age one is: FPL 195.00% 2. The amount of the income standard for children age one through five is: FPL 142.00% 3. The amount of the income standard for children age six through eighteen is: FPL 133.00%

Infants and Children under Age 19 MEDICAID I Medicaid State Plan I Eligibility I TN2020MS0002O I TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 Approval Date 3/23/2022 Superseded SPA ID TN 14-0005 System-Derived D. Basis for the Income Standard for Infants under Age 1 1. Minimum income standard 2. Maximum income standard a. The state had an income standard higher than 133% FPL established as of December 19, 1989 for determining eligibility for infants under age one, or as of July 1, 1989, had authorizing legislation to do so. 0 Yes 0 No b. The minimum income standard for infants under age one is 133% FPL a. The state certifies that it has submitted and received approval for its converted income standard{s) for infants under age one to MAGI-equivalent standards and the determination of the maximum income standard to be used for infants under age one. b. The state"s maximum income standard for this age group is: 0 i. The state's highest effective income level for coverage of infants under age one under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(1 0)(A)(i)(IV) (mandatory poverty level-related infants), 1902(a) (10)(A)(ii)(IX) (optional poverty level-related infants) and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 201 o, converted to a MAGI-equivalent percent of FPL O ii. The state's highest effective income level for coverage of infants under age one under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(1 0)(A)(i)(IV) (mandatory poverty level-related infants), 1902(a) (10)(A)(ii)(IX) (optional poverty level-related infants) and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. O iii. The state"s effective income level for any population of infants under age one under a Medicaid 11 15 demonstration as of March 23, 201 o, converted to a MAGI-equivalent percent of FPL. 0 iv. The state"s effective income level for any population of infants under age one under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. Ov. 185%FPL c. The amount of the maximum income standard is: FPL 195.00%

Infants and Children under Age 19 MEDICAID I Medicaid State Plan I Eligibility I TN2020MS0002O I TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 Approval Date 3/23/2022 Superseded SPA ID TN 14-0005 System-Derived E. Basis for the Income Standard for Children Age One through Age Five 1. Minimum income standard 2. Maximum income standard The minimum income standard used for this age group is 133% FPL. a. The state certifies that it has submitted and received approval for its converted income standard{s) for children age one through five to MAGI-equivalent standards and the determination of the maximum income standard to be used for children age one through five. b. The state"s maximum income standard for this age group is: O i. The state's highest effective income level for coverage of children age one through five under sections 1931 (low- income families). 1902(a)(10)(A)(i)(III) (qualified children). 1902(a)(1 0)(A)(i)(VI) (mandatory poverty level-related children age one through five), and 1902(a)(1 0)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of March 23. 201 o. converted to a MAGI-equivalent percent of FPL. O ii. The state's highest effective income level for coverage of children age one through five under sections 1931 (low- income families). 1902(a)(10)(A)(i)(III) (qualified children). 1902(a)(1 0)(A)(i)(VI) (mandatory poverty level-related children age one through five), and 1902(a)(1 0)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013. coriverted to a MAGI-equivalent percent of FPL. O iii. The state"s effective income level for any population of children age one through five under a Medicaid 1115 demonstration as of March 23. 201 o. converted to a MAGI-equivalent percent of FPL. O iv. The state"s effective income level for any population of children age one through five under a Medicaid 1115 demonstration as of December 31, 2013. converted to a MAGI-equivalent percent of FPL. O v. 133%FPL c. The amount of the maximum income standard is: FPL 142.00% F. Basis for the Income Standard for Children Age Six through Age Eighteen 1. Minimum income standard 2. Maximum income standard The minimum income standard used for this age group is 133% FPL. a. The state certifies that it has submitted and received approval for its converted income standard{s) for children age six through eighteen to MAGI-equivalent standards and the determination of the maximum income standard to be used for children age six through age eighteen. b. The state"s maximum income standard for this age group is: 0 i. The state's highest effective income level for coverage of children age six through eighteen under sections 1931 (low- income families). 1902(a)(10)(A)(i)(III) (qualified children). 1902(a)(1 0)(A)(i)(VII) (mandatory poverty level-related children age six through eighteen) and 1902(a)(1 0)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 201 o. converted to a MAGI-equivalent percent of FPL. 0 ii. The state's highest effective income level for coverage of children age six through eighteen under sections 1931 (low- income families). 1902(a)(10)(A)(i)(III) (qualified children). 1902(a)(1 0)(A)(i)(VII) (mandatory poverty level-related children age six through eighteen) and 1902(a)(1 0)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. O iii. The state"s effective income level for any population of children age six through eighteen under a Medicaid 1115 demonstration as of March 23. 201 o. converted to a MAGI-equivalent percent of FPL. O iv. The state"s effective income level for any population of children age six through eighteen under a Medicaid 1115 demonstration as of December 31, 2013. converted to a MAGI-equivalent percent of FPL. O v. 133%FPL

Infants and Children under Age 19 MEDICAID | Medicaid State Plan | Eligibility | TN2020MS0002O | TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 14-0005 System-Derived SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 G. Additional Information (optional)

Medicaid State Plan Eligibility Eligibility Groups - Mandatory Coverage Parents and Other Caretaker Relatives MEDICAID I Medicaid State Plan I Eligibility I TN2020MS0002O I TN-21-0010 Parents and other caretaker relatives of dependent children with household income at or below a standard established by the state. Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 14-0005 System-Derived SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 The state covers the mandatory parents and other caretaker relatives group in accordance with the following provisions: A. Characteristics Individuals qualifying under this eligibility group must meet the following criteria: 1. Are parents or other caretaker relatives (defined at 42 CFR 435.4). including pregnant women. of dependent children (defined at 42 CFR 435.4) under age 18. Spouses of parents and other caretaker relatives are also included. The state elects the following options: a. This eligibility group includes individuals who are parents or other caretakers of children who are 18 years old. provided the children are full-time students in a secondary school or the equivalent level of vocational or technical training. b. Options relating to the definition of caretaker relative: c. Options relating to the definition of dependent child: O i. The state elects to eliminate the requirement that a dependent child must be deprived of parental support or care by reason of the death. physical or mental incapacity, or absence from the home or unemployment of at least one parent. O ii. The child must be deprived of parental support or care. but a less restrictive standard is used to measure unemployment of the parent (select the one that applies): 2. Have household income at or below the standard established by the state.

Parents and Other Caretaker Relatives MEDICAID I Medicaid State Plan I Eligibility I TN2020MS0002O I TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 14-0005 System-Derived B. Financial Methodologies SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 MAGI-based methodologies are used in calculating household income. Please refer as necessary to MAGI-Based Methodologies, completed by the state. C. Income Standard Used 1. The income standard for this group is based on a percentage of the federal poverty level. 0 Yes 0 No 2. The state uses the following income standard for this group: O g. The state's TANF payment standard. converted to a MAGI-equivalent standard. The standard is described in AFDC Income Standards.

Parents and Other Caretaker Relatives MEDICAID I Medicaid State Plan I Eligibility I TN2020MS0002O I TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 Approval Date 3/23/2022 Superseded SPA ID TN 14-0005 System-Derived D. Basis for Income Standard 1. Minimum Income Standard a. The minimum income standard used for this group is the state's AFDC payment standard in effect as of May 1. 1988, converted to MAGI-equivalent amounts by household size. The standard is described in AFDC Income Standards. b. The state certifies that it has submitted and received approval for its converted May 1. 1988 AFDC payment standard. 2. Maximum income standard a. The state certifies that it has submitted and received approval for its converted income standard{s) for parents and other caretaker relatives to MAGI- equivalent standards and the determination of the maximum income standard to be used for parents and other caretaker relatives under this eligibility group. b. The state's maximum income standard for this eligibility group is: O i. The state's effective income level for section 1931 families under the Medicaid state plan as of March 23. 201 o. converted to a MAGI-equivalent percent of FPL or amounts by household size. O ii. The state's effective income level for section 1931 families under the Medicaid state plan as of December 31. 2013, converted to a MAGI-equivalent percent of FPL or amounts by household size. O iii. The state's effective income level for any population of parents/caretaker relatives under a Medicaid 1115 demonstration as of March 23. 201 o. converted to a MAGI-equivalent percent of FPL or amounts by household size. O iv. The state's effective income level for any population of parents/caretaker relatives under a Medicaid 1115 demonstration as of December 31, 2013. converted to a MAGI-equivalent percent of FPL or amounts by household size. c. The amount of the maximum income standard is: 0 i. A percentage of the federal poverty level: O ii. The state's AFDC payment standard in effect as of July 16. 1996, converted to a MAGI-equivalent standard. The standard is described in AFDC Income Standards. O iii. The state's AFDC payment standard in effect as of July 16. 1996. increased by no more than the percentage increase in the Consumer Price Index for urban consumers (CPI-U) since such date. converted to a MAGI-equivalent standard. The standard is described in AFDC Income Standards. O iv. The state's TANF payment standard converted to a MAGI-equivalent standard. The standard is described in AFDC Income Standards. O v. Other dollar amount

Parents and Other Caretaker Relatives MEDICAID I Medicaid State Plan I Eligibility I TN2020MS0002O I TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 14-0005 System-Derived E. Additional Information (optional) Medicaid State Plan Eligibility Eligibility Groups - Mandatory Coverage Pregnant Women MEDICAID I Medicaid State Plan I Eligibility I TN2020MS0002O I TN-21-0010 SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 Women who are pregnant or post-partum. with household income at or below a standard established by the state. Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 16-0002 System-Derived SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 The state covers the mandatory pregnant women group in accordance with the following provisions: A. Characteristics 1. Individuals qualifying under this eligibility group must be pregnant or post-partum, as defined in 42 CFR 435.4. 2. Pregnant women in the last trimester of their pregnancy without dependent children are eligible for full benefits under this group in accordance with section 1931 of the Act. if they meet the income standard for state plan Parents and Other Caretaker Relatives at 42 C.F.R. 435.110. 0 Yes 0 No B. Financial Methodologies MAGI-based methodologies are used in calculating household income. Please refer as necessary to MAGI-Based Methodologies, completed by the state. C. Income Standard Used The state uses the following income standard for this group: FPL 195.00%

Pregnant Women MEDICAID I Medicaid State Plan I Eligibility I TN2020MS0002O I TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/ 23/ 2022 Superseded SPA ID TN 16-0002 System-Derived D. Benefits for Pregnant Women Benefits for individuals in this eligibility group consist of the following: SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/ 2021 O 1. All pregnant women eligible under this group receive full Medicaid coverage under this state plan. 0 2. Pregnant women whose income exceeds the income limit specified for full coverage of pregnant women receive only pregnancy-related services.

Pregnant Women MEDICAID I Medicaid State Plan I Eligibility I TN2020MS0002O I TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 16-0002 System-Derived SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 E. Basis for Pregnant Women Income Standard 1. Minimum income standard The state had an income standard higher than 133% FPL established as of December 19, 1989 for determining eligibility for pregnant women. or as of July 1, 1989, had authorizing legislation to do so. Q Yes O No 2. Maximum income standard b. The minimum income standard for this eligibility group is 133% FPL. a. The state certifies that it has submitted and received approval for its converted income standard{s) for pregnant women to MAGI-equivalent standards and the determination of the maximum income standard to be used for pregnant women under this eligibility group. b. The state"s maximum income standard for this eligibility group is: O i. The state's highest effective income level for coverage of pregnant women under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified pregnant women). 1902(a)(10)(A)(i)(IV) (mandatory poverty level-related pregnant women). 1902(a)(10)(A)(ii)(IX) (optional poverty level-related pregnant women). 1902(a)(10)(A)(ii)(I) (pregnant women who meet AFDC financial eligibility criteria) and 1902(a)(10)(A)(ii)(IV) (institutionalized pregnant women) in effect under the Medicaid state plan as of March 23. 201 o. converted to a MAGI-equivalent percent of FPL O ii. The state's highest effective income level for coverage of pregnant women under sections 1931 (low-income families). 1902(a)(10)(A)(i)(III) (qualified pregnant women). 1902(a)(10)(A)(i)(IV) (mandatory poverty level-related pregnant women). 1902(a)(10)(A)(ii)(IX) (optional poverty level-related pregnant women). 1902(a)(10)(A)(ii)(I) (pregnant women who meet AFDC financial eligibility criteria) and 1902(a)(10)(A)(ii)(IV) (institutionalized pregnant women) in effect under the Medicaid state plan as of December 31, 2013. converted to a MAGI-equivalent percent of FPL. O iii. The state"s effective income level for any population of pregnant women under a Medicaid 1115 demonstration as of March 23. 201 o. converted to a MAGI-equivalent percent of FPL O iv. The state"s effective income level for any population of pregnant women under a Medicaid 1115 demonstration as of December 31, 2013. converted to a MAGI-equivalent percent of FPL. Ov. 185%FPL c. The amount of the maximum income standard is: FPL 195.00% G. Additional Information (optional)

Medicaid State Plan Eligibility Eligibility Groups - Mandatory Coverage Deemed Newborns MEDICAID | Medicaid State Plan | Eligibility | TN2020MS0002O | TN-21-0010 Children born to women covered under Medicaid or a separate CHIP program for the date of the child's birth, who are deemed eligible for Medicaid without application until the child turns one. Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 92-23 User-Entered SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 The state covers the mandatory deemed newborns group in accordance with the following provisions: A. Characteristics 1. A child qualifies under this group provided the birth mother meets one of the following requirements for the date of the child's birth: a. Was covered under any eligibility group in the Medicaid state plan, including during a period of retroactive eligibility or coverage of emergency services as defined in section 1903(v)(3) of the Act; or b. Was covered as a targeted low-income pregnant woman under the state's CHIP state plan (if the state elected the option in CHIP), with household income at or below the income standard established by the state for infants under age one in the infants and children under age 19 eligibility group (42 CFR 435.118). 2. Individuals may not be required to file an application for this group.

Deemed Newborns MEDICAID I Medicaid State Plan I Eligibility I TN2020MS0002O I TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 92-23 User-Entered B. Optional Individuals Covered SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 1. In addition to the children described in A., the state extends coverage to other newborns. • Q Yes O No

Deemed Newborns MEDICAID | Medicaid State Plan | Eligibility | TN2020MS0002O | TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 92-23 User-Entered SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 C. Financial Methodologies When eligibility for the newborn is based on the birth mother's CHIP eligibility or on the birth mother's eligibility under an 1115 demonstration, MAGI-based methodologies are used in calculating household income. Please refer as necessary to MAGI-Based Methodologies, completed by the state. D. Period of Eligibility 1. The period of eligibility extends from the date of the child's birth until the child's first birthday. 2. The period of eligibility is not impacted by changes in household income or household composition.

Deemed Newborns MEDICAID | Medicaid State Plan | Eligibility | TN2020MS0002O | TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 92-23 User-Entered SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 E. Additional Information (optional)

Medicaid State Plan Eligibility Eligibility Groups - Mandatory Coverage Children with Title IV-E Adoption Assistance, Foster Care or Guardianship Care MEDICAID | Medicaid State Plan | Eligibility | TN2020MS0002O | TN-21-0010 Individuals for whom an adoption assistance agreement is in effect or foster care or kinship guardianship assistance maintenance payments are made under Title IV-E of the Act. Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 92-6 User-Entered SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 The state covers the mandatory children with Title IV-E adoption assistance, foster care or guardianship care group in accordance with the following provisions: A. Characteristics 1. Individuals qualifying under this eligibility group must meet one of the following criteria: a. An adoption assistance agreement is in effect for the individual with any state or Tribe under title IV-E of the Act, regardless of whether adoption assistance is being provided or an interlocutory or other judicial decree of adoption has been issued; or

b. Foster care or kinship guardian assistance maintenance payments are being made by a state or Tribe under Title IV-E of the Act. 2. The upper age limit for eligibility under this group is determined by the terms of the adoption assistance agreement or the terms of the foster care or kinship guardianship assistance maintenance payments, as established by the IV-E plan of the state or Tribe that established the agreement or is making the payments. 3. Individuals may not be required to file an application for this group.

Children with Title IV-E Adoption Assistance, Foster Care or Guardianship Care MEDICAID | Medicaid State Plan | Eligibility | TN2020MS0002O | TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 92-6 User-Entered SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 B. Additional Information (optional)

Medicaid State Plan Eligibility Eligibility Groups - Mandatory Coverage Former Foster Care Children MEDICAID I Medicaid State Plan I Eligibility I TN2020MS0002O I TN-21-0010 Individuals under the age of 26. not otherwise mandatorily eligible, who were on Medicaid and foster care when they turned age 18 or aged out of foster care. Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 14-0005 User-Entered SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 The state covers the mandatory former foster care children group in accordance with the following provisions: A. Characteristics Individuals qualifying under this eligibility group must meet the following criteria: 1. Are under age 26 2. Are not otherwise eligible for and enrolled for mandatory coverage under the state plan, except that eligibility under this group takes precedence over eligibility under the Adult Group B. Individuals Covered 1. The state covers individuals who were in foster care under the responsibility of the state or a Tribe within the state (including children who were cared for through a grant to the state under the unaccompanied refugee minor program) and were enrolled in Medicaid under the state's Medicaid state plan or 111S demonstration when they turned 18 or a higher age at which that state's or Tribe's foster care assistance ends under title IV-E of the Act. 2. Additionally, the state covers individuals who were in foster care under the responsibility of the state or a Tribe within the state (including children who were cared for through a grant to the state under the unaccompanied refugee minor program) when they turned 18 or a higher age at which the state's or Tribe's foster care assistance ends under title IV-E of the Act. and meet the following criteria: a. They were enrolled in Medicaid under the state's Medicaid state plan or 1115 demonstration at any time during the foster care period in which they turned 18 or a higher age at which the state's or Tribe's foster care assistance ends. b. They were placed by the state or Tribe in another state and were enrolled in Medicaid under the other state's Medicaid state plan or 1115 demonstration project when they turned 18 or a higher age at which the state's or Tribe's foster care assistance ends. c. They were placed by the state or Tribe in another state and were enrolled in Medicaid under the other state's Medicaid state plan or 1115 demonstration project at any time during the foster care period in which they turned 18 or a higher age at which the state's or Tribe's foster care assistance ends.

