1.4 Please provide the effective (date costs begin to be incurred) and implementation (date services begin to be provided) dates for this plan or plan amendment (42 CFR 457.65): Original start date: August 1, 1998 Effective date: July 10, 1998 Implementation date: August 1, 1998 Amendment #1 Submitted: January 28, 1999 Amendment#1 Disapproved: November 29, 1999 Amendment #2 Submitted: March 1, 2002 Effective Date: December 15, 2001; January 1, 2002; February 1, 2002 Implementation Date: January 1, 2002 Amendment #3 Submitted: November 14, 2002 Effective Date: July 1, 2002; Dental Benefits - July 1, 2003 Amendment#4 Submitted: June 2, 2005 Effective Date: July 1, 2005 Amendment#5 Submitted: August 27, 2007 Effective Date: July 1, 2007 Amendment#6 Submitted: August 8, 2008 Effective Date: July 1, 2008 Amendment#7 Submitted: April 15, 2009 Effective Date: April 15, 2009

9.10. Provide a one year projected budget. A suggested financial form for the budget is attached. The budget must describe: (Section 2107(d)) (42CFR 457.140) Planned use of funds, including -­ - Projected amount to be spent on health services; - Projected amount to be spent on administrative costs, such as outreach, child health initiatives, and evaluation; and - Assumptions on which the budget is based, including cost per child and expected enrollment. Projected sources of non-Federal plan expenditures, including any requirements for cost-sharing by enrollees. The State is seeking a federal match on funds received from the Robert Wood Johnson Foundation (RWJ) grant, Maximizing Enrollment for Kids: Making Medicaid and SCHIP Work. The grant was awarded to the State on February 11, 2009 and the grant period is from February 15, 2009 through February 14, 2013. The State’s initiative is entitled Working Smart for Utah’s Kids. The State was granted a total of $999,934 and below is a summary of general grant functions. RWJ will conduct a diagnostic assessment and improvement plan. The final budget is subject to approval from the RWJ National Program Office and will be based on the results of the diagnostic assessment. Working Smart for Utah’s Kids seeks to maximize enrollment of eligible Utah children by removing administrative barriers to enrollment and retention. Working Smart plans to achieve this goal by implementing four specific objectives: (1) Streamline the Application Process (2) Simplify Renewal Process and Improve Client Education (3) Integrate School Data from Free and Reduced School Lunch Program and (4) Evaluate Multicultural Outreach to Develop Best Practices. The State assures that RWJ has less than 25% in annual revenue generated from health care providers and that RWJ does not provide services (including administrative) directly or indirectly under the Medicaid or SCHIP state plan. The award letter from RWJ is attached to this amendment request.

UTAH TITLE XXI PROGRAM FACT SHEET

Name of Plan:

Utah’s Children’s Health Insurance Program

Date Plan Submitted:

April 2, 1998 Date Plan Approved:

July 10, 1998 Effective Date:

August 3, 1998

Date Amendment #1 Submitted: January 28, 1999 Date Amendment #1 Disapproved: November 29, 1999

Date Amendment #2 Submitted: March 1, 2002 Date Amendment #2 Approved: June 25, 2002 Date Amendment #2 Effective: December 15, 2001; January 1, 2002;

February 1, 2002

Date Amendment #3 Submitted: November 14, 2002 Date Amendment #3 Approved: April 2, 2004 Date Amendment #3 Effective: July 1, 2002; July 1, 2003

Date Amendment #4 Submitted: June 1, 2005 Date Amendment #4 Approved: August 25, 2005 Date Amendment #4 Effective: July 1, 2005

Date Amendment #5 Submitted: August 29, 2007 Date Amendment #5 Approved: November 27, 2007 Date Amendment #5 Effective: July 1, 2007

Date Amendment #6 Submitted: August 12, 2008 Date Amendment #6 Approved: April 3, 2009 Date Amendment #6 Effective: July 1, 2008

Date Amendment #7 Submitted: April 17, 2009 Date Amendment #7 Approved: July 15, 2009 Date Amendment #7 Effective: April 17, 2009

Date Amendment #8 Submitted: July 28, 2009 Date Amendment #8 Approved: May 2, 2011 Date Amendment #8 Effective: July 1, 2009

Date Amendment #9 Submitted: September 1, 2010 Date Amendment #9 Approved: May 2, 2011 Date Amendment #9 Effective: July 1, 2010

Background

• On July 10, 1998, CMS approved Utah's separate child health program, which provides coverage for children under age 19 with family income at or below 200 percent of the Federal Poverty Level (FPL).

Amendments

• On November 29, 1999, CMS disapproved a State plan amendment (SPA) to add cost sharing for families with incomes below 100 percent of the FPL. The State requested approval to apply the same cost-sharing schedule for families with incomes below 100 percent of the FPL that was previously approved for families with incomes from 100 to 150 percent of the FPL.

• The State’s second amendment submitted on March 1, 2002, allowed the State to establish an enrollment cap of 24,000 enrollees; require premiums and increase copayments for enrollees above 100 percent of the FPL; disregard the child’s income when determining family income; and modifies the dental, vision and hearing services within the benefit package.

• The State’s third amendment submitted on November 14, 2002, updates and amends the SCHIP State plan to indicate the State’s compliance with the final SCHIP regulations. The amendment also restored dental benefits to the pre-January 2002 level, and revised the State’s enrollment cap by raising the limit from 24,000 enrollees on average to 28,000 enrollees on average.

• The State’s fourth amendment submitted on June 1, 2005, raises the enrollment cap from 28,000 to 40,000 enrollees and added an exception to the 90-day crowd out period. Additionally, clarifications were made to explain the renewal process, clarify the disenrollment process for failure to pay quarterly premiums, and describe the process to notify families of their cost-sharing maximum and the procedures a family must follow once their maximum has been reached.

• The State’s fifth amendment submitted on August 29, 2007, decreases the amount of time applicants have to pay cost sharing, increases premiums and cost sharing and modifies the scope of some of the benefits.

• The State’s sixth amendment, submitted on August 13, 2008, makes changes to its enrollment procedures, cost sharing, and benefits. Specifically, the SPA provides open enrollment throughout the year rather than limiting enrollment to specified periods, changes the deadline for applicants to provide verification to determine eligibility from 45 to 30 days, increases cost sharing, and changes benefits. The State requests a retroactive effective date of July 1, 2008.

• The State’s seventh amendment, submitted on April 17, 2009, provide for a new source of state funds from a Robert Wood Johnson Foundation (RWJF) grant. These funds will be used to fine tune Utah’s outreach program by working closely with

school nutrition programs for low income children and by reaching out to multicultural communities.

• Utah’s eighth amendment, submitted on July 28, 2009, increases premiums and cost sharing, and imposes a $15 fee for late premium payment for families above 150 percent of the Federal poverty level (FPL). Through this SPA, Utah demonstrated compliance with section 504 of the Children’s Health Insurance Program Reauthorization Act (CHIPRA) which requires States to grant individuals, enrolled in separate child health programs a 30-day grace period to pay any required premium before enrollment is terminated. This SPA is also a good faith effort toward meeting the mental health parity requirements in section 502 of CHIPRA. Utah’s eighth amendment has a retroactive effective date of July 1, 2009.

• Utah’s ninth amendment, submitted on September 1, 2010, makes additional changes to the State’s cost-sharing requirements by increasing coinsurance requirements for dental services, and raising copayments for upper income enrollees for specialist visits, urgent care, vision and hearing screening, physical therapy, and mental health outpatient visits. Utah’s SPA number 9 also comes into compliance with section 501 of CHIPRA, by providing dental coverage that is equal to a benchmark dental package (Utah’s dental plan with the largest commercial, non-Medicaid enrollment). Utah’s ninth amendment has a retroactive effective date of July 1, 2010.

Children Covered Under the Program

• The State reported that 62,071 children were ever enrolled in its program during Federal Fiscal Year 2010.

Administration

• The Utah Department of Health administers the Utah Children's Health Insurance Program. CHIP contracts with two managed care organizations to provide medical care for children enrolled in CHIP. These managed care organizations have extensive provider networks throughout the State.

Health Care Delivery System

• Health services in the urban areas (Davis, Salt Lake, Utah and Weber counties) and in the rural areas (all other counties) are delivered by Managed Care Organizations (MCOs).

Benefit Package

• Utah offers benchmark-equivalent coverage. The State's plan includes an actuarial analysis comparing the benefit package to the benefit plan provided to Utah State employees.

Crowd-Out Strategy

• The application requests information about health insurance coverage for the children in the household. Every SCHIP application is screened through the Medicaid eligibility determination process to determine if the child qualifies for Medicaid.

• A child is found ineligible for SCHIP if the child has been voluntarily terminated from health insurance coverage within the 3 months prior to the application date for coverage under SCHIP.

Exceptions to the 90-day ineligibility period are:

1. Voluntary termination of COBRA coverage.

2. Voluntary termination of coverage by a non-custodial parent.

3. Involuntary termination from a group health plan.

4. Voluntary termination of the State Health Insurance Pool (HIP)

5. Voluntary termination of health insurance coverage purchased after the previous SCHIP open enrollment period ended but before the beginning of the current open enrollment period and who met SCHIP eligibility requirements at time of purchase.

Premiums and Copayments, Effective July 1, 2010 Benefit Family Income up to 100% FPL Family Income 101%- 150% FPL Family Income 151%- 200% FPL Premium None $30/family/quarter $75/family/quarter Deductibles None $40/family $500 per person /$1500 per family Medical Benefits Hospital Inpatient $50 $150 after deductible 20 % of approved amount after deductible Ambulatory Surgical & Outpatient Hospital $3 5% of approved amount after deductible 20% of approved amount after deductible Ambulance 5% of approved amount 5% of approved amount after deductible 20% of approved amount after deductible Physician Office visits $3 $5 $20 Specialist visits $3 $5 $35 Residential Treatment 5% of approved amount (25 day limit/year) 5% of approved amount (25 day limit/year) 50% of approved amount after deductible (25 day limit/year) Physical Therapy $3 (20 visit limit/year) $5 (20 visit limit/year) $35 after deductible (20 visit limit/year) Prescriptions $1 preferred generic drugs; $1 preferred brand name drugs; 5% of approved amount for non-preferred drugs $5 preferred generic drugs; 5% of approved amount for preferred brand name drugs; 5% of approved amount for non-preferred drugs $15 preferred generic drugs; 25% of approved amount for preferred brand name drugs; 50% of approved amount for non- preferred drugs Surgeon $0 5% of approved amount 5% of approved amount Anesthesiologist $0 5% of approved amount after deductible 20% of approved amount after deductible Emergency Room $3 $5; $10 non-emergency $200; $400 out-of-network Urgent Care Center $3 $5 $35 Lab & X-ray Services Under $350 $0 for minor diagnostic tests and x-rays; $3 for major diagnostic tests and x-rays $0 for minor diagnostic tests and x-rays; 5% of approved amount after deductible for major diagnostic tests and x-rays $0 for minor diagnostic tests and x-rays; 20% of approved amount after deductible for major diagnostic tests and x-rays Vision Screening $3 (1 visit limit/year) $5 (1 visit limit/year) $35 (1 visit limit/year) Hearing Screening $3 (1 visit limit/year) $5 (1 visit limit/year) $35 (1 visit limit/year) Mental Health Mental Health Inpatient $50 $150 co-payment after deductible 20% of approved amount after deductible Mental Health Outpatient $3 $5 $35 Dental Deductible $0 $0 $50/child; $150/family Maximum Benefit $1,000/ plan year $1,000/plan year $1,000/plan year Basic Services (Fillings, Extractions, Oral Surgery) $0 5% of approved amount 20% of approved amount after deductible Major Services (Crowns, Bridges, Dentures, Endodontics, Periodontics) 5% of approved amount

5% of approved amount

50% of approved amount after deductible Orthodontics (Orthodontics are not included in the annual maximum benefit) 5% of approved amount (12-month waiting period, $1,000 lifetime maximum) 5% of approved amount (12-month waiting period, $1,000 lifetime maximum) 50% of approved amount (12-month waiting period, $1,000 lifetime maximum) Specialists 5% of approved amount 5% of approved amount Provided by the plan

State Outreach and Enrollment Activities

• The State utilizes many strategies to identify and enroll eligible children. These activities include:

• Computer matches of families already on Medicaid who have children without coverage and of families receiving child-care assistance without Medicaid.

• Medicaid eligibility workers already in place in almost 100 locations determine eligibility for SCHIP. These eligibility determination sites are located in hospitals, community health centers, local health departments, Department of Workforce Services’ offices and many other allied agencies.

• Dissemination of information through community presentations, press coverage, toll- free telephone line, brochures, flyers and postcards. Information is also disseminated by housing assistance organizations, hospitals, medical-care sites, community-based organizations and other Medicaid outreach campaigns.

Coordination Between SCHIP and Medicaid

• The application contains the information necessary to determine eligibility for Medicaid and CHIP. The application is screened first for Medicaid eligibility prior to determining eligibility for CHIP.

Financial Information Total FFY ’11 CHIP Allotment -- $63,915,866 FFY ’11 Enhanced Federal Matching Rate – 79.79%

Date Last Updated: CMS, CMCS, CAHPG, DCHIP, May 27, 2011

_____________________________________________________________________________ Table of Contents State/Territory Name: Utah State Plan Amendment (SPA) #: UT-14-0001 This file contains the following documents in the order listed: 1) Approval Letter 2) Approved SPA Pages 3) SPA Summary Form The complete title XXI state plan for Utah consists of the most recent state plan posted on Medicaid.gov under CHIP and State Plan Amendments. The link is provided below. The following approved templates are in addition to, or replace sections of the state’s posted current state plan. The attached approval letter(s) explain how these templates fit into that state plan. Link to state title XXI state plans and amendments: XXI state plans and amendments: http://medicaid.gov/chip/state-program-information/chipstate- program-information.html

DEPARTMENT OF HEALTH & HUMAN SERVICES gem Centers for Medicare & Medicaid Services la Cc | — 7500 Security Boulevard, Mail Stop: S2-26-12 ‘

Baltimore, Maryland 21244-1850 carvonsanatan tae ar

Children and Adults Health Programs Group

DEC 1 9 2013

Ms. Emma Chacon

CHIP Director

Bureau of Managed Health Care

Division of Medicaid and Health Financing P.O. Box 143108

Salt Lake City, UT 84114-3108

Dear Ms. Chacon:

I am pleased to inform you that your Title XXI Children’s Health Insurance Program (CHIP) state plan amendments (SPA) UT-14-0001 and UT-14-0004 submitted on August 27, 2013 and with additional information submitted on December 2, 2013, related to Modified Adjusted Gross Income (MAGI) Eligiblity, have been approved with an effective date of January 1, 2014.

MAGI Eligiblity & Methods:

SPA number UT-14-0001 provides assurance on page CS15 that the state will apply methodologies based on MAGI for all separate CHIP covered groups; and using the approved MAGI conversion plan income thresholds, the state indicates on page CS7 that it will cover targeted low-income children. A copy of the approved CS15 is attached and should be incorporated within a separate subsection under Section 4.3 of the state’s approved CHIP state plan. A copy of the approved CS7 is attached and supersedes the current Age and Income Sections 4.1.2 and 4.1.3 of the current CHIP state plan.

Non-Financial Eligibility:

SPA number UT-14-0004 is approved to clarify the state’s non-financial eligibility policies on residency; citizenship; social security number; substitution of coverage; non-payment of premiums; and, continuous eligibility. Copies of the approved state plan pages are attached and these approved pages supersede sections of Utah’s current state plan as listed below:

New State Plan Page Impact on Current State Plan Section

CS17: Non-Financial Eligibility — Residency Section 4.1.5

CS18: Non-Financial Eligibility — Citizenship Section 4.1.0

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

CS20: Non-Financial Eligibility — Substitution of | Section 4.4.4 Coverage

Page 2 —- Ms. Emma Chacon

C821: Non-Financial Eligibility: Non-Payment of Premiums

Section 8.7

C827: General Eligibility — Continuous Eligibility

Section 4.1.9.2

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

is as follows:

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

7500 Security Boulevard

Baltimore, MD 21244-1850

Telephone: (410) 786-3413

Facsimile: (410) 786-5882

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

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

Centers for Medicare & Medicaid Services

Denver Regional Office Colorado State Bank Building 1600 Broadway, Suite# 700 Denver, Colorado 80202-4967

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

5143. We look forward to continuing to work with you and your staff. Sincerely,

Eliot Fishman Director

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

OMB Control Number: 0938-1148

Expiration date: 10/31/2014

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

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

a state.

[Y] The CHIP Agency operates this covered group in accordance with the following provisions: Age

Must be under age 19.

Income Standards

Income standards are applied statewide.

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

Statewide Income Standards

Begin with lowest age range first.

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

From Age To Age Above (% FPL) Up to & including (% FPL) 6 139 200 19 133 200

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

Special Program for Children with Disabilities

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

PRA Disclosure Statement

SPA# UT-14-0001 Approval vaeDEC { 9 2013 Effective Date: January 1, 2014

Page 1 of 2

CHIP Eligibility

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

V.20130709

SPA# UT-14-0001 Approval Date: DEC { 9 2013 Effective Date: January 1, 2014 Page 2 of 2

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

CHIP Eligibility

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

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

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

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

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

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

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

by the person claiming an individual described at §435.603(f)(2)(i) as a tax dependent. No

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

PRA Disclosure Statement

SPA# UT-14-0001 Approval Date: DEC { g 2013 Effective Date: January 1, 2014 Page 1 of 2

CHIP Eligibility

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

SPA# UT-14-0001 Approval Date: DEC { +] 2013

Effective Date: January 1, 2014 Page 2 of 2

CHIP Eligibility

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

seat ee B ee

42 CFR 457.320

Residency

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

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

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

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

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

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

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

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

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

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

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

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

im An institutionalized pregnant woman residing in an in-state-institution, as defined in 42 CFR 435.1010, whether or not the individual established residency in the state prior to entering the institution, or

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

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

SPA# UT-14-0004 Approval Date: DEC i 9 2013. Effective Date: January 1, 2014

Page | of 2

cms CHIP Eligibility

One or more interstate agreement(s). No

A policy related to individuals in the state only for educational purposes. No

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

SPA# UT-14-0004 Approval Date:, DEC { 9 2013 Effective Date: January 1, 2014 Page 2 of 2

CHIP Eligibility

OMB Control Number: 0938-1148 irati : 4

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

Citizenship

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

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

Who are citizens or nationals of the United States; or

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

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

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

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

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

The agency begins to furnish benefits to otherwise eligible individuals during the reasonable opportunity period on a date

earlier than the date the notice is received by the individual. Yes

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

@ Other date, as described:

Proof of Citizenship and Identity Eligibility

As of January 1, 2010, U.S. Citizens must document their Citizenship and Identity to be eligible for CHIP. Applicants: The State does not delay or deny benefits when an individual declares to be a U.S. Citizen or U.S. National, and there is no evidence that contradicts their claim.

If otherwise eligible, the State allows CHIP coverage and gives the client reasonable time to provide the documentation by the end of the time frame given, or provide proof they are working to obtain the documentation.

“Reasonable time” is defined as (at least) 90 days. A client needs to either provide the documentation by the end of the time frame given, or provide proof that they are working to obtain the documentation. If the client still needs more

SPA# UT-14-0004 Approval Date: DEC. | i] 2013 Effective Date: January 1, 2014

Page 1 of 2

cmMs CHIP Eligibility

time, the State gives them at least another 30 days to obtain it.

obtaining it, the State removes the child from the CHIP coverage with proper notice.

If the client has been given reasonable time and does not provide the documentation or proof that they are working on

The CHIP Agency elects the option to provide CHIP coverage to otherwise eligible children up to age 19, lawfully residing in the United States, as provided in Section 2107(e)(1)(J) of the SSA (Section 214 of CHIPRA 2009, P.L. 111-3).

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

No

INo

PRA Disclosure Statement

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

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

SPA# UT-14-0004 Approval Date: DEC { 9 2013 Effective Date: January 1, 2014 Page 2 of 2

42 CFR 457.340(b)

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

ee oe

eB

eel

Social Security Number

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

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

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

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

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

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

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

How the state will use the SSN.

The CHIP Agency provides assurance that it will verify each SSN furnished by an applicant or beneficiary with the Social Security Administration, not deny or delay services to an otherwise eligible applicant pending issuance or verification of the individual's SSN by the Social Security Administration and that the state's utilization of the SSNs is consistent with sections 205 and 1137 of the Social Security Act and the Privacy Act of 1974.

The state requests non-applicant household members to voluntarily provide their No SSN.

PRA Disclosure Statement

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

SPA# UT-14-0004 Approval Date: DEC { 3 2013

Effective Date: January 1, 2014 Page 1 of 1

CHIP Eligibility

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

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

Substitution of Coverage

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

[mf] Substitution of coverage prevention strategy:

Name of policy Description

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

How long is the waiting period?

C One month C. Two months @ 90 days

C Other

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

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

The child’s parent is determined eligible for advance payment of the premium tax credit for enrollment in a QHP [through the Marketplace because the ESI in which the family was enrolled is determined unaffordable in accordance with 26 CFR 1.36B—2(c)(3)(v).

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

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

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

[Ml] The child has special health care needs.

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

Does the state allow other exemptions in addition to those listed above? |Yes

SPA# UT-14-0004 Approval Date:. DEC 1 9 2013 Effective Date: January 1, 2014

Page 1 of 2

CHIP Eligibility

Describe

Voluntary termination of COBRA coverage.

Voluntary termination of HIPUtah (Health Insurance Pool) coverage. Voluntary termination of coverage by a non-custodial parent.

Voluntary termination of UPP reimbursed, employer-sponsored coverage.

Voluntary termination of insurance that does not provide coverage in Utah.

Voluntary termination of a limited health insurance plan. (See section 220-3.)

Title IV-D agency forces enrollment under NMSN (National Medical Support Notice). Then, because the cost of insurance exceeds 5% of the gross monthly income, the Title IV-D agency reverses the forced enrollment and the child is terminated from the TPL of the custodial parent.

The State will be applying all required exceptions to waiting period beginning January 1, 2014 as specified in 42 CFR 457.805

(C1 If the state covers pregnant women, the waiting period does not apply to pregnant women.

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

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

(2 The waiting period does not apply to children eligible for dental only supplemental coverage.