Former Foster Care Children MEDICAID | Medicaid State Plan | Eligibility | TN2020MS0002O | TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 14-0005 User-Entered SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 C. Additional Information (optional)

Medicaid State Plan Eligibility Eligibility Groups - Mandatory Coverage Transitional Medical Assistance MEDICAID I Medicaid State Plan I Eligibility I TN2020MS0002O I TN-21-0010 Families with Medicaid eligibility extended for up to 12 months because of earnings. Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 16-0001 User-Entered SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 The state covers the mandatory transitional medical assistance group in accordance with the following provisions: A. Characteristics 1. An individual qualifying under this eligibility group must meet one of the following criteria: a. Lost coverage under the parents and other caretaker relatives group (42 CFR 435.1 10) due to work hours or income from employment or b. Is the child of a parent or caretaker relative described in A. 1.a. 2. In accordance with the requirements described in section 1925 of the Act and in this reviewable unit the state provides extended Medicaid eligibility, as follows: 0 a. The initial extended eligibility period is for 6 months, followed by a second extended eligibility period of 6 months. O b. The initial extended eligibility period is for 12 months, with no second extended eligibility period.

Transitional Medical Assistance MEDICAID I Medicaid State Plan I Eligibility I TN2020MS0002O I TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 16-0001 User-Entered B. Individuals Covered 1. Parents or other caretaker relatives SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 a. A parent or other caretaker relative must meet the following criteria to qualify for an initial extended eligibility period: i. Was eligible and enrolled in the parents and other caretaker relatives eligibility group. during the six months immediately preceding the month that eligibility was lost for at least 0 (1)1 month 0 (2) 2 months 0 (3) 3 months ii. Lost eligibility under the parents and other caretaker relatives eligibility group because: iii. Continues to live with a child. 2. A child qualifying under this eligibility group must meet all of the following requirements: (1) The earnings of a parent or caretaker relative caused household income to exceed the income standard of that group; or (2) The hours of employment of a parent or caretaker relative resulted in the individual no longer being considered to have a dependent child (as described in 42 CFR 435.4 and the Parents and Other caretaker Relatives RU). a. Uves with a parent or other caretaker relative who is eligible under this eligibility group. b. Is not eligible for the infants and children under age 19 eligibility group (42 CFR 435.118).

Transitional Medical Assistance MEDICAID | Medicaid State Plan | Eligibility | TN2020MS0002O | TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 16-0001 User-Entered SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 C. Initial Extended Eligibility Period 1. Income/Resource Standard Used

There is no income or resource standard.

2. Medical Assistance Provided a. The amount, duration, and scope of coverage provided is the same as that provided to parents and caretaker relatives enrolled in the parents and other caretaker relatives eligibility group and to children enrolled in the eligibility group for infants and children under age 19.

b. The state's election to provide premium assistance for employer sponsored coverage is described in the benefits section of the state plan. 3. Termination of Extension a. If the family ceases to include a child, the initial extension of eligibility will end prior to the scheduled end date. In such cases, eligibility is terminated at the close of the first month in which the family no longer includes a child. b. Termination of eligibility will occur in accordance with all requirements described in the Eligibility Process RU.

Transitional Medical Assistance MEDICAID | Medicaid State Plan | Eligibility | TN2020MS0002O | TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 16-0001 User-Entered SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 F. Additional Information (optional)

Medicaid State Plan Eligibility Eligibility Groups - Mandatory Coverage Extended Medicaid due to Spousal Support Collections MEDICAID | Medicaid State Plan | Eligibility | TN2020MS0002O | TN-21-0010 Families with Medicaid eligibility extended for 4 months as the result of the collection of spousal support. Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 92-6 User-Entered SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 The state covers the mandatory extended Medicaid due to spousal support collections group in accordance with the following provisions: A. Characteristics 1. Parents or other caretaker relatives qualifying under this eligibility group must meet the following criteria: a. The individual must have lost eligibility under the parents and other caretaker relatives eligibility group (42 CFR 435.110) because the household's income exceeds the income standard due to increased collection of spousal support under Title IV-D of the Act.

b. The individual was covered under the parents and other caretaker relatives eligibility group (42 CFR 435.110) for at least three months out of the six months immediately preceding the month that eligibility was lost. 2. Dependent children qualify under this group if and when they lose eligibility for the infants and children under age 19 eligibility group (42 CFR 435.118) during their parents or caretaker relative's extended period of eligibility under this group. B. Period of Extension The extended eligibility period is four months.

Extended Medicaid due to Spousal Support Collections MEDICAID | Medicaid State Plan | Eligibility | TN2020MS0002O | TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 92-6 User-Entered SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 C. Additional Information (optional)

Medicaid State Plan Eligibility Eligibility Groups - Mandatory Coverage SSI Beneficiaries MEDICAID | Medicaid State Plan | Eligibility | TN2020MS0002O | TN-21-0010 Individuals who are age 65 or older, or who have blindness or disability, who receive SSI. Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 92-23; TN 92-6 User-Entered SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 The state covers the mandatory SSI beneficiaries group in accordance with the following provisions: A. Characteristics Individuals qualifying under this eligibility group must be receiving SSI, including: 1. Receiving SSI pending a final determination of blindness or disability; 2. Receiving SSI under an agreement with the Social Security Administration to dispose of resources that exceed the SSI dollar limits on resources; or 3. Receiving SSI benefits under section 1619(a) of the Act.

SSI Beneficiaries MEDICAID | Medicaid State Plan | Eligibility | TN2020MS0002O | TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 92-23; TN 92-6 User-Entered SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 B. Additional Information (optional)

Medicaid State Plan Eligibility Eligibility Groups - Mandatory Coverage Closed Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | TN2020MS0002O | TN-21-0010 Certain individuals who were eligible in the 1970s and 1980s and continue to qualify under specified requirements. Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 92-6 User-Entered SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 The state covers mandatory individuals who were previously eligible for Medicaid in the 1970s or 1980s and continue to meet the eligibility requirements. These individuals are described in one or more of the following sections A through F. A. Individuals Receiving Mandatory State Supplements Individuals qualifying under this eligibility group must be receiving mandatory state supplements.

Closed Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | TN2020MS0002O | TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 92-6 User-Entered SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 B. Individuals Who Are Essential Spouses Individuals qualifying under this eligibility group must meet all of the following criteria: 1. In December, 1973 were eligible for Medicaid as essential spouses; 2. Have continued to live with and be essential to the well-being of an individual who continues to meet the eligibility requirements for one of the cash assistance programs under OAA, AB, APTD, or AABD; and 3. Continue to meet the December, 1973 criteria that applied in determining the amount of the cash payment.

Closed Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | TN2020MS0002O | TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 92-6 User-Entered SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 C. Institutionalized Individuals Continuously Eligible Since 1973 Individuals qualifying under this eligibility group must meet all of the following criteria: 1. Were eligible for Medicaid in December, 1973 as inpatients of medical institutions or residents of intermediate care facilities participating in Medicaid; 2. For each consecutive month after December, 1973, continue to meet the requirements for Medicaid eligibility in effect under the state plan in December, 1973 for institutionalized individuals, and remain institutionalized; and 3. Are determined by the state or a professional standards review organization to continue to need institutional care.

Closed Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | TN2020MS0002O | TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 92-6 User-Entered SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 D. Individuals Eligible in 1973 Who Have Blindness or a Disability Individuals qualifying under this eligibility group must meet all of the following criteria: 1. Meet all the current Medicaid eligibility requirements, except for blindness and disability; 2. Were eligible for Medicaid in December, 1973 as blind or disabled; and 3. Continue to meet the December, 1973 criteria for Medicaid.

Closed Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | TN2020MS0002O | TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 92-6 User-Entered SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 E. Individuals Who Lost Eligibility for SSI/SSP Due to an Increase in OASDI Benefits in 1972 Individuals qualifying under this eligibility group must meet the following criteria: 1. Were entitled to and receiving cash assistance in August, 1972, or would have been eligible had they applied or not been institutionalized (and the state covered these optional groups); and 2. Would currently be eligible for SSI or state supplement, except for the increase in OASDI under Public Law No. 92-336.

Closed Eligibility Groups MEDICAID I Medicaid State Plan I Eligibility I TN2020MS0002O I TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 92-6 User-Entered SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 F. Disabled Widows and Widowers Ineligible for SSI due to Increase in OASDI 1. Individuals qualifying under this eligibility group must meet all of the following criteria: a. Are disabled widows or widowers who are deemed to be SSI or state supplement beneficiaries. b. Became ineligible for SSI or state supplement as a result of the elimination of the reduction factor required by section 134 of Public. Law No. 98-21. c. Would be eligible for SSI or state supplement except for the increase under Public Law No. 98-21 and subsequent cost- of-living increases in widoW's or widower's benefits under section 21 S(i) of the Act d. Filed a written application for Medicaid on or before June 30.1988. 2. Individuals receiving only state supplement qualify for this group. 0 Yes 0 No 3. SSI Methodologies are used in calculating household income. O a. The state does not make state supplementary payments. 0 b. The state does make state supplement payments but has elected not to provide Medicaid eligibility on the basis of the receipt of such optional state supplement.

Closed Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | TN2020MS0002O | TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 92-6 User-Entered SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 G. Additional Information (optional)

Medicaid State Plan Eligibility Eligibility Groups - Mandatory Coverage Individuals Deemed To Be Receiving 551 MEDICAID I Medicaid State Plan I Eligibility I TN2020MS0002O I TN-21-0010 Individuals who would be eligible for S51, but for certain OASDI increases. Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 92-6; TN 92-20 User-Entered SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 The state covers mandatory individuals who would be eligible for SSI. but for an increase related to Social Security. in accordance with the following provisions: A. Individuals Who Would be Eligible for SSI/SSP but for OASDI COLA Increases Since April, 1977 1. Individuals qualifying under this eligibility group must meet all of the following criteria: a. Currently receive OASDI benefits; b. Received SSI or state supplement in the past but became ineligible for these payments after April. 1977; and c. Would still be eligible for SSI or state supplement if the amount of OASDI cost-of-living increases paid under section 21 S(i) of the Act since the individual lost SSI or state supplement were deducted from current OASDI benefits. 2. Individuals receiving only state supplement qualify for this group. Q Yes O No O a. The state does not make state supplementary payments. O b. The state does make state supplement payments but has elected not to provide Medicaid eligibility on the basis of the receipt of such optional state supplement

Individuals Deemed To Be Receiving 551 MEDICAID I Medicaid State Plan I Eligibility I TN2020MS0002O I TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 92-6; TN 92-20 User-Entered SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 B. Disabled Widows and Widowers Ineligible for SSI due to Early Receipt of Social Security 1. Individuals qualifying under this eligibility group must be widows or widowers with a disability who meet all of the following criteria: a. Are at least age 60; b. Are not entitled to hospital insurance benefits under Medicare Part A; and c. Become ineligible for SSI or state supplement because of mandatory application (under section 1611(e)(2)) for and receipt of widow"s or widower's social security disability benefits under section 202(e) or (f) of the Act. 2. Individuals receiving only state supplement qualify for this group. Q Yes O No O a. The state does not make state supplementary payments. O b. The state does make state supplement payments but has elected not to provide Medicaid eligibility on the basis of the receipt of such optional state supplement

Individuals Deemed To Be Receiving SSI MEDICAID | Medicaid State Plan | Eligibility | TN2020MS0002O | TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 92-6; TN 92-20 User-Entered SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 C. Adult Children with Disabilities Individuals qualifying under this eligibility group must meet the following criteria: 1. Had blindness or a disability before the age of 22;

2. Are at least age 18;

3. Lost eligibility for SSI because they became entitled, based on their disability or blindness, to OASDI child's benefits under section 202(d) of the Act, or because they received an increase to those benefits;

4. Would be eligible for SSI, if not for their OASDI benefits or the increase in those benefits.

Individuals Deemed To Be Receiving SSI MEDICAID | Medicaid State Plan | Eligibility | TN2020MS0002O | TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 92-6; TN 92-20 User-Entered SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 D. Financial Methodologies SSI methodologies are used in calculating household income.

Individuals Deemed To Be Receiving SSI MEDICAID | Medicaid State Plan | Eligibility | TN2020MS0002O | TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 92-6; TN 92-20 User-Entered SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 E. Additional Information (optional)

Medicaid State Plan Eligibility Eligibility Groups - Mandatory Coverage Working Individuals under 1619(b) MEDICAID | Medicaid State Plan | Eligibility | TN2020MS0002O | TN-21-0010 Individuals who have blindness or a disability who participated in Medicaid as SSI beneficiaries or who were considered to be receiving SSI, who would still qualify for SSI except for earnings. Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 92-6 User-Entered SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 The state covers the working individuals under 1619(b) mandatory eligibility group in accordance with the following provisions: A. Characteristics Individuals qualifying under this eligibility group must meet the following criteria: 1. In the month preceding the month of qualification under this group: a. Received SSI or state supplement; and

b. Were eligible for Medicaid under the state plan. 2. Continue to have blindness or a disability.

3. Continue to meet all non-disability-related requirements for eligibility for SSI or state supplement.

4. Would qualify for SSI or State Supplement, except for earned income.

5. For whom the loss of eligibility for Medicaid would seriously inhibit the individual's ability to continue or obtain employment.

6. For whom the individual's earnings are not sufficient to provide a reasonable equivalent of SSI (including state supplement), Medicaid, and publicly funded attendant care services.

Working Individuals under 1619(b) MEDICAID | Medicaid State Plan | Eligibility | TN2020MS0002O | TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 92-6 User-Entered SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 B. Additional Information (optional)

Medicaid State Plan Eligibility Eligibility Groups - Mandatory Coverage Qualified Medicare Beneficiaries MEDICAID | Medicaid State Plan | Eligibility | TN2020MS0002O | TN-21-0010 Individuals with income equal to or less than 100% of the FPL, who are entitled to Medicare Part A, and who qualify for Medicare cost-sharing. Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 10-001 User-Entered SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 The state covers the mandatory qualified Medicare beneficiaries group in accordance with the following provisions: A. Characteristics Individuals qualifying under this eligibility group must meet the following criteria: 1. Are entitled to hospital insurance benefits under part A of title XVIII (Medicare Part A), including individuals who have purchased a premium to enroll in Part A.

2. Have income and resources at or below the standard for this group.

Qualified Medicare Beneficiaries MEDICAID I Medicaid State Plan I Eligibility I TN2020MS0002O I TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 10-001 User-Entered B. Financial Methodologies SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 1. S51 methodologies are used in calculating household income. Please refer as necessary to Non-MAGI Methodologies, completed by the state. 2.. Less restrictive methodologies are used in calculating countable income. 0 Yes Q No The less restrictive income methodologies are: General income disregard: Census Bureau wages are disregarded. 3. Less restrictive methodologies are used in calculating countable resources. o ves Q No The less restrictive resource methodologies are: A specified type of resource is disregarded: Name of disregard: Dependent child disregard Description: An amount per month per child will be disregarded from the QMB applicanUrecipient's countable income in situations where minor dependent children, under age 21. live in the home with the QMB applicanUrecipient. The amount of this disregard will be reasonably related to the difference between the poverty level income standard for each family size. Description of disregard: All wages paid by the Census Bureau for temporary Name of resource type: Income producing business/non- business resources employment activities in connection with the full Census that occurs every 10 years are excluded. Description: All of the individual's equity value in business/non-business resources used to produce income is excluded as a resource. Business/Non-Business Resources are defined as land, buildings, equipment supplies. inventory, tools of a tradesperson, livestock of a farmer, cash on hand, accounts receivable, etc. which are used in the person"s trade or business, or in the employment of a family member or by the individual as an employee.

The following less restrictive methodologies are used: Name of methodology: Resource eligibility by month Description: The individual/couple whose countable resources are valued at or below the resource limit at any time during the month meet resource eligibility throughout the entire month.

Qualified Medicare Beneficiaries MEDICAID | Medicaid State Plan | Eligibility | TN2020MS0002O | TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 10-001 User-Entered SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 C. Income Standard Used The amount of the income standard for this group is 100% FPL. D. Resource Standard Used The resource standard is the same used to determine eligibility for the Medicare Part D full-benefit low-income subsidy (LIS) (but without regard to the life insurance policy exclusion applied in LIS resource eligibility determinations). This standard is three times the SSI resource standard, adjusted annually in accordance with the consumer price index. E. Medical Assistance Provided Medical assistance is limited to payment of co-insurance and deductibles for Medicare Parts A, B and C and payment for the premiums for Medicare Parts A and B.

Medical assistance begins the first day of the month following the month in which the individual is determined to qualify for this eligibility group.

Qualified Medicare Beneficiaries MEDICAID | Medicaid State Plan | Eligibility | TN2020MS0002O | TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 10-001 User-Entered SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 F. Additional Information (optional)

Medicaid State Plan Eligibility Eligibility Groups - Mandatory Coverage Qualified Disabled and Working Individuals MEDICAID | Medicaid State Plan | Eligibility | TN2020MS0002O | TN-21-0010 Working individuals with a disability, with income equal to or less than 200% of the FPL, who are entitled to Medicare Part A under section 1818A, and who qualify for payment of Medicare Part A premiums. Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 10-001 User-Entered SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 The state covers the mandatory qualified disabled and working individuals group in accordance with the following provisions: A. Characteristics Individuals qualifying under this eligibility group must meet the following criteria: 1. Are entitled to purchase a premium to enroll for hospital insurance benefits under part A of title XVIII (Medicare Part A) pursuant to section 1818A (hospital insurance benefits for disabled individuals who have exhausted other entitlement).

2. Have income and resources at or below the standard for this group.

3. Are not otherwise eligible for medical assistance. B. Financial Methodologies SSI methodologies are used in calculating household income. Please refer as necessary to Non-MAGI Methodologies, completed by the state. C. Income Standard Used The amount of the income standard for this group is 200% FPL. D. Resource Standard Used The resource standard is two times the standard used in the SSI program. E. Medical Assistance Provided Medical assistance is limited to payment for Medicare Part A premiums.

Qualified Disabled and Working Individuals MEDICAID | Medicaid State Plan | Eligibility | TN2020MS0002O | TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 10-001 User-Entered SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 F. Additional Information (optional)

Medicaid State Plan Eligibility Eligibility Groups - Mandatory Coverage Specified Low Income Medicare Beneficiaries MEDICAID | Medicaid State Plan | Eligibility | TN2020MS0002O | TN-21-0010 Individuals with income above 100% and below 120% of the FPL who are entitled to Medicare Part A, who qualify for payment of Medicare Part B premiums. Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 10-001 User-Entered SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 The state covers the mandatory specified low income Medicare beneficiaries group in accordance with the following provisions: A. Characteristics Individuals qualifying under this eligibility group must meet the following criteria: 1. Would qualify as Qualified Medicare Beneficiaries (described in section 1905(p)(1) of the Act), except that their income exceeds the income level for that eligibility group.

2. Have income below the income standard and resources at or below the resource standard for this group.

Specified Low Income Medicare Beneficiaries MEDICAID I Medicaid State Plan I Eligibility I TN2020MS0002O I TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 10-001 User-Entered B. Financial Methodologies SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 1. S51 methodologies are used in calculating household income. Please refer as necessary to Non-MAGI Methodologies, completed by the state. 2.. Less restrictive methodologies are used in calculating countable income. 0 Yes Q No The less restrictive income methodologies are: General income disregard: Census Bureau wages are disregarded. 3. Less restrictive methodologies are used in calculating countable resources. 0 Yes Q No The less restrictive resource methodologies are: A specified type of resource is disregarded: Name of disregard: Dependent child disregard Description: An amount per month per child will be disregarded from the SLMB applicanUrecipient's countable income in situations where minor dependent children, under age 21. live in the home with the SLMB applicanUrecipient. The amount of this disregard will be reasonably related to the difference between the poverty level income standard for each family size. Description of disregard: All wages paid by the Census Bureau for temporary Name of resource type: Income producing business/non- business resources employment activities in connection with the full Census that occurs every 10 years are excluded. Description: All of the individual's equity value in business/non-business resources used to produce income is excluded as a resource. Business/Non-Business Resources are defined as land, buildings, equipment supplies. inventory, tools of a tradesperson, livestock of a farmer, cash on hand, accounts receivable, etc. which are used in the person"s trade or business, or in the employment of a family member or by the individual as an employee.

The following less restrictive methodologies are used: Name of methodology: Resource eligibility by month Description: The individual/couple whose countable resources are valued at or below the resource limit at any time during the month meet resource eligibility throughout the entire month.

Specified Low Income Medicare Beneficiaries MEDICAID | Medicaid State Plan | Eligibility | TN2020MS0002O | TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 10-001 User-Entered SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 C. Income Standard Used Family income must be above 100% FPL and below 120% FPL. D. Resource Standard Used The resource standard is the same used to determine eligibility for the Medicare Part D full-benefit low-income subsidy (LIS) (but without regard to the life insurance policy exclusion applied in LIS resource eligibility determinations). This standard is three times the SSI resource standard, adjusted annually in accordance with the consumer price index. E. Medical Assistance Provided Medical assistance is limited to payment for Medicare Part B premiums.

Specified Low Income Medicare Beneficiaries MEDICAID | Medicaid State Plan | Eligibility | TN2020MS0002O | TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 10-001 User-Entered SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 F. Additional Information (optional)

Medicaid State Plan Eligibility Eligibility Groups - Mandatory Coverage Qualifying Individuals MEDICAID | Medicaid State Plan | Eligibility | TN2020MS0002O | TN-21-0010 Individuals with income at or above 120% and below 135% of the FPL who are entitled to Medicare Part A, who qualify for payment of Medicare Part B premiums. Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 10-001 User-Entered SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 The state covers the mandatory qualifying individuals group in accordance with the following provisions: A. Characteristics Individuals qualifying under this eligibility group must meet all of the following criteria: 1. Would qualify as Qualified Medicare Beneficiaries (described in section 1905(p)(1) of the Act), except that their income exceeds the income level for that eligibility group.

2. Are not otherwise eligible for Medicaid under the state plan.

3. Have income below the income standard and resources at or below the resource standard for this group.

Qualifying Individuals MEDICAID I Medicaid State Plan I Eligibility I TN2020MS0002O I TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 10-001 User-Entered B. Financial Methodologies SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 1. S51 methodologies are used in calculating household income. Please refer as necessary to Non-MAGI Methodologies, completed by the state. 2.. Less restrictive methodologies are used in calculating countable income. o ves Q No The less restrictive income methodologies are: General income disregard: Census Bureau wages are disregarded. 3. Less restrictive methodologies are used in calculating countable resources. 0 Yes Q No The less restrictive resource methodologies are: A specified type of resource is disregarded: Name of disregard: Dependent child disregard Description: An amount per month per child will be disregarded from the QI applicanUrecipient's countable income in situations where minor dependent children, under age 21. live in the home with the QI applicanUrecipient. The amount of this disregard will be reasonably related to the difference between the poverty level income standard for each family size. Description of disregard: All wages paid by the Census Bureau for temporary Name of resource type: Income producing business/non- business resources employment activities in connection with the full Census that occurs every 10 years are excluded. Description: All of the individual's equity value in business/non-business resources used to produce income is excluded as a resource. Business/Non-Business Resources are defined as land, buildings, equipment supplies. inventory, tools of a tradesperson, livestock of a farmer, cash on hand, accounts receivable, etc. which are used in the person"s trade or business, or in the employment of a family member or by the individual as an employee.

~ The following less restrictive methodologies are used: Name of methodology: Resource eligibility by month Description: The individual/couple whose countable resources are valued at or below the resource limit at any time during the month meet resource eligibility throughout the entire month.

Qualifying Individuals MEDICAID | Medicaid State Plan | Eligibility | TN2020MS0002O | TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 10-001 User-Entered SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 C. Income Standard Used Family income must be at or above 120% FPL and below 135% FPL. D. Resource Standard Used The resource standard is the same used to determine eligibility for the Medicare Part D full-benefit low-income subsidy (LIS) (but without regard to the life insurance policy exclusion applied in LIS resource eligibility determinations). This standard is three times the SSI resource standard, adjusted annually in accordance with the consumer price index. E. Medical Assistance Provided Medical assistance is limited to payment for Medicare Part B premiums.

Qualifying Individuals MEDICAID | Medicaid State Plan | Eligibility | TN2020MS0002O | TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 10-001 User-Entered SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 F. Additional Information (optional)

Medicaid State Plan Eligibility Optional Eligibility Groups MEDICAID I Medicaid State Plan I Eligibility I TN2020MS0002O I TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID NEW User-Entered A. Options for Coverage The state provides Medicaid to specified optional groups of individuals. 0 Yes O No SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 The optional eligibility groups covered in the state plan are (elections made in this screen may not be comprehensive during the transition period from the paper- based state plan to MACPro): Families and Adults Eligibility Group Name Optional Coverage of Parents and Other Caretaker Relatives Reasonable Classifications of Individuals under Age 21 Children with Non-lV-E Adoption Assistance Independent Foster Care Adolescents Optional Targeted Low Income Children Individuals above 133% FPL under Age 6S Individuals Needing Treatment for Breast or Cervical cancer Individuals Eligible for Family Planning Services Individuals with Tuberculosis Individuals Electing COBRA Continuation Coverage Aged, Blind and Disabled Eligibility Group Name Individuals Eligible for but Not Receiving Cash Assistance Covered In State Plan □ □ □ □ □ □ Covered In State Plan Include RU In Package 8 □ □ □ □ □ □ Include RU In Package 8 Included in Another Submission Package 0 0 0 0 0 0 0 0 0 0 Included in Another Submission Package 0 Source Type 8 NEW NEW APPROVED NEW NEW NEW APPROVED NEW NEW NEW Source Type 8 NEW

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

Optional Eligibility Groups MEDICAID I Medicaid State Plan I Eligibility I TN2020MS0002O I TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID NEW User-Entered B. Medically Needy Options for Coverage SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 The state provides Medicaid to specified groups of individuals who are medically needy. 0 Yes Q No The medically needy eligibility groups covered in the state plan are: 1. Mandatory Medically Needy: Families and Adults Eligibility Group Name Medically Needy Pregnant Women Medically Needy Children under Age 18 Aged, Blind and Disabled Eligibility Group Name Protected Medically Needy Individuals Who Were Eligible in 1973 2. Optional Medically Needy: Families and Adults Eligibility Group Name Medically Needy Reasonable ~ Classifications of Individuals under Age 21 Medically Needy ~ Parents and Other Caretaker Relatives Aged, Blind and Disabled Eligibility Group Name Medically Needy Populations Based on ~ Age, Blindness or Disability Covered In State Plan Covered In State Plan Covered In State Plan □ Covered In State Plan Include RU In Package 8 Include RU In Package 8 Include RU In Package 8 □ Include RU In Package 8 Included in Another Submission Package 0 0 Included in Another Submission Package 0 Included in Another Submission Package 0 0 Included in Another Submission Package 0 Source Type 8 APPROVED APPROVED Source Type 8 NEW Source Type 8 APPROVED NEW Source Type 8 NEW

Optional Eligibility Groups MEDICAID I Medicaid State Plan I Eligibility I TN2020MS0002O I TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID NEW User-Entered C. Additional Information (optional) Eligibility Groups Deselected from Coverage SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 The following eligibility groups were previously covered in the source approved version of the state plan and deselected from coverage as part of this submission package: • N/A

Medicaid State Plan Eligibility Eligibility Groups - Options for Coverage Children with Non IV-E Adoption Assistance MEDICAID | Medicaid State Plan | Eligibility | TN2020MS0002O | TN-21-0010 Children with special needs for medical or rehabilitative care for whom there is a non IV-E adoption assistance agreement in effect with a state, who were eligible for Medicaid immediately before the adoption agreement was executed, or who had income at that point in time at or below a standard established by the state . Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 14-0005 System-Derived SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 The state covers the children with non IV-E adoption assistance group in accordance with the following provisions: A. Characteristics Individuals qualifying under this eligibility group must meet the following criteria: 1. Are under age 21 or a lower age, as specified in C. 2. Have a state adoption assistance agreement in effect between the adoptive parent(s) and a state. 3. The state adoption agency has determined that they cannot be placed for adoption without Medicaid coverage because of special needs for medical or rehabilitative care. 4. Immediately prior to execution of the adoption agreement, were eligible under the Medicaid state plan of the state with the adoption assistance agreement or, at the state's option, immediately prior to execution of the adoption agreement had income no more than the income standard (which could be no income test) specified in Section D. 5. Are not otherwise eligible for and enrolled in mandatory coverage under the state plan. B. Financial Methodologies When income is considered, MAGI-based methodologies are used in calculating household income. Please refer as necessary to MAGI-Based Methodologies, completed by the state.

Children with Non IV-E Adoption Assistance MEDICAID I Medicaid State Plan I Eligibility I TN2020MS0002O I TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 14-0005 System-Derived C. Individuals Covered SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 1. The state covers all children under a specified age limit for whom there is an adoption assistance agreement in place from any state. O Yes Q No a. The age of children covered under this eligibility group is. O i. Under age 21 O ii. Under age 20 O iii. Under age 19 O iv. Under age 18 b. In addition, the state covers reasonable classifications of children. Q Yes O No

Children with Non IV-E Adoption Assistance MEDICAID I Medicaid State Plan I Eligibility I TN2020MS0002O I TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 14-0005 System-Derived D. Income Standard Used SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 1. The state covered this eligibility group in the Medicaid state plan as of December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 201 o or December 31, 2013. O Yes Q No 2. The state used an income standard or disregarded all income for this group either in the Medicaid state plan as of March 23, 201 o or December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 201 O or December 31, 2013. Q Yes O No 3. The state does not use an income standard or disregard all income for this group.

Children with Non IV-E Adoption Assistance MEDICAID | Medicaid State Plan | Eligibility | TN2020MS0002O | TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 14-0005 System-Derived SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 F. Additional Information (optional)

Medicaid State Plan Eligibility Eligibility Groups - Options for Coverage Individuals Needing Treatment for Breast or Cervical Cancer MEDICAID | Medicaid State Plan | Eligibility | TN2020MS0002O | TN-21-0010 Individuals under the age of 65 who have been screened for breast or cervical cancer and need treatment. Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 2002-3 User-Entered SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 The state operates the optional Individuals Needing Treatment for Breast or Cervical Cancer eligibility group in accordance with the following provisions: A. Characteristics Individuals (including women and men) qualifying under this eligibility group must meet the following criteria: 1. Are under the age of 65.

2. Are not otherwise eligible for and enrolled in mandatory coverage under the state plan.

3. Have been screened under the Centers for Disease Control and Prevention (CDC) Breast and Cervical Cancer Early Detection Program.

4. As a result of the screening, a determination has been made that the individual needs treatment for breast or cervical cancer, as defined at 42 CFR 435.213(c).

5. Do not otherwise have creditable coverage for treatment of breast or cervical cancer.

Individuals Needing Treatment for Breast or Cervical Cancer MEDICAID | Medicaid State Plan | Eligibility | TN2020MS0002O | TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 2002-3 User-Entered SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 B. Financial Methodologies This eligibility group has no income or resource test.

Individuals Needing Treatment for Breast or Cervical Cancer MEDICAID | Medicaid State Plan | Eligibility | TN2020MS0002O | TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 2002-3 User-Entered SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 C. Additional Information (optional)

Medicaid State Plan Eligibility Eligibility Groups - Options for Coverage Individuals Eligible for Cash Except for Institutionalization MEDICAID I Medicaid State Plan I Eligibility I TN2020MS0002O I TN-21-0010 Individuals who would be eligible for federal cash assistance or an optional state supplement except for institutionalization. Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 94-1 User-Entered SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 The state covers the optional Individuals Eligible for Cash Except for Institutionalization eligibility group in accordance with the following provisions: A. Characteristics Individuals qualifying under this eligibility group must meet the following criteria: 1. Are in a medical institution. 2. Would meet the eligibility requirements for at least one of the following cash assistance programs. but for the lower income standards used to determine eligibility for institutionalized individuals: a. SSI b. Optional State Supplement c.AFDC

Individuals Eligible for Cash Except for Institutionalization MEDICAID I Medicaid State Plan I Eligibility I TN2020MS0002O I TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 94-1 User-Entered B. Individuals Covered 1. The state covers all individuals who meet the characteristics described in section A. 0 Yes 0 No SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021

Individuals Eligible for Cash Except for Institutionalization MEDICAID I Medicaid State Plan I Eligibility I TN2020MS0002O I TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 94-1 User-Entered C. Financial Methodologies SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 1. In calculating household income and resources for individuals who are seeking eligibility on the basis of being age 65 or older or having blindness or disability. SSI methodologjes are used. Please refer as necessary to Non-MAGI Methodologjes, completed by the state. 2. In calculating household income and resources for populations for which AFDC is the most closely related program. the following methodology(ies) are used: O a. MAGI-like methodologjes. Please refer as necessary to Non-MAGI Methodologjes, completed by the state. O b. AFDC methodologies. Please refer as necessary to Non-MAGI Methodologies, completed by the state. 3. Less restrictive methodologies are used in calculating countable income. o ves Q No The less restrictive income methodologjes are: Census Bureau wages are disregarded. 4. Less restrictive methodologies are used in calculating countable resources. 0 Yes Q No The less restrictive resource methodologjes are: A specified type of resource is disregarded: Description of disregard: All wages paid by the Census Bureau for temporary Name of resource type: Income producing business/non- business resources employment activities in connection with the full Census that occurs every 10 years are excluded. Description: All of the individual's equity value in business/non-business resources used to produce income is excluded as a resource. Business/Non-Business Resources are defined as land, buildings, equipment supplies. inventory. tools of a tradesperson. livestock of a farmer. cash on hand, accounts receivable, etc. which are used in the person's trade or business, or in the employment of a family member or by the individual as an employee.

~ The following less restrictive methodologies are used: Name of resource type: Resources accrued during the COVID-19 public health emergency Name of methodology: Resource eligibility by month Description: To the extent that CMS advises states that they may not increase an individual's patient liability amount under the post-eligibility treatment of income rules under 42 CFR 43S.725 and 435.733 and continue to receive the enhanced FMAP provided under Section 6008 of Families First Coronavirus Response Act the state will disregard any resources that a recipient accrues as a result of the state's inability to adjust patient liability during the COVID-19 public health emergency for a period of 12 months following the end of the emergency. Description: The individual/couple whose countable resources are valued at or below the resource limit at any time during the month meet resource eligibility throughout the entire month.