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

V.20130718

SPA# UT-14-0004 Approval Date:. DEC i 9 2013 Effective Date: January 1, 2014

Page 2 of 2

CHIP Eligibility

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

42 CFR 457.570 Non-Payment of Premiums Does the state impose premiums or enrollment fees? rY es Can non-payment of premiums or enrollment fees result in loss of CHIP eligibility? Yes Does the state have a premium lock out period? Yes

Please describe the lock-out period:

Households with incomes above 133% FPL must pay a quarterly premium to be eligible for CHIP. Households with children that have different MAGI incomes will always pay the lower quarterly premium. If the household does not pay the premium by the due date, a late fee is accesses. There is a process for waiving the late fee for good cause or hardship.

If the household fails to pay the quarterly premium the case is closed. If the household makes an application and is approved within 90 days after case closure, the household must pay the past due premium and late fee to reopen the case. If the household applies for and is approved for CHIP more than 90 days after case closure, no repayment of past due premium or late fee is required.

What is the length of the time premium lock-out period? Select a length of time:

C One month

C_ Two months

@ 90 days

C: Other (not to exceed 90 days)

Are there exceptions to the required lock-out period? Yes

[X] Individua!'s income decreased to a level where no premium is required or within Medicaid standards

(C] Other financial hardship (J Other The state assures that:

It does not require the collection of past due premiums or enrollment fees as a condition of eligibility for enrollment once the lock-out period has expired; and

It provides enrollees with an opportunity for an impartial review to address disenrollment from the program in accordance with section 457.1130(a)(3); and

The child will be reenrolled in CHIP during the lock-out period upon payment of past due premiums or enrollment fees.

SPA# UT-14-0004 Approval Date: DEC { 9 2013 Effective Date: January 1, 2014 Page 1 of 2

CHIP Eligibility

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

V.20130709

SPA# UT-14-0004 Approval Date: DEI { 9 2013 Effective Date: January 1, 2014

Page 2 of 2

CHIP Eligibility

OMB Control Number: 0938-1148

Expiration date: 10/31/2014

2105(a)(4)(A) of the SSA and 42 CFR 457.342 and 435.926

The CHIP Agency may provide that children who have been determined eligible under the state plan shall remain eligible, regardless of any changes in the family’s circumstances, during a continuous eligibility period up to 12 months, or until the time the child reaches an lage specified by the state (not to exceed age 19), whichever is earlier.

The CHIP Agency elects to provide continuous eligibility to children under this provision. ]Yes

@ For children up to age 19

© For children up to age

The continuous eligibility period begins on the effective date of the child's most recent determination or redetermination of eligibility, and ends:

[mJ Atthe end ofthe |12 | months continuous eligibility period.

Exceptions to the continuous eligibility period: [ml] The child attains the age specified by the state Agency or age 19. [Mj The child or child's representative requests voluntary disenrollment. [Mf] The child is no longer a resident of the state.

im The Agency determines that eligibility was erroneously granted at the most recent determination or renewal of eligibility because of Agency error or fraud, abuse, or perjury attributed to child or child's representative.

[By The child dies.

[Ml There is a failure to pay required premiums or enrollment fees on behalf of a child, as provided for in the state plan.

(7) Other

PRA Disclosure Statement

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

V.20130717

SPA# UT-14-0004 Approval Date: DEC 4 i] 2013 Effective Date: January 1, 2014

Page 1 of 1

logged in as TONIABROWN(CMS CO Staff) read only mode application rev p01 Children's Health Insurance Program Eligibility UT.0239.R00.00 - Jan 01, 2014 Home Logout Finder Save Validate Print Help Control Panel General Information File Management Tribal Input Summary State/Territory name: Utah State Funds: $ Federal Funds: $ Children's Health Insurance Program Eligibility: Summary Page Transmittal Number: Please enter the Transmittal Number (TN) in the format ST- YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. UT-14-0001 Type of SPA:  MAGI Eligibility & Methods XXI Medicaid Expansion Establish 2101(f) Group Eligibility Processing Non-Financial Eligibility Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation Pub. L. No. 111-148 Federal Budget Impact This SPA has a budget impact. Total budget impact: Subject of Amendment Please provide a brief summary of SPA changes. Page 1 of 2 Children's Health Insurance Program Eligibility: Summary Page 09/15/2016 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01...

Submitted By: Emma Chacon Last Revision Date: Dec 17, 2013 Submit Date: Aug 27, 2013 Character Count:123 out of 2000   This amendment sets the MAGI income standard for targeted low- income children and also establishes MAGI income methodology. Signature of State Agency Official FAQs | Site Map | Contact | Medicaid.gov | CMS.gov Page 2 of 2 Children's Health Insurance Program Eligibility: Summary Page 09/15/2016 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01...

_____________________________________________________________________________ Table of Contents State/Territory Name: Utah State Plan Amendment (SPA) #: UT-14-0002 This file contains the following documents in the order listed: 1) Approval Letter 2) Approved SPA Pages 3) SPA Summary Form The complete title XXI state plan for Utah consists of the most recent state plan posted on Medicaid.gov under CHIP and State Plan Amendments. The link is provided below. The following approved templates are in addition to, or replace sections of the state’s posted current state plan. The attached approval letter(s) explain how these templates fit into that state plan. Link to state title XXI state plans and amendments: XXI state plans and amendments: http://medicaid.gov/chip/state-program-information/chipstate- program-information.html

DEPARTMENT OF HEALTH & HUMAN SERVICES a Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop: S2-26-12 Baltimore, Maryland 21244-1850

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

Children and Adults Health Program Group

NOV 0 1 2013

Ms. Emma Chacon

CHIP Director

Director, Bureau of Managed Health Care Division of Medicaid and Health Financing P.O. Box 143108

Salt Lake City, UT 84114-3108

Dear Ms. Chacon:

I am pleased to inform you that your Title XXI Children’s Health Insurance Program (CHIP) state plan amendment (SPA) UT-14-0002 submitted on August 27, 2013 and related to the Modified Adjusted Gross Income (MAGI) Eligiblity has been approved with an effective date of January 1, 2014.

Establish 2101(f) Group:

SPA number UT-14-0002 provides coverage in a separate CHIP, as specified in the state’s submission of CS14: Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards. A copy of the approved state plan page (CS14) is attached, and should be incorporated within a separate subsection under Section 4.1 of Utah’s approved CHIP state plan.

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

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

7500 Security Boulevard

Baltimore, MD 21244-1850

Telephone: (410) 786-3413

Facsimile: (410) 786-5882

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

If you have questions or wish to discuss this determination further, please contact Mr. Richard Allen, Associate Regional Administrator (ARA) in our Denver Regional Office. Mr. Allen’s address is:

Page 2 — Ms. Emma Chacon

Centers for Medicare & Medicaid Services Denver Regional Office

Colorado State Bank Building

1600 Broadway, Suite# 700

Denver, Colorado 80202-4967

Congratulations on the approval. We look forward to continuing to work with you and your staff toward the approval of your remaining MAGI Eligibility SPAs. If you have additional questions,

please contact Ms. Linda Nablo, Director, Division of State Coverage Programs at (410) 786- 5143.

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

Sincerely,

Eliot Fishman Director

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

cms. CHIP Eligibility

OMB Control Number: 0938-1148 iration dat

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

{@] Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards

The CHIP agency provides coverage for this group of children as follows:

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

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

Cc

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

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

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

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

(% FPL

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

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

C Other.

Describe the benefits provided to this population:

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

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

Describe premiums and cost sharing required of this population:

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

SPA # UT-14-0002 Approval Date: NOV 0 | 2013 Effective Date: January 1, 2014

Page | of 2

CMS CHIP Eligibility

Csi, Fo marr aim MaEbec a SHiTNaNS

@ Premiums and cost sharing are the same as for targeted low-income children in the state's separate CHIP.

No premiums, copayments, deductibles, coinsurance or other cost sharing is required.

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

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

SPA # UT-14-0002 Approval Date: NOV 0 1 2013 Effective Date: January 1, 2014

Page 2 of 2

logged in as TONIABROWN(CMS CO Staff) read only mode application rev p01 Children's Health Insurance Program Eligibility UT.0240.R00.00 - Jan 01, 2014 Home Logout Finder Save Validate Print Help Control Panel General Information File Management Tribal Input Summary State/Territory name: Utah State Funds: $ Federal Funds: $ Children's Health Insurance Program Eligibility: Summary Page Transmittal Number: Please enter the Transmittal Number (TN) in the format ST- YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. UT-14-0002 Type of SPA: MAGI Eligibility & Methods XXI Medicaid Expansion  Establish 2101(f) Group Eligibility Processing Non-Financial Eligibility Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation Pub L. No. 111-148 Federal Budget Impact This SPA has a budget impact. Total budget impact: Subject of Amendment Please provide a brief summary of SPA changes. Page 1 of 2 Children's Health Insurance Program Eligibility: Summary Page 09/15/2016 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01...

Submitted By: Craig Devashrayee Last Revision Date: Aug 27, 2013 Submit Date: Aug 27, 2013 Character Count:135 out of 2000   This amendment establishes a new coverage group for children who lose Medicaid eligiblity as a result of discontinuation of disregards. Signature of State Agency Official FAQs | Site Map | Contact | Medicaid.gov | CMS.gov Page 2 of 2 Children's Health Insurance Program Eligibility: Summary Page 09/15/2016 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01...

_____________________________________________________________________________ Table of Contents State/Territory Name: Utah State Plan Amendment (SPA) #: UT-14-0004 This file contains the following documents in the order listed: 1) Approval Letter 2) Approved SPA Pages 3) SPA Summary Form The complete title XXI state plan for Utah consists of the most recent state plan posted on Medicaid.gov under CHIP and State Plan Amendments. The link is provided below. The following approved templates are in addition to, or replace sections of the state’s posted current state plan. The attached approval letter(s) explain how these templates fit into that state plan. Link to state title XXI state plans and amendments: XXI state plans and amendments: http://medicaid.gov/chip/state-program-information/chipstate- program-information.html

DEPARTMENT OF HEALTH & HUMAN SERVICES

Centers for Medicare & Medicaid Services i” 4 gq” iY | Gag 7500 Security Boulevard, Mail Stop: $2-26-12 \ Baltimore, Maryland 21244-1850 cesar eb cr sees

Children and Adults Health Programs Group

DEC 1 9 2013

Ms. Emma Chacon

CHIP Director

Bureau of Managed Health Care

Division of Medicaid and Health Financing P.O. Box 143108

Salt Lake City, UT 84114-3108

Dear Ms. Chacon:

I am pleased to inform you that your Title XXI Children’s Health Insurance Program (CHIP) state plan amendments (SPA) UT-14-0001 and UT-14-0004 submitted on August 27, 2013 and with additional information submitted on December 2, 2013, related to Modified Adjusted Gross Income (MAGI) Eligiblity, have been approved with an effective date of January 1, 2014.

MAGI Eligiblity & Methods:

SPA number UT-14-0001 provides assurance on page CS15 that the state will apply methodologies based on MAGI for all separate CHIP covered groups; and using the approved MAGI conversion plan income thresholds, the state indicates on page CS7 that it will cover targeted low-income children. A copy of the approved CS15 is attached and should be incorporated within a separate subsection under Section 4.3 of the state’s approved CHIP state plan. A copy of the approved CS7 is attached and supersedes the current Age and Income Sections 4.1.2 and 4.1.3 of the current CHIP state plan.

Non-Financial Eligibility:

SPA number UT-14-0004 is approved to clarify the state’s non-financial eligibility policies on residency; citizenship; social security number; substitution of coverage; non-payment of premiums; and, continuous eligibility. Copies of the approved state plan pages are attached and these approved pages supersede sections of Utah’s current state plan as listed below:

New State Plan Page Impact on Current State Plan Section CS17: Non-Financial Eligibility —- Residency Section 4.1.5 CS18: Non-Financial Eligibility — Citizenship Section 4.1.0 CS19: Non-Financial Eligibility — Social Security | Section 4.1.9.1

Number

CS20: Non-Financial Eligibility — Substitution of | Section 4.4.4 Coverage

Page 2 —- Ms. Emma Chacon

C821: Non-Financial Eligibility: Non-Payment of Premiums

Section 8.7

C827: General Eligibility — Continuous Eligibility

Section 4.1.9.2

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

is as follows:

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

7500 Security Boulevard

Baltimore, MD 21244-1850

Telephone: (410) 786-3413

Facsimile: (410) 786-5882

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

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

Centers for Medicare & Medicaid Services

Denver Regional Office Colorado State Bank Building 1600 Broadway, Suite# 700 Denver, Colorado 80202-4967

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

5143. We look forward to continuing to work with you and your staff. Sincerely,

Eliot Fishman Director

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

CHIP Eligibility

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

seat ee B ee

42 CFR 457.320

Residency

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

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

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

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

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

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

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

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

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

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

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

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

im An institutionalized pregnant woman residing in an in-state-institution, as defined in 42 CFR 435.1010, whether or not the individual established residency in the state prior to entering the institution, or

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

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

SPA# UT-14-0004 Approval Date: DEC i 9 2013. Effective Date: January 1, 2014

Page | of 2

cms CHIP Eligibility

One or more interstate agreement(s). No

A policy related to individuals in the state only for educational purposes. No

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

SPA# UT-14-0004 Approval Date:, DEC { 9 2013 Effective Date: January 1, 2014 Page 2 of 2

CHIP Eligibility

OMB Control Number: 0938-1148 Expiration date: 10/31/2014 Eee e ee eee ee ee |

Bes i

ee : He i 3

ee se

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

Citizenship

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

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

Who are citizens or nationals of the United States; or

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

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

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

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

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

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

(@ Other date, as described:

Proof of Citizenship and Identity Eligibility

As of January 1, 2010, U.S. Citizens must document their Citizenship and Identity to be eligible for CHIP. Applicants: The State does not delay or deny benefits when an individual declares to be a U.S. Citizen or U.S. (National, and there is no evidence that contradicts their claim.

If otherwise eligible, the State allows CHIP coverage and gives the client reasonable time to provide the documentation by the end of the time frame given, or provide proof they are working to obtain the documentation.

“Reasonable time” is defined as (at least) 90 days. A client needs to either provide the documentation by the end of the time frame given, or provide proof that they are working to obtain the documentation. If the client still needs more

SPA# UT-14-0004 Approval Date: DEC. i i] 2013 Effective Date: January 1, 2014

Page 1 of 2

CHIP Eligibility

time, the State gives them at least another 30 days to obtain it.

If the client has been given reasonable time and does not provide the documentation or proof that they are working on obtaining it, the State removes the child from the CHIP coverage with proper notice.

The CHIP Agency elects the option to provide CHIP coverage to otherwise eligible children up to age 19, lawfully residing

in the United States, as provided in Section 2107(e)(1)(J) of the SSA (Section 214 of CHIPRA 2009, P.L. 111-3). No

The CHIP Agency elects the option to provide CHIP coverage to otherwise eligible pregnant women, lawfully residing in the

United States, as provided in Section 214 of CHIPRA 2009, P.L. 111-3. The state may not select this option unless the state IN 0

also elects to cover lawfully residing children. A state may not select this option unless the state also covers Targeted Low- Income Pregnant Women.

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

SPA# UT-14-0004 Approval Date: DEC { 9 2013 Effective Date: January 1, 2014 Page 2 of 2

42 CFR 457.340(b)

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

ee oe

eB

eel

Social Security Number

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

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

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

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

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

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

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

How the state will use the SSN.

The CHIP Agency provides assurance that it will verify each SSN furnished by an applicant or beneficiary with the Social Security Administration, not deny or delay services to an otherwise eligible applicant pending issuance or verification of the individual's SSN by the Social Security Administration and that the state's utilization of the SSNs is consistent with sections 205 and 1137 of the Social Security Act and the Privacy Act of 1974.

The state requests non-applicant household members to voluntarily provide their No SSN.

PRA Disclosure Statement

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

SPA# UT-14-0004 Approval Date: DEC { 3 2013

Effective Date: January 1, 2014 Page 1 of 1

CHIP Eligibility

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

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

Substitution of Coverage

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

[mf] Substitution of coverage prevention strategy:

Name of policy Description

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

How long is the waiting period?

C One month C. Two months @ 90 days

C Other

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

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

The child’s parent is determined eligible for advance payment of the premium tax credit for enrollment in a QHP [through the Marketplace because the ESI in which the family was enrolled is determined unaffordable in accordance with 26 CFR 1.36B—2(c)(3)(v).

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

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

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

[Ml] The child has special health care needs.

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

Does the state allow other exemptions in addition to those listed above? |Yes

SPA# UT-14-0004 Approval Date:. DEC 1 9 2013 Effective Date: January 1, 2014

Page 1 of 2

CHIP Eligibility

Describe

Voluntary termination of COBRA coverage. Voluntary termination of HIPUtah (Health Insurance Pool) coverage.

Voluntary termination of coverage by a non-custodial parent.

Voluntary termination of UPP reimbursed, employer-sponsored coverage.

Voluntary termination of insurance that does not provide coverage in Utah.

Voluntary termination of a limited health insurance plan. (See section 220-3.)

Title IV-D agency forces enrollment under NMSN (National Medical Support Notice). Then, because the cost of insurance exceeds 5% of the gross monthly income, the Title IV-D agency reverses the forced enrollment and the child is terminated from the TPL of the custodial parent.

The State will be applying all required exceptions to waiting period beginning January 1, 2014 as specified in 42 CFR 457.805

(1 If the state covers pregnant women, the waiting period does not apply to pregnant women.

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

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

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

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

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

SPA# UT-14-0004 Approval Date: DEC | 9 2013 Effective Date: January 1, 2014

Page 2 of 2

CHIP Eligibility

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

42 CFR 457.570 Non-Payment of Premiums Does the state impose premiums or enrollment fees? rY es Can non-payment of premiums or enrollment fees result in loss of CHIP eligibility? Yes Does the state have a premium lock out period? Yes

Please describe the lock-out period:

Households with incomes above 133% FPL must pay a quarterly premium to be eligible for CHIP. Households with children that have different MAGI incomes will always pay the lower quarterly premium. If the household does not pay the premium by the due date, a late fee is accesses. There is a process for waiving the late fee for good cause or hardship.

If the household fails to pay the quarterly premium the case is closed. If the household makes an application and is approved within 90 days after case closure, the household must pay the past due premium and late fee to reopen the case. If the household applies for and is approved for CHIP more than 90 days after case closure, no repayment of past due premium or late fee is required.

What is the length of the time premium lock-out period? Select a length of time:

C One month

C_ Two months

@ 90 days

C: Other (not to exceed 90 days)

Are there exceptions to the required lock-out period? Yes

[X] Individua!'s income decreased to a level where no premium is required or within Medicaid standards

(C] Other financial hardship (J Other The state assures that:

It does not require the collection of past due premiums or enrollment fees as a condition of eligibility for enrollment once the lock-out period has expired; and

It provides enrollees with an opportunity for an impartial review to address disenrollment from the program in accordance with section 457.1130(a)(3); and

The child will be reenrolled in CHIP during the lock-out period upon payment of past due premiums or enrollment fees.

SPA# UT-14-0004 Approval Date: DEC { 9 2013 Effective Date: January 1, 2014 Page 1 of 2

CHIP Eligibility

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

V.20130709

SPA# UT-14-0004 Approval Date: DEI { 9 2013 Effective Date: January 1, 2014

Page 2 of 2

CHIP Eligibility

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

es ae ee ie He s Ze Hes fy

2105(a)(4)(A) of the SSA and 42 CFR 457.342 and 435.926

The CHIP Agency may provide that children who have been determined eligible under the state plan shall remain eligible, regardless of any changes in the family’s circumstances, during a continuous eligibility period up to 12 months, or until the time the child reaches an age specified by the state (not to exceed age 19), whichever is earlier.

The CHIP Agency elects to provide continuous eligibility to children under this provision. [Yes

@ For children up to age 19

© For children up to age

The continuous eligibility period begins on the effective date of the child's most recent determination or redetermination of eligibility, and ends:

[MW] Atthe end ofthe |12 | months continuous eligibility period.

Exceptions to the continuous eligibility period: [lM] The child attains the age specified by the state Agency or age 19. [i] The child or child's representative requests voluntary disenrollment. [Mf] The child is no longer a resident of the state.

ry The Agency determines that eligibility was erroneously granted at the most recent determination or renewal of eligibility because of Agency error or fraud, abuse, or perjury attributed to child or child's representative.

[Wf The child dies. [Mi] There is a failure to pay required premiums or enrollment fees on behalf of a child, as provided for in the state plan.

( Other

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

Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. V.20130717

SPA# UT-14-0004 Approval Date: DEL 4 9 2013 Effective Date: January 1, 2014

Page 1 of 1

_____________________________________________________________________________ Table of Contents State/Territory Name: State Plan Amendment (SPA) #: This file contains the following documents in the order listed: 1) Approval Letter 2) State Plan Pages Utah UT-18-0020

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-01-16 Baltimore, MD 21244-1850 Children and Adults Health Programs Group November 10, 2021 Jeff Nelson CHIP Director Division of Medicaid and Health Financing P.O. Box 143101 Salt Lake City, UT 84114-3101 Dear Mr. Nelson: Your title XXI Children’s Health Insurance Program (CHIP) state plan amendment (SPA) UT-18-0020 submitted on June 30, 2018 with additional information submitted on November 9, 2021 has been approved. UT-18-0020 implements mental health parity requirements to ensure that treatment limitations applied to mental health (MH) and substance use disorder (SUD) benefits are no more restrictive than those applied to medical/surgical (M/S) benefits. This SPA has an effective date of July 1, 2017, except for the change noted below. Section 2103(c)(7)(A) of the Social Security Act (the Act), as implemented through regulations at 42 CFR 457.496(d)(3)-(5), requires states that provide both M/S and MH/SUD benefits to ensure that financial requirements (FRs) and treatment limitations applied to MH/SUD benefits covered under the state child health plan are consistent with the mental health parity requirements of section 2705(a) of the Public Health Service Act, in the same manner that such requirements apply to a group health plan. Utah demonstrated compliance by providing the necessary assurances and supporting documentation that the state’s application of FRs and treatment limitations to MH/SUD benefits are consistent with section 2103(c)(7)(A) of the Act. The state also removed FRs applicable to behavioral health services provided in an urgent care center to come into compliance with parity regulations, effective July 1, 2021. This approval relates only to benefits provided under the CHIP state plan; Medicaid benefits will be analyzed separately. Your title XXI project officer is Ms. Joyce Jordan. She is available to answer questions concerning this amendment and other CHIP-related issues. Her contact information is as follows: Centers for Medicare & Medicaid Services Center for Medicaid and CHIP Services Mail Stop: S2-01-16 7500 Security Boulevard Baltimore, MD 21244-1850 Telephone: (410) 786-3413 E-mail: Joyce.Jordan@cms.hhs.gov

Page 2 – Mr. Jeff Nelson If you have any questions, please contact Meg Barry, Director, Division of State Coverage Programs, at (410) 786-1536. We look forward to continuing to work with you and your staff. Sincerely, Amy Lutzky Deputy Director /Signed by Amy Lutzky/

14 Proposed implementation date: July 1, 2016

SPA #20 Purpose of SPA: CHIP Mental Health Parity and Addiction Equity Act Analysis, Removal of Co-Payment Requirements for Residential Treatment and the Removal of Co-payment Requirements for Mental Health and Substance Use Disorder Services in an Urgent Care Clinic Proposed effective date: July 1, 2021

Proposed implementation date: July 1, 2021

SPA# 21, Purpose of SPA: Update CHIP benefits Proposed effective date: July 1, 2019

Proposed implementation date: July 1, 2019

SPA# 22, Purpose of SPA: Add CHIP Disaster Relief Plan Proposed effective date: March 1, 2020

Proposed implementation date: March 1, 2020

SPA# 24, Delay timeliness requirements on ex parte renewals.