Individuals Eligible for Cash Except for Institutionalization MEDICAID | Medicaid State Plan | Eligibility | TN2020MS0002O | TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 94-1 User-Entered SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 D. Income Standard Used The income standard used is the standard of the most closely related cash assistance program. E. Resource Standard Used The resource standard used is the standard of the most closely related cash assistance program.

Individuals Eligible for Cash Except for Institutionalization MEDICAID | Medicaid State Plan | Eligibility | TN2020MS0002O | TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 94-1 User-Entered SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 F. Additional Information (optional)

Medicaid State Plan Eligibility Eligibility Groups - Options for Coverage Individuals Receiving Home and Community-Based Waiver Services under Institutional Rules MEDICAID | Medicaid State Plan | Eligibility | TN2020MS0002O | TN-21-0010 Individuals who would be eligible for Medicaid if they were in an institution and who receive home and community-based services. Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 11-014 User-Entered SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 The state operates the Individuals Receiving Home and Community-Based Waiver Services under Institutional Rules eligibility group in accordance with the following provisions: A. Characteristics Individuals qualifying under this eligibility group must meet the following criteria: 1. Would be eligible for Medicaid if in a medical institution.

2. But for the provision of home and community-based services under a waiver granted under section 1915(c), (d) or (e) of the Act: a. For waivers granted under 1915(c), the individuals would otherwise require the level of care furnished in a hospital, a nursing facility or an intermediate care facility for individuals with intellectual disabilities.

b. For waivers granted under 1915(d) or (e), the individuals would otherwise require the level of care furnished in a hospital or nursing facitlity. 3. Will receive the waivered services.

Individuals Receiving Home and Community-Based Waiver Services under Institutional Rules MEDICAID I Medicaid State Plan I Eligibility I TN2020MS0002O I TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPAID TN 11-014 User-Entered B. Income and Resource Methodologies SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 1. The income and resource methodologies used for this group are those used to determine eligibility for a state plan group under which the individual would be eligible if in an institution. 2.. Less restrictive methodologies are used in calculating countable income. 0 Yes Q No The less restrictive income methodologies are: The following less restrictive methodologies are used: 3. Less restrictive methodologies are used in calculating countable resources. e ves 0 No Name of methodology Earned income disregard Description Earned income up to 250 percent FPL is disregarded.

Individuals Receiving Home and Community-Based Waiver Services under Institutional Rules MEDICAID | Medicaid State Plan | Eligibility | TN2020MS0002O | TN-21-0010 Package Header Package ID TN2020MS0002O ubmission Type Official Approval Date / / 0 Superseded SPA ID TN 11-014 User-Entered SPA ID TN-21-0010 Initial ubmission Date 1 / 9/ 0 1 Effective Date 10/1/ 0 1 C. Income and Resource Standards The income and resource standards used for this group are those used to determine eligibility for a state plan group under which the individual would be eligible if in an institution.

Individuals Receiving Home and Community-Based Waiver Services under Institutional Rules MEDICAID | Med ca d State Plan | Elig b l ty | TN2020MS0002O | TN 21 0010 Package Header Package ID TN2020MS0002O ubmission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 11-014 User-Entered SPA ID TN-21-0010 Initial ubmission Date 1 / 9/ 0 1 Effective Date 10/1/2021 D. Additional Information (optional)

Medicaid State Plan Eligibility Eligibility Groups - Options for Coverage Individuals in Institutions Eligible under a Special Income Level MEDICAID | Medicaid State Plan | Eligibility | TN2020MS0002O | TN-21-0010 Individuals who are in medical institutions for at least 30 consecutive days who are eligible under a special income level. Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 92-6 User-Entered SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 The state covers Individuals in Institutions Eligible under a Special Income Level in accordance with the following provisions: A. Characteristics Individuals qualifying under this eligibility group must meet the following criteria: 1. Have been in a medical institution for at least 30 consecutive days. 2. Have income at or below a standard described in section D.

Individuals in Institutions Eligible under a Special Income Level MEDICAID I Medicaid State Plan I Eligibility I TN2020MS0002O I TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/ 23/ 2022 Superseded SPA ID TN 92-6 User-Entered B.lndividuals Covered 1. The state covers all individuals who meet the characteristics described in section A. 0 Yes 0 No SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/ 2021

Individuals in Institutions Eligible under a Special Income Level MEDICAID I Medicaid State Plan I Eligibility I TN2020MS0002O I TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 92-6 User-Entered C. Financial Methodologies SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 1. In calculating household income, the methodologies of the most closely related cash assistance program are used, except that disregards are not applied. 2. In calculating household resources, the methodologies of the most closely related cash assistance program are used Please refer as necessary to Non-MAGI Methodologies, completed by the state. 3. Less restrictive methodologies are used in calculating countable resources. 0 Yes Q No The less restrictive resource methodologies are: A specified type of resource is disregarded: Name of resource type: Income producing business/non- business resources Resources accrued during the COVID-19 public health emergency Description: All of the individual's equity value in business/non-business resources used to produce income is excluded as a resource. Business/Non-Business Resources are defined as land, buildings, equipment supplies. inventory. tools of a tradesperson, livestock of a farmer. cash on hand, accounts receivable, etc. which are used in the person's trade or business, or in the employment of a family member or by the individual as an employee. To the extent that CMS advises states that they may not increase an individual's patient liability amount under the post-eligibility treatment of income rules under 42 CFR 43S.725 and 435.733 and continue to receive the enhanced FMAP provided under Section 6008 of Families First Coronavirus Response Act the state will disregard any resources that a recipient accrues as a result of the state's inability to adjust patient liability during the COVID-19 public health emergency for a period of 12 months following the end of the emergency. A beneficiary of a "qualified state long-term care insurance partnership" policy (partnership policy), as defined in section 1917(b)(1XC) of the Social Security Act and 45 CFR 144.200 et seq., is provided a resource disregard. equal to the amount of the insurance benefit payments made to or on behalf of the individual from the partnership policy. The following less restrictive methodologies are used: Name of methodology: Description:

Name of methodology: Resource eligibility by month Description: The individual/couple whose countable resources are valued at or below the resource limit at any time during the month meet resource eligibility throughout the entire month.

Individuals in Institutions Eligible under a Special Income Level MEDICAID I Medicaid State Plan I Eligibility I TN2020MS0002O I TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 92-6 User-Entered D. Income Standard Used The income standard for this group is: 0 1. 300% of the SSI Federal Benefit Rate (FBR) for an individual 0 2. Other lower income level SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021

Individuals in Institutions Eligible under a Special Income Level MEDICAID | Medicaid State Plan | Eligibility | TN2020MS0002O | TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 92-6 User-Entered SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 E.Resource Standard Used The resource standard for this group is the one used for the most closely-related cash assistance program.

Individuals in Institutions Eligible under a Special Income Level MEDICAID | Medicaid State Plan | Eligibility | TN2020MS0002O | TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 92-6 User-Entered SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 F.Additional Information (optional)

Medicaid State Plan Eligibility Eligibility Groups - Options for Coverage PACE Participants MEDICAID I Medicaid State Plan I Eligibility I TN2020MS0002O I TN-21-0010 Individuals who would be eligible for Medicaid under institutional rules and who participate in the PACE program. Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/ 23/2022 Superseded SPA ID TN 11-014 User-Entered SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 The state operates the PACE Participants eligibility group in accordance with the following provisions: A. Characteristics Individuals qualifying under this eligibility group must meet the following criteria: 1. Would be eligible for one or more of the following Medicaid eligibility groups if in a medical institution: a. Individuals in Institutions Eligible under a Special Income Level b. Age and Disability-related Poverty Level c. Medically Needy Individuals d. Individuals Eligible for but Not Receiving Cash Assistance e. Other eligibility group(s): 2. Are enrolled in a Program of All-Inclusive Care for the Elderly (PACE) program under a PACE program agreement. 3. Require, or will require in the absence of the continued provision of PACE services, the level of care furnished by a nursing facility.

PACE Participants MEDICAID | Medicaid State Plan | Eligibility | TN2020MS0002O | TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 11-014 User-Entered SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 B. Financial Methodologies The income and resource methodologies used for this group are those used to determine eligibility for a state plan group under which the individual would be eligible if in an institution.

PACE Participants MEDICAID | Medicaid State Plan | Eligibility | TN2020MS0002O | TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 11-014 User-Entered SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 C. Income and Resource Standards 1. The income and resource standards used for this group are those used to determine eligibility for a state plan group under which the individual would be eligible if in an institution. 2. An individual's gross income may not exceed 300% of the SSI federal benefit rate.

PACE Participants MEDICAID | Medicaid State Plan | Eligibility | TN2020MS0002O | TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 11-014 User-Entered SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 D. Additional Information (optional)

Medicaid State Plan Eligibility Eligibility Groups - Medically Needy Medically Needy Pregnant Women MEDICAID | Medicaid State Plan | Eligibility | TN2020MS0002O | TN-21-0010 Woman who are pregnant or post-partum who would qualify under the state's Pregnant Women eligibility group, except for income. Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 92-6 User-Entered SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 The state covers the Medically Needy Pregnant Women eligibility group in accordance with the following provisions: A. Characteristics Individuals qualifying under this eligibility group must meet the following criteria: 1. Are pregnant or post-partum, as defined in 42 CFR 435.4. 2. Would qualify under the Pregnant Women eligibility group, except for income. 3. Are not otherwise eligible for categorically needy coverage under the state plan. 4. Have income at or below the medically needy income level and resources at or below the medically needy resource level.

Medically Needy Pregnant Women MEDICAID I Medicaid State Plan I Eligibility I TN2020MS0002O I TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 92-6 User-Entered B. Financial Methodologies 1. The financial methodology used is: SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 O a. AFDC methodologies. Please refer as necessary to Non-MAGI Methodologies, completed by the state. O b. MAGI-like methodologies. Please refer as necessary to Non-MAGI Methodologies, completed by the state. 2. Less restrictive methodologies are used in calculating countable income. 0 Yes Q No The less restrictive income methodologies are: Census Bureau wages are disregarded. A less restrictive methodology is used with respect to lump sum income: Description of disregard: All wages paid by the Census Bureau for temporary employment activities in connection with the full Census that occurs every 10 years are excluded. Specified methodology for the treatment of lump sums as income: ~ The following less restrictive methodologies are used: 3. Less restrictive methodologies are used in calculating countable resources. 0 Yes Q No The less restrictive resource methodologies are: Name of methodology: Lump sum payments Name of methodology: Med Needy Earned Income Disregard Description: Lump sum payments will be considered as a resource in the month received and thereafter if retained. Description: Earned income deduction that is equal to $90 plus $30 and 1/3 or the current TANF general earned income disregard, whichever is higher. for applicants and recipients. The state uses a less restrictive methodology with respect to the treatment of motor vehicles. The value of a countable motor vehicle is disregarded, up to a limit The limit is: $4600.00 Description: The first $4,600 of equity value in an automobile will be disregarded. Any excess equity value of the automobile or the equity value of any other vehicle(s) will be considered as a resource.

The state uses a less restrictive methodology with respect to the treatment of resources set aside in specified types of accounts. Resources set aside in an Assets for Independence Act (IDAJ account Description: Escrow profits for low-income entrepreneurs and Individual Development Accounts (IDA) of up to SS.000 each plus interest earned are excluded as countable resources.

Medically Needy Pregnant Women MEDICAID | Medicaid State Plan | Eligibility | TN2020MS0002O | TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 92-6 User-Entered SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 C. Income Standard Used The income standard used for this group is described in the Medically Needy Income Level RU. D. Resource Standard Used The resource standard used for this group is described in the Medically Needy Resource Level RU. E. Spenddown The state allows individuals to deduct incurred medical and remedial expenses (spend down) to become eligible under this group. Spenddown is defined in the Handling of Excess Income (Spenddown) RU.

Medically Needy Pregnant Women MEDICAID | Medicaid State Plan | Eligibility | TN2020MS0002O | TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 92-6 User-Entered SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 F. Additional Information (optional) Medicaid State Plan Eligibility Eligibility Groups - Medically Needy Medically Needy Children under Age 18 MEDICAID | Medicaid State Plan | Eligibility | TN2020MS0002O | TN-21-0010 Children under age 18 who would qualify under the state's categorically needy eligibility groups, except for income. Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 92-6 User-Entered SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 The state covers the Medically Needy Children under Age 18 eligibility group in accordance with the following provisions: A. Characteristics Individuals qualifying under this eligibility group must meet the following criteria: 1. Are under age 18. 2. Would qualify as categorically needy, except for income. 3. Are not otherwise eligible for categorically needy coverage under the state plan. 4. Have income at or below the medically needy income level and resources at or below the medically needy resource level.

Medically Needy Children under Age 18 MEDICAID I Medicaid State Plan I Eligibility I TN2020MS0002O I TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 92-6 User-Entered B. Financial Methodologies 1. The financial methodology used is: SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 0 a. AFDC methodologies. Please refer as necessary to Non-MAGI Methodologies, completed by the state. 0 b. MAGI-like methodologies. Please refer as necessary to Non-MAGI Methodologies, completed by the state. 2. Less restrictive methodologies are used in calculating countable income. 0 Yes Q No The less restrictive income methodologies are: Census Bureau wages are disregarded. A less restrictive methodology is used with respect to lump sum income: Description of disregard: All wages paid by the Census Bureau for temporary employment activities in connection with the full Census that occurs every 10 years are excluded. Specified methodology for the treatment of lump sums as income: The following less restrictive methodologies are used: 3. Less restrictive methodologies are used in calculating countable resources. 0 Yes Q No The less restrictive resource methodologies are: Name of methodology: Lump sum payments Name of methodology: Med Needy Earned Income Disregard Description: Lump sum payments will be considered as a resource in the month received and thereafter if retained. Description: Earned income deduction that is equal to $90 plus $30 and 1/3 or the current TANF general earned income disregard, whichever is higher. for applicants and recipients. The state uses a less restrictive methodology with respect to the treatment of motor vehicles. The value of a countable motor vehicle is disregarded, up to a limit The limit is: $4600.00 Description: The first $4,600 of equity value in an automobile will be disregarded. Any excess equity value of the automobile or the equity value of any other vehicle(s) will be considered as a resource. The state uses a less restrictive methodology with respect to the treatment of resources set aside in specified types of accounts.

Resources set aside in an Assets for Independence Act (IDAJ account Description: Escrow profits for low-income entrepreneurs and Individual Development Accounts (IDA) of up to SS.000 each plus interest earned are excluded as countable resources.

Medically Needy Children under Age 18 MEDICAID | Medicaid State Plan | Eligibility | TN2020MS0002O | TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 92-6 User-Entered SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 C. Income Standard Used The income standard used for this group is described in the Medically Needy Income Level RU. D. Resource Standard Used The resource standard used for this group is described in the Medically Needy Resource Level RU. E. Spenddown The state allows individuals to deduct incurred medical and remedial expenses (spend down) to become eligible under this group. Spenddown is defined in the Handling of Excess Income (Spenddown) RU.

Medically Needy Children under Age 18 MEDICAID | Medicaid State Plan | Eligibility | TN2020MS0002O | TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 92-6 User-Entered SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 F. Additional Information (optional)

Medically Needy Children under Age 18 MEDICAID | Medicaid State Plan | Eligibility | TN2020MS0002O | TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 92-6 User-Entered SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 Medicaid State Plan Eligibility Eligibility Groups - Medically Needy Medically Needy Reasonable Classifications of Individuals under Age 21 MEDICAID | Medicaid State Plan | Eligibility | TN2020MS0002O | TN-21-0010 One or more reasonable classifications of individuals under age 21 who do not qualify as categorically needy. Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 92-6 User-Entered SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 The state covers the optional Medically Needy Reasonable Classifications of Individuals under Age 21 eligibility group in accordance with the following provisions: A. Characteristics Individuals qualifying under this eligibility group must meet the following criteria:

1. Are under age 21, or a lower age, as specified in section C. 2. Would not qualify under the Medically Needy Children under Age 18 eligibility group (42 CFR 435.301) 3. Are not otherwise eligible for categorically needy coverage under the state plan.

4. Have income at or below the medically needy income level and resources at or below the medically needy resource level.

Medically Needy Reasonable Classifications of Individuals under Age 21 MEDICAID I Medicaid State Plan I Eligibility I TN2020MS0002O I TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 92-6 User-Entered B. Individuals Covered The state covers the following populations: 1. All children under a specified age limit 0 i. Under age 21 0 ii. Under age 20 0 iii. Under age 19 2. Reasonable classifications of children SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021

Medically Needy Reasonable Classifications of Individuals under Age 21 MEDICAID I Medicaid State Plan I Eligibility I TN2020MS0002O I TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 92-6 User-Entered C. Financial Methodologies 1. The state uses the same financial methodology for all individuals covered. 0 Yes Q No 2. The financial methodology used is: SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 0 a. AFDC methodologies. Please refer as necessary to Non-MAGI Methodologies, completed by the state. O b. MAGI-like methodologies. Please refer as necessary to Non-MAGI Methodologies, completed by the state. 3. Less restrictive methodologies are used in calculating countable income. 0 Yes Q No The less restrictive income methodologies are: Census Bureau wages are disregarded. A less restrictive methodology is used with respect to lump sum income: Description of disregard: All wages paid by the Census Bureau for temporary employment activities in connection with the full Census that occurs every 10 years are excluded. Specified methodology for the treatment of lump sums as income: The following less restrictive methodologies are used: 4. Less restrictive methodologies are used in calculating countable resources. 0 Yes Q No The less restrictive resource methodologies are: Name of methodology: Lump sum payments Name of methodology: Med Needy Earned Income Disregard Description: Lump sum payments will be considered as a resource in the month received and thereafter if retained. Description: Earned income deduction that is equal to $90 plus $30 and 1/3 or the current TANF general earned income disregard, whichever is higher. for applicants and recipients. The state uses a less restrictive methodology with respect to the treatment of motor vehicles. The value of a countable motor vehicle is disregarded, up to a limit The limit is: $4600.00 Description: The first $4,600 of equity value in an automobile will be disregarded. Any

excess equity value of the automobile or the equity value of any other vehicle(s) will be considered as a resource. The state uses a less restrictive methodology with respect to the treatment of resources set aside in specified types of accounts. Resources set aside in an Assets for Independence Act (IDA) account Description: Escrow profits for low-income entrepreneurs and Individual Development Accounts (IDA) of up to SS.000 each plus interest earned are excluded as countable resources.

Medically Needy Reasonable Classifications of Individuals under Age 21 MEDICAID | Medicaid State Plan | Eligibility | TN2020MS0002O | TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 92-6 User-Entered SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 D. Income Standard Used The income standard used for this group is described in the Medically Needy Income Level RU. E. Resource Standard Used The resource standard used for this group is described in the Medically Needy Resource Level RU. F. Spenddown The state allows individuals to deduct incurred medical and remedial expenses (spend down) to become eligible under this group. Spenddown is defined in the Handling of Excess Income (Spenddown) RU.

Medically Needy Reasonable Classifications of Individuals under Age 21 MEDICAID | Medicaid State Plan | Eligibility | TN2020MS0002O | TN-21-0010 Package Header Package ID TN2020MS0002O Submission Type Official Approval Date 3/23/2022 Superseded SPA ID TN 92-6 User-Entered SPA ID TN-21-0010 Initial Submission Date 12/29/2021 Effective Date 10/1/2021 G. Additional Information (optional)

PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state’s program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. This view was generated on 3/23/2022 1:32 PM EDT

Table of Contents

State/Territory Name: Tennessee State Plan Amendment (SPA) #: 23-0001 This file contains the following documents in the order listed: 1) Approval Letter 2) Summary Form (with 179-like data) 3) Approved SPA Pages

Records / Submission Packages - View All TN - Submission Package - TN2023MS0001O - (TN-23-0001) - Eligibility Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter Transaction Logs News Related Actions DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Medicaid and CHIP Operations Group 601 E. 12th Street, Room 255 Kansas City, MO 64106 Center for Medicaid & CHIP Services April 13, 2023 Stephen M. Smith Director Department of TennCare 310 Great Circle Road Nashville, TN 37243 Re: Approval of State Plan Amendment TN-23-0001 Dear Stephen M. Smith, On February 20, 2023, the Centers for Medicare and Medicaid Services (CMS) received Tennessee State Plan Amendment (SPA) TN-23-0001, in which the state proposed to adopt the changes to the eligibility rules for the Former Foster Care Children eligibility group, as enacted by the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities (SUPPORT) Act, Pub. L. No. 115-217, section 1002. We approve Tennessee State Plan Amendment (SPA) TN-23-0001 with an effective date(s) of January 01, 2023. If you have any questions regarding this amendment, please contact Tandra Hodges at Tandra.Hodges@cms.hhs.gov. Sincerely, Ruth A. Hughes Acting Director, Division of Program Operations Center for Medicaid & CHIP Services CMS Cf US JOR MEDICARE &MEDICAJO SIIMCES

Records / Submission Packages - View All TN - Submission Package - TN2023MS0001O - (TN-23-0001) - Eligibility Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter Transaction Logs News Related Actions Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | TN2023MS0001O | TN-23-0001 CMS-10434 OMB 0938-1188 Package Header Package ID TN2023MS0001O Submission Type Official Approval Date 4/13/2023 Superseded SPA ID N/A SPA ID TN-23-0001 Initial Submission Date 2/20/2023 Effective Date N/A State Information State/Territory Name: Tennessee Medicaid Agency Name: Department of Finance & Administration Submission Component State Plan Amendment Medicaid CHIP 0 0 0

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | TN2023MS0001O | TN-23-0001 Package Header Package ID TN2023MS0001O Submission Type Official Approval Date 4/13/2023 Superseded SPA ID N/A SPA ID TN-23-0001 Initial Submission Date 2/20/2023 Effective Date N/A SPA ID and Effective Date SPA ID TN-23-0001 Reviewable Unit Proposed Effective Date Superseded SPA ID Mandatory Eligibility Groups 1/1/2023 TN-21-0010 Former Foster Care Children 1/1/2023 TN-21-0010

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | TN2023MS0001O | TN-23-0001 Package Header Package ID TN2023MS0001O Submission Type Official Approval Date 4/13/2023 Superseded SPA ID N/A SPA ID TN-23-0001 Initial Submission Date 2/20/2023 Effective Date N/A Executive Summary Summary Description Including Goals and Objectives SPA TN 23-0001 reflects Tennessee's coverage of youth formerly in foster care, consistent with Section 1002(a) of the SUPPORT Act. Federal Budget Impact and Statute/Regulation Citation Federal Budget Impact Federal Fiscal Year Amount First 2023 $977795 Second 2024 $1287554 Federal Statute / Regulation Citation Section 1002(a)(2) of the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act Supporting documentation of budget impact is uploaded (optional). Name Date Created No items available

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | TN2023MS0001O | TN-23-0001 Package Header Package ID TN2023MS0001O Submission Type Official Approval Date 4/13/2023 Superseded SPA ID N/A SPA ID TN-23-0001 Initial Submission Date 2/20/2023 Effective Date N/A Governor's Office Review PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state’s program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. This view was generated on 4/21/2023 12:55 PM EDT No comment Comments received No response within 45 days Other 0 0 0 0

Records / Submission Packages - View All TN - Submission Package - TN2023MS0001O - (TN-23-0001) - Eligibility Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter Transaction Logs News Related Actions Medicaid State Plan Eligibility Mandatory Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | TN2023MS0001O | TN-23-0001 CMS-10434 OMB 0938-1188 Package Header Package ID TN2023MS0001O Submission Type Official Approval Date 4/13/2023 Superseded SPA ID TN-21-0010 System-Derived SPA ID TN-23-0001 Initial Submission Date 2/20/2023 Effective Date 1/1/2023 Mandatory Coverage A. The state provides Medicaid to mandatory groups of individuals. The mandatory groups covered are: Families and Adults Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Infants and Children under Age 19 APPROVED Parents and Other Caretaker Relatives APPROVED Pregnant Women APPROVED Deemed Newborns APPROVED Children with Title IV-E Adoption Assistance, Foster Care or Guardianship Care APPROVED Former Foster Care Children APPROVED Transitional Medical Assistance APPROVED Extended Medicaid due to Spousal Support Collections APPROVED Aged, Blind and Disabled Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  SSI Beneficiaries APPROVED Closed Eligibility Groups APPROVED Individuals Deemed To Be Receiving SSI APPROVED

~ ~ ~ ~ ~ ~ ~ ~ S1I &i!I Iii &i!I ■ &i!I &i!I &i!I □ □ □ □ □ ■ □ □ □ □ □ 0 • • 0 0 0 0 0 0 0 0 -

Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Working Individuals under 1619(b) APPROVED Qualified Medicare Beneficiaries APPROVED Qualified Disabled and Working Individuals APPROVED Specified Low Income Medicare Beneficiaries APPROVED Qualifying Individuals APPROVED

~ ■ ■ 0 ~ 621 □ 0 ~ ii □ 0 ~ ii □ 0 ~ ii □ 0

Mandatory Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | TN2023MS0001O | TN-23-0001 Package Header Package ID TN2023MS0001O Submission Type Official Approval Date 4/13/2023 Superseded SPA ID TN-21-0010 System-Derived SPA ID TN-23-0001 Initial Submission Date 2/20/2023 Effective Date 1/1/2023 B. The state elects the Adult Group, described at 42 CFR 435.119. C. Additional Information (optional) Eligibility Groups Deselected from Coverage The following eligibility groups were previously covered in the source approved version of the state plan and deselected from coverage as part of this submission package: N/A PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state’s program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. This view was generated on 4/21/2023 1:46 PM EDT Yes No 0 0

Records / Submission Packages - View All TN - Submission Package - TN2023MS0001O - (TN-23-0001) - Eligibility Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter Transaction Logs News Related Actions Medicaid State Plan Eligibility Eligibility Groups - Mandatory Coverage Former Foster Care Children MEDICAID | Medicaid State Plan | Eligibility | TN2023MS0001O | TN-23-0001 Individuals under the age of 26, who were in foster care and on Medicaid when they turned age 18 or aged out of foster care. CMS-10434 OMB 0938-1188 Package Header Package ID TN2023MS0001O Submission Type Official Approval Date 4/13/2023 Superseded SPA ID TN-21-0010 System-Derived SPA ID TN-23-0001 Initial Submission Date 2/20/2023 Effective Date 1/1/2023 The state covers the mandatory former foster care children group in accordance with the following provisions: A. Characteristics Individuals qualifying under this eligibility group must meet the following criteria: 1. Are under age 26 2. Were in foster care upon attaining age 18 or a higher age at which the state's or Tribe's foster care assistance ends under title IV-E of the Act (up to age 21). 3. Are described under either Section B. or C. B. Individuals Covered For individuals who turn 18 before January 1, 2023: 1. The state covers individuals who: a. Upon attaining age 18 or a higher age at which the state's or Tribe's foster care assistance ends under title IV-E of the Act (up to age 21) were: i. In foster care under the responsibility of the state or a Tribe within the state (including children who were cared for through a grant to the state under the unaccompanied refugee minor program); and ii. Enrolled in Medicaid under the state's Medicaid state plan or 1115 demonstration; and b. Are not otherwise eligible for and enrolled for mandatory coverage under the state plan, except that eligibility under this group takes precedence over eligibility under the Adult Group. 2. In addition to B.1., the state elects to cover individuals who were in foster care under the responsibility of the state or a Tribe within the state (including children who were cared for through a grant to the state under the unaccompanied refugee minor program) when they turned 18 or a higher age at which the state's or Tribe's foster care assistance ends under title IV-E of the Act, and meet the following criteria: C. Individuals Covered For individuals who turn 18 on or after January 1, 2023: 1. The state covers individuals who: a. Upon attaining age 18 or a higher age at which the state's or Tribe's foster care assistance ends under title IV-E of the Act (up to age 21) were: i. In foster care under the responsibility of any state or a Tribe within any state (including children who were cared for through a grant to the state under the unaccompanied refugee minor program); and ii. Enrolled in Medicaid under a state's Medicaid state plan or 1115 demonstration; and b. Are not enrolled in mandatory coverage under the state plan, except that eligibility under this group takes precedence over eligibility under the Adult Group. a. They were enrolled in Medicaid under the state's Medicaid state plan or 1115 demonstration at any time during the foster care period in which they turned 18 or a higher age at which the state's or Tribe's foster care assistance ends. b. They were placed by the state or Tribe in another state and were enrolled in Medicaid under the other state’s Medicaid state plan or 1115 demonstration project when they turned 18 or a higher age at which the state's or Tribe's foster care assistance ends. c. They were placed by the state or Tribe in another state and were enrolled in Medicaid under the other state’s Medicaid state plan or 1115 demonstration project at any time during the foster care period in which they turned 18 or a higher age at which the state's or Tribe's foster care assistance ends. □ □ □

2. In addition to C.1., the state elects to cover individuals who were in foster care under the responsibility of any state or a Tribe within any state (including children who were cared for through a grant to a state under the unaccompanied refugee minor program) when they turned 18 or a higher age at which that state's or Tribe's foster care assistance ends under title IV-E of the Act, and meet the following criteria: a. They were enrolled in Medicaid under a state's Medicaid state plan or 1115 demonstration at any time during the foster care period in which they turned 18 or a higher age at which a state's or Tribe's foster care assistance ends. b. They were placed by a state or Tribe in another state and were enrolled in Medicaid under the other state’s Medicaid state plan or 1115 demonstration project when they turned 18 or a higher age at which a state's or Tribe's foster care assistance ends. c. They were placed by a state or Tribe in another state and were enrolled in Medicaid under the other state’s Medicaid state plan or 1115 demonstration project at any time during the foster care period in which they turned 18 or a higher age at which a state's or Tribe's foster care assistance ends. □ □ □

Former Foster Care Children MEDICAID | Medicaid State Plan | Eligibility | TN2023MS0001O | TN-23-0001 Package Header Package ID TN2023MS0001O Submission Type Official Approval Date 4/13/2023 Superseded SPA ID TN-21-0010 System-Derived SPA ID TN-23-0001 Initial Submission Date 2/20/2023 Effective Date 1/1/2023 D. Additional Information (optional) PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state’s program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. This view was generated on 4/21/2023 1:48 PM EDT

Table of Contents

State/Territory Name: Tennessee State Plan Amendment (SPA) #: 23-0002 This file contains the following documents in the order listed: 1) Approval Letter 2) Summary Form (with 179-like data) 3) Approved SPA Page



  

 

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Table of Contents State/Territory Name: Tennessee State Plan Amendment (SPA)#: 24-0001 This file contains the following documents in the order listed: 1) Approval Letter 2) Form CMS-179 3) Approved SP A Page .

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 601 E. 12th St., Room 355 Kansas City, Missouri 64106 Medicaid and CHIP Operations Group April 24, 2024 Stephen M. Smith Director, Division of TennCare 310 Great Circle Road Nashville, TN 37243 CTERS FOR MEOICARE & MEOICAIO SERVICES CENTER FOR MEDICAID & CHIP SERVICE§ Re: Tennessee State Plan Amendment (SPA)-Transmittal #24-0001 Dear Director Smith: The Centers for Medicare & Medicaid Services (CMS) reviewed your Medicaid State Plan Amendment (SPA) submitted under transmittal number (TN) #24-0001. This amendment proposes to prohibit third party payers from refusing payment for an item or service solely on the basis that such item or service did not receive prior authorization under the third-party payer's rules, consistent with the Consolidated Appropriations Act, 2022. We conducted our review of your submittal according to statutory requirements in Title XIX of the Social Security Act, section 1902(a)(25)(1). This letter informs you that Tennessee's Medicaid SPA TN #24-0001 was approved on April 24, 2024, with an effective date of March 7, 2024. Enclosed are copies of Form CMS-179 and approved SPA page to be incorporated into the Tennessee State Plan. If you have any questions, please contact Tandra Hodges at (404) 562-7409 or via email at Tandra.Hodges@cms.hhs.gov. Enclosures cc: Aaron Butler James G. Scott, Director Division of Program Operations

DEPARTMENT OF HEAL TH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES 1. TRANSMITTAL NUMBER 2.STATE FORM APPROVED 0MB No. 0938-0193 TRANSMITTAL AND NOTICE OF APPROVAL OF 2 4 _Q 0 0 1 TN STATE PLAN MATERIAL -- ---- -- FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES 3. PROGRAM IDENTIFICATION TITLE OF THE SOCIAL SECURITY ACT @ XIX 0 XXI TO: CENTER DIRECTOR 4. PROPOSED EFFECTIVE DATE CENTERS FOR MEDICAID & CHIP SERVICES March 7, 2024 DEPARTMENT OF HEAL TH AND HUMAN SERVICES 5. FEDERAL STATUTE/REGULATION CITATION 6. FEDERAL BUDGET IMPACT (Amounts in WHOLE dollars) Section 1902(a)(25)(I) of the Social Security Act a FFY 2023 $ 0 b. FFY 2024 $ 0 7. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT 8. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable) Supplement to Attachment 4.22-A, Page 1 of 1 Supplement to Attachment 4.22-A, Page 1 of 1 9. SUBJECT OF AMENDMENT Prohibits third party payers from refusing payment for an item or service solely on the basis that such item or service did not receive prior authorization under the third-party payer's rules, consistent with the Consolidated Appropriations Act, 2022. 10. GOVERNOR'S REVIEW (Check One) ® GOVERNOR'S OFFICE REPORTED NO COMMENT 0 COMMENTS OF GOVERNOR'S OFFICE ENCLOSED 0 NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL 11. SIGNATURE OF STATE AGENCY OFFICIAL 12. TYPED NAME Stephen Smith 13. TITLE Director, Division of TennCare 14. DATE SUBMITTED March 26, 2024 0 OTHER, AS SPECIFIED 15. RETURN TO Tennessee Department of Finance & Administration Division of TennCare 310 Great Circle Road Nashville, Tennessee 37243 Attention: Aaron Butler FOR CMS USE ONLY 16. DATE RECEIVED March 26, 2024 17. DATE APPROVED A ril 24, 2024 PLAN APPROVED - ONE COPY A TT ACHED 18. EFFECTIVE DATE OF APPROVED MATERIAL March 7, 2024 20. TYPED NAME OF APPROVING OFFICIAL James G. Scott 22. REMARKS FORM CMS-179 (09/24) 19. SI r - - - - -- - - - - - 21. TITLE OF APPROVING OFFICIAL Director, Division of Program Operations Instructions on Back J

Citation l 902(a)(25)(I) SUPPLEMENT TO ATTACHMENT 4.22-A Page 1 of 1 STATE PLAN UNDER TITLE XIX OF 1HE SOCIAL SECURITY ACT STATE: TENNESSEE STATE LAWS REQUIRING THIRD PARTIES TO PROVIDE COVERAGE ELIGIBILITY AND CLAIMS DATA The State has in effect laws which require third parties to comply with the provisions, including those which require third parties to provide the State with coverage, eligibility and claims data, of l 902(a)(25)(1) of the Social Security Act. This includes lav,,s that bar liable third parties from refusing payment for an item or service solely on the basis that such item or service did not receive prior authorization under the third-party payer's rules. TN No.: 24-000 l Supersedes A pproval Date: 04/24/24 Effective Date: 03/07/24 TN No.: 07-005

Table of Contents State/Territory Name: Tennessee State Plan Amendment (SPA)#: 24-0004 This file contains the following documents in the order listed: I) Approval Letter 2) Form CMS-179 3) Approved SPA Pages .