Proposed implementation date: February 1, 2021

118 6.2.10. Inpatient mental health services, other than services described in 6.2.18., but including services furnished in a state-operated mental hospital and including residential or other 24-hour therapeutically planned structural services (Section 2110(a)(10))

Scope of Coverage

Inpatient and outpatient services are covered. Medically necessary services from contracted hospitals, residential treatment centers, inpatient pain clinics, day treatment facilities or intensive outpatient programs are covered.

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

Scope of Coverage

Inpatient and outpatient services are covered. Medically necessary services from contracted hospitals, residential treatment centers, inpatient pain clinics, day treatment facilities or intensive outpatient programs are covered. 6.2.12. Durable medical equipment and other medically-related or remedial devices (such as prosthetic devices, implants, eyeglasses, hearing aids, dental devices, and adaptive devices) (Section 2110(a)(12))

Scope of Coverage

144 allowed to the extent permitted by HIPAA/ERISA. If the State is contracting with a group health plan or provides benefits through group health coverage, describe briefly any limitations on pre-existing conditions. Previously 8.6

6.2- MHPAEA Section 2103(c)(6)(A) of the Social Security Act requires that, to the extent that it provides both medical/surgical benefits and mental health or substance use disorder benefits, a State child health plan ensures that financial requirements and treatment limitations applicable to mental health and substance use disorder benefits comply with the mental health parity requirements of section 2705(a) of the Public Health Service Act in the same manner that such requirements apply to a group health plan. If the state child health plan provides for delivery of services through a managed care arrangement, this requirement applies to both the state and managed care plans. These requirements are also applicable to any additional benefits provided voluntarily to the child health plan population by managed care entities and will be considered as part of CMS’s contract review process at 42 CFR 457.1201(l).

6.2.1- MHPAEA Before completing a parity analysis, the State must determine whether each covered benefit is a medical/surgical, mental health, or substance use disorder benefit based on a standard that is consistent with state and federal law and generally recognized independent standards of medical practice. (42 CFR 457.496(f)(1)(i))

145 Response: Please see the attached covered services section of the CHIP contracts.

6.2.1.1- MHPAEA Please choose the standard(s) the state uses to determine whether a covered benefit is a medical/surgical benefit, mental health benefit, or substance use disorder benefit. The most current version of the standard elected must be used. If different standards are used for different benefit types, please specify the benefit type(s) to which each standard is applied. If “Other” is selected, please provide a description of that standard.

International Classification of Disease (ICD) SelectHealth only. Diagnostic and Statistical Manual of Mental Disorders (DSM) SelectHealth only. State guidelines (Describe: Molina uses the contract with the State to determine whether a covered benefit is M/S or MH/SUD. SelectHealth uses state guidelines when appropriate.)

Other (Describe: SelectHealth uses procedures and provider specialty.)

146 6.2.1.2- MHPAEA Does the State provide mental health and/or substance use disorder benefits?

Yes No Guidance: If the State does not provide any mental health or substance use disorder benefits, the mental health parity requirements do not apply ((42 CFR 457.496(f)(1)). Continue on to Section 6.3.

6.2.2- MHPAEA Section 2103(c)(6)(B) of the Social Security Act (the Act) provides that to the extent a State child health plan includes coverage of early and periodic screening, diagnostic, and treatment services (EPSDT) defined in section 1905(r) of the Act and provided in accordance with section 1902(a)(43) of the Act, the plan shall be deemed to satisfy the parity requirements of section 2103(c)(6)(A) of the Act.

6.2.2.1- MHPAEA Does the State child health plan provide coverage of EPSDT? The State must provide for coverage of EPSDT benefits, consistent with Medicaid statutory requirements, as indicated in section 6.2.26 of the State child health plan in order to answer “yes.”

147 Yes No Guidance: If the State child health plan does not provide EPSDT consistent with Medicaid statutory requirements at sections 1902(a)(43) and 1905(r) of the Act, go to Section 6.2.3- MHPAEA to complete the required parity analysis of the State child health plan.

If the state does provide EPSDT benefits consistent with Medicaid requirements, please continue this section to demonstrate compliance with the statutory requirements of section 2103(c)(6)(B) of the Act and the mental health parity regulations of 42 CFR 457.496(b) related to deemed compliance. Please provide supporting documentation, such as contract language, provider manuals, and/or member handbooks describing the state’s provision of EPSDT.

6.2.2.2- MHPAEA EPSDT benefits are provided to the following:

All children covered under the State child health plan. A subset of children covered under the State child health plan.

148 Please describe the different populations (if applicable) covered under the State child health plan that are provided EPSDT benefits consistent with Medicaid statutory requirements.

Guidance: If only a subset of children are provided EPSDT benefits under the State child health plan, 42 CFR 457.496(b)(3) limits deemed compliance to those children only and Section 6.2.3- MHPAEA must be completed as well as the required parity analysis for the other children.

6.2.2.3- MHPAEA To be deemed compliant with the MHPAEA parity requirements, States must provide EPSDT in accordance with sections 1902(a)(43) and 1905(r) of the Act (42 CFR 457.496(b)). The State assures each of the following for children eligible for EPSDT under the separate State child health plan:

All screening services, including screenings for mental health and substance use disorder conditions, are provided at intervals that align with a periodicity schedule that meets reasonable standards of medical or dental practice as well as when medically necessary to determine the existence of suspected illness or conditions. (Section 1905(r))

149

All diagnostic services described in 1905(a) of the Act are provided as needed to diagnose suspected conditions or illnesses discovered through screening services, whether or not those services are covered under the Medicaid state plan. (Section 1905(r))

All items and services described in section 1905(a) of the Act are provided when needed to correct or ameliorate a defect or any physical or mental illnesses and conditions discovered by the screening services, whether or not such services are covered under the Medicaid State plan. (Section 1905(r)(5))

Treatment limitations applied to services provided under the EPSDT benefit are not limited based on a monetary cap or budgetary constraints and may be exceeded as medically necessary to correct or ameliorate a medical or physical condition or illness. (Section 1905(r)(5))

Non-quantitative treatment limitations, such as definitions of medical necessity or criteria for medical necessity, are applied in an individualized manner that does not preclude coverage of any items or services necessary to correct or ameliorate any medical or physical condition or illness. (Section 1905(r)(5))

150 EPSDT benefits are not excluded on the basis of any condition, disorder, or diagnosis. (Section 1905(r)(5))

The provision of all requested EPSDT screening services, as well as any corrective treatments needed based on those screening services, are provided or arranged for as necessary. (Section 1902(a)(43))

All families with children eligible for the EPSDT benefit under the separate State child health plan are provided information and informed about the full range of services available to them. (Section 1902(a)(43)(A)) Guidance: For states seeking deemed compliance for their entire State child health plan population, please continue to Section 6.3. If not all of the covered populations are offered EPSDT, the State must conduct a parity analysis of the benefit packages provided to those populations. Please continue to 6.2.3- MHPAEA.

Mental Health Parity Analysis Requirements for States Not Providing EPSDT to All Covered Populations

Guidance: The State must complete a parity analysis for each population under the State child health plan that is not provided the EPSDT benefit consistent with the

151 requirements 42 CFR 457.496(b). If the State provides benefits or limitations that vary within the child or pregnant woman populations, states should perform a parity analysis for each of the benefit packages. For example, if different financial requirements are applied according to a beneficiary’s income, a separate parity analysis is needed for the benefit package provided at each income level.

Please ensure that changes made to benefit limitations under the State child health plan as a result of the parity analysis are also made in Section 6.2.

6.2.3 MHPAEA In order to conduct the parity analysis, the State must place all medical/surgical and mental health and substance use disorder benefits covered under the State child health plan into one of four classifications: Inpatient, outpatient, emergency care, and prescription drugs. (42 CFR 457.496(d)(2)(ii); 42 CFR 457.496(d)(3)(ii)(B))

6.2.3.1 MHPAEA Please describe below the standard(s) used to place covered benefits into one of the four classifications.

Utah CHIP uses the following definitions for each of the four classifications: Inpatient, Outpatient, Emergency Care and Prescription Drugs:

152

Inpatient hospital services are services that a hospital provides for the care and treatment of inpatients with disorders other than mental illness, under the direction of a physician or other practitioner of the healing arts.

Outpatient services means any service covered by a managed health care plan other than inpatient hospital stays or outpatient hospital services.

Prescribed drugs means simple or compound substances or mixtures of substances prescribed for the cure, mitigation, or prevention of disease, or for health maintenance that are— (1) Prescribed by a physician or other licensed practitioner of the healing arts within the scope of this professional practice as defined and limited by Federal and State law; (2) Dispensed by licensed pharmacists and licensed authorized practitioners in accordance with the State Medical Practice Act; and (3) Dispensed by the licensed pharmacist or practitioner on a written prescription that is recorded and maintained in the pharmacist's or practitioner's records.

Emergency Services means covered inpatient and outpatient services that are furnished by a Provider that is qualified to furnish these services and that are needed to evaluate or stabilize an Emergency Medical Condition.

6.2.3.1.1 MHPAEA The State assures that:

153

The State has classified all benefits covered under the State plan into one of the four classifications. The same reasonable standards are used for determining the classification for a mental health or substance use disorder benefit as are used for determining the classification of medical/surgical benefits. 6.2.3.1.2- MHPAEA Does the State use sub-classifications to distinguish between office visits and other outpatient services?

Yes No

6.2.3.1.2.1- MHPAEA If the State uses sub-classifications to distinguish between outpatient office visits and other outpatient services, the State assures the following:

The sub-classifications are only used to distinguish office visits from other outpatient items and services, and are not used to distinguish between similar services on other bases (ex: generalist vs. specialist visits). Guidance: For purposes of this section, any reference to “classification(s)” includes sub-classification(s) in states using sub-classifications to distinguish between outpatient

154 office visits from other outpatient services.

6.2.3.2 MHPAEA The State assures that:

Mental health/ substance use disorder benefits are provided in all classifications in which medical/surgical benefits are provided under the State child health plan. Guidance: States are not required to cover mental health or substance use disorder benefits (42 CFR 457.496(f)(2)). However if a state does provide any mental health or substance use disorder benefits, those mental health or substance use disorder benefits must be provided in all the same classifications in which medical/surgical benefits are covered under the State child health plan (42 CFR 457.496(d)(2)(ii).

Annual and Aggregate Lifetime Dollar Limits

6.2.4- MHPAEA A State that provides both medical/surgical benefits and mental health and/or substance use disorder benefits must comply with parity requirements related to annual and aggregate lifetime dollar limits for benefits covered under the State child health plan. (42 CFR 457.496(c))

6.2.4.1- MHPAEA Please indicate whether the State applies an aggregate lifetime dollar limit and/or an annual dollar limit on any mental health or substance abuse disorder benefits covered under the State child health plan.

155

Aggregate lifetime dollar limit is applied Aggregate annual dollar limit is applied No dollar limit is applied Guidance: A monetary coverage limit that applies to all CHIP services provided under the State child health plan is not subject to parity requirements.

If there are no aggregate lifetime or annual dollar limits on any mental health or substance use disorder benefits, please go to section 6.2.5- MHPAEA.

6.2.4.2- MHPAEA Are there any medical/surgical benefits covered under the State child health plan that have either an aggregate lifetime dollar limit or an annual dollar limit? If yes, please specify what type of limits apply.

Yes (Type(s) of limit: ) No

156 Guidance: If no aggregate lifetime dollar limit is applied to medical/ surgical benefits, the State may not impose an aggregate lifetime dollar limit on any mental health or substance use disorder benefits. If no aggregate annual dollar limit is applied to medical/surgical benefits, the State may not impose an aggregate annual dollar limit on any mental health or substance use disorder benefits. (42 CFR 457.496(c)(1))

6.2.4.3 – MHPAEA. States applying an aggregate lifetime or annual dollar limit on medical/surgical benefits and mental health or substance use disorder benefits must determine whether the portion of the medical/surgical benefits to which the limit applies is less than one-third, at least one-third but less than two- thirds, or at least two-thirds of all medical/surgical benefits covered under the State plan (42 CFR 457.496(c)). The portion of medical/surgical benefits subject to the limit is based on the dollar amount expected to be paid for all medical/surgical benefits under the State plan for the State plan year or portion of the plan year after a change in benefits that affects the applicability of the aggregate lifetime or annual dollar limits. (42 CFR 457.496(c)(3))

The State assures that it has developed a reasonable methodology to calculate the portion of covered medical/surgical benefits which are subject to the aggregate lifetime and/or annual dollar limit, as applicable.

157 Guidance: Please include the state’s methodology to calculate the portion of covered medical/surgical benefits which are subject to the aggregate lifetime and/or annual dollar limit and the results as an attachment to the State child health plan.

6.2.4.3.1- MHPAEA Please indicate the portion of the total costs for medical and surgical benefits covered under the State plan which are subject to a lifetime dollar limit:

Less than 1/3 At least 1/3 and less than 2/3 At least 2/3

6.2.4.3.2- MHPAEA Please indicate the portion of the total costs for medical and surgical benefits covered under the State plan which are subject to an annual dollar limit:

Less than 1/3 At least 1/3 and less than 2/3 At least 2/3 Guidance: If an aggregate lifetime limit is applied to less than one-third of all medical/surgical benefits, the State may not

158 impose an aggregate lifetime limit on any mental health or substance use disorder benefits. If an annual dollar limit is applied to less than one-third of all medical surgical benefits, the State may not impose an annual dollar limit on any mental health or substance use disorder benefits (42 CFR 457.496(c)(1)). Skip to section 6.2.5-MHPAEA.

If the State applies an aggregate lifetime or annual dollar limit to at least one-third of all medical/surgical benefits, please continue below to provide the assurances related to the determination of the portion of total costs for medical/surgical benefits that are subject to either an annual or lifetime limit.

6.2.4.3.2.1- MHPAEA If the State applies an aggregate lifetime or annual dollar limit to at least 1/3 and less than 2/3 of all medical/surgical benefits, the State assures the following (42 CFR 457.496(c)(4)(i)(B)); (42 CFR 457.496(c)(4)(ii)):

The State applies an aggregate lifetime or annual dollar limit on mental health or substance use disorder benefits that is no more restrictive than an average limit calculated for medical/surgical benefits.

159 Guidance: The state’s methodology for calculating the average limit for medical/surgical benefits must be consistent with 42 CFR 457.496(c)(4)(i)(B) and 42 CFR 457.496(c)(4)(ii). Please include the state’s methodology and results as an attachment to the State child health plan.

6.2.4.3.2.2- MHPAEA If at least 2/3 of all medical/surgical benefits are subject to an annual or lifetime limit, the State assures either of the following (42 CFR 457.496(c)(2)(i)); (42 CFR 457.496(c)(2)(ii)):

The aggregate lifetime or annual dollar limit is applied to both medical/surgical benefits and mental health and substance use disorder benefits in a manner that does not distinguish between medical/surgical benefits and mental health and substance use disorder benefits; or The aggregate lifetime or annual dollar limit placed on mental health and substance use disorder benefits is no more restrictive than the aggregate lifetime or annual dollar limit on medical/surgical benefits. Quantitative Treatment Limitations

160

6.2.5- MHPAEA Does the State apply quantitative treatment limitations (QTLs) on any mental health or substance use disorder benefits in any classification of benefits? If yes, specify the classification(s) of benefits in which the State applies one or more QTLs on any mental health or substance use disorder benefits.

Yes No Guidance: If the state does not apply any type of QTLs on any mental health or substance use disorder benefits in any classification, the state meets parity requirements for QTLs and should continue to Section 6.2.6 - MHPAEA. If the state does apply QTLs to any mental health or substance use disorder benefits, the state must conduct a parity analysis. Please continue.

6.2.5.1- MHPAEA Does the State apply any type of QTL on any medical/surgical benefits?

Yes No

161 Guidance: If the State does not apply QTLs on any medical/surgical benefits, the State may not impose quantitative treatment limitations on mental health or substance use disorder benefits, please go to Section 6.2.6- MHPAEA related to non-quantitative treatment limitations.

6.2.5.2- MHPAEA Within each classification of benefits in which the State applies a type of QTL on any mental health or substance use disorder benefits, the State must determine the portion of medical and surgical benefits in the classification which are subject to the limitation. More specifically, the State must determine the ratio of (a) the dollar amount of all payments expected to be paid under the State plan for medical and surgical benefits within a classification which are subject to the type of quantitative treatment limitation for the plan year (or portion of the plan year after a mid-year change affecting the applicability of a type of quantitative treatment limitation to any medical/surgical benefits in the class) to (b) the dollar amount expected to be paid for all medical and surgical benefits within the classification for the plan year. For purposes of this paragraph, all payments expected to be paid under the State plan includes payments expected to be made directly by the State and payments which are expected to be made by MCEs contracting with the State. (42 CFR 457.496(d)(3)(i)(C))

162 The State assures it has applied a reasonable methodology to determine the dollar amounts used in the ratio described above for each classification within which the State applies QTLs to mental health or substance use disorder benefits. (42 CFR 457.496(d)(3)(i)(E)) Guidance: Please include the state’s methodology and results as an attachment to the State child health plan.

6.2.5.3- MHPAEA For each type of QTL applied to any mental health or substance use disorder benefits within a given classification, does the State apply the same type of QTL to “substantially all” (defined as at least two-thirds) of the medical/surgical benefits within the same classification? (42 CFR 457.496(d)(3)(i)(A))

Yes No Guidance: If the State does not apply a type of QTL to substantially all medical/surgical benefits in a given classification of benefits, the State may not impose that type of QTL on mental health or substance use disorder benefits in that classification. (42 CFR 457.496(d)(3)(i)(A))

163 6.2.5.3.1- MHPAEA For each type of QTL applied to mental health or substance use disorder benefits, the State must determine the predominant level of that type which is applied to medical/surgical benefits in the classification. The “predominant level” of a type of QTL in a classification is the level (or least restrictive of a combination of levels) that applies to more than one-half of the medical/surgical benefits in that classification, as described in 42 CFR 457.496(d)(3)(i)(B). The portion of medical/surgical benefits in a classification to which a given level of a QTL type is applied is based on the dollar amount of payments expected to be paid for medical/surgical benefits subject to that level as compared to all medical/surgical benefits in the classification, as described in 42 CFR 457.496(d)(3)(i)(C). For each type of quantitative treatment limitation applied to mental health or substance use disorder benefits, the State assures:

The same reasonable methodology applied in determining the dollar amounts used to determine whether substantially all medical/surgical benefits within a classification are subject to a type of quantitative treatment limitation also is applied in determining the dollar amounts used to determine the predominant level of a type of quantitative treatment limitation applied to medical/surgical benefits within a classification. (42 CFR 457.496(d)(3)(i)(E))

164 The level of each type of quantitative treatment limitation applied by the State to mental health or substance use disorder benefits in any classification is no more restrictive than the predominant level of that type which is applied by the State to medical/surgical benefits within the same classification. (42 CFR 457.496(d)(2)(i)) Guidance: If there is no single level of a type of QTL that exceeds the one-half threshold, the State may combine levels within a type of QTL such that the combined levels are applied to at least half of all medical/surgical benefits within a classification; the predominant level is the least restrictive level of the levels combined to meet the one-half threshold. (42 CFR 457.496(d)(3)(i)(B)(2))

Non-Quantitative Treatment Limitations

6.2.6- MHPAEA The State may utilize non-quantitative treatment limitations (NQTLs) for mental health or substance use disorder benefits, but the State must ensure that those NQTLs comply with all the mental health parity requirements. (42 CFR 457.496(d)(4)); (42 CFR 457.496(d)(5)) 6.2.6.1 – MHPAEA If the State imposes any NQTLs, complete this subsection. If the State does not impose NQTLs, please go to Section 6.2.7-MHPAEA.

165 The State assures that the processes, strategies, evidentiary standards or other factors used in the application of any NQTL to mental health or substance use disorder benefits are no more stringent than the processes, strategies, evidentiary standards or other factors used in the application of NQTLs to medical/surgical benefits within the same classification+. Guidance: Examples of NQTLs include medical management standards to limit or exclude benefits based on medical necessity, restrictions based on geographic location, provider specialty, or other criteria to limit the scope or duration of benefits and provider network design (ex: preferred providers vs. participating providers). Additional examples of possible NQTLs are provided in 42 CFR 457.496(d)(4)(ii). States will need to provide a summary of its NQTL analysis, as well as supporting documentation as requested.

Response: Please see the two attachments (6.2.6 NQTL Analysis & Supporting Documentation - PART I; and 6.2.6 NQTL Analysis & Supporting Documentation - PART II).

6.2.6.2 – MHPAEA The State or MCE contracting with the State must comply with parity if they provide coverage of medical or surgical benefits furnished by out-of-network providers.

6.2.6.2.1- MHPAEA Does the State or MCE contracting with the State provide coverage of medical or surgical benefits provided by out-of-network providers?