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 601 E. 12th St., Room 355 Kansas City, Missouri 64106 Medicaid and CHIP Operations Group February 26, 2025 Stephen M. Smith Director, Division of TennCare 31 O Great Circle Road Nashville, TN 37243 Re: Tennessee State Plan Amendment (SPA) 24-0004 Dear Mr. Smith: CENTERS fOK MfOICARE & MEOICAIO SERVICES CENTER FOR MEDICAID & CHIP SERVICE§ The Centers for Medicare & Medicaid Services (CMS) reviewed your Medicaid State Plan Amendment (SPA) submitted under transmittal number (TN) 24-0004. This amendment updates the allowance for personal needs for institutionalized individuals and couples. We conducted our review of your submittal according to statutory requirements in Title XIX of the Social Security Act, section 1924 and 42 CFR 435. This letter informs you that Tennessee's Medicaid SPA TN 24-0004 was approved on February 26, 2025, effective January I, 2025. Enclosed are copies of Form CMS-179 and approved SPA pages to be incorporated into the Tennessee State Plan. If you have any questions, please contact Tandra Hodges at (404) 562-7409 or via email at Tandra.Hodges@cms.hhs.gov. Enclosures cc: Aaron Butler Sincerely, James G. Scott, Director Division of Program Operations

DEPARTMENT OF HEALTH ANDHUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES 1. TRANSMITTAL NUMBER 2. STATE FORMAPPROVEO 0MB No. 0938-0193 TRANSMITTAL AND NOTICE OF APPROVAL OF 2 4 _Q 0 0 4 TN STATE PLAN MATERIAL FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES TO: CENTER DIRECTOR CENTERS FOR MEDICAID & CHIP SERVICES DEPARTMENT OF HEAL TH AND HUMAN SERVICES 5. FEDERAL STATUTE/REGULATION CITATION Section 1924 of the Social Security Act 42 CFR 435 7. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT Attachment 2.6-A, Page 4a Supplement 13 to Attachment 2.6-A, Page 1 9. SUBJECT OF AMENDMENT -- ---- -- 3. PROGRAM IDENTIFICATION: TITLE OF THE SOCIAL SECURITY ACT @ XIX 0 XXI 4. PROPOSED EFFECTIVE DATE January 1, 2025 6. FEDERAL BUDGET IMPACT (Amounts in WHOLE dollars) a FFY 2025 $ 1.573.076 b. FFY 2026 $ 2,097,434 8. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable) Attachment 2.6-A, Page 4a Supplement 13 to Attachment 2.6-A, Page 1 Updates the Personal Needs Allowance for an institutionalized individual from $50 to $70 and for an institutionalized couple from $100 to $140. 10. GOVERNOR'S REVIEW (Check One) {!) GOVERNOR'S OFFICE REPORTED NO COMMENT 0 COMMENTS OF GOVERNOR'S OFFICE ENCLOSED 0 NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL 11. SIGNATURE OF STATE AGENCY OFFICIAL 12. TYPED NAME Stephen Smith 13. TITLE Director, Division of TennCare 14. DATE SUBMITTED December 30, 2024 0 OTHER, AS SPECIFIED: 15. RETURN TO Tennessee Department of Finance & Administration Division of TennCare 310 Great Circle Road Nashville, Tennessee 37243 Attention: Aaron Butler FOR CMS USE ONLY 16. DATE RECEIVED December 30, 2024 17. DATE APPROVED PLAN APPROVED - ONE COPY ATTACHED 18. EFFECTIVE DATE OF APPROVED MATERIAL January 1, 2025 20. TYPED NAME OF APPROVING OFFICIAL James G. Scott 22. REMARKS FORM CMS-179 (09/24) 19. SI 21. Tl Director, Division of Program Operations Instructions on Back T I - ' - - - I - - -- - - I - - - February 26 202s =---=c

Revision: HCFA-PM-97-2 December 1997 ATIACHMENT2.6-A Page 4a 0MB No.: 0938-0673 State: Tennessee Citation 1924 of the Act 435.725 435.733 435.832 TN No. 24-0004 Supersedes TNNo. 10-002 2. Condition or Requirement The following monthly amounts for personal needs are deducted from total monthly income in the application of an institutionalized individual's or couple's income to the cost of institutionalized care: Personal Needs Allowance (PNA) of not less than $70 For Individuals and $140 For Couples For All Institutionalized Persons. a. Aged, blind, disabled: Individuals $ 70 Couples $ 140 For the following persons with greater need: Supplement 13 to Attachment 2.6-A describes the greater need; describes the basis or formula for determining the deductible amount when a specific amount is not listed above; lists the criteria to be met; and where appropriate, identifies the organizational unit which determines that a criterion is met. b. AFDC related: Children$ 70 Adults $ 70 For the following persons with greater need: Supplement 13 to Attachment 2.6-A describes the greater need; describes the basis or formula for determining the deductible amount when a specific amount is not listed above; lists the criteria to be met; and, where appropriate, identifies the organizational unit which determines that a criterion is met. c. Individual under age 21 covered in the plan as specified in Item 8.7. of Attachment 2.2-A. N/A Approval Date 02/26/25 Effective Date 01/01/25

Revision: HCF A-PM-97-2 December 1997 SUPPLEMENT 13 TO A ITACHMENT 2.6-A Pagel 0MB No.: 0938-0673 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT TN No. 24-0004 Supersedes TN No. 10-002 State: Tennessee VARIATIONS FROM THE BASIC PERSONAL NEEDS ALLOWANCE Not Applicable Approval Date 02/26/25 Effective Date 0 1/0 l/25

TableofContents State/Territory Name: StatePlanAmendment (SPA)#: 2 Thisfilecontainsthefollowing documents intheorderlisted: ApprovalLetter Approved SPAPage

Records ‘ Submission Packages - View All

TN - Submission Package - TN2024MS00040 - (TN-25-0002) - Eligibility

Summary Reviewable Units Versions Correspondence Log

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Medicaid and CHIP Operations Group

601 E. 12th Street Room 355

Kansas City, MO 64106

Center for Medicaid & CHIP Services

May 16, 2025

Stephen M. Smith Director

Division of TennCare 310 Great Circle Road Nashville, TN 37243

Re: Approval of State Plan Amendment TN-25-0002

Dear Stephen M. Smith,

Analyst Notes al Lett

Transaction Logs News Related Actions

CENTERS FOR MEDICARE & MEDICAID SERVICES

On March 28, 2025, the Centers for Medicare and Medicaid Services (CMS) received Tennessee State Plan Amendment (SPA) TN-25-0002, in which the state proposed to create a new reasonable classification of medically needy individuals under age 21.

We approve Tennessee State Plan Amendment (SPA) TN-25-0002 with an effective date(s) of January 01, 2025.

If you have any questions regarding this amendment, please contact Tandra Hodges at Tandra. Hodges@cms.hhs.gov

Sincerely, Shantrina Roberts

Acting Director, Division of Program Operations

Center for Medicaid & CHIP Services

Records /

Submission Packages - View All

TN - Submission Package - TN2024MS00040 - (TN-25-0002) - Eligibility

Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter Transaction Logs News | Related Actions |

Submission - Summary

MEDICAID | Medicaid State Plan | Eligibility | TN2024MS00040 | TN-25-0002

CMS-10434 OMB 0938-1188 Package Header Package ID

Submission Type Approval Date Superseded SPA ID

State Information

State/Territory Name:

TN2024MS00040 Official 05/16/2025

N/A

Tennessee

Submission Component

State Plan Amendment

SPAID Initial Submission Date

Effective Date

Medicaid Agency Name:

Medicaid CHIP

TN-25-0002 3/28/2025 N/A

Department of Finance & Administration

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | TN2024MS00040 | TN-25-0002 Package Header

Package ID TN2024MS00040 Submission Type Official Approval Date 05/16/2025 Superseded SPAID N/A

SPA ID and Effective Date

SPAID TN-25-0002

Reviewable Unit Proposed Effective Date Optional Eligibility Groups 1/1/2025

Medically Needy Reasonable Classifications of

Individuals under Age 21 ciao

SPAID TN-25-0002 Initial Submission Date 3/28/2025 Effective Date N/A

Superseded SPA ID

TN-21-0010

TN-21-0010

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | TN2024MS00040 | TN-25-0002 Package Header

Package ID TN2024MS00040 SPAID TN-25-0002 Submission Type Official Initial Submission Date 3/28/2025 Approval Date 05/16/2025 Effective Date N/A

Superseded SPAID N/A

Executive Summary

Summary Description Including This SPA extends Medicaid coverage to children adopted from state custody who do not qualify for Title IV-E or non-IV-E Goals and Objectives adoption assistance.

Federal Budget Impact and Statute/Regulation Citation

Federal Budget Impact

Federal Fiscal Year Amount First 2025 $130664 Second 2026 $195991

Federal Statute / Regulation Citation 42 CFR 435.308

Supporting documentation of budget impact is uploaded (optional).

Name Date Created

No items available

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | TN2024MS00040 | TN-25-0002 Package Header

Package ID TN2024MS00040 SPAID TN-25-0002 Submission Type Official Initial Submission Date 3/28/2025 Approval Date 05/16/2025 Effective Date N/A

Superseded SPAID N/A

Governor's Office Review

(No comment

(© Comments received

No response within 45 days © Other

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

This view was generated on 5/16/2025 3:02 PM EDT

Records © Submission Packages - View All

TN - Submission Package - TN2024MS00040 - (TN-25-0002) - Eligibility

Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter Transaction Logs News Related Actions |

Medicaid State Plan Eligibility Optional Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | TN2024MS00040 | TN-25-0002

CMS-10434 OMB 0938-1188.

Package Header

Package ID TN2024MS00040 SPAID TN-25-0002 Submission Type Official Initial Submission Date 3/28/2025 Approval Date 05/16/2025 Effective Date 1/1/2025

Superseded SPAID TN-21-0010

System-Derived

A. Options for Coverage

The state provides Medicaid to specified optional groups of individuals. Yes No

The optional eligibility groups covered in the state plan are (elections made in this screen may not be comprehensive during the transition period from the paper- based state plan to MACPro):

Families and Adults

Include RU In Package Included in Another e Submission Package

ity Group Name Covered In State Plan Source Type @

Optional Coverage of Parents and Other r NEW Caretaker Relatives Reasonable Classifications of Individuals under Age 21

NEW

fe]

Children with Non-lV-E

Adoption Assistance APPROVED

Independent Foster

Care Adolescents NEW

Optional Targeted Low Income Children

NEW Individuals above 133%

FPL under Age 65 NEW

[e] [2] [eo] fe

Individuals Needing Treatment for Breast or

Cervical Cancer

APPROVED

g

Individuals Eligible for Family Planning Services

NEW

Individuals with NEW Tuberculosis

Individuals Electing COBRA Continuation

Coverage

NEW

008 080000 0

fe] fe]

Aged, Blind and Disabled

El

ity Group Name

Individuals Eligible for but Not Receiving Cash Assistance

Individuals Eligible for Cash Except for Institutionalization

Individuals Receiving Home and Community- Based Waiver Services under Institutional Rules

Optional State Supplement Beneficiaries

Individuals in Institutions Eligible under a Special Income Level

PACE Participants

Individuals Receiving Hospice

Children under Age 19 with a Disability

Age and Disability- Related Poverty Level

Work Incentives

Ticket to Work Basic

Ticket to Work Medical Improvements

Family Opportunity Act Children with a Disability

Individuals Receiving State Plan Home and Community-Based Services

Individuals Receiving State Plan Home and Community-Based Services Who Are Otherwise Eligible for HCBS Waivers

[P|

[e] [=] [| fe) [e) fe) fe

[®]

[s]

Covered In State Plan

Include RU In Package e

Included in Another Submission Package

e)

O

000080 800 0 0

O

Source Type @

NEW

APPROVED

APPROVED

NEW

APPROVED

APPROVED

NEW

NEW

NEW

NEW

NEW

NEW

NEW

NEW

NEW

Optional Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | TN2024MS00040 | TN-25-0002 Package Header

Package ID TN2024MS00040

SPAID TN-25-0002

Submission Type Official Initial Submission Date 3/28/2025

Approval Date 05/16/2025 Effective Date 1/1/2025

Superseded SPAID TN-21-0010

System-Derived

B. Medically Needy Options for Coverage

The state provides Medicaid to specified groups of individuals who are medically needy.

Yes No

The medically needy eligibility groups covered in the state plan are:

1. Mandatory Medically Needy:

Families and Adults

Include RU In Package

Eligibility Group Name Covered In State Plan ° Medically Needy [e|

Pregnant Women [|

Medically Needy

Children under Age 18

Aged, Blind and Disabled

Eligibility Group Name Covered In State Plan Include eS Package

Protected Medically

Needy Individuals Who

Were Eligible in 1973

2. Optional Medically Needy:

Families and Adults

Eligibility Group Name Covered In State Plan Include RU In Package

e Medically Needy Reasonable Classifications of iv]

Individuals under Age 21

Medically Needy

Parents and Other [P|

Caretaker Relatives

Aged, Blind and Disabled

Eligibility Group Name Covered In State Plan Include Package Medically Needy Populations Based on Age, Blindness or Disability

Included in Another Submission Package

O O

Included in Another Submission Package

O

Included in Another Submission Package

O

O

Included in Another Submission Package

O

Source Type @

APPROVED

APPROVED

Source Type @

NEW

Source Type @

APPROVED

NEW

Source Type @

NEW

Optional Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | TN2024MS00040 | TN-25-0002 Package Header

Package ID TN2024MS00040 SPAID TN-25-0002 Submission Type Official Initial Submission Date 3/28/2025 Approval Date 05/16/2025 Effective Date 1/1/2025

Superseded SPAID TN-21-0010

System-Derived

C. Additional Information (optional)

Eligibility Groups Deselected from Coverage

The following eligibility groups were previously covered in the source approved version of the state plan and deselected from coverage as part of this submission package:

« NA

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

This view was generated on 5/16/2025 3:03 PM EDT

Records ‘ Submission Packages - View All

TN - Submission Package - TN2024MS00040 - (TN-25-0002) - Eligibility

Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter Transaction Logs News Related Actions |

Medicaid State Plan Eligibility

Eligibility Groups - Medically Needy

Medically Needy Reasonable Classifications of Individuals under Age 21 MEDICAID | Medicaid State Plan | Eligibility | TN2024MS00040 | TN-25-0002

One or more reasonable classifications of individuals under age 21 who do not qualify as categorically needy.

CMS-10434 OMB 0938-1188

Package Header

Package ID TN2024MS00040 SPAID TN-25-0002 Submission Type Official Initial Submission Date 3/28/2025 Approval Date 05/16/2025 Effective Date 1, 5

Superseded SPAID TN-21-0010

System-Derived

The state covers the optional Medically Needy Reasonable Classifications of Individuals under Age 21 eligibility group in accordance with the following provisions:

A. Characteristics

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

1. Are under age 21, or a lower age, as specified in section C. 2. Would not qualify under the Medically Needy Children under Age 18 eligibility group (42 CFR 435.301)

3. Are not otherwise eligible for categorically needy coverage under the state plan.

4. Have income at or below the medically needy income level and resources at or below the medically needy resource level.

Medically Needy Reasonable Classifications of Individuals under Age 21

MEDICAID | Medicaid State Plan | Eligibility | TN2024MS00040 | TN-25-0002 Package Header Package ID TN2024MS00040 Submission Type Official Approval Date 05/16/2025 Superseded SPAID TN-21-0010

System-Derived

B. Individuals Covered

The state covers the following populations: 1. All children under a specified age limit: Under age 2 ii. Under age 20 iii, Under age 19

2. Reasonable classifications of children

Name of classification Children adopted from state custody

Name: Children adopted from state custody

Age Covered: Under age 19

SPAID TN-25-0002 Initial Submission Date 3/28/2025 Effective Date 1/1/2025

Age Range Under age 19

Description: Children adopted from state custody, other than children for whom an adoption assistance agreement is in effect under Title IV-E of the Act or for whom a state (non IV-E) adoption assistance agreement is in effect.

Medically Needy Reasonable Classifications of Individuals under Age 21 MEDICAID | Medicaid State Plan | Eligibility | TN2024MS00040 | TN-25-0002 Package Header

Package ID 1TN2024MS00040 Submission Type Official Initial Submission Date Approval Date 05/16/2025 Effective Date Superseded SPAID TN-21-0010

System-Derived

C. Financial Methodologies

1. The state uses the same financial methodology for all individuals covered. Yes No

2. The financial methodologies are:

All children under age 21

The financial methodology used is:

SPAID TN-25-0002

3/28/2025 1/1/2025

a. AFDC methodologies. Please refer as necessary to Non-MAGI Methodologies, completed by the state.

b. MAGI-like methodologies. Please refer as necessary to Non-MAGI Methodologies, completed by the state.

3. Less restrictive methodologies are used in calculating countable income.

Yes

No The less restrictive income methodologies are:

Census Bureau wages are disregarded. Description of disregard:

WA less restrictive methodology is used with respect to lump sum income:

Specified methodology for the treatment of lump sums as income:

Name of methodology:

Lump sum payments

BW The following less restrictive methodologies are used:

Name of methodology:

Med Needy Earned Income Disregard

4. Less restrictive methodologies are used in calculating countable resources. Yes No The less restrictive resource methodologies are: WW The state uses a less restrictive methodology with respect to the treatment of motor vehicles. Wi The value of a countable motor vehicle is disregarded, up to a limit.

The limi

is:

All wages paid by the Census Bureau for temporary

employment activities in connection with the full Census that occurs every 10 years are excluded.

Description:

Lump sum payments will be considered as a resource in the month received and thereafter if retained.

Description:

Earned income deduction that is equal to $90 plus $30 and 1/3 or the current TANF general earned income disregard, whichever is higher, for applicants and recipients.

$4600.00

Description: The first $4,600 of equity value in an automobile will be disregarded. Any excess equity value of the automobile or the equity value of any other vehicle(s) will be considered as a resource.

The state uses a less restrictive methodology with respect to the treatment of resources set aside in specified types of accounts.

Resources set aside in an Assets for Description: Escrow profits for low-income Independence Act (IDA) account entrepreneurs and Individual Development Accounts (IDA) of up to $5,000 each plus interest earned are excluded as countable resources.

Children adopted from state custody The financial methodology used is: a. AFDC methodologies. Please refer as necessary to Non-MAGI Methodologies, completed by the state.

b. MAGI-like methodologies. Please refer as necessary to Non-MAGI Methodologies, completed by the state.

3. Less restrictive methodologies are used in calculating countable income.

Yes No

The less restrictive income methodologies are:

BAI income is disregarded. No income test is applied.

4. Less restrictive methodologies are used in calculating countable resources.

Yes

No The less restrictive resource methodologies are:

BAAIl resources are disregarded. No resource test is applied.

Medically Needy Reasonable Classifications of Individuals under Age 21 MEDICAID | Medicaid State Plan | Eligibility | TN2024MS00040 | TN-25-0002 Package Header

Package ID TN2024MS00040 SPAID TN-25-0002 Submission Type Official Initial Submission Date 3/28/2025 Approval Date 05/16/2025 Effective Date 1/1/2025

Superseded SPAID TN-21-0010

System-Derived

D. Income Standard Used

The income standard used for this group is described in the Medically Needy Income Level RU.

E. Resource Standard Used

The resource standard used for this group is described in the Medically Needy Resource Level RU.

F. Spenddown

The state allows individuals to deduct incurred medical and remedial expenses (spend down) to become eligible under this group. Spenddown is defined in the Handling of Excess Income (Spenddown) RU.

Medically Needy Reasonable Classifications of Individuals under Age 21 MEDICAID | Medicaid State Plan | Eligibility | TN2024MS00040 | TN-25-0002 Package Header

Package ID TN2024MS00040 SPAID TN-25-0002 Submission Type Official Initial Submission Date 3/28/2025 Approval Date 05/16/2025 Effective Date 1/1/2025

Superseded SPAID TN-21-0010

System-Derived

G. Additional Information (optional)

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

This view was generated on 5/16/2025 3:04 PM EDT

Table of Contents State/Territory Name: 7HQQHVVHH State Plan Amendment (SPA)#: 2 This file contains the following documents in the order listed:  Approval Letter  6XPPDU\)RUP ZLWK OLNHGDWD

 Approved SPA PageV

Records / Submission Packages - View All TN - Submission Package - TN2025MS0002O - (TN-25-0007) - Eligibility Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter Transaction Logs News Related Actions DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Medicaid and CHIP Operations Group 601 E. 12th Street Room 355 Kansas City, MO 64106 Center for Medicaid & CHIP Services October 03, 2025 Steven M. Smith Director Department of Finance & Administration 310 Great Circle Road Nashville, TN 37243 Re: Approval of State Plan Amendment TN-25-0007 Dear Steven M. Smith, On August 05, 2025, the Centers for Medicare and Medicaid Services (CMS) received Tennessee State Plan Amendment (SPA) TN-25-0007, in which the state proposed an income disregard for Beneţciary Advisory Council compensation. We approve Tennessee State Plan Amendment (SPA) TN-25-0007 with an eſective date(s) of July 01, 2025. If you have any questions regarding this amendment, please contact Tandra Hodges at Tandra.Hodges@cms.hhs.gov. Sincerely, Nicole McKnight On Behalf of Courtney Miller, MCOG Director Center for Medicaid & CHIP Services MS Cf,ff"ERS FOR MEDICAi£ &, Mf:OICAJ0 SUtVICf.S

Records / Submission Packages - View All TN - Submission Package - TN2025MS0002O - (TN-25-0007) - Eligibility Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter Transaction Logs News Related Actions Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | TN2025MS0002O | TN-25-0007 CMS-10434 OMB 0938-1188 Package Header Package ID TN2025MS0002O Submission Type OŰcial Approval Date 10/03/2025 Superseded SPA ID N/A SPA ID TN-25-0007 Initial Submission Date 8/5/2025 Eſective Date N/A State Information State/Territory Name: Tennessee Medicaid Agency Name: Department of Finance & Administration Submission Component State Plan Amendment Medicaid CHIP 0 0 0

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | TN2025MS0002O | TN-25-0007 Package Header Package ID TN2025MS0002O Submission Type OŰcial Approval Date 10/03/2025 Superseded SPA ID N/A SPA ID TN-25-0007 Initial Submission Date 8/5/2025 Eſective Date N/A SPA ID and Eſective Date SPA ID TN-25-0007 Reviewable Unit Proposed Eſective Date Superseded SPA ID Mandatory Eligibility Groups 7/1/2025 TN-23-0001 Qualiţed Medicare Beneţciaries 7/1/2025 TN-21-0010 Speciţed Low Income Medicare Beneţciaries 7/1/2025 TN-21-0010 Qualifying Individuals 7/1/2025 TN-21-0010 Optional Eligibility Groups 7/1/2025 TN-25-0002 Individuals Eligible for Cash Except for Institutionalization 7/1/2025 TN-21-0010 Individuals Receiving Home and Community- Based Waiver Services under Institutional Rules 7/1/2025 TN-21-0010 Individuals in Institutions Eligible under a Special Income Level 7/1/2025 TN-21-0010 Medically Needy Pregnant Women 7/1/2025 TN-21-0010 Medically Needy Children under Age 18 7/1/2025 TN-21-0010 Medically Needy Reasonable Classiţcations of Individuals under Age 21 7/1/2025 TN-25-0002

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | TN2025MS0002O | TN-25-0007 Package Header Package ID TN2025MS0002O Submission Type OŰcial Approval Date 10/03/2025 Superseded SPA ID N/A SPA ID TN-25-0007 Initial Submission Date 8/5/2025 Eſective Date N/A Executive Summary Summary Description Including Goals and Objectives SPA TN 25-0007 establishes an income disregard for compensation provided to beneţciaries participating in the Beneţciary Advisory Council described at 42 CFR 431.12. Federal Budget Impact and Statute/Regulation Citation Federal Budget Impact Federal Fiscal Year Amount First 2025 $0 Second 2026 $0 Federal Statute / Regulation Citation Section 1902(r)(2) of the Social Security Act Supporting documentation of budget impact is uploaded (optional). Name Date Created No items available

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | TN2025MS0002O | TN-25-0007 Package Header Package ID TN2025MS0002O Submission Type OŰcial Approval Date 10/03/2025 Superseded SPA ID N/A SPA ID TN-25-0007 Initial Submission Date 8/5/2025 Eſective Date N/A Governor's OŰce Review PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format deţned by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reŤects the characteristics of the particular state’s program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in eſorts to boost program integrity eſorts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance OŰcer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. This view was generated on 10/9/2025 10:31 AM EDT No comment Comments received No response within 45 days Other 0 0 0 0

Records / Submission Packages - View All TN - Submission Package - TN2025MS0002O - (TN-25-0007) - Eligibility Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter Transaction Logs News Related Actions Medicaid State Plan Eligibility Mandatory Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | TN2025MS0002O | TN-25-0007 CMS-10434 OMB 0938-1188 Package Header Package ID TN2025MS0002O Submission Type OŰcial Approval Date 10/03/2025 Superseded SPA ID TN-23-0001 System-Derived SPA ID TN-25-0007 Initial Submission Date 8/5/2025 Eſective Date 7/1/2025 Mandatory Coverage A. The state provides Medicaid to mandatory groups of individuals. The mandatory groups covered are: Families and Adults Eligibility Group Name Covered In State Plan Include RU In Package a Included in Another Submission Package Source Type a Infants and Children under Age 19 APPROVED Parents and Other Caretaker Relatives APPROVED Pregnant Women APPROVED Deemed Newborns APPROVED Children with Title IV-E Adoption Assistance, Foster Care or Guardianship Care APPROVED Former Foster Care Children APPROVED Transitional Medical Assistance APPROVED Extended Medicaid due to Spousal Support Collections APPROVED Aged, Blind and Disabled Eligibility Group Name Covered In State Plan Include RU In Package a Included in Another Submission Package Source Type a SSI Beneţciaries APPROVED Closed Eligibility Groups APPROVED Individuals Deemed To Be Receiving SSI APPROVED ~ ~ ~ ~ ~ ~ ~ ~ r.a r.a r.a r.a r.a r.a r.a r.a r.a □ □ □ □ □ □ □ □ □ □ □ 0 • • 0 0 0 • 0 0 0 0 -

Eligibility Group Name Covered In State Plan Include RU In Package a Included in Another Submission Package Source Type a Working Individuals under 1619(b) APPROVED Qualiţed Medicare Beneţciaries APPROVED Qualiţed Disabled and Working Individuals APPROVED Speciţed Low Income Medicare Beneţciaries APPROVED Qualifying Individuals APPROVED r.a r.a r.a r.a r.a □ r.a □ r.a r.a 0 0 0 0 0

Mandatory Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | TN2025MS0002O | TN-25-0007 Package Header Package ID TN2025MS0002O Submission Type OŰcial Approval Date 10/03/2025 Superseded SPA ID TN-23-0001 System-Derived SPA ID TN-25-0007 Initial Submission Date 8/5/2025 Eſective Date 7/1/2025 B. The state elects the Adult Group, described at 42 CFR 435.119. C. Additional Information (optional) Eligibility Groups Deselected from Coverage The following eligibility groups were previously covered in the source approved version of the state plan and deselected from coverage as part of this submission package: N/A PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format deţned by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reŤects the characteristics of the particular state’s program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in eſorts to boost program integrity eſorts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance OŰcer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. This view was generated on 10/9/2025 10:35 AM EDT Yes No 0 0

Records / Submission Packages - View All TN - Submission Package - TN2025MS0002O - (TN-25-0007) - Eligibility Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter Transaction Logs News Related Actions Medicaid State Plan Eligibility Eligibility Groups - Mandatory Coverage Qualiţed Medicare Beneţciaries MEDICAID | Medicaid State Plan | Eligibility | TN2025MS0002O | TN-25-0007 Individuals with income equal to or less than 100% of the FPL, who are entitled to Medicare Part A, and who qualify for Medicare cost-sharing. CMS-10434 OMB 0938-1188 Package Header Package ID TN2025MS0002O Submission Type OŰcial Approval Date 10/03/2025 Superseded SPA ID TN-21-0010 System-Derived SPA ID TN-25-0007 Initial Submission Date 8/5/2025 Eſective Date 7/1/2025 The state covers the mandatory qualiţed Medicare beneţciaries group in accordance with the following provisions: A. Characteristics Individuals qualifying under this eligibility group must meet the following criteria: 1. Are entitled to hospital insurance beneţts under part A of title XVIII (Medicare Part A), including individuals who have purchased a premium to enroll in Part A. 2. Have income and resources at or below the standard for this group.

Qualiţed Medicare Beneţciaries MEDICAID | Medicaid State Plan | Eligibility | TN2025MS0002O | TN-25-0007 Package Header Package ID TN2025MS0002O Submission Type OŰcial Approval Date 10/03/2025 Superseded SPA ID TN-21-0010 System-Derived SPA ID TN-25-0007 Initial Submission Date 8/5/2025 Eſective Date 7/1/2025 B. Financial Methodologies 1. SSI methodologies are used in calculating household income. Please refer as necessary to Non-MAGI Methodologies, completed by the state. 2. Less restrictive methodologies are used in calculating countable income. The less restrictive income methodologies are: Name of disregard: Description: Dependent child disregard An amount per month per child will be disregarded from the QMB applicant/recipient's countable income in situations where minor dependent children, under age 21, live in the home with the QMB applicant/recipient. The amount of this disregard will be reasonably related to the diſerence between the poverty level income standard for each family size. Description of disregard: All wages paid by the Census Bureau for temporary employment activities in connection with the full Census that occurs every 10 years are excluded. Name of income type: Description: BAC participation Compensation for participation in the Beneţciary Advisory Council is excluded. 3. Less restrictive methodologies are used in calculating countable resources. The less restrictive resource methodologies are: Name of resource type: Description: Income producing business/non-business resources All of the individual's equity value in business/non-business resources used to produce income is excluded as a resource. Business/Non-Business Resources are deţned as land, buildings, equipment, supplies, inventory, tools of a tradesperson, livestock of a farmer, cash on hand, accounts receivable, etc. which are used in the person's trade or business, or in the employment of a family member or by the individual as an employee. Yes No General income disregard: Census Bureau wages are disregarded. A speciţed type of income is disregarded: Yes No A speciţed type of resource is disregarded: The following less restrictive methodologies are used: 0 0 0 0

Name of methodology: Description: Resource eligibility by month The individual/couple whose countable resources are valued at or below the resource limit at any time during the month meet resource eligibility throughout the entire month.

Qualiţed Medicare Beneţciaries MEDICAID | Medicaid State Plan | Eligibility | TN2025MS0002O | TN-25-0007 Package Header Package ID TN2025MS0002O Submission Type OŰcial Approval Date 10/03/2025 Superseded SPA ID TN-21-0010 System-Derived SPA ID TN-25-0007 Initial Submission Date 8/5/2025 Eſective Date 7/1/2025 C. Income Standard Used The amount of the income standard for this group is 100% FPL. D. Resource Standard Used The resource standard is the same used to determine eligibility for the Medicare Part D full-beneţt low-income subsidy (LIS) (but without regard to the life insurance policy exclusion applied in LIS resource eligibility determinations). This standard is three times the SSI resource standard, adjusted annually in accordance with the consumer price index. E. Medical Assistance Provided Medical assistance is limited to payment of co-insurance and deductibles for Medicare Parts A, B and C and payment for the premiums for Medicare Parts A and B. Medical assistance begins the ţrst day of the month following the month in which the individual is determined to qualify for this eligibility group.

Qualiţed Medicare Beneţciaries MEDICAID | Medicaid State Plan | Eligibility | TN2025MS0002O | TN-25-0007 Package Header Package ID TN2025MS0002O Submission Type OŰcial Approval Date 10/03/2025 Superseded SPA ID TN-21-0010 System-Derived SPA ID TN-25-0007 Initial Submission Date 8/5/2025 Eſective Date 7/1/2025 F. Additional Information (optional) PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format deţned by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reŤects the characteristics of the particular state’s program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in eſorts to boost program integrity eſorts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance OŰcer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. This view was generated on 10/9/2025 10:36 AM EDT

Records / Submission Packages - View All TN - Submission Package - TN2025MS0002O - (TN-25-0007) - Eligibility Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter Transaction Logs News Related Actions Medicaid State Plan Eligibility Eligibility Groups - Mandatory Coverage Speciţed Low Income Medicare Beneţciaries MEDICAID | Medicaid State Plan | Eligibility | TN2025MS0002O | TN-25-0007 Individuals with income above 100% and below 120% of the FPL who are entitled to Medicare Part A, who qualify for payment of Medicare Part B premiums. CMS-10434 OMB 0938-1188 Package Header Package ID TN2025MS0002O Submission Type OŰcial Approval Date 10/03/2025 Superseded SPA ID TN-21-0010 System-Derived SPA ID TN-25-0007 Initial Submission Date 8/5/2025 Eſective Date 7/1/2025 The state covers the mandatory speciţed low income Medicare beneţciaries group in accordance with the following provisions: A. Characteristics Individuals qualifying under this eligibility group must meet the following criteria: 1. Would qualify as Qualiţed Medicare Beneţciaries (described in section 1905(p)(1) of the Act), except that their income exceeds the income level for that eligibility group. 2. Have income below the income standard and resources at or below the resource standard for this group.

Speciţed Low Income Medicare Beneţciaries MEDICAID | Medicaid State Plan | Eligibility | TN2025MS0002O | TN-25-0007 Package Header Package ID TN2025MS0002O Submission Type OŰcial Approval Date 10/03/2025 Superseded SPA ID TN-21-0010 System-Derived SPA ID TN-25-0007 Initial Submission Date 8/5/2025 Eſective Date 7/1/2025 B. Financial Methodologies 1. SSI methodologies are used in calculating household income. Please refer as necessary to Non-MAGI Methodologies, completed by the state. 2. Less restrictive methodologies are used in calculating countable income. The less restrictive income methodologies are: Name of disregard: Description: Dependent child disregard An amount per month per child will be disregarded from the SLMB applicant/recipient's countable income in situations where minor dependent children, under age 21, live in the home with the SLMB applicant/recipient. The amount of this disregard will be reasonably related to the diſerence between the poverty level income standard for each family size. Description of disregard: All wages paid by the Census Bureau for temporary employment activities in connection with the full Census that occurs every 10 years are excluded. Name of income type: Description: BAC participation Compensation for participation in the Beneţciary Advisory Council is excluded. 3. Less restrictive methodologies are used in calculating countable resources. The less restrictive resource methodologies are: Name of resource type: Description: Income producing business/non-business resources All of the individual's equity value in business/non-business resources used to produce income is excluded as a resource. Business/Non-Business Resources are deţned as land, buildings, equipment, supplies, inventory, tools of a tradesperson, livestock of a farmer, cash on hand, accounts receivable, etc. which are used in the person's trade or business, or in the employment of a family member or by the individual as an employee. Yes No General income disregard: Census Bureau wages are disregarded. A speciţed type of income is disregarded: Yes No A speciţed type of resource is disregarded: The following less restrictive methodologies are used: 0 0 0 0

Name of methodology: Description: Resource eligibility by month The individual/couple whose countable resources are valued at or below the resource limit at any time during the month meet resource eligibility throughout the entire month.