166

Yes No Guidance: The State can answer no if the State or MCE only provides out of network services in specific circumstances, such as emergency care, or when the network is unable to provide a necessary service covered under the contract.

6.2.6.2.2- MHPAEA If yes, the State must provide access to out-of- network providers for mental health or substance use disorder benefits. Please assure the following:

The State attests that when determining access to out-of- network providers within a benefit classification, the processes, strategies, evidentiary standards, or other factors used to determine access to those providers for mental health/ substance use disorder benefits are comparable to and applied no more stringently than the processes, strategies, evidentiary standards or other factors used to determine access for out- of-network providers for medical/surgical benefits. Availability of Plan Information

167 6.2.7- MHPAEA The State must provide beneficiaries, potential enrollees, and providers with information related to medical necessity criteria and denials of payment or reimbursement for mental health or substance use disorder services (42 CFR 457.496(e)) in addition to existing notice requirements at 42 CFR 457.1180.

6.2.7.1- MHPAEA Medical necessity criteria determinations must be made available to any current or potential enrollee or contracting provider, upon request. The state attests that the following entities provide this information:

State Managed Care entities Both Other

Guidance: If other is selected, please specify the entity.

6.2.7.2- MHPAEA Reason for any denial for reimbursement or payment for

mental health or substance use disorder benefits must be made available to the enrollee by the health plan or the State. The state attests that the following

entities provide denial information: State

168 Managed Care entities Both Other

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

The state assures that it will not permit the imposition of any pre-existing Medical condition exclusion for covered services.

6.3.1.

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

The state assures that it will not permit the imposition of any pre- existing medical condition exclusion for covered services.

6.3.2.

The State contracts with a group health plan or group health insurance coverage, or contracts with a group health plan to provide family coverage under a waiver (see Section 6.6.2. formerly 6.4.2 of the template). Pre-existing medical conditions are permitted to the extent allowed by HIPAA/ERISA (Section 2103(f)). Describe: Previously 8.6

Guidance: States may request two additional purchase options in Title XXI: cost

195 Laboratory and X-ray Services:

$0 co-payment for laboratory and x-ray services for minor diagnostic tests and x-rays

Co-insurance, 5% after deductible for major diagnostic tests and x-rays

Vision Screening Services:

$5 co-payment (limit of one exam per plan year).

Hearing Screening Services:

$5 co-payment (limit of one exam per plan year).

Dental Services :

Maximum benefit of $1,000 per person, per year

$0 co-payment for cleanings, exams, x-rays, fluoride, and sealants.

5% co-insurance for all other covered services.

Orthodontic benefits are only covered if the client scores 30 or greater on the Salzmann Index

Mental Health Services, Inpatient Facility:

196 $150 co-payment after deductible for each visit

Mental Health Services, Outpatient Office Visit and Urgent Care:

$0 co-payment for each visit

Residential Treatment:

$0 co-payment

Home Health and Hospice Care:

Co-insurance of 5% after deductible per visit.

Medical Equipment and Supplies:

Co-insurance of 5% after deductible

Physical, Occupational and Speech Therapy:

$5 co-payment, 20 visits combined limit per child, per plan year.

Out- of-Pocket Maximum:

5% of a family’s annual gross countable income. Only out of pocket costs for covered services, deductibles, co-pays, and premiums will be used to calculate the maximum out of pocket limit.

199

Co-insurance, 50% after deductible for porcelain-fused crowns (not Covered for non-adult and back teeth).

Orthodontic benefits are only covered if the client scores 30 or greater on the Salzmann Index.

Mental Health Services In-Patient Facility

Co-insurance, 20% after deductible.

Mental Health Services Outpatient Office Visit and, Urgent Care:

$40 co-payment for each visit

Residential Treatment:

$0 co-payment

Home Health and Hospice Care:

Co-insurance, 20% after deductible

Medical Equipment and Supplies:

Co-insurance, 20% after deductible

Physical, Occupational and Speech Therapy:

200

$40 co-payment after deductible, 20 visits combined limit, per child, per plan year.

Out-of-Pocket Maximum

The maximum out of pocket expense is 5% of a family's annual gross income. Only out of pocket costs for covered services, deductibles, co- pays, and premiums will be used to calculate the maximum out of pocket limit.

Co-Insurance and Co-payment requirements for CHIP clients/enrollees who are Native American.

No co-payments or premiums are charged to CHIP enrollees who are American Indian/Alaska Native

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

Consequences for an enrollee or applicant who does not pay copayments or coinsurance will be handled between the enrollee or applicant and the health care provider who has rendered the services.

The invoice regarding the quarterly premium is mailed to enrollees on the 1st day of the first month of the quarter.”

204 age-appropriate immunizations. (Section 2103(e)(2)) (42CFR 457.520) 8.4.3

No additional cost-sharing applies to the costs of emergency medical services delivered outside the network. (Section 2103(e)(1)(A)) (42CFR 457.515(f))

8.4.1- MHPAEA There is no separate accumulation of cumulative financial requirements, as defined in 42 CFR 457.496(a), for mental health and substance abuse disorder benefits compared to medical/surgical benefits. (42 CFR 457.496(d)(3)(iii))

8.4.2- MHPAEA If applicable, any different levels of financial requirements that are applied to different tiers of prescription drugs are determined based on reasonable factors, regardless of whether a drug is generally prescribed for medical/surgical benefits or mental health/substance use disorder benefits. (42 CFR 457.496(d)(3)(ii)(A))

8.4.3- MHPAEA Cost sharing applied to benefits provided under the State child health plan will remain capped at five percent of the beneficiary’s income as required by 42 CFR 457.560 (42 CFR 457.496(d)(3)(i)(D)).

8.4.4- MHPAEA Does the State apply financial requirements to any mental health or substance use disorder benefits? If yes, specify the classification(s) of

205 benefits in which the State applies financial requirements on any mental health or substance use disorder benefits.

Yes (Specify: Inpatient mental health and prescription drugs)

No

Guidance: For the purposes of parity, financial requirements include deductibles, copayments, coinsurance, and out of pocket maximums; premiums are excluded from the definition. If the state does not apply financial requirements on any mental health or substance use disorder benefits, the state meets parity requirements for financial requirements. If the state does apply financial requirements to mental health or substance use disorder benefits, the state must conduct a parity analysis. Please continue below.

Please ensure that changes made to financial requirements under the State child health plan as a result of the parity analysis are also made in Section 8.2.

8.4.5- MHPAEA Does the State apply any type of financial requirements on any medical/surgical benefits?

206

Yes Inpatient, outpatient, prescription drugs, urgent care and emergency room. No Guidance: If the State does not apply financial requirements on any medical/surgical benefits, the State may not impose financial requirements on mental health or substance use disorder benefits.

8.4.6- MHPAEA Within each classification of benefits in which the State applies a type of financial requirement on any mental health or substance use disorder benefits, the State must determine the portion of medical and surgical benefits in the class which are subject to the limitation.

The State assures it has applied a reasonable methodology to determine the dollar amounts used in the ratio described above (Section 6.2.5.2-MHPAEA) for each classification or within which the State applies financial requirements to mental health or substance use disorder benefits. (42 CFR 457.496(d)(3)(i)(E)) Guidance: Please include the state’s methodology and results of the parity analysis as an attachment to the State child health plan.

8.4.7- MHPAEA For each type of financial requirement applied to any mental health or substance use disorder benefits within a given classification, does the

207 State apply the same type of financial requirement to at least two-thirds (“substantially all”) of all the medical/surgical benefits within the same classification? (42 CFR 457.496(d)(3)(i)(A))

Yes No Guidance: If the State does not apply a type of financial requirement to substantially all medical/surgical benefits in a given classification of benefits, the State may not impose financial requirements on mental health or substance use disorder benefits in that classification. (42 CFR 457.496(d)(3)(i)(A))

8.4.8- MHPAEA For each type of financial requirement applied to substantially all medical/surgical benefits in a classification, the State must determine the predominant level (as defined in 42 CFR 457.496(d)(3)(i)(B)) of that type which is applied to medical/surgical benefits in the classification. For each type of financial requirement applied to substantially all medical/surgical benefits in a classification, the State assures:

The same reasonable methodology applied in determining the dollar amounts used in determining whether substantially all medical/surgical benefits within a classification are subject to a type of financial requirement also is applied in determining the dollar amounts used to determine the predominant level of a type of

208 financial requirement applied to medical/surgical benefits within a classification. (42 CFR 457.496(d)(3)(i)(E)) The level of each type of financial requirement applied by the State to mental health or substance use disorder benefits in any classification is no more restrictive than the predominant level of that type which is applied by the State to medical/surgical benefits within the same classification. (42 CFR 457.496(d)(2)(i)) Guidance: If there is no single level of a type of financial requirement that exceeds the one-half threshold, the State may combine levels within a type of financial requirement such that the combined levels are applied to at least half of all medical/surgical benefits within a classification; the predominant level is the least restrictive level of the levels combined to meet the one-half threshold. (42 CFR 457.496(d)(3)(i)(B)(2))

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

_____________________________________________________________________________ Table of Contents State/Territory Name: Utah State Plan Amendments (SPA) #: UT-19-0021 This file contains the following documents in the order listed: 1) Approval Letter 2) State Plan Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES

Centers for Medicare & Medicaid Services

7500 Security Boulevard, Mail Stop $2-01-16 | x, Baltimore, MD 21244-1850

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

Children and Adults Health Programs Group

NOV 07 2019

Jeff Nelson

CHIP Director

Division of Medicaid and Health Financing P.O. Box 143101

Salt Lake City, UT 84114-3101

Dear Mr. Nelson:

1 am pleased to inform you that your title XXI Children’s Health Insurance Program (CHIP) state plan amendment (SPA), UT-19-0021, submitted on June 26, 2019, with additional information submitted on November 7, 2019, has been approved. UT-19-0021 demonstrates compliance with the CHIP managed care regulations and removes the 25-day limitation on residential treatment per plan year and the co-payment for an outpatient facility or office visit for mental health services. In addition, this SPA excludes Applied Behavior Analysis (ABA) for the treatment of autism spectrum disorder from CHIP coverage and updates the dental delivery contractor. These benefit changes are effective as of July 1, 2019.

SPA UT-19-0021 demonstrates compliance with the CHIP managed care regulations at 42 CFR 457, Subpart L, for utilization of a managed care delivery system with an effective date of July 1, 2018. Sections 2101(a), 2103(f(3), 2107(b), and 2107(e) of the Social Security Act, as implemented through regulations at 42 CFR 457 Subpart L, describe the application of managed care requirements to CHIP. Utah has provided the necessary assurances indicating that the state complies with the managed care requirements in the delivery of CHIP services and benefits covered under the state’s separate child health plan as of July 1, 2018.

This SPA approval does not substitute for CMS review of any contracts between the state and managed care entities that serve the state’s CHIP populations. All managed care contracts for CHIP populations in effect as of the state fiscal year beginning on or after July 1, 2018 must comply with the CHIP managed care regulations and be submitted for CMS review.

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

/signed Anne Marie Costello/

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

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

State/Territory: The State of Utah

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

________________________________________________________________________ (Signature of Governor, or designee, of State/Territory, Date Signed)

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

The following State officials are responsible for program administration and financial oversight (42 CFR 457.40(c)):

Name: Nathan Checketts Position/Title: Director, Medicaid and Health Financing Name: Jeff Nelson Position/Title: CHIP Director Name: Jennifer Wiser Position/Title: CHIP Program Manager

*Disclosure. 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 09380707. The time required to complete this information collection is estimated to average 160 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, write to: CMS, 7500 Security Blvd., Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

2 Introduction: Section 4901 of the Balanced Budget Act of 1997 (BBA), public law 1005-33 amended the Social Security Act (the Act) by adding a new title XXI, the Children’s Health Insurance Program (CHIP). In February 2009, the Children’s Health Insurance Program Reauthorization Act (CHIPRA) renewed the program. The Patient Protection and Affordable Care Act of 2010 further modified the program.

This template outlines the information that must be included in the state plans and the state plan amendments (SPAs). It reflects the regulatory requirements at 42 CFR Part 457 as well as the previously approved SPA templates that accompanied guidance issued to States through State Health Official (SHO) letters. Where applicable, we indicate the SHO number and the date it was issued for your reference. The CHIP SPA template includes the following changes: o Combined the instruction document with the CHIP SPA template to have a single document. Any modifications to previous instructions are for clarification only and do not reflect new policy guidance. o Incorporated the previously issued guidance and templates (see the Key following the template for information on the newly added templates), including: • Prenatal care and associated health care services (SHO #02-004, issued November 12, 2002) • Coverage of pregnant women (CHIPRA #2, SHO # 09-006, issued May 11, 2009) • Tribal consultation requirements (ARRA #2, CHIPRA #3, issued May 28, 2009) • Dental and supplemental dental benefits (CHIPRA # 7, SHO # #09-012, issued October 7, 2009) • Premium assistance (CHIPRA # 13, SHO # 10-002, issued February 2, 2010) • Express lane eligibility (CHIPRA # 14, SHO # 10-003, issued February 4, 2010) • Lawfully Residing requirements (CHIPRA # 17, SHO # 10-006, issued July 1, 2010)

3 o Moved sections 2.2 and 2.3 into section 5 to eliminate redundancies between sections 2 and 5. o Removed crowd-out language that had been added by the August 17 letter that later was repealed. The Centers for Medicare & Medicaid Services (CMS) is developing regulations to implement the CHIPRA requirements. When final regulations are published in the Federal Register, this template will be modified to reflect those rules and States will be required to submit SPAs illustrating compliance with the new regulations. States are not required to resubmit their State plans based on the updated template. However, States must use the updated template when submitting a State Plan Amendment.

Federal Requirements for Submission and Review of a Proposed SPA. (42 CFR Part 457 Subpart A) In order to be eligible for payment under this statute, each State must submit a Title XXI plan for approval by the Secretary that details how the State intends to use the funds and fulfill other requirements under the law and regulations at 42 CFR Part 457. A SPA is approved in 90 days unless the Secretary notifies the State in writing that the plan is disapproved or that specified additional information is needed. Unlike Medicaid SPAs, there is only one 90 day review period, or clock for CHIP SPAs, that may be stopped by a request for additional information and restarted after a complete response is received. More information on the SPA review process is found at 42 CFR 457 Subpart A.

When submitting a State plan amendment, states should redline the changes that are being made to the existing State plan and provide a “clean” copy including changes that are being made to the existing state plan.

The template includes the following sections:

4 1. General Description and Purpose of the Children’s Health Insurance Plans and the Requirements- This section should describe how the State has designed their program. It also is the place in the template that a State updates to insert a short description and the proposed effective date of the SPA, and the proposed implementation date(s) if different from the effective date. (Section 2101); (42 CFR, 457.70) 2. General Background and Description of State Approach to Child Health Coverage and Coordination- This section should provide general information related to the special characteristics of each state’s program. The information should include the extent and manner to which children in the State currently have creditable health coverage, current State efforts to provide or obtain creditable health coverage for uninsured children and how the plan is designed to be coordinated with current health insurance, public health efforts, or other enrollment initiatives. This information provides a health insurance baseline in terms of the status of the children in a given State and the State programs currently in place. (Section 2103); (42 CFR 457.410(A)) 3. Methods of Delivery and Utilization Controls- This section requires a description that must include both proposed methods of delivery and proposed utilization control systems. This section should fully describe the delivery system of the Title XXI program including the proposed contracting standards, the proposed delivery systems and the plans for enrolling providers. (Section 2103); (42 CFR 457.410(A)) 4. Eligibility Standards and Methodology- The plan must include a description of the standards used to determine the eligibility of targeted low-income children for child health assistance under the plan. This section includes a list of potential eligibility standards the State can check off and provide a short description of how those standards will be applied. All eligibility standards must be consistent with the provisions of Title XXI and may not discriminate on the basis of diagnosis. In addition, if the standards vary within the state, the State should describe how they will be applied and

5 under what circumstances they will be applied. In addition, this section provides information on income eligibility for Medicaid expansion programs (which are exempt from Section 4 of the State plan template) if applicable. (Section 2102(b)); (42 CFR 457.305 and 457.320) 5. Outreach- This section is designed for the State to fully explain its outreach activities. Outreach is defined in law as outreach to families of children likely to be eligible for child health assistance under the plan or under other public or private health coverage programs. The purpose is to inform these families of the availability of, and to assist them in enrolling their children in, such a program. (Section 2102(c)(1)); (42CFR, 457.90) 6. Coverage Requirements for Children’s Health Insurance- Regarding the required scope of health insurance coverage in a State plan, the child health assistance provided must consist of any of the four types of coverage outlined in Section 2103(a) (specifically, benchmark coverage; benchmark-equivalent coverage; existing comprehensive state- based coverage; and/or Secretary-approved coverage). In this section States identify the scope of coverage and benefits offered under the plan including the categories under which that coverage is offered. The amount, scope, and duration of each offered service should be fully explained, as well as any corresponding limitations or exclusions. (Section 2103); (42 CFR 457.410(A)) 7. Quality and Appropriateness of Care- This section includes a description of the methods (including monitoring) to be used to assure the quality and appropriateness of care and to assure access to covered services. A variety of methods are available for State’s use in monitoring and evaluating the quality and appropriateness of care in its child health assistance program. The section lists some of the methods which states may consider using. In addition to methods, there are a variety of tools available for State adaptation and use with this program. The section lists some of these tools. States also

6 have the option to choose who will conduct these activities. As an alternative to using staff of the State agency administering the program, states have the option to contract out with other organizations for this quality of care function. (Section 2107); (42 CFR 457.495) 8. Cost Sharing and Payment- This section addresses the requirement of a State child health plan to include a description of its proposed cost sharing for enrollees. Cost sharing is the amount (if any) of premiums, deductibles, coinsurance and other cost sharing imposed. The cost-sharing requirements provide protection for lower income children, ban cost sharing for preventive services, address the limitations on premiums and cost-sharing and address the treatment of pre-existing medical conditions. (Section 2103(e)); (42 CFR 457, Subpart E) 9. Strategic Objectives and Performance Goals and Plan Administration- The section addresses the strategic objectives, the performance goals, and the performance measures the State has established for providing child health assistance to targeted low income children under the plan for maximizing health benefits coverage for other low income children and children generally in the state. (Section 2107); (42 CFR 457.710) 10. Annual Reports and Evaluations- Section 2108(a) requires the State to assess the operation of the Children’s Health Insurance Program plan and submit to the Secretary an annual report which includes the progress made in reducing the number of uninsured low income children. The report is due by January 1, following the end of the Federal fiscal year and should cover that Federal Fiscal Year. In this section, states are asked to assure that they will comply with these requirements, indicated by checking the box. (Section 2108); (42 CFR 457.750) 11. Program Integrity- In this section, the State assures that services are provided in an effective and efficient manner through free and open competition or through basing rates on other public and private rates that are actuarially sound. (Sections 2101(a) and

7 2107(e); (42 CFR 457, subpart I) 12. Applicant and Enrollee Protections- This section addresses the review process for eligibility and enrollment matters, health services matters (i.e., grievances), and for states that use premium assistance a description of how it will assure that applicants and enrollees are given the opportunity at initial enrollment and at each redetermination of eligibility to obtain health benefits coverage other than through that group health plan. (Section 2101(a)); (42 CFR 457.1120)

Program Options. As mentioned above, the law allows States to expand coverage for children through a separate child health insurance program, through a Medicaid expansion program, or through a combination of these programs. These options are described further below: o Option to Create a Separate Program- States may elect to establish a separate child health program that are in compliance with title XXI and applicable rules. These states must establish enrollment systems that are coordinated with Medicaid and other sources of health coverage for children and also must screen children during the application process to determine if they are eligible for Medicaid and, if they are, enroll these children promptly in Medicaid. o Option to Expand Medicaid- States may elect to expand coverage through Medicaid. This option for states would be available for children who do not qualify for Medicaid under State rules in effect as of March 31, 1997. Under this option, current Medicaid rules would apply.

Medicaid Expansion- CHIP SPA Requirements In order to expedite the SPA process, states choosing to expand coverage only through an expansion of Medicaid eligibility would be required to complete sections: • 1 (General Description)

8 • 2 (General Background) They will also be required to complete the appropriate program sections, including: • 4 (Eligibility Standards and Methodology) • 5 (Outreach) • 9 (Strategic Objectives and Performance Goals and Plan Administration including the budget) • 10 (Annual Reports and Evaluations).

Medicaid Expansion- Medicaid SPA Requirements States expanding through Medicaid-only will also be required to submit a Medicaid State Plan Amendment to modify their Title XIX State plans. These states may complete the first check-off and indicate that the descriptions of the requirements for these sections are incorporated by reference through their State Medicaid plans for sections: • 3 (Methods of Delivery and Utilization Controls) • 4 (Eligibility Standards and Methodology) • 6 (Coverage Requirements for Children's Health Insurance) • 7 (Quality and Appropriateness of Care) • 8 (Cost Sharing and Payment) • 11 (Program Integrity) • 12 (Applicant and Enrollee Protections) indicating State

• Combination of Options- CHIP allows states to elect to use a combination of the Medicaid program and a separate child health program to increase health coverage for children. For example, a State may cover optional targeted-low income children in families with incomes of up to 133 percent of poverty through Medicaid and a targeted group of children above that level through a separate child health program. For the children the State chooses to

9 cover under an expansion of Medicaid, the description provided under “Option to Expand Medicaid” would apply. Similarly, for children the State chooses to cover under a separate program, the provisions outlined above in “Option to Create a Separate Program” would apply. States wishing to use a combination of approaches will be required to complete the Title XXI State plan and the necessary State plan amendment under Title XIX.

Proposed State plan amendments should be submitted electronically and one signed hard copy to the Centers for Medicare & Medicaid Services at the following address: Amy Lutzky Centers for Medicare & Medicaid Services 7500 Security Blvd Baltimore, Maryland 21244 Attn: Children and Adults Health Programs Group Center for Medicaid, CHIP and Survey & Certification Mail Stop - S2-01-16

SPA# 17, Purpose of SPA: Rebenchmark CHIP dental benefits

Proposed effective date: July 1, 2016

Proposed implementation date: July 1, 2016 SPA# 18, Purpose of SPA: FQHC Payment Methodology

Proposed effective date: July 1, 2016

Proposed implementation date: July 1, 2016

SPA# 19-0021, Purpose of SPA: Update CHIP benefits

Sections 6 and 8

Proposed effective date: July 1, 2019

Proposed implementation date: July 1, 2019

Section 3:

Proposed effective date: July 1, 2018

Proposed implementation date: July 1, 2018

Superseding Pages of MAGI CHIP State Plan Material

State: Utah Transmittal SPA Group PDF # Description Superseded Plan Section(s) Number UT-13-0001 MAGI Eligibility | CS7 Eligibility— Targeted _} Supersedes the current sections & Methods Low Income Children | Geographic Area 4.1.1: Age

4.1.2; and Income 4.1.3

12

Transmittal SPA Group PDF # Description Superseded Plan Section(s) Number

Approval Date: cSs15 MAGI-Based Income _]| Incorporate within a separate

12/19/13 Methodologies subsection under section 4.3

Effective/Impleme

ntation Date:

January 1, 2014

UT-13-0005 XXI Medicaid CS3 Eligibility for Medicaid | Supersedes the current Expansion Expansion Program Medicaid expansion section 4.0

Approval Date:

10/08/14

Effective/Impleme

ntation Date:

January 1, 2014

UT-13-0002 Establish 2101(f) |} CS14 | Children Ineligible for | Incorporate within a separate Group Medicaid as a Result of }| subsection under section 4.1

the Elimination of

Approval Date: Income Disregards

11/01/13

Effective/Impleme

ntation Date:

January 1, 2014

UT-13-0003 Eligibility CS24 | Eligibility Process Supersedes the current sections Processing 4.3 and 4.4

Approval Date:

11/01/13

Effective/Impleme

ntation Date:

October 1, 2013

UT-13-0004 Non-Financial CS17_—_| Non-Financial Supersedes the current section Eligibility Eligibility — Residency | 4.1.5

Approval Date: CS18 | Non-Financial

12/19/13 Eligibility — Supersedes the current sections

Effective/Impleme Citizenship 4.1.0; 4.1-LR; 4.1.1-LR

ntation Date:

January 1, 2014 CcS19

13

Transmittal SPA Group PDF # Description Superseded Plan Section(s) Number _ Non-Financial Supersedes the current section CS20 | Eligibility — Social 4.1.9.1 Security Number CcSs21 Non-Financial Supersedes the current section Eligibility -Substitution | 4.4.4 of Coverage CS27 Non-Financial Supersedes the current section Eligibility — Non- 8.7 Payment of Premiums Continuous Eligibility | Supersedes the current section 4.18 UT-16-0001 Non-Financial CS18 | Non-Financial Supersedes the current sections Eligibility Eligibility — 4.1.0; 4.1-LR; 4.1.1-LR Citizenship (CHIPRA. Approval Date: section 214) 08/18/16 Effective Date: Tuly 1, 2016 UT-17-0003 MAGI Eligibility | CS15 MAGI-Based Income _| Incorporate within a separate & Methods Methodologies subsection under section 4.3 (Estranged spouses) Approval Date: 04/27/17 Effective Date: January 1, 2017

14

15

State Plan Amendment 13 was presented at the Utah Indian Health Advisory Board meeting on August 3, 2012. Consultation was not requested.

State Plan Amendment 14 was presented at the Utah Indian Health Advisory Board meeting on 08/08/2014. Consultation was not requested.

State Plan Amendment 15 was presented at the Utah Indian Health Advisory Board meeting on 12/12/2014. Consultation was not requested.

State Plan Amendment 16 was presented at the Utah Indian Health Advisory Board meeting on 10/9/2015. Consultation was not requested.

State Plan Amendment 17 was presented at the Utah Indian Health Advisory Board meeting on 7/8/2016. Consultation was not requested.

State Plan Amendment 18 was presented at the Utah Indian Health Advisory Board meeting on 3/10/2017. Consultation was not requested.

State Plan Amendment 19-0021 was presented at the Utah Indian Health Advisory Board meeting on June 7, 2019. Consultation was not requested.

TN No: Approval Date Effective Date _____

6.2.3.

Physician services (Section 2110(a)(3))

16

Scope of Coverage

Services provided directly by licensed physicians or osteopaths, or by other licensed professionals such as physician assistants, nurse practitioners, or nurse midwives under the physician’s or osteopath's supervision. Includes surgery and anesthesia.

Exclusions

1. Acupuncture and acupressure 2. Services obtained for administrative purposes. Such administrative purposes include services obtained for or pursuant to legal proceedings, court orders, employment, continuing or obtaining insurance coverage, governmental licensure, home health recertification, travel, military service, school, or institutional requirements. Provider and Facility charges for completing insurance forms, duplication services, interest (except where required by Utah Administration Code R590-192), finance charges, late fees, shipping and handling, missed appointments, and other administrative charges. 3. The following allergy test are not covered: Cytotoxic test, leukocyte histamine release test, mediator release test, passive cutaneous transfer test, provocative conjunctival test, provocative nasal test, rebuck skin window test, rinkel test, subcutaneous provocative food and chemical test, sublingual provocative food and chemical test. The following allergy treatments are not covered: allergoids, autogenous urine immunizations, LEAP therapy, medical devices (filtering air cleaner, electrostatic air

17 cleaner, air conditioners etc.), neutralization therapy, photo-inactivated extracts, polymerized extracts, oral desensitization/ immunotherapy. 4. General anesthesia in a provider’s office.

5. Cognitive or behavioral therapies for the treatment of attention deficit/hyperactivity disorder. 6. Biofeedback/neurofeedback 7. The following cancer therapies are not covered: neutron beam therapy and proton beam therapy. 8. Services or an illness, condition, accident, or injury are not covered if occurred: a. While the member was a voluntary participant in the commission of a felony b. While the member was a voluntary participant in disorderly conduct, riot, or other breach of the peace c. While the member was engaged in any conduct involving the illegal use or misuse of a firearm or other deadly weapon d. While the member was driving or otherwise in physical control of a car, truck, motorcycle, scooter, off-road vehicle, boat, or other motor driven vehicle if the member either had sufficient alcohol in the member’s body that a subsequent test shows that the member has either a blood or breath alcohol concentration of .08 grams or greater at the time of the test or had any illegal drug or their illegal substance in the member’s body to a degree that it affected the members’ ability to drive or operate the vehicle e. While the member was driving or otherwise in physical control of a car, truck, motorcycle, scooter, off road vehicle, boat, or other motor driven vehicle either without a valid driver’s permit or license, if required under

18 the circumstances or without the permission of the owner of the vehicle f. As a complication of, or as the result of, or as follow up care for, any illness, condition, accident, or injury that is not covered as the result of this exclusion 9. Generally, claims with a date of service over one year old should be denied by the plan. Exceptions to this general rule should be addressed by the plan’s policy and in its procedures. 10. Complementary, alternative and nontraditional services. Such services include acupuncture, homeopathy, homeopathic drugs, certain bioidentical hormones, massage therapies, aromatherapies, yoga, hypnosis, rolfing, and thermography 11. All services provided or ordered to treat complications of non-covered services are not covered unless stated otherwise in this document. 12. Custodial care 13. Dry needling procedures 14. Services for which the member has obtained a payment, settlement, judgment, or other recover for future payment intended as compensation 15. Services received by a member incarcerated in a prison, jail, or other correctional facility at the time services are provided, including care provided outside of a correctional facility to a person who has been arrested or is under a court order of incarceration 16. Experimental and/or investigational services for which one or more of the following apply: it cannot be lawfully marketed without the approval of the Food and Drug Administration (FDA) and such approval has not been granted at the time of its use or proposed use; it is the subject of a current investigational new drug or new device application on file with the FDA; it

19 is being provided pursuant to a Phase I or Phase II clinical trial or as the experimental or research arm of a Phase III clinical trial; it is being or should be delivered or provided subject to the approval and supervision of an Institutional Review Board (IRB) as required and defined by federal regulations, particularly those of the FDA or the Department of Health and Human Services (HHS); if the predominant opinion among the appropriate experts as expressed in the peer reviewed medical literature is that further research is necessary in order to define safety, toxicity, effectiveness, or comparative effectiveness, or there is no clear medical consensus about the role and value of the service. 17. Fitness training, conditioning, exercise equipment, and membership fees to a spa or health club. 18. Except for dietary products as defined by the Health Plan, food supplements and substitutes are not covered. 19. Gene therapy or gene based therapies 20. Services designed to create or establish function that was not previously present 21. The following immunizations are not covered: anthrax, BCG (tuberculosis), cholera, plague, typhoid, and yellow fever. 22. When a non-covered service is performed as part of the same operation or process as a covered service, only charges relating to the covered service will be considered. Allowed amounts may be calculated and fairly apportioned to exclude any charges related to the non-covered service. 23. The following pain management services are not covered: prolotherapy, radiofrequency ablation of dorsal root ganglion,

20 acupuncture, IV pamidronate therapy for the treatment of reflex sympathetic dystrophy 24. Services for pervasive developmental disorder 25. Services provided to a member by a provider who ordinarily resides in the same household as the member 26. Service related to sexual dysfunction 27. Coverage for specific specialty services may be restricted to only those providers who are board certified or have other formal training that is considered necessary to perform those services 28. The following specific services are not covered: anodyne infrared device for any indication; auditory brain implantation; chronic intermittent insulin IV therapy/metabolic activation therapy; coblation therapy of the soft tissues of the mouth, nose, throat, or tongue; computer assisted interpretation of xrays (except mammograms); extracorporeal shock wave therapy for musculoskeletal indications; cryoablation therapy for plantar fasciitis and Morton’s neuroma; freestanding/home cervical traction; home anticoagulation or hemoglobin A1C testing; infrared light coagulation for the treatment of hemorrhoids,; interferential/neuromuscular stimulator; intimal media thickness testing to assess risk of coronary disease; lovaas therapy; magnetic source imaging; microprocessor controlled, computerized lower extremity limb prostheses; mole mapping; nonsurgical spinal decompression therapy; nucleoplasty or other forms of percutaneous disc decompression; pressure specified sensory device for neuropathy testing; prolotherapy; radiofrequency ablation for lateral epicondylitis; radiofrequency ablation of the dorsal root ganglion; secretin infusion therapy for the treatment of autism; virtual colonoscopy; whole

21 body scanning 29. Charges for provider telephone, email, or other electronic consultations 30. Services for an illness, injury, or connected disability are not covered when caused by or arising out of an act of international or domestic terrorism, as defined by United States Code, Title 18, Section 2331, or from an accidental, negligent, or intentional release of nuclear material or nuclear byproduct material as defined by United States Code, Title 18, Section 831. 31. Cost associated with travel to a local or distant medical provider, including accommodation and meal costs, are not covered. 32. Services for an illness, injury, or connected disability are not covered when caused by or arising out of a war or an act of war (whether or not declared) or service in the armed services of any country 33. Charges prior to coverage or after termination of coverage even if illness or injury occurred while the insured is covered by CHIP 34. Charges for educational material, literature or charges made by a provider to the extent that they are related to scholastic education, vocational training, learning disabilities, behavior modification, dealing with normal living such as dies, or medication management for illnesses such as diabetes 35. Charges for services primarily for convenience, contentment or other non therapeutic purpose 36. Charges for any service or supply not reasonable or necessary for medical care of the patient’s illness or injury 37. Charges which the insured is not, in the absence of coverage, legally

22 obligated to pay 38. Charges for services, treatments or supplies received as a result of an act of war occurring when the insured was covered by CHIP 39. Charges for any services received as a result of an industrial injury or illness, any portion of which is payable under workman’s compensation or employer’s liability laws 40. Charges for services or supplies resulting from participating in or in consequence of having participated in the commission of an assault or felony 41. Charges made for completion or submission of insurance forms 42. Charges for care, treatment, or surgery performed primarily for cosmetic purposes, except for expenses incurred as a result of an injury suffered in the preceding five years 43. Shipping, handling, or finance charges 44. Charges for medical care rendered by an immediate family member are subject to review by CHIP and may be determined by CHIP as ineligible 45. Charges for expenses in connection with appointments scheduled and not kept 46. Charges for telephone calls or consultations. 47. Applied Behavior Analysis for the treatment of Autism Spectrum Disorder (ASD)

6.2.4.

Surgical services (Section 2110(a)(4))

23

Scope of Coverage

Services provided directly by licensed physicians or osteopaths, or by other licensed professionals such as physician assistants, nurse practitioners, or nurse midwives under the physician’s or osteopath's supervision. Includes surgery and anesthesia.

Exclusions

1. Surgery to facilitate weight loss is not covered. The reversal or revision of such procedures and services required for the treatment of complications from such procedures are not covered. However, medical or surgical complications that can be reasonably attributed to such a surgery will be considered for coverage if they arise ten years or more after the surgery. 2. Reconstructive, corrective, and cosmetic services provided for the following reasons are not covered: a. To improve form or appearance b. to correct a deformity, whether congenital or acquired, without restoring physical function c. to cope with psychological factors such as poor self image or difficult social relations d. the service is rendered within 12 months of the cause or onset of the injury, illness, or therapeutic intervention, or a planned, staged series of services is initiated within the 12 month period e. to revise a scar, whether acquired through injury or surgery,

24 except when the primary purpose is to improve or correct a functional impairment f. Breast reduction g. Congenital cleft lip except for treatment rendered within 12 months of birth, or a planned, staged series of services is initiated, or when congenital cleft lip surgery is performed as part of a cleft palate repair h. Port wine stain treatment i. Sclerotherapy of superficial varicose veins

6.2.5.

Clinic services (including health center services) and other ambulatory health care services. (Section 2110(a)(5)) 6.2.6.

Prescription drugs (Section 2110(a)(6))

Scope of Coverage

Prescribed drugs and preparations provided in a licensed pharmacy. Over the counter (OTC) drugs are not covered. Prescriptions must be medically necessary and may be limited to generic medications where medically acceptable. The DEPARTMENT advisory board of medical professionals may establish an approved list of covered name brand drugs, or a formulary/approved list of drugs will be developed by the Health Plan, reviewed and approved by the DEPARTMENT.

Prospective drug utilization review at the point of sale and

25 retrospective drug utilization review will be done by the health plan or its pharmacy benefit manager.

Exclusions

1. Appetite suppressants and weight loss medications 2. Certain off label drug usage, unless the use has been approved by a health plan medical director or clinical pharmacist 3. Compound drugs when alternative products are available commercially 4. Cosmetic health and beauty aids 5. Drugs purchased from nonparticipating providers over the internet 6. Flu symptom medications 7. Drugs and medications purchased through a foreign pharmacy, unless approved by the health plan 8. Human growth hormone for the treatment of idiopathic short stature 9. Infertility medications 10. Medications not meeting the minimum levels of evidence based upon FDA approval and/or DrugDex level IIa strength of recommendations, and National Comprehensive Cancer Network category 2A, if applicable. 11. Minerals, fluoride, and vitamins other than prenatal or when determined to be medically necessary to treat a specifically diagnosed disease

26 12. Nicotine and smoking cessations medications, except in conjunction with a health plan sponsored smoking cessations program 13. Over the counter medications, except as approved by the health plan 14. Prescription drugs used for cosmetic purposes 15. Prescriptions written by a licenses dentist, except for the prevention of infection or pain in conjunction with a dental procedure 16. Replacement of lost, stolen, or damaged drugs and medications 17. Sexual dysfunction medications 18. Travel related medications, including preventive medication for the purpose of travel to other countries. 19. Charges for unproven medical practices or care, treatment or drugs which are experimental or investigational in nature or generally considered experimental or investigational by the medical professional or non-FDA approved.

6.2.7.

Over-the-counter medications (Section 2110(a)(7)) 6.2.8.

Laboratory and radiological services (Section 2110(a)(8))

Scope of Coverage

Professional and technical laboratory and X-ray services furnished by licensed and certified providers. All laboratory testing sites providing services under this Contract must have either a Clinical

27 Laboratory Improvement Amendments (CLIA) certificate of waiver or a certificate of registration along with a CLIA identification number.

Those laboratories with certificates of waiver will provide only the eight types of tests permitted under the terms of their waiver. Laboratories with certificates of registration may perform a full range of laboratory tests.

6.2.9.

Prenatal care and pre-pregnancy family services and supplies (Section 2110(a)(9))

Scope of Coverage

This service includes disseminating information, counseling, and treatments relating to family planning services. All services must be provided by or authorized by a physician, certified nurse midwife, or nurse practitioner. All services provided must include prior written consent of a minor’s parent or legal guardian. All services must be provided in concert with Utah law. The following family planning services are not covered: A. Norplant B. Infertility drugs C. In-vitro fertilization D. Genetic counseling

28 The Health Plan must ensure that high-risk pregnant Enrollees receive an appropriate level of quality prenatal care that is coordinated, comprehensive and continuous either by direct service or referral to an appropriate provider or facility.

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

Scope of Coverage

Inpatient and outpatient services are covered. Medically necessary services from contracted hospitals, inpatient treatment centers, inpatient pain clinics, day treatment facilities or intensive outpatient programs are covered. Residential treatment is limited to 25 days per plan year.

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

Scope of Coverage

Inpatient and outpatient services are covered. Medically necessary services from contracted hospitals, inpatient treatment centers, inpatient pain clinics, day treatment facilities or intensive outpatient programs are

29 covered. Residential treatment is limited to 25 days per plan year.

6.2.2.3-DC HMO with largest insured commercial enrollment (Section 2103(c)(5)(C)(iii)) (If checked, identify the plan and attach a copy of the benefits description and the applicable CDT codes. If the State chooses to provide supplemental services, also attach a description of the services and applicable CDT codes)

Delta Dental Dental Select has the largest insured commercial enrollment and is the current benchmark.

Reference: D0100-D0999 – Diagnostic D1000-D1999 – Preventive D2000-D2999 – Restorative D3000-D3999 – Endodontics D4000-D4999 – Periodontics D5000-D5999 – Prosthodontics (Removable) D6000-D6199 – Implant Services D6200-D6999 – Prosthodontics, Fixed D7000-D7999 – Oral and Maxillofacial Surgery D8000-D8999 – Orthodontics D9000-D9999 – Adjunctive General Services

Specifically, only the following dental services based on American Dental Association (ADA) codes are covered:

30

D0120 D1351 D2544 D2910 D3348 D4355 D5721 D6603 D7260 D7530 D8040 D0140 D1352 D2610 D2915 D3351 D4910 D5730 D6604 D7261 D7540 D8050 D0145 D1353 D2620 D2920 D3352 D5110 D5731 D6605 D7270 D7550 D8060 D0150 D1510 D2630 D2921 D3353 D5120 D5740 D6606 D7280 D7560 D8070 D0160 D1516 D2642 D2929 D3410 D5130 D5741 D6607 D7282 D7610 D8080 D0170 D1517 D2643 D2930 D3421 D5140 D5750 D6624 D7283 D7620 D8090 D0171 D1520 D2644 D2931 D3425 D5211 D5751 D6634 D7285 D7630 D8210 D0180 D1526 D2650 D2932 D3426 D5212 D5760 D6720 D7286 D7640 D8220 D0210 D1527 D2651 D2933 D3430 D5213 D5761 D6721 D7290 D7670 D8660 D0220 D1550 D2652 D2934 D3450 D5214 D5820 D6722 D7291 D7710 D8680 D0230 D1555 D2662 D2940 D3920 D5225 D5821 D6750 D7310 D7720 D8690 D0240 D1575 D2663 D2950 D4210 D5226 D5850 D6751 D7311 D7730 D8691 D0270 D2140 D2664 D2951 D4211 D5410 D5851 D6752 D7320 D7740 D8693 D0272 D2150 D2710 D2952 D4212 D5411 D5863 D6780 D7321 D7910 D8694 D0273 D2160 D2712 D2953 D4240 D5421 D5864 D6781 D7340 D7911 D8695 D0274 D2161 D2720 D2954 D4241 D5422 D5865 D6782 D7350 D7912 D8999 D0277 D2330 D2721 D2957 D4245 D5511 D5866 D6790 D7410 D7920 D9110 D0330 D2331 D2722 D2980 D4249 D5512 D6210 D6791 D7411 D7950 D9222 D0340 D2332 D2740 D3220 D4260 D5520 D6211 D6792 D7412 D7960 D9223 D0350 D2335 D2750 D3221 D4261 D5611 D6212 D6794 D7413 D7970 D9239 D0460 D2390 D2751 D3222 D4263 D5612 D6214 D6930 D7414 D7971 D9243 D0470 D2391 D2752 D3230 D4264 D5621 D6240 D6940 D7450 D7979 D9310 D0472 D2392 D2780 D3240 D4266 D5622 D6241 D7111 D7451 D7980 D9440 D0473 D2393 D2781 D3310 D4267 D5630 D6242 D7140 D7460 D7981 D9951 D0474 D2394 D2782 D3320 D4270 D5640 D6250 D7210 D7461 D7982 D9999 D0485 D2510 D2783 D3330 D4276 D5650 D6251 D7220 D7465 D7983 D1110 D2520 D2790 D3332 D4277 D5660 D6252 D7230 D7471 D7999 D1120 D2530 D2791 D3333 D4278 D5710 D6545 D7240 D7510 D8010 D1206 D2542 D2792 D3346 D4341 D5711 D6549 D7241 D7511 D8020 D1208 D2543 D2794 D3347 D4342 D5720 D6602 D7250 D7520 D8030

D0120 D0602 D2542 D2792 D3333 D4341 D5731 D6069 D6242 D7220 D7471 D8030 D0140 D0603 D2543 D2794 D3346 D4342 D5741 D6070 D6250 D7230 D7520 D8040

31

8.2.3. Coinsurance or copayments:

The following are the co-payment and co-insurance requirements for participation in CHIP. Levels of co-payments will be limited to the income groups identified in the federal enabling legislation 2103(e)(3)(A) & (B).

Plan B Co-Payment requirements: D0145 D1110 D2544 D2910 D3347 D4910 D5750 D6071 D6252 D7240 D7530 D8050 D0150 D1120 D2610 D2915 D3348 D5110 D5751 D6073 D6545 D7241 D7540 D8060 D0160 D1206 D2620 D2920 D3351 D5120 D5760 D6074 D6549 D7250 D7550 D8070 D0170 D1208 D2630 D2921 D3353 D5130 D5761 D6075 D6602 D7260 D7560 D8080 D0171 D1351 D2642 D2929 D3410 D5140 D5820 D6076 D6603 D7261 D7610 D8090 D0180 D1352 D2643 D2930 D3421 D5211 D5821 D6077 D6604 D7270 D7620 D8210 D0190 D1353 D2644 D2931 D3425 D5212 D5850 D6092 D6605 D7280 D7630 D8220 D0191 D1510 D2650 D2932 D3426 D5213 D5851 D6093 D6606 D7282 D7640 D8660 D0210 D1515 D2651 D2934 D3430 D5214 D5863 D6094 D6607 D7283 D7670 D8680 D0220 D1520 D2652 D2940 D3450 D5225 D5864 D6101 D6624 D7285 D7710 D8690 D0230 D1525 D2662 D2941 D3920 D5226 D5866 D6102 D6634 D7286 D7720 D8691 D0240 D1550 D2663 D2949 D4210 D5281 D6010 D6103 D6720 D7291 D7730 D8692 D0250 D1555 D2664 D2950 D4211 D5410 D6040 D6104 D6721 D7310 D7740 D8693 D0260 D2140 D2710 D2951 D4212 D5411 D6050 D6110 D6722 D7311 D7910 D8680 D0270 D2150 D2712 D2952 D4240 D5421 D6055 D6111 D6750 D7320 D7911 D8694 D0272 D2160 D2720 D2953 D4241 D5422 D6056 D6112 D6751 D7321 D7912 D8999 D0273 D2161 D2721 D2954 D4245 D5510 D6057 D6113 D6752 D7340 D7920 D9110 D0274 D2330 D2722 D2957 D4249 D5520 D6058 D6114 D6780 D7350 D7950 D9219 D0277 D2331 D2740 D2980 D4260 D5610 D6059 D6115 D6781 D7410 D7960 D9220 D0330 D2332 D2750 D3220 D4261 D5630 D6060 D6116 D6782 D7411 D7970 D9221 D0340 D2335 D2751 D3221 D4263 D5640 D6061 D6117 D6790 D7412 D7971 D9241 D0350 D2390 D2752 D3222 D4264 D5650 D6062 D6194 D6791 D7413 D7980 D9242 D0460 D2391 D2780 D3230 D4266 D5660 D6063 D6210 D6792 D7414 D7981 D9310 D0470 D2392 D2781 D3240 D4267 D5710 D6064 D6211 D6930 D7450 D7982 D9940 D0472 D2393 D2782 D3310 D4270 D5711 D6065 D6212 D6940 D7451 D7983 D9951 D0473 D2394 D2783 D3320 D4273 D5720 D6066 D6214 D7111 D7460 D7999 D9999 D0485 D2520 D2790 D3330 D4277 D5721 D6067 D6240 D7140 D7461 D8010

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Hospital Services:

$150 co-payment after deductible for inpatient services.

Co-insurance, 5% for surgeon and anesthesiologist services.

$5 co-payment for urgent care center services and emergency use of the emergency room.

$10 co-payment for non emergency use of the emergency room

Co-insurance, 5% after deductible for outpatient hospital services.

Ambulance (air and ground) for medical emergencies:

Co-insurance, 5% after deductible

Physician Office Visits (includes visits to a Specialist):

$5 co-payment per visit.

No co-payment for well-baby care, well-child care, and immunizations.

Prescription Drugs:

33 $5 co-payment per prescription for generics

Co-insurance, 5% per prescription for brand name drugs.

Laboratory and X-ray Services:

$0 co-payment for laboratory and x-ray services for minor diagnostic tests and x- rays

Co-insurance, 5% after deductible for major diagnostic tests and x-rays

Vision Screening Services:

$5 co-payment (limit of one exam per plan year).

Hearing Screening Services:

$5 co-payment (limit of one exam per plan year).

Dental Services :

Maximum benefit of $1,000 per person, per year

$0 co-payment for cleanings, exams, x-rays, fluoride, and sealants.

5% co-insurance for all other covered services.

34

Orthodontic benefits are only covered if the client scores 30 or greater on the Salzmann Index

Mental Health Services, Inpatient & Outpatient Facility:

$150 co-payment after deductible for each visit

Mental Health Services, Outpatient & Office Visit :

$5 0 co-payment for each visit

Home Health and Hospice Care:

Co-insurance of 5% after deductible per visit.

Medical Equipment and Supplies:

Co-insurance of 5% after deductible

Physical, Occupational and Speech Therapy:

$5 co-payment, 20 visits combined limit per child, per plan year.

Out- of-Pocket Maximum:

35 5% of a family’s annual gross countable income. Only out of pocket costs for covered services, deductibles, co-pays, and premiums will be used to calculate the maximum out of pocket limit.

Plan C Co-Insurance and Co-Payment requirements:

Hospital Services:

Co-insurance, 20% after deductible for inpatient services

$300 co-payment for emergency or non-emergency use of the emergency room, after deductible ; $300 per visit for non participating hospitals, after deductible

$40 co-payment each urgent care center visit

Co-insurance of 20% of total charges for surgeon and anesthesiologist services, after deductible.

Co-insurance, 20% after deductible for outpatient services.

Ambulance (air and ground) for medical emergencies:

Co-insurance, 20% after deductible

Physician office visits:

36 $25 co-payment per visit (excluding visits to a Specialist)

$40 co-payment per visit to a Specialist.

No co-payment for well-baby care, well-child care and immunizations.

Prescription Drugs:

$15 co-payment per prescription for generic drugs; Co-insurance 25% of total or brand name drugs on the approved list. Co-insurance 50% of total per prescription for brand name drugs not on the approved list.

Laboratory and X-Ray Services:

$0 co-payment for minor diagnostic tests and x-rays.

Co-insurance, 20% after deductible for major diagnostic tests and x-rays.

Vision Screening Services:

$25 co-payment, limit of one exam per plan year.

Hearing Screening Services:

$25 co-payment, limit of one exam per plan year.

37 Dental Services:

Maximum benefit of $1,000 per person, per year.

Plan pays 100% for cleanings, exams, x-rays, fluoride, and sealants.

Co-insurance, 20% after deductible for all other covered services.

Co-insurance, 50% after deductible for porcelain-fused crowns (not Covered for non-adult and back teeth).

Orthodontic benefits are only covered if the client scores 30 or greater on the Salzmann Index.

Mental Health Services In-Patient & Outpatient Facility

Co-insurance, 20% after deductible.

Mental Health Services Outpatient & Office Visit

$40 co-payment for each visit

Home Health and Hospice Care:

Co-insurance, 20% after deductible

38 Medical Equipment and Supplies:

Co-insurance, 20% after deductible

Physical, Occupational and Speech Therapy:

$40 co-payment after deductible, 20 visits combined limit, per child, per plan year.

Out-of-Pocket Maximum

The maximum out of pocket expense is 5% of a family's annual gross income. Only out of pocket costs for covered services, deductibles, co-pays, and premiums will be used to calculate the maximum out of pocket limit.

Co-Insurance and Co-payment requirements for CHIP clients/enrollees who are Native American.

No co-payments or premiums are charged to CHIP enrollees who are Native American.

_____________________________________________________________________________ Table of Contents State/Territory Name: State Plan Amendment (SPA) #: This file contains the following documents in the order listed: 1) Approval Letter 2) State Plan Pages Utah UT-20-0023

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-01-16 Baltimore, MD 21244-1850 Children and Adults Health Programs Group December 6, 2022 Jennifer Strohecker Medicaid Director Director, Division of Integrated Healthcare P.O. Box 143101 Salt Lake City, UT 84114-3101 Dear Ms. Strohecker: Your title XXI Children’s Health Insurance Program (CHIP) State Plan Amendment (SPA), UT-20-0023, with additional information submitted on November 29, 2022, has been approved. Through this SPA, Utah has demonstrated compliance with section 5022 of the Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities (SUPPORT) Act. This SPA has an effective date of July 1, 2020. Section 5022 of the SUPPORT Act added Section 2103(c)(5) to the Social Security Act (the Act) and requires child health and pregnancy-related assistance to include coverage of services necessary to prevent, diagnose, and treat a broad range of behavioral health symptoms and disorders. Additionally, Section 2103(c)(5)(B) of the Act requires that these behavioral health services be delivered in a culturally and linguistically appropriate manner. Utah demonstrated compliance by providing the necessary assurances and benefit descriptions that the state covers a range of behavioral health services in a culturally and linguistically appropriate manner. Your Project Officer is Joyce Jordan. She is available to answer your questions concerning this amendment and other CHIP-related matters. Ms. Jordan’s contact information is as follows: Centers for Medicare & Medicaid Services Center for Medicaid and CHIP Services Mail Stop: S2-01-16 7500 Security Boulevard Baltimore, MD 21244-1850 Telephone: (410) 786-3413 E-mail: Joyce.Jordan@cms.hhs.gov

Page 2 – Ms. Jennifer Strohecker

If you have additional questions, please contact Meg Barry, Director, Division of State Coverage Programs, at (410) 786-1536. We look forward to continuing to work with you and your staff.

Sincerely,

Sarah deLone Director /Signed by Sarah deLone/

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

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

State/Territory: Utah (Name of State/Territory)

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

(Signature of Governor, or designee, of State/Territory, Date Signed)

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

The following State officials are responsible for program administration and financial oversight (42 CFR 457.40(c)):

Name: Jennifer Strohecker Position/Title: Medicaid Director, Director of Integrated Healthcare Name: Jeff Nelson

Position/Title: CHIP Director

Name: Jennifer Wiser

Position/Title: CHIP Program Manager

*Disclosure. 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 (CMS-10398 #34). The time required to complete this information collection is estimated to average 80 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, write to: CMS, 7500 Security Blvd., Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

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1.4. Provide the effective (date costs begin to be incurred) and implementation (date services begin to be provided) dates for this SPA (42 CFR 457.65). A SPA may only have one effective date, but provisions within the SPA may have different implementation dates that must be after the effective date.

Original Plan Effective Date: July 10, 1998

Implementation Date: August 1, 1998

SPA #20 Purpose of SPA: CHIP Mental Health Parity Analysis Proposed effective date: 10/02/2018

Proposed implementation date: 10/02/2018

SPA #23 Purpose of SPA: Implement the requirements of section 5022 of the SUPPORT Act

Proposed effective date: 07/01/2020

1.4- TC Tribal Consultation (Section 2107(e)(1)(C)) Describe the consultation process that occurred specifically for the development and submission of this State Plan Amendment, when it occurred and who was involved.

State Plan Amendment 23 was presented at the Indian Health Advisory Board meeting on August 14, 2020. There was no request for consultation.

TN No: Approval Date Effective Date

6.2-BH Behavioral Health Coverage Section 2103(c)(5) requires that states provide coverage to prevent, diagnose, and treat a broad range of mental health and substance use disorders in a culturally and linguistically appropriate manner for all CHIP enrollees, including pregnant women and unborn children.

Guidance: Please attach a copy of the state’s periodicity schedule. For pregnancy-related coverage, please describe the recommendations being followed for those services.

6.2.1- BH Periodicity Schedule The state has adopted the following periodicity schedule for behavioral health screenings and assessments. Please specify any differences between any covered CHIP populations:

State-developed schedule American Academy of Pediatrics/ Bright Futures Other Nationally recognized periodicity schedule (please specify: )

3 Other (please describe: )

6.3- BH Covered Benefits Please check off the behavioral health services that are provided to the state’s CHIP populations, and provide a description of the amount, duration, and scope of each benefit. For each benefit, please also indicate whether the benefit is available for mental health and/or substance use disorders. If there are differences in benefits based on the population or type of condition being treated, please specify those differences.

If EPSDT is provided, as described at Section 6.2.22 and 6.2.22.1, the state should only check off the applicable benefits. It does not have to provide additional information regarding the amount, duration, and scope of each covered behavioral health benefit.

Guidance: Please include a description of the services provided in addition to the behavioral health screenings and assessments described in the assurance below at 6.3.1.1- BH.

6.3.1- BH Behavioral health screenings and assessments. (Section 2103(c)(6)(A))

A Behavioral Health related screening is a covered service. Either the Patient Health Questionnaire PHQ2 and PHQ9 or tools from the AAP list in CCA may be used to conduct this screening.

6.3.1.1- BH The state assures that all developmental and behavioral health recommendations outlined in the AAP Bright Futures periodicity schedule and United States Public Preventive Services Task Force (USPSTF) recommendations graded as A and B are covered as a part of the CHIP benefit package, as appropriate for the covered populations.

Guidance: Examples of facilitation efforts include requiring managed care organizations and their networks to use such tools in primary care practice, providing education, training, and technical resources, and covering the costs of administering or purchasing the tools.

6.3.1.2- BH The state assures that it will implement a strategy to facilitate the use of age-appropriate validated behavioral health screening tools in primary care settings. Please describe how the state will facilitate the use of validated screening tools.

Children eligible for Utah CHIP are enrolled in a managed care plan (MCP). The MCP contract includes provisions that the MCP’s must require the use of age-appropriate screenings for behavioral health in primary care settings. The MCP contract also requires the plans to implement a work plan to for sharing information, coordination of care and monitoring and reporting results of health screenings.

To help members and their families receive integrated mental health

4 services within the primary care setting, and reduce primary care provider (PCP) burden, the MCP’s maintain websites and publications that provide support and screening toolkits for PCPs that include behavioral health related to mental health integration (MHI), substance use disorders, opioid prescribing and suicide prevention. The MCP toolkits include information and instructions on the use of the PHQ-2 and PHQ-9 screening tools, guidance for prescribing opioids, and assistance with the authorization process.

6.3.2- BH Outpatient services (Sections 2110(a)(11) and 2110(a)(19))

Guidance: Psychosocial treatment includes services such as psychotherapy, group therapy, family therapy and other types of counseling services.

The following outpatient Mental Health/SUD benefits are covered: Medically necessary services from contracted hospitals, inpatient treatment centers, inpatient pain clinics, residential treatment centers, day treatment facilities and intensive outpatient programs are covered.

6.3.2.1- BH Psychosocial treatment Provided for: Mental Health Substance Use Disorder

Psychosocial rehabilitative services are designed to increase compliance with medication regimen and restore the patient to his or her maximum functional level through interventions that model daily living and life skills. Coverage of Psychosocial treatment includes: Psychotherapy, group therapy, family therapy and other types of counseling services.

6.3.2.2- BH Tobacco cessation Provided for: Substance Use Disorder

Tobacco Cessation services are covered for all CHIP members. The Utah Tobacco Quit line covers case management, counseling and peer support service Participant services include support via online, over the phone, through their doctor and special services for teens. All four options include a free 2-week OTC Nicotine Replacement Therapy, (gum, patches, or lozenges) starter kit, educational materials based on individual needs, text and email messaging and up to 5 counseling visits. In addition to the Utah Tobacco Quit Line services, the MCP covers Food and Drug Administration (FDA) nicotine replacement therapy (NRT) prescription and over-the-Counter (OTC) medications in combination with education and counseling. Coverage is limited to generic medications and those approved under the plans drug formulary. Two attempts per year are covered and prior authorization is not required.

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Guidance: In order to provide a benefit package consistent with section 2103(c)(5) of the Act, MAT benefits are required for the treatment of opioid use disorders. However, if the state provides MAT for other SUD conditions, please include a description of those benefits below at section 6.3.2.3- BH.

6.3.2.3- BH Medication Assisted Treatment Provided for: Substance Use Disorder

Medication Assisted Treatment MAT Substance Use Disorder (SUD) is covered for all members. The MCP covers all medications with an FDA approved indication for SUD treatment. Prior authorization is required for some medications on the plan’s formulary. As a component of MAT benefits, the MCP covers outpatient counseling without limitations, and in-patient hospitalization, residential treatment centers, and intensive outpatient behavioral health therapy when the member has a substance use disorder diagnosis by a licensed mental health professional in accordance with those described in the DMS-V.

6.3.2.3.1- BH Opioid Use Disorder

Medication Assisted Treatment MAT for opioid use disorder is covered for all members. The MCP covers all medications with an FDA approved indication for opioid use treatment. Prior authorization is required for some medications on the plan’s formulary. As a component of MAT benefits, the MCP covers outpatient counseling without limitations, and in-patient hospitalization, residential treatment centers, and intensive outpatient behavioral health therapy when the member has a substance use disorder diagnosis by a licensed mental health professional in accordance with those described in the DMS-V.

6.3.2.3.2- BH Alcohol Use Disorder

Medication Assisted Treatment MAT for alcohol use disorder is covered for all members. The MCP covers all medications with an FDA approved indication for alcohol use treatment. Prior authorization is required for some medications on the plan’s formulary. As a component of MAT benefits, the MCP covers outpatient counseling without limitations, and in-patient hospitalization, residential treatment centers, and intensive outpatient behavioral health therapy when the member has a substance use disorder diagnosis by a licensed mental health professional in accordance

6 with those described in the DMS-V.

6.3.2.3.3- BH Other

6.3.2.4- BH Peer Support Provided for: Mental Health Substance Use Disorder

6.3.2.5- BH Caregiver Support Provided for: Mental Health Substance Use Disorder

6.3.2.6- BH Respite Care Provided for: Mental Health Substance Use Disorder

6.3.2.7- BH Intensive in-home services Provided for: Mental Health Substance Use Disorder

6.3.2.8- BH Intensive outpatient Provided for: Mental Health Substance Use Disorder

Multidisciplinary, structured services provided at a greater frequency and intensity than routine outpatient treatment is a covered services for mental health and substance use disorder. Common treatment modalities include individual, family, and group psychotherapy, and medication management. A psychiatric disorder diagnosis by a licensed mental health professional is required and systems must accord with those described in the DMS-V.

6.3.2.9- BH Psychosocial rehabilitation Provided for: Mental Health Substance Use Disorder

Guidance: If the state considers day treatment and partial hospitalization to be the same benefit, please indicate that in the benefit description. If there are differences between these benefits, such as the staffing or intensity of the setting, please specify those in the description of the benefit’s amount, duration, and scope.

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6.3.3- BH Day Treatment Provided for: Mental Health Substance Use Disorder

6.3.3.1- BH Partial Hospitalization Provided for: Mental Health Substance Use Disorder

Partial hospitalization requires pre-authorization and is covered when medically necessary. Treatment includes individual and group therapies, medication management and treatment of mental health disorders. Coverage requires symptoms and a psychiatric disorder diagnosis by a licensed mental health professional in accord with DSM-V. The use of ASM guidelines is required in the development of the treatment plan and the length of the program is based on the individual’s medical need.

6.3.4- BH

Inpatient services, including services furnished in a state-operated mental hospital and including residential or other 24-hour therapeutically planned structural services (Sections 2110(a)(10) and 2110(a)(18)) Provided for: Mental Health Substance Use Disorder

Inpatient Mental Health/SUD services are covered. Coverage is the highest intensity of medically necessary 24-hour skilled nursing and medical care from contracted hospitals, inpatient treatment centers, inpatient pain clinics and residential treatment centers. Inpatient services also include coverage of withdrawal management for detoxification. Prior authorization is required for non-emergent inpatient services.

Guidance: If applicable, please clarify any differences within the residential treatment benefit (e.g. intensity of services, provider types, or settings in which the residential treatment services are provided).

6.3.4.1- BH Residential Treatment Provided for: Mental Health Substance Use Disorder

Residential treatment is a covered benefit for both mental health and substance use disorder. The Contractor must verify medical necessity for residential treatment after the first thirty days and every thirty days thereafter. Services must be individualized and provided according to each patient’s assessment/reassessment, treatment plan and patient’s documented mental health disorder. Residential treatment can be covered both short-term and long-term. Long-term involves a stay more than 30 days.

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6.3.4.2- BH Detoxification Provided for: Substance Use Disorder

Withdrawal management in a hospital facility is covered for substance use disorder. The MCP adheres to ASAM criteria for outpatient withdrawal management services and InterQual criteria for inpatient withdrawal management services. Discharge is based on demonstration that withdrawal signs and symptoms are resolved and can be managed n a less intensive level of care.

Guidance: Crisis intervention and stabilization could include services such as mobile crisis, or short term residential or other facility based services in order to avoid inpatient hospitalization.

6.3.5- BH Emergency services Provided for: Mental Health Substance Use Disorder

Members with life-threatening behavioral health problems (crisis) will have access to acute medical care with participating or nonparticipating providers 24 hours a day, 365 days of the year. A crisis is defined as persons presenting with acute symptoms of immediate, actual, or potential danger to self, others, or property. Providers direct members to an emergency room (ER) or a behavioral health crisis center if they are experiencing a behavioral health emergency. Members with non-life-threatening emergent behavioral health problems will have access to care within six hours. A non-life-threatening emergent behavioral health problem is defined as persons not at risk to harm themselves or others. However, if the problem is left unattended, it would exacerbate into a crisis. Members with urgent behavioral health problems will have access to care within 48 hours.

6.3.5.1- BH Crisis Intervention and Stabilization Provided for: Mental Health Substance Use Disorder

Members with life-threatening behavioral health problems (crisis) will have access to acute medical care with participating or nonparticipating providers 24 hours a day, 365 days of the year. Crisis Services are intended to stabilize the person in crisis, prevent further deterioration and provide immediate treatment and intervention in a location best suited to meet the needs of the individual.

6.3.6- BH Continuing care services Provided for: Mental Health Substance Use Disorder

Continuing care is covered when there is a continuation of symptoms consistent with intensive outpatient care and the treatment plan requires ongoing interventions to alleviate impairments and there is evidence that lower-level care would exacerbate the illness.

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6.3.7- BH Care Coordination Provided for: Mental Health Substance Use Disorder

The MCP is responsible to implement a plan to coordinate care and services that must include an assessment of the members needs and an ongoing source of care that is appropriate to the member’s needs. Members are assigned a person or entity that coordinates services between settings of care including appropriate discharge planning for short- and long-term hospital and institutional stays. The plans coordinate care between any other MCO, PHIP or PAHP. If a member requires an individual care coordinator they will work with family, community and social support workers to ensure access to care and continuity of services.

6.3.7.1- BH Intensive wraparound Provided for: Mental Health Substance Use Disorder

6.3.7.2- BH Care transition services Provided for: Mental Health Substance Use Disorder

The MCP plans are required to implement a transition of care policy that is consistent with federal requirements. The care plan must include coverage of inpatient hospital stays through the discharge date when a member is enrolled with their CHIP plan on the date of admission, coverage of home health and medical equipment when the member transitions to another CHIP or Medicaid plan during the 90 days transition period, coverage of service authorizations for 90 days and the development of a care plan.

6.3.8- BH Case Management Provided for: Mental Health Substance Use Disorder

Case management services include coordination and monitoring of physical health, mental health and substance use disorder services. When an Enrollee is identified has having special health care needs the CHIP MCP will coordinate and manage services necessary for such Enrollees. Case managers monitor risk assessments, arrange for special care, service authorizations and assist with language proficiency needs. The MCP is required to submit an annual case management report to the department annually that provides the details of all case management services that were provided for their members.

6.3.9- BH Other Provided for: Mental Health Substance Use Disorder

6.4- BH Assessment Tools

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6.4.1- BH Please specify or describe all of the tool(s) required by the state and/or each managed care entity:

ASAM Criteria (American Society Addiction Medicine) Mental Health Substance Use Disorders

InterQual Mental Health Substance Use Disorders

MCG Care Guidelines Mental Health Substance Use Disorders

CALOCUS/LOCUS (Child and Adolescent Level of Care Utilization System)

Mental Health Substance Use Disorders

CASII (Child and Adolescent Service Intensity Instrument) Mental Health Substance Use Disorders

CANS (Child and Adolescent Needs and Strengths) Mental Health Substance Use Disorders

State-specific criteria (e.g., state law or policies) (please describe) Mental Health Substance Use Disorders

The state does not require the use of any specific evidence-based tool. However, the state does require that an evidence-based tool be used.

Plan-specific criteria (please describe)

Mental Health Substance Use Disorders

Other (please describe) Mental Health Substance Use Disorders

No specific criteria or tools are required Mental Health Substance Use Disorders

Guidance: Examples of facilitation efforts include requiring managed care organizations

11 and their networks to use such tools to determine possible treatments or plans of care, providing education, training, and technical resources, and covering the costs of administering or purchasing the assessment tools.

6.4.2- BH Please describe the state’s strategy to facilitate the use of validated assessment tools for the treatment of behavioral health conditions.

The managed care contract requires the MCP to assure that their network providers use age- appropriate validated behavioral health screening and assessment tools in primary care practice, and they shall provide education, training, and technical resources which includes the cost of administering or purchasing the tools.

6.2.5- BH Covered Benefits The State assures the following related to the provision of behavioral health benefits in CHIP:

All behavioral health benefits are provided in a culturally and linguistically appropriate manner consistent with the requirements of section 2103(c)(6), regardless of delivery system.

The state will provide all behavioral health benefits consistent with 42 CFR 457.495 to ensure there are procedures in place to access covered services as well as appropriate and timely treatment and monitoring of children with chronic, complex or serious conditions.

_____________________________________________________________________________ Table of Contents State/Territory Name: State Plan Amendment (SPA) #: This file contains the following documents in the order listed: 1) Approval Letter 2) State Plan Pages Utah UT-21-0025

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-01-16 Baltimore, MD 21244-1850 Children and Adults Health Programs Group November 19, 2021 Jeff Nelson CHIP Director Division of Medicaid and Health Financing P.O. Box 143101 Salt Lake City, UT 84114-3101 Dear Mr. Nelson: I am pleased to inform you that your title XXI Children’s Health Insurance Program (CHIP) state plan amendment (SPA), UT-21-0025, submitted on October 15, 2021, has been approved. Through SPA UT-21-0025, Utah adds coverage of behavioral therapy and other services for the treatment of autism spectrum disorder, including applied behavioral analysis, to its CHIP benefit package, with an effective date of July 1, 2021. This SPA also updates the CHIP state plan by removing non-substantive outdated references. Your title XXI project officer is Ms. Joyce Jordan. She is available to answer questions concerning this amendment and other CHIP-related issues. Ms. Jordan’s contact information is as follows: Centers for Medicare & Medicaid Services Center for Medicaid and CHIP Services 7500 Security Boulevard, Mail Stop: S2-01-16 Baltimore, MD 21244-1850 Telephone: (410) 786-3413 E-mail: Joyce.Jordan@cms.hhs.gov If you have additional questions, please contact Emily King, Deputy Director, Division of State Coverage Programs at (443) 478-6811. We look forward to continuing to work with you and your staff. Sincerely, Amy Lutzky Deputy Director /Signed by Amy Lutzky/

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

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

State/Territory: The State of Utah

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

________________________________________________________________________ (Signature of Governor, or designee, of State/Territory, Date Signed)

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

The following State officials are responsible for program administration and financial oversight (42 CFR 457.40(c)):

Name: Emma Chacon Position/Title: Director, Medicaid and Health Financing Name: Jeff Nelson Position/Title: CHIP Director Name: Jennifer Wiser Position/Title: CHIP Program Manager

*Disclosure. 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 09380707. The time required to complete this information collection is estimated to average 160 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, write to: CMS, 7500 Security Blvd., Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

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1.4 Provide the effective (date costs begin to be incurred) and implementation (date services begin to be provided) dates for this SPA (42 CFR 457.65). A SPA may only have one effective date, but provisions within the SPA may have different implementation dates that must be after the effective date.

Original Plan Effective Date: July 10, 1998 Implementation Date: August 1, 1998

SPA #_10_, Purpose of SPA: Rebenchmark CHIP benefits Proposed effective date: November 19, 2011 Proposed implementation date: November 19, 2011

SPA #_11_, Purpose of SPA:_ Express Lane Eligibility and Presumptive Eligibility - pending Proposed effective date: ELE- September 1, 2011; Presumptive Eligibility- April 1, 2012 Proposed implementation date: ELE- September 1, 2011; PE- April 1, 2012

SPA #_12_, Purpose of SPA: Rebenchmark CHIP benefits Proposed effective date: July 1, 2012 Proposed implementation date: July 1, 2012 Withdrawn

SPA #_13_, Purpose of SPA: Rebenchmark CHIP benefits Proposed effective date: July 1, 2012 Proposed implementation date: July 1, 2012

SPA #_14_, Purpose of SPA: Eliminate Presumptive Eligibility for children that meet the requirements of section 1920A of the Act. (Section 2107 (e)(1)(L)); (42 CFR 457.355) Removing references to Plan A. Proposed effective date: November 1, 2014 Proposed implementation date: November 1, 2014

SPA# 15, Purpose of SPA: Ex Parte Reviews Proposed effective date: February 1, 2015 Proposed implementation date: February 1, 2015

SPA# 16, Purpose of SPA: Change Reports Proposed effective date: November 1, 2015 Proposed implementation date: November 1, 2015

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SPA# 17, Purpose of SPA: Rebenchmark CHIP dental benefits Proposed effective date: July 1, 2016 Proposed implementation date: July 1, 2016

SPA# 18, Purpose of SPA: FQHC Payment Methodology Proposed effective date: July 1, 2016 Proposed implementation date: July 1, 2016

SPA# 21 Purpose of SPA: Update CHIP benefits Proposed effective date: July 1, 2019 Proposed implementation date: July 1, 2019

SPA# 22, Purpose of SPA: Add CHIP Disaster Relief Plan Proposed effective date: March 1, 2020 Proposed implementation date: March 1, 2020

SPA# 24, Purpose of SPA: Delay timeliness requirements on ex parte renewals. Proposed effective date: February 1, 2021 Proposed Implementation date: February 1, 2021

SPA# 25, Purpose of SPA: Update CHIP Benefits Proposed implementation date: July 1, 2021 Proposed Implementation date: July 1, 2021

1.4- TC Tribal Consultation (Section 2107(e)(1)(C)) Describe the consultation process that occurred specifically for the development and submission of this State Plan Amendment, when it occurred and who was involved.

State Plan Amendments 10 & 11 was presented at the Indian Health Advisory Board meeting on October 7, 2011. There was no request for consultation.

State Plan Amendment 13 was presented at the Utah Indian Health Advisory Board meeting on August 3, 2012. Consultation was not requested.

State Plan Amendment 14 was presented at the Utah Indian Health Advisory Board meeting on 08/08/2014. Consultation was not requested.

State Plan Amendment 15 was presented at the Utah Indian Health Advisory Board meeting on 12/12/2014. Consultation was not requested.

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State Plan Amendment 16 was presented at the Utah Indian Health Advisory Board meeting on 10/9/2015. Consultation was not requested.

State Plan Amendment 17 was presented at the Utah Indian Health Advisory Board meeting on 7/8/2016. Consultation was not requested.

State Plan Amendment 18 was presented at the Utah Indian Health Advisory Board meeting on 3/10/2017. Consultation was not requested.

State Plan Amendment 21 was presented at the Utah Indian Health Advisory Board meeting on June 7, 2019. Consultation was not requested.

State Plan Amendment 22 in concept was presented at the Utah Indian Health Advisory Board meeting on April 10, 2020. The final SPA was presented to the board on May 8, 2020, after the SPA was submitted to CMS. To address the Federal COVID-19 public health emergency, the State received waiver approval under section 1135(b)(5) of the Act, for flexibility to modify the timeframes associated with tribal consultation, including conducting consultation after submission of the SPA. Consultation was not requested.

State Plan Amendment 24 was presented to the Utah Indian Health Advisory Board meeting on February 12, 2021, again after CMS guidance on March 12, 2021, and finally a status update on April 9, 2021. Consultation was not requested.

State Plan Amendment 25 was presented to the Utah Indian Health Advisory Board meeting on August 13, 2021. Consultation was not requested.

TN No: Approval Date Effective Date _____

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

☒ Check here if the State child health program delivers services using a managed care delivery model. The State provides an assurance that its managed care contract(s) complies with the relevant provisions of section 1932 of the Act,

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including section 1932(a)(4), Process for Enrollment and Termination and Change of Enrollment; section 1932(a)(5), Provision of Information; section 1932(b), Beneficiary Protections; section 1932(c), Quality Assurance Standards; section 1932(d), Protections Against Fraud and Abuse; and section 1932(e), Sanctions for Noncompliance. The State also assures that it will submit the contract(s) to the CMS’ Regional Office for review and approval. (Section 2103(f)(3))

CHIP contracts with two managed care organizations (MCO) to provide medical care for children enrolled in CHIP: SelectHealth Molina Health Care of Utah

CHIP contracts with Premier Access statewide to provide dental services for children enrolled in CHIP:

These managed care organizations have extensive provider networks and include all the major hospitals, physician groups and clinics (both primary care and specialists), and specialty providers such as home health, physical therapy, and hospice. The experience of CHIP, in contracting with multiple managed care organizations, demonstrates an ability to develop and maintain provider networks. The availability of these extensive networks within the managed care organizations improves access and continuity of care provided to CHIP enrollees.

As the agency designated to implement the Utah Children’s Health Insurance Program, CHIP and the DOH will offer its long-time experience in working with managed care organizations and negotiate contracts with any willing provider to serve CHIP enrollees in both urban and rural areas of the state. Offering services through more than one network of providers will give CHIP enrollee’s greater access and continuity of care through a greater choice of health care providers.

The issues of language and hours of service barriers will be critical in serving CHIP enrollees. CHIP contracts require interpretive services to be provided. For example, current contracts state:

Health Plans shall provide interpretive services for languages on an as needed basis at no cost to the enrollees. These requirements shall extend to both in- person and telephone communications to ensure that enrollees are able to communicate with the Health Plan and Health Plan providers and receive covered benefits. Professional interpreters shall be used when needed where technical, medical, or treatment information is to be discussed, or where use of a family member or friend, as interpreter is inappropriate. Family members may be used as interpreters at the enrollee’s request only after the enrollee has been

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notified that professional interpreters are available at no cost. Family members, especially children, should not be used as interpreters in assessments, therapy and other situations where impartiality is critical…

Materials written in a language other than English are a contract requirement of MCOs when the non-English speaking population represents 5% of the total population.

Hours of service barriers are a general problem of the health delivery system-— public or private. CHIP and its contracting MCO’s use Community Health Centers, extended hour clinics, and urgent care centers to partially address this systemic problem. In addition, divisional contracts hold the MCOs responsible for all covered emergency services 24 hours a day and 7 days a week, whether services were provided in or out of the respective managed care organization.

Standards for waiting times for appointments and office waiting times have been established with all contracting MCOs. These standards are monitored.

The described requirements and standards are part of the contracts the Department has developed with participating MCO’s to serve the Children’s Health Insurance Program.

All of the above areas are part of the state’s MCO Quality Assurance Monitoring Plan and are monitored during annual on-site reviews. CHIP will be included in this monitoring.

Federally Qualified Health Center (FQHC) and Rural Health Clinic (RHC) Payments from CHIP Managed Care Plans (MCPs)

The CHIP MCPs shall pay to Federally Qualified (“FQHCs”) and Rural Health Clinics (“RHCs”) with which it is contracted an amount not less than what it pays other similar providers that are not FQHCs and RHCs.

The CHIP MCPs shall pay an Indian health care provider that is both an FQHC and a non-participating provider at the same rate that they would pay a participating provider.

FQHC Payment by the Division of Medicaid and Health Financing

Beginning February 3, 2004, FQHCs may elect to be paid under one of two payment methods–the Prospective Payment Method (PPS) or the Alternative Payment Method (APM). Each FQHC must elect its payment methodology

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preference and give notice to the Division of Medicaid Health Financing (DMHF) on or before January 1, 2004, to be effective February 3, 2004. If an FQHC elects to change payment methods in subsequent years, an election to do so must be made no later than thirty (30) days prior to the beginning of the FQHC’s fiscal year by written notice to (DMHCF).

A. Prospective Payment System (PPS).

1. Payment under PPS methodology conforms to the Federal methodology as contained in section 702 of the Benefits Improvement and Protection Act of 2001. PPS is the only approved methodology for the time period January 1, 2001 thru February 2, 2004, under the State Plan in effect for that time period.

PPS rates for each FQHC are determined on the basis of their 1999 and 2000 fiscal years’ reasonable costs, adjusted for any subsequent change in scope of services (See Section C, below). The average of the two-year costs are divided by the average number of visits for the same two-year period. The resulting prospective rate is increased on January 1 of each subsequent year by the applicable Medicare Economic Index for primary care services.

2. Regarding FQHCs which contract with CHIP Managed Care Plans (MCPs), supplemental payments will be estimated and paid quarterly to the FQHCs for the difference between amounts paid by the MCPs and amounts the FQHCs are entitled to under the PPS. Quarterly interim payments will be made no later than thirty (30) days after the end of the quarter. Annual reconciliations will be made and settled.

3. The PPS rate for newly qualified FQHCs in 2001 and later will be established by reference to PPS rates of other FQHCs in the same or adjacent areas with similar caseload, or by cost reporting methods. 4. FQHCs located out-of-state that serve Utah CHIP clients will be paid the reimbursement rate applicable to the state in which services are provided.

B. Alternative Payment Method (APM) - Ratio of Covered Beneficiary Charges to Total Charges Applied to the Allowable Cost (RCCAC)

1. Beginning February 3, 2004, an alternative payment method

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(APM) was adopted and available for election. Under RCCAC, allowable costs are determined using applicable Medicare cost principles, as addressed in 42 CFR and CMS Publication 15-1, and allowable costs are allocated to CHIP using the percentage of CHIP covered billed charges to total charges for all patients. Total allowable costs are multiplied by the CHIP charge percentage to determine the amount of allowable cost to be paid by CHIP. Interim payments will be made on the basis of billed charges and valid claims processed and paid by CHIP will reduce the final settlements.

2. FQHCs participating in the alternative payment method will provide DMHF with annual cost reports and other information required by DMHF within ninety (90) days from the close of their fiscal year-end to include the provider calculations of their anticipated settlement. DMHF will review submitted cost reports and provide a preliminary payment, if applicable, to FQHCs on the basis of a desk settlement. About 6 months after the FQHC’s fiscal year-end, DF will conduct a desk review or audit of submitted cost reports and perform final settlements. This will allow for the inclusion of late filed claims and adjustments processed after the submitted cost report was prepared. Claims data changes from the final settlement through one year will be added to the following year’s settlement. If over-payments to the FQHC occur, pay-back to the State is required. If underpayment occurs, a payment adjustment will be made to the FQHC.

3. The alternative payment method described herein will be compared with the reimbursements calculated using the PPS methodology described in Section A. above. The greater amount will be paid to the FQHCs.

C. Scope of Service Changes

Scope of service changes must be substantiated by adequate documentation. FQHCs electing the PPS method must submit documentation with an estimate of the cost of the change in scope of service to receive an adjustment in their encounter rate. Scope changes need to be accounted for by all FQHCs because annual comparisons to APM need to be made. Actual detail cost elements need to be tracked in the general ledger accounts or otherwise to allow for verification and testing. Overstated estimated costs require pay-back. Underestimated costs will be reimbursed.

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D. CHIP Managed Care Settlements

For FQHCs servicing CHIP clients, the difference between FQHC costs minus MCO/PAHP reimbursement will be determined annually and settled. The determination of cost will be on the basis of the RCCAC as noted in Section B. Quarterly estimated payments will be made to FQHCs on the basis of the most recent prior year annual reconciliation.

RHC Payment by the Division of Medicaid and Health Financing

A. Prospective Payment System (PPS)

1. Payment for Rural Health Clinic services conforms to section 702 of the Benefits Improvement and Protection Act (BIPA) of 2000. All Rural Health Clinics are reimbursed on a prospective payment system beginning with Fiscal Year 2001 with respect to services furnished on or after January 1, 2001, and each succeeding year.

2. Payment rates will be set prospectively using the total of the clinic’s reasonable costs for the clinic’s fiscal years 1999 and 2000, adjusted to take into account any increase or decrease in the scope of services furnished during the clinic’s fiscal year 2001. These costs are divided by the average number of visits for the two-year period to arrive at a cost per visit. The cost per visit is the prospective rate for calendar year 2001. Beginning in FY 2002, and for each clinic fiscal year thereafter, each clinic will be paid the amount (on a per visit basis) equal to the amount paid in the previous clinic fiscal year, increased by the percentage increase in the Medicare Economic Index (MEI) for primary care services, and adjusted to take into account any increase (or decrease) in the scope of services furnished by the clinic during that fiscal year. The clinic must supply documentation to justify scope of service adjustments.

3. For newly qualified RHCs after State fiscal year 2000, initial payments are established either by reference to payments to other clinics in the same or adjacent areas with similar case load, or in the absence of other clinics, by cost reporting methods. After the initial year, payment is set using the MEI methods used for other clinics, and adjustments for increases or decreases in the scope of service furnished by the clinic during that fiscal year.

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4. Until a prospective payment methodology is established, the state will reimburse RHCs based on the State Plan in effect on July 1, 2016. The state will reconcile payments made under this methodology to the amounts to which the clinic is entitled under the prospective payment system. This is done by multiplying the encounters during the interim period by the prospective rate and determining the amounts due to (or from) the clinics for the interim period.

5. RHCs located out-of-state that serve Utah CHIP clients will be paid the reimbursement rate applicable to the state in which services are provided.

B. CHIP Managed Care Settlements

In the case of any RHC which contracts with a CHIP MCP, supplemental payments will be made quarterly to the clinic for the difference between the payment amounts paid by the MCP and the amount to which the clinic is entitled under the prospective payment system.

Cost Settlement

A. The DMHF shall perform a cost settlement of the quarterly interim payments by utilizing the following formula:

Per Encounter Prospective Payment rate multiplied by the number of Encounters included in the reconciliation period minus the amount paid by the CHIP MCP to the FQHC during this period, minus the total quarterly interim payments made by the DMHF for the reconciliation period.

B. If the Cost Settlement formula shows that the quarterly interim payments made to the FQHC exceeded the amount allowed by the cost settlement, the DMHF shall recover the overpaid amount by making proportional adjustments to future supplemental payments.

C. If the Cost Settlement formula shows the quarterly interim payments made to the FQHC were less than the amount to which the FQHC is entitled, the DMHF shall pay the FQHC the remaining amount owed.

D. The DMHF, in its sole discretion, determines the period of time which constitutes the cost settlement reconciliation period.

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Cost Settlement Review Process

A. The DMHF shall review and edit the Encounter Data (or raw claims data) sent in by the CHIP MCPs. The DMHF may, at its discretion, disallow an Encounter/Claim where the Encounter/Claim: 1. was not appropriately paid by the contractor under the CHIP program; 2. was duplicative; 3. was untimely; or 4. should otherwise be disallowed per the DMHFs determination.

B. The DMHF shall provide the FQHC with an electronic file of the Encounters/Claims that it will use in the cost settlement calculation. If the FQHC determines that the Encounters/Claims are incomplete or believes the DMHF has incorrectly disallowed Encounters/Claims, the FQHC shall send to the DMHF any missing claims records that it believes should be included. The FQHC shall provide this information to the DMHF within any deadlines the DMHF sets. The DMHF shall review the FQHC’s additional claims, make changes based on the FQHC’s input, and shall send a final file of the Encounters/Claims that the DMHF will include as part of the Cost Settlement. If the FQHC disagrees with the final Encounter/Claim record provided by the DMHF, the FQHC may request a hearing.

Guidance: In Section 3.2., note that utilization control systems are those administrative mechanisms that are designed to ensure that enrollees receiving health care services under the State plan receive only appropriate and medically necessary health care consistent with the benefit package.

Examples of utilization control systems include, but are not limited to: requirements for referrals to specialty care; requirements that clinicians use clinical practice guidelines; or demand management systems (e.g., use of an 800 number for after-hours and urgent care). In addition, the State should describe its plans for review, coordination, and implementation of utilization controls, addressing both procedures and State developed standards for review, in order to assure that necessary care is delivered in a cost-effective and efficient manner. (42CFR, 457.490(b))

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

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Scope of Coverage

Services provided directly by licensed physicians or osteopaths, or by other licensed professionals such as physician assistants, nurse practitioners, or nurse midwives under the physician’s or osteopath's supervision. Includes surgery and anesthesia.

Exclusions

1. Acupuncture and acupressure 2. Services obtained for administrative purposes. Such administrative purposes include services obtained for or pursuant to legal proceedings, court orders, employment, continuing or obtaining insurance coverage, governmental licensure, home health recertification, travel, military service, school, or institutional requirements. Provider and Facility charges for completing insurance forms, duplication services, interest (except where required by Utah Administrative Code R590-192), finance charges, late fees, shipping and handling, missed appointments, and other administrative charges. 3. The following allergy test are not covered: Cytotoxic test, leukocyte histamine release test, mediator release test, passive cutaneous transfer test, provocative conjunctival test, provocative nasal test, rebuck skin window test, rinkel test, subcutaneous provocative food and chemical test, sublingual provocative food and chemical test. The following allergy treatments are not covered: allergoids, autogenous urine immunizations, LEAP therapy, medical devices (filtering air cleaner, electrostatic air cleaner, air conditioners etc.), neutralization therapy, photo-inactivated extracts, polymerized extracts, oral desensitization/ immunotherapy. 4. General anesthesia in a provider’s office. 5. Cognitive or behavioral therapies for the treatment of attention deficit/hyperactivity disorder. 6. Biofeedback/neurofeedback 7. The following cancer therapies are not covered: neutron beam therapy and proton beam therapy. 8. Services or an illness, condition, accident, or injury are not covered if they occurred: a. While the member was a voluntary participant in the commission of a felony b. While the member was a voluntary participant in disorderly conduct, riot, or other breach of the peace c. While the member was engaged in any conduct involving the illegal use or misuse of a firearm or other deadly weapon d. While the member was driving or otherwise in physical control of a car, truck,

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motorcycle, scooter, off-road vehicle, boat, or other motor driven vehicle if the member either had sufficient alcohol in the member’s body that a subsequent test shows that the member has either a blood or breath alcohol concentration of .08 grams or greater at the time of the test or had any illegal drug or their illegal substance in the member’s body to a degree that it affected the members’ ability to drive or operate the vehicle e. While the member was driving or otherwise in physical control of a car, truck, motorcycle, scooter, off road vehicle, boat, or other motor driven vehicle either without a valid driver’s permit or license, if required under the circumstances or without the permission of the owner of the vehicle f. As a complication of, or as the result of, or as follow up care for, any illness, condition, accident, or injury that is not covered as the result of this exclusion 9. Generally, claims with a date of service over one year old should be denied by the plan. Exceptions to this general rule should be addressed by the plan’s policy and in its procedures. 10. Complementary, alternative and nontraditional services. Such services include acupuncture, homeopathy, homeopathic drugs, certain bioidentical hormones, massage therapies, aromatherapies, yoga, hypnosis, rolfing, and thermography 11. All services provided or ordered to treat complications of non-covered services are not covered unless stated otherwise in this document. 12. Custodial care 13. Dry needling procedures 14. Services for which the member has obtained a payment, settlement, judgment, or other recovery for future payment intended as compensation 15. Services received by a member incarcerated in a prison, jail, or other correctional facility at the time services are provided, including care provided outside of a correctional facility to a person who has been arrested or is under a court order of incarceration 16. Experimental and/or investigational services for which one or more of the following apply: it cannot be lawfully marketed without the approval of the Food and Drug Administration (FDA) and such approval has not been granted at the time of its use or proposed use; it is the subject of a current investigational new drug or new device application on file with the FDA; it is being provided pursuant to a Phase I or Phase II clinical trial or as the experimental or research arm of a Phase III clinical trial; it is being or should be delivered or provided subject to the approval and supervision of an Institutional Review Board (IRB) as required and defined by federal regulations, particularly those of the FDA or the Department of Health and Human Services (HHS); if the predominant opinion among the appropriate experts as expressed in the peer reviewed medical literature is that further research is necessary in order to define safety, toxicity, effectiveness, or comparative effectiveness, or there is no clear medical consensus about the role

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and value of the service. 17. Fitness training, conditioning, exercise equipment, and membership fees to a spa or health club. 18. Except for dietary products as defined by the Health Plan, food supplements and substitutes are not covered. 19. Gene therapy or gene based therapies 20. Services designed to create or establish function that was not previously present 21. The following immunizations are not covered: anthrax, BCG (tuberculosis), cholera, plague, typhoid, and yellow fever. 22. When a non-covered service is performed as part of the same operation or process as a covered service, only charges relating to the covered service will be considered. Allowed amounts may be calculated and fairly apportioned to exclude any charges related to the non-covered service. 23. The following pain management services are not covered: prolotherapy, radiofrequency ablation of dorsal root ganglion, acupuncture, IV pamidronate therapy for the treatment of reflex sympathetic dystrophy 24. Services for pervasive developmental disorder 25. Services provided to a member by a provider who ordinarily resides in the same household as the member 26. Service related to sexual dysfunction 27. Coverage for specific specialty services may be restricted to only those providers who are board certified or have other formal training that is considered necessary to perform those services 28. The following specific services are not covered: anodyne infrared device for any indication; auditory brain implantation; chronic intermittent insulin IV therapy/metabolic activation therapy; coblation therapy of the soft tissues of the mouth, nose, throat, or tongue; computer assisted interpretation of x-rays (except mammograms); extracorporeal shock wave therapy for musculoskeletal indications; cryoablation therapy for plantar fasciitis and Morton’s neuroma; freestanding/home cervical traction; home anticoagulation or hemoglobin A1C testing; infrared light coagulation for the treatment of hemorrhoids,; interferential/neuromuscular stimulator; intimal media thickness testing to assess risk of coronary disease; lovaas therapy; magnetic source imaging; microprocessor controlled, computerized lower extremity limb prostheses; mole mapping; nonsurgical spinal decompression therapy; nucleoplasty or other forms of percutaneous disc decompression; pressure specified sensory device for neuropathy testing; prolotherapy; radiofrequency ablation for lateral epicondylitis; radiofrequency ablation of the dorsal root ganglion; secretin infusion therapy for the treatment of autism; virtual colonoscopy; whole body scanning 29. Charges for provider telephone, email, or other electronic consultations

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30. Services for an illness, injury, or connected disability are not covered when caused by or arising out of an act of international or domestic terrorism, as defined by United States Code, Title 18, Section 2331, or from an accidental, negligent, or intentional release of nuclear material or nuclear byproduct material as defined by United States Code, Title 18, Section 831. 31. Costs associated with travel to a local or distant medical provider, including accommodation and meal costs, are not covered. 32. Services for an illness, injury, or connected disability are not covered when caused by or arising out of a war or an act of war (whether or not declared) or service in the armed services of any country 33. Charges prior to coverage or after termination of coverage even if illness or injury occurred while the insured is covered by CHIP 34. Charges for educational material, literature or charges made by a provider to the extent that they are related to scholastic education, vocational training, learning disabilities, behavior modification, dealing with normal living such as dies, or medication management for illnesses such as diabetes 35. Charges for services primarily for convenience, contentment or other non- therapeutic purpose 36. Charges for any service or supply not reasonable or necessary for medical care of the patient’s illness or injury 37. Charges which the insured is not, in the absence of coverage, legally obligated to pay 38. Charges for services, treatments or supplies received as a result of an act of war occurring when the insured was covered by CHIP 39. Charges for any services received as a result of an industrial injury or illness, any portion of which is payable under workman’s compensation or employer’s liability laws 40. Charges for services or supplies resulting from participating in or in consequence of having participated in the commission of an assault or felony 41. Charges made for completion or submission of insurance forms 42. Charges for care, treatment, or surgery performed primarily for cosmetic purposes, except for expenses incurred as a result of an injury suffered in the preceding five years 43. Shipping, handling, or finance charges 44. Charges for medical care rendered by an immediate family member are subject to review by CHIP and may be determined by CHIP as ineligible 45. Charges for expenses in connection with appointments scheduled and not kept 46. Charges for telephone calls or consultations.

6.2.11. ☒ Outpatient mental health services, other than services described in

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6.2.19, but including services furnished in a state-operated mental hospital and including community-based services (Section 2110(a)(11)

Scope of Coverage

Inpatient and outpatient services are covered. Medically necessary services from contracted hospitals, inpatient treatment centers, inpatient pain clinics, day treatment facilities or intensive outpatient programs are covered.

Effective July 2021 treatment for Autism Spectrum Disorder (ASD) for all members on CHIP with a valid ASD diagnosis. The service goal of these services is to provide counseling and treatment programs, including applied behavioral analysis (ABA) that: (1) Are necessary to develop, maintain, or restore, to the maximum extent practicable, the functioning of an individual; (2) are provided or supervised by board certified clinicians, psychologists and behavior analysts who have been trained on the use and interpretation of assessment tools, and can render an ASD diagnosis under the scope of their licensure; and (3) diagnosis ASD by means of medically necessary assessments, evaluations, or tests that are: (i) Performed by a clinicians, and psychologists with experience diagnosing ASD; and

(ii) necessary to diagnose whether an individual has ASD. Coverage for the treatment of ASD includes behavioral health treatment, pharmacy care, psychiatric care and therapeutic care. Services that are part of the behavioral health treatment including ABA are not subject to cost sharing.

8.2.3. Coinsurance or Co-payments:

The following are the co-payment and co-insurance requirements for participation in CHIP. Levels of co-payments will be limited to the income groups identified in the federal enabling legislation 2103(e)(3)(A) & (B).

Plan B Co-Payment requirements:

Hospital Services:

-$150 co-payment after deductible for inpatient services

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-Co-insurance, 5% for surgeon and anesthesiologist services

-$5 co-payment for urgent care center services and emergency use of the emergency room

-$10 co-payment for non-emergency use of the emergency room -Co-insurance, 5% after deductible for outpatient hospital services.

Ambulance (air and ground) for medical emergencies:

-Co-insurance, 5% after deductible

Physician Office Visits (includes visits to a Specialist):

-$5 co-payment per visit

-No co-payment for well-baby care, well-child care, and immunizations.

Prescription Drugs:

-$5 co-payment per prescription for generics

-Co-insurance, 5% per prescription for brand name drugs.

Laboratory and X-ray Services:

-$0 co-payment for laboratory and x-ray services for minor diagnostic tests and x-rays

-Co-insurance, 5% after deductible for major diagnostic tests and x-rays

Vision Screening Services:

-$5 co-payment (limit of one exam per plan year)

Hearing Screening Services:

-$5 co-payment (limit of one exam per plan year)

Dental Services:

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-Maximum benefit of $1,000 per person, per year

-$0 co-payment for cleanings, exams, x-rays, fluoride, and sealants

-5% co-insurance for all other covered services

-Orthodontic benefits are only covered if the client scores 30 or greater on the Salzmann Index

Mental Health Services, Inpatient Facility:

-$150 co-payment after deductible for each visit

Mental Health Services, Outpatient, Office Visit & Urgent Care:

-$0 co-payment for each visit

Residential Treatment:

$0 co-payment

Home Health and Hospice Care:

-Co-insurance of 5% after deductible per visit

Medical Equipment and Supplies:

-Co-insurance of 5% after deductible

Physical, Occupational and Speech Therapy:

-$5 co-payment, 20 visits combined limit per child, per plan year

Applied Behavior Analysis for the Treatment of Autism Spectrum Disorder:

-$0 co-payment

Out- of-Pocket Maximum:

-5% of a family’s annual gross countable income. Only out of pocket costs for covered services, deductibles, co-pays, and premiums will be used to calculate the maximum out of pocket limit.

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Plan C Co-Insurance and Co-Payment requirements:

Hospital Services:

-Co-insurance, 20% after deductible for inpatient services

-$300 co-payment for emergency or non-emergency use of the emergency room, after deductible ; $300 per visit for non participating hospitals, after deductible

-$40 co-payment each urgent care center visit

-Co-insurance of 20% of total charges for surgeon and anesthesiologist services, after deductible.

-Co-insurance, 20% after deductible for outpatient services.

Ambulance (air and ground) for medical emergencies:

-Co-insurance, 20% after deductible

Physician office visits:

-$25 co-payment per visit (excluding visits to a Specialist)

-$40 co-payment per visit to a Specialist

-No co-payment for well-baby care, well-child care and immunizations

Prescription Drugs:

-$15 co-payment per prescription for generic drugs; Co-insurance 25% of total or brand name drugs on the approved list. Co-insurance 50% of total per prescription for brand name drugs not on the approved list

Laboratory and X-Ray Services:

-$0 co-payment for minor diagnostic tests and x-rays

-Co-insurance, 20% after deductible for major diagnostic tests and x-rays

Vision Screening Services:

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-$25 co-payment, limit of one exam per plan year

Hearing Screening Services:

-$25 co-payment, limit of one exam per plan year

Dental Services:

-Maximum benefit of $1,000 per person, per year

-Plan pays 100% for cleanings, exams, x-rays, fluoride, and sealants

-Co-insurance, 20% after deductible for all other covered services

-Co-insurance, 50% after deductible for porcelain-fused crowns (not Covered for non-adult and back teeth)

-Orthodontic benefits are only covered if the client scores 30 or greater on the Salzmann Index

Mental Health Services In-Patient Facility

-Co-insurance, 20% after deductible.

Mental Health Services Outpatient, Office Visit & Urgent Care

-$0 co-payment for each visit

Residential Treatment

-$0 co-payment

$ Home Health and Hospice Care:

-Co-insurance, 20% after deductible

Medical Equipment and Supplies:

-Co-insurance, 20% after deductible

Physical, Occupational and Speech Therapy:

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-$40 co-payment after deductible, 20 visits combined limit, per child, per plan year.

Applied Behavior Analysis for the Treatment of Autism Spectrum Disorder:

-$0 co-payment

Out-of-Pocket Maximum:

-5% of a family’s annual gross countable income. Only out of pocket costs for covered services, deductibles, co-pays, and premiums will be used to calculate the maximum out of pocket limit.

9.10 Provide a 1-year projected budget. A suggested financial form for the budget is below. The budget must describe: (Section 2107(d)) (42CFR 457.140)

· Planned use of funds, including: · Projected amount to be spent on health services; · Projected amount to be spent on administrative costs, such as outreach, child health initiatives, and evaluation; and · Assumptions on which the budget is based, including cost per child and expected enrollment. · projected expenditures for the separate child health plan, including but not limited to expenditures for targeted low income children, the optional coverage of the unborn, lawfully residing eligibles, dental services, etc. All cost sharing, benefit, payment, eligibility need to be reflected in the budget.

· Projected sources of non-Federal plan expenditures, including any requirements for cost-sharing by enrollees. · Include a separate budget line to indicate the cost of providing coverage to pregnant women. · States must include a separate budget line item to indicate the cost of providing coverage to premium assistance children. · Include a separate budget line to indicate the cost of providing dental-only supplemental coverage. · Include a separate budget line to indicate the cost of implementing Express Lane Eligibility. · Provide a 1-year projected budget for all targeted low-income children covered under the state plan using the attached form. Additionally, provide the following:

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- Total 1-year cost of adding prenatal coverage - Estimate of unborn children covered in year 1

CHIP Budget STATE: UTAH FFY Budget Federal Fiscal Year FFY 2022 State's enhanced FMAP rate 23.22%

Benefit Costs

Insurance payments

Managed care (CHIP) $28,041,600 Managed Care Payments (MCHIP) $97,094,900 per member/per month rate $184.64 Fee for Service

Health Services Initiatives - Cost of Proposed SPA changes $2,100,000 Total Benefit Costs $127,236,500 (Offsetting beneficiary cost sharing payments) $(9,112,400 ) Net Benefit Costs $118,124,100

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Administration Costs

Personnel $532,400 General administration $375,600 Contractors/Brokers $2,128,300 Claims Processing - Outreach/marketing costs - Other $2,008,000 Total Administration Costs $5,044,300 10% Administrative Cap $10,037,500

Federal Share $94,568,700 State Share $28,599,700 Total Costs of Approved CHIP Plan $123,168,400 NOTE: Include the costs associated with the current SPA. The Source of State Share Funds: State General Funds/Tobacco Settlement Funds

_____________________________________________________________________________ Table of Contents State/Territory Name: State Plan Amendment (SPA) #: This file contains the following documents in the order listed: 1) Approval Letter 2) State Plan Pages Utah UT-22-0026

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-01-16 Baltimore, MD 21244-1850 Children and Adults Health Programs Group April 22, 2022 Jennifer Strohecker Medicaid Director Director, Division of Integrated Healthcare P.O. Box 143101 Salt Lake City, UT 84114-3101 Dear Ms. Strohecker: Your title XXI Children’s Health Insurance Program (CHIP) State Plan Amendment (SPA) number UT-22-0026, submitted on March 24, 2022, has been approved. Through this SPA, Utah has demonstrated compliance with the American Rescue Plan Act of 2021 (ARP). This SPA has an effective date of March 11, 2021 and extends through the last day of the first calendar quarter that begins one year after the last day of the COVID-19 emergency period, as described in section 1135(g)(1)(B) of the Social Security Act (the Act). Section 9821 of the ARP amended sections 2103(c)(11)(B) and 2103(e)(2) of the Act to mandate coverage of COVID-19 testing, treatment, and vaccines and their administration without cost- sharing or amount, duration, or scope limitations. Sections 2103(c)(11)(B) and 2103(e)(2) of the Act also require states to cover, without cost sharing, the treatment of conditions that may seriously complicate COVID-19 treatment, during the period when a beneficiary is diagnosed with or is presumed to have COVID-19. The state provided the necessary assurances to demonstrate compliance with the ARP in accordance with the requirements of sections 2103(c)(11)(B) and 2103(e)(2) of the Act. Pursuant to section 1135(b)(5) of the Act, for the period of the public health emergency, CMS is modifying the requirement at 42 C.F.R. 457.65 that the state submit SPAs that are related to the COVID-19 public health emergency by the end of the state fiscal year in which they take effect. CMS is allowing states that submit SPAs after the last day of the state fiscal year to have an effective date in the prior state fiscal year, but no earlier than the effective date of the public health emergency. Utah requested a waiver to obtain an earlier effective date of March 11, 2021. Pursuant to section 1135(b)(5) of the Act, CMS is also allowing states to modify the timeframes associated with tribal consultation required under section 2107(e)(1)(f) of the Act, including shortening the number of days before submission or conducting consultation after submission of the SPA. Utah requested a waiver to modify the tribal consultation timeline by completing tribal consultation after the effective date of the SPA.

Page 2 – Ms. Jennifer Strohecker

This letter approves Utah’s request for a March 11, 2021 effective date and provides the state with the authority to modify the tribal consultation timeline.

Your Project Officer is Joyce Jordan. She is available to answer your questions concerning this amendment and other CHIP-related matters. Her contact information is as follows:

Centers for Medicare & Medicaid Services

Center for Medicaid and CHIP Services

7500 Security Boulevard, Mail Stop: S2-01-16

Baltimore, MD 21244-1850

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

If you have additional questions, please contact Ms. Meg Barry, Director, Division of State Coverage Programs, at (410) 786-1536. We look forward to continuing to work with you and your staff.

Sincerely,

Amy Lutzky Deputy Director On Behalf of Anne Marie Costello, Deputy Director Center for Medicaid and CHIP Services

cc: Courtney Miller, Director, Medicaid and CHIP Operations Group

Jackie Glaze, Deputy Director, Medicaid and CHIP Operations Group /Signed by Amy Lutzky/

CHIP SPA UT-22-0026 Template for Coverage Required by the American Rescue Plan Act

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

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

State/Territory: The State of Utah

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

________________________________________________________________________ (Signature of Governor, or designee, of State/Territory, Date Signed)

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

The following State officials are responsible for program administration and financial oversight (42 CFR 457.40(c)):

Name: Jennifer Strohecker Position/Title: Director, Medicaid and Health Financing Name: Jeff Nelson Position/Title: CHIP Director Name: Jennifer Wiser Position/Title: CHIP Program Manager

*Disclosure. 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 09380707. The time required to complete this information collection is estimated to average 160 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, write to: CMS, 7500 Security Blvd., Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

1.4 Provide the effective (date costs begin to be incurred) and implementation (date services begin to be provided) dates for this SPA (42 CFR 457.65). A SPA may only have one effective date, but provisions within the SPA may have different implementation dates that must be after the effective date.

1.4 Provide the effective (date costs begin to be incurred) and implementation (date services begin to be provided) dates for this SPA (42 CFR 457.65). A SPA may only have one effective date, but provisions within the SPA may have different implementation dates that must be after the effective date.

Original Plan

Effective Date: July 10, 1998

Implementation Date: August 1, 1998

SPA #_10_, Purpose of SPA: Rebenchmark CHIP benefits Proposed effective date: November 19, 2011

Proposed implementation date: November 19, 2011

SPA #_11_, Purpose of SPA:_ Express Lane Eligibility and Presumptive Eligibility -pending Proposed effective date: ELE- September 1, 2011; Presumptive Eligibility- April 1, 2012

Proposed implementation date: ELE- September 1, 2011; PE- April 1, 2012

SPA #_12_, Purpose of SPA: Rebenchmark CHIP benefits Proposed effective date: July 1, 2012

Proposed implementation date: July 1, 2012 Withdrawn

SPA #_13_, Purpose of SPA: Rebenchmark CHIP benefits Proposed effective date: July 1, 2012

Proposed implementation date: July 1, 2012

SPA #_14_, Purpose of SPA: Eliminate Presumptive Eligibility for children that meet the requirements of section 1920A of the Act. (Section 2107 (e)(1)(L)); (42 CFR 457.355) Removing references to Plan A. Proposed effective date: November 1, 2014

Proposed implementation date: November 1, 2014

SPA# 15, Purpose of SPA: Ex Parte Reviews Proposed effective date: February 1, 2015

Proposed implementation date: February 1, 2015

SPA# 16, Purpose of SPA: Change Reports Proposed effective date: November 1, 2015

Proposed implementation date: November 1, 2015

SPA# 17, Purpose of SPA: Rebenchmark CHIP dental benefits Proposed effective date: July 1, 2016

Proposed implementation date: July 1, 2016 SPA# 18, Purpose of SPA: FQHC Payment Methodology Proposed effective date: July 1, 2016

Proposed implementation date: July 1, 2016

SPA #20 Purpose of SPA: CHIP Mental Health Parity and Addiction Equity Act Analysis, Removal of Co-Payment Requirements for Residential Treatment and the Removal of Co-payment Requirements for Mental Health and Substance Use Disorder Services in an Urgent Care Clinic Proposed effective date: July 1, 2021

Proposed implementation date: July 1, 2021

SPA# 21, Purpose of SPA: Update CHIP benefits Proposed effective date: July 1, 2019

Proposed implementation date: July 1, 2019

SPA# 22, Purpose of SPA: Add CHIP Disaster Relief Plan Proposed effective date: March 1, 2020

Proposed implementation date: March 1, 2020

SPA# 24, Purpose of SPA: Delay timeliness requirements on ex parte renewals. Proposed effective date: February 1, 2021

Proposed implementation date: February 1, 2021

SPA# 25, Purpose of SPA: Update CHIP Benefits

Proposed implementation date: July 1, 2021

Proposed Implementation date: July 1, 2021

SPA# 26, Purpose