Speciţed Low Income Medicare Beneţciaries MEDICAID | Medicaid State Plan | Eligibility | TN2025MS0002O | TN-25-0007 Package Header Package ID TN2025MS0002O Submission Type OŰcial Approval Date 10/03/2025 Superseded SPA ID TN-21-0010 System-Derived SPA ID TN-25-0007 Initial Submission Date 8/5/2025 Eſective Date 7/1/2025 C. Income Standard Used Family income must be above 100% FPL and below 120% FPL. D. Resource Standard Used The resource standard is the same used to determine eligibility for the Medicare Part D full-beneţt low-income subsidy (LIS) (but without regard to the life insurance policy exclusion applied in LIS resource eligibility determinations). This standard is three times the SSI resource standard, adjusted annually in accordance with the consumer price index. E. Medical Assistance Provided Medical assistance is limited to payment for Medicare Part B premiums.

Speciţed Low Income Medicare Beneţciaries MEDICAID | Medicaid State Plan | Eligibility | TN2025MS0002O | TN-25-0007 Package Header Package ID TN2025MS0002O Submission Type OŰcial Approval Date 10/03/2025 Superseded SPA ID TN-21-0010 System-Derived SPA ID TN-25-0007 Initial Submission Date 8/5/2025 Eſective Date 7/1/2025 F. Additional Information (optional)

PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format deţned by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reŤects the characteristics of the particular state’s program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in eſorts to boost program integrity eſorts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance OŰcer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. This view was generated on 10/9/2025 10:37 AM EDT

Records / Submission Packages - View All TN - Submission Package - TN2025MS0002O - (TN-25-0007) - Eligibility Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter Transaction Logs News Related Actions Medicaid State Plan Eligibility Eligibility Groups - Mandatory Coverage Qualifying Individuals MEDICAID | Medicaid State Plan | Eligibility | TN2025MS0002O | TN-25-0007 Individuals with income at or above 120% and below 135% of the FPL who are entitled to Medicare Part A, who qualify for payment of Medicare Part B premiums. CMS-10434 OMB 0938-1188 Package Header Package ID TN2025MS0002O Submission Type OŰcial Approval Date 10/03/2025 Superseded SPA ID TN-21-0010 System-Derived SPA ID TN-25-0007 Initial Submission Date 8/5/2025 Eſective Date 7/1/2025 The state covers the mandatory qualifying individuals group in accordance with the following provisions: A. Characteristics Individuals qualifying under this eligibility group must meet all of the following criteria: 1. Would qualify as Qualiţed Medicare Beneţciaries (described in section 1905(p)(1) of the Act), except that their income exceeds the income level for that eligibility group. 2. Are not otherwise eligible for Medicaid under the state plan. 3. Have income below the income standard and resources at or below the resource standard for this group.

Qualifying Individuals MEDICAID | Medicaid State Plan | Eligibility | TN2025MS0002O | TN-25-0007 Package Header Package ID TN2025MS0002O Submission Type OŰcial Approval Date 10/03/2025 Superseded SPA ID TN-21-0010 System-Derived SPA ID TN-25-0007 Initial Submission Date 8/5/2025 Eſective Date 7/1/2025 B. Financial Methodologies 1. SSI methodologies are used in calculating household income. Please refer as necessary to Non-MAGI Methodologies, completed by the state. 2. Less restrictive methodologies are used in calculating countable income. The less restrictive income methodologies are: Name of disregard: Description: Dependent child disregard An amount per month per child will be disregarded from the QI applicant/recipient's countable income in situations where minor dependent children, under age 21, live in the home with the QI applicant/recipient. The amount of this disregard will be reasonably related to the diſerence between the poverty level income standard for each family size. Description of disregard: All wages paid by the Census Bureau for temporary employment activities in connection with the full Census that occurs every 10 years are excluded. Name of income type: Description: BAC participation Compensation for participation in the Beneţciary Advisory Council is excluded. 3. Less restrictive methodologies are used in calculating countable resources. The less restrictive resource methodologies are: Name of resource type: Description: Income producing business/non-business resources All of the individual's equity value in business/non-business resources used to produce income is excluded as a resource. Business/Non-Business Resources are deţned as land, buildings, equipment, supplies, inventory, tools of a tradesperson, livestock of a farmer, cash on hand, accounts receivable, etc. which are used in the person's trade or business, or in the employment of a family member or by the individual as an employee. Yes No General income disregard: Census Bureau wages are disregarded. A speciţed type of income is disregarded: Yes No A speciţed type of resource is disregarded: The following less restrictive methodologies are used: 0 0 0 0

Name of methodology: Description: Resource eligibility by month The individual/couple whose countable resources are valued at or below the resource limit at any time during the month meet resource eligibility throughout the entire month.

Qualifying Individuals MEDICAID | Medicaid State Plan | Eligibility | TN2025MS0002O | TN-25-0007 Package Header Package ID TN2025MS0002O Submission Type OŰcial Approval Date 10/03/2025 Superseded SPA ID TN-21-0010 System-Derived SPA ID TN-25-0007 Initial Submission Date 8/5/2025 Eſective Date 7/1/2025 C. Income Standard Used Family income must be at or above 120% FPL and below 135% FPL. D. Resource Standard Used The resource standard is the same used to determine eligibility for the Medicare Part D full-beneţt low-income subsidy (LIS) (but without regard to the life insurance policy exclusion applied in LIS resource eligibility determinations). This standard is three times the SSI resource standard, adjusted annually in accordance with the consumer price index. E. Medical Assistance Provided Medical assistance is limited to payment for Medicare Part B premiums.

Qualifying Individuals MEDICAID | Medicaid State Plan | Eligibility | TN2025MS0002O | TN-25-0007 Package Header Package ID TN2025MS0002O Submission Type OŰcial Approval Date 10/03/2025 Superseded SPA ID TN-21-0010 System-Derived SPA ID TN-25-0007 Initial Submission Date 8/5/2025 Eſective Date 7/1/2025 F. Additional Information (optional)

PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format deţned by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reŤects the characteristics of the particular state’s program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in eſorts to boost program integrity eſorts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance OŰcer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. This view was generated on 10/9/2025 10:38 AM EDT

Records / Submission Packages - View All TN - Submission Package - TN2025MS0002O - (TN-25-0007) - Eligibility Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter Transaction Logs News Related Actions Medicaid State Plan Eligibility Optional Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | TN2025MS0002O | TN-25-0007 CMS-10434 OMB 0938-1188 Package Header Package ID TN2025MS0002O Submission Type OŰcial Approval Date 10/03/2025 Superseded SPA ID TN-25-0002 System-Derived SPA ID TN-25-0007 Initial Submission Date 8/5/2025 Eſective Date 7/1/2025 A. Options for Coverage The state provides Medicaid to speciţed optional groups of individuals. The optional eligibility groups covered in the state plan are (elections made in this screen may not be comprehensive during the transition period from the paper- based state plan to MACPro): Families and Adults Eligibility Group Name Covered In State Plan Include RU In Package a Included in Another Submission Package Source Type a Optional Coverage of Parents and Other Caretaker Relatives NEW Reasonable Classiţcations of Individuals under Age 21 NEW Children with Non-IV-E Adoption Assistance APPROVED Independent Foster Care Adolescents NEW Optional Targeted Low Income Children NEW Individuals above 133% FPL under Age 65 NEW Individuals Needing Treatment for Breast or Cervical Cancer APPROVED Individuals Eligible for Family Planning Services NEW Individuals with Tuberculosis NEW Individuals Electing COBRA Continuation Coverage NEW Yes No - • 0 ~ □ □ • ~ □ □ 0 ~ r.il □ 0 ~ □ □ 0 ~ □ □ 0 ~ □ □ • ~ □ 0 ~ □ □ • ~ □ □ 0 ~ □ □ 0

Aged, Blind and Disabled Eligibility Group Name Covered In State Plan Include RU In Package a Included in Another Submission Package Source Type a Individuals Eligible for but Not Receiving Cash Assistance NEW Individuals Eligible for Cash Except for Institutionalization APPROVED Individuals Receiving Home and Community- Based Waiver Services under Institutional Rules APPROVED Optional State Supplement Beneţciaries NEW Individuals in Institutions Eligible under a Special Income Level APPROVED PACE Participants APPROVED Individuals Receiving Hospice NEW Children under Age 19 with a Disability NEW Age and Disability- Related Poverty Level NEW Work Incentives NEW Ticket to Work Basic NEW Ticket to Work Medical Improvements NEW Family Opportunity Act Children with a Disability NEW Individuals Receiving State Plan Home and Community-Based Services NEW Individuals Receiving State Plan Home and Community-Based Services Who Are Otherwise Eligible for HCBS Waivers NEW □ ~ □ ~ ~ r.a ~ □ ~ □ ~ □ ~ □ ~ □ ~ □ ~ □ ~ □ □ □ □ □ □ □ □ □ □ □ □ □ □ 0 0 • 0 • 0 • 0 • 0 0 0 0 0 0

Optional Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | TN2025MS0002O | TN-25-0007 Package Header Package ID TN2025MS0002O Submission Type OŰcial Approval Date 10/03/2025 Superseded SPA ID TN-25-0002 System-Derived SPA ID TN-25-0007 Initial Submission Date 8/5/2025 Eſective Date 7/1/2025 B. Medically Needy Options for Coverage The state provides Medicaid to speciţed groups of individuals who are medically needy. The medically needy eligibility groups covered in the state plan are: 1. Mandatory Medically Needy: Families and Adults Eligibility Group Name Covered In State Plan Include RU In Package a Included in Another Submission Package Source Type a Medically Needy Pregnant Women APPROVED Medically Needy Children under Age 18 APPROVED Aged, Blind and Disabled Eligibility Group Name Covered In State Plan Include RU In Package a Included in Another Submission Package Source Type a Protected Medically Needy Individuals Who Were Eligible in 1973 NEW 2. Optional Medically Needy: Families and Adults Eligibility Group Name Covered In State Plan Include RU In Package a Included in Another Submission Package Source Type a Medically Needy Reasonable Classiţcations of Individuals under Age 21 APPROVED Medically Needy Parents and Other Caretaker Relatives NEW Aged, Blind and Disabled Eligibility Group Name Covered In State Plan Include RU In Package a Included in Another Submission Package Source Type a Medically Needy Populations Based on Age, Blindness or Disability NEW Yes No • 0 ~ □ □ ca □ □ □ 0 0 0 0 • 0

Optional Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | TN2025MS0002O | TN-25-0007 Package Header Package ID TN2025MS0002O Submission Type OŰcial Approval Date 10/03/2025 Superseded SPA ID TN-25-0002 System-Derived SPA ID TN-25-0007 Initial Submission Date 8/5/2025 Eſective Date 7/1/2025 C. Additional Information (optional) Eligibility Groups Deselected from Coverage The following eligibility groups were previously covered in the source approved version of the state plan and deselected from coverage as part of this submission package: N/A PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format deţned by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reŤects the characteristics of the particular state’s program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in eſorts to boost program integrity eſorts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance OŰcer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. This view was generated on 10/9/2025 10:39 AM EDT

Records / Submission Packages - View All TN - Submission Package - TN2025MS0002O - (TN-25-0007) - Eligibility Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter Transaction Logs News Related Actions Medicaid State Plan Eligibility Eligibility Groups - Options for Coverage Individuals Eligible for Cash Except for Institutionalization MEDICAID | Medicaid State Plan | Eligibility | TN2025MS0002O | TN-25-0007 Individuals who would be eligible for federal cash assistance or an optional state supplement, except for institutionalization. CMS-10434 OMB 0938-1188 Package Header Package ID TN2025MS0002O Submission Type OŰcial Approval Date 10/03/2025 Superseded SPA ID TN-21-0010 System-Derived SPA ID TN-25-0007 Initial Submission Date 8/5/2025 Eſective Date 7/1/2025 The state covers the optional Individuals Eligible for Cash Except for Institutionalization eligibility group in accordance with the following provisions: A. Characteristics Individuals qualifying under this eligibility group must meet the following criteria: 1. Are in a medical institution. 2. Would meet the eligibility requirements for at least one of the following cash assistance programs, but for the lower income standards used to determine eligibility for institutionalized individuals: a. SSI b. Optional State Supplement c. AFDC

Individuals Eligible for Cash Except for Institutionalization MEDICAID | Medicaid State Plan | Eligibility | TN2025MS0002O | TN-25-0007 Package Header Package ID TN2025MS0002O Submission Type OŰcial Approval Date 10/03/2025 Superseded SPA ID TN-21-0010 System-Derived SPA ID TN-25-0007 Initial Submission Date 8/5/2025 Eſective Date 7/1/2025 B. Individuals Covered 1. The state covers all individuals who meet the characteristics described in section A. Yes No 0 0

Individuals Eligible for Cash Except for Institutionalization MEDICAID | Medicaid State Plan | Eligibility | TN2025MS0002O | TN-25-0007 Package Header Package ID TN2025MS0002O Submission Type OŰcial Approval Date 10/03/2025 Superseded SPA ID TN-21-0010 System-Derived SPA ID TN-25-0007 Initial Submission Date 8/5/2025 Eſective Date 7/1/2025 C. Financial Methodologies 1. In calculating household income and resources for individuals who are seeking eligibility on the basis of being age 65 or older or having blindness or disability, SSI methodologies are used. Please refer as necessary to Non-MAGI Methodologies, completed by the state. 2. In calculating household income and resources for populations for which AFDC is the most closely related program, the following methodology(ies) are used: 3. Less restrictive methodologies are used in calculating countable income. The less restrictive income methodologies are: Description of disregard: All wages paid by the Census Bureau for temporary employment activities in connection with the full Census that occurs every 10 years are excluded. Name of income type: Description: BAC participation Compensation for participation in the Beneţciary Advisory Council is excluded. 4. Less restrictive methodologies are used in calculating countable resources. The less restrictive resource methodologies are: Name of resource type: Description: Income producing business/non-business resources All of the individual's equity value in business/non-business resources used to produce income is excluded as a resource. Business/Non-Business Resources are deţned as land, buildings, equipment, supplies, inventory, tools of a tradesperson, livestock of a farmer, cash on hand, accounts receivable, etc. which are used in the person's trade or business, or in the employment of a family member or by the individual as an employee. Name of methodology: Description: Resource eligibility by month The individual/couple whose countable resources are valued at or below the resource limit at any time during the month meet resource eligibility throughout the entire month. a. MAGI-like methodologies. Please refer as necessary to Non-MAGI Methodologies, completed by the state. b. AFDC methodologies. Please refer as necessary to Non-MAGI Methodologies, completed by the state. Yes No Census Bureau wages are disregarded. A speciţed type of income is disregarded: Yes No A speciţed type of resource is disregarded: The following less restrictive methodologies are used: • 0 • 0 0 •

Individuals Eligible for Cash Except for Institutionalization MEDICAID | Medicaid State Plan | Eligibility | TN2025MS0002O | TN-25-0007 Package Header Package ID TN2025MS0002O Submission Type OŰcial Approval Date 10/03/2025 Superseded SPA ID TN-21-0010 System-Derived SPA ID TN-25-0007 Initial Submission Date 8/5/2025 Eſective Date 7/1/2025 D. Income Standard Used The income standard used is the standard of the most closely related cash assistance program. E. Resource Standard Used The resource standard used is the standard of the most closely related cash assistance program.

Individuals Eligible for Cash Except for Institutionalization MEDICAID | Medicaid State Plan | Eligibility | TN2025MS0002O | TN-25-0007 Package Header Package ID TN2025MS0002O Submission Type OŰcial Approval Date 10/03/2025 Superseded SPA ID TN-21-0010 System-Derived SPA ID TN-25-0007 Initial Submission Date 8/5/2025 Eſective Date 7/1/2025 F. Additional Information (optional)

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Records / Submission Packages - View All TN - Submission Package - TN2025MS0002O - (TN-25-0007) - Eligibility Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter Transaction Logs News Related Actions Medicaid State Plan Eligibility Eligibility Groups - Options for Coverage Individuals Receiving Home and Community-Based Waiver Services under Institutional Rules MEDICAID | Medicaid State Plan | Eligibility | TN2025MS0002O | TN-25-0007 Individuals who would be eligible for Medicaid if they were in an institution and who receive home and community-based services. CMS-10434 OMB 0938-1188 Package Header Package ID TN2025MS0002O Submission Type OŰcial Approval Date 10/03/2025 Superseded SPA ID TN-21-0010 System-Derived SPA ID TN-25-0007 Initial Submission Date 8/5/2025 Eſective Date 7/1/2025 The state operates the Individuals Receiving Home and Community-Based Waiver Services under Institutional Rules eligibility group in accordance with the following provisions: A. Characteristics Individuals qualifying under this eligibility group must meet the following criteria: 1. Would be eligible for Medicaid if in a medical institution. 2. But for the provision of home and community-based services under a waiver granted under section 1915(c), (d) or (e) of the Act: a. For waivers granted under 1915(c), the individuals would otherwise require the level of care furnished in a hospital, a nursing facility or an intermediate care facility for individuals with intellectual disabilities. b. For waivers granted under 1915(d) or (e), the individuals would otherwise require the level of care furnished in a hospital or nursing facitlity. 3. Will receive the waivered services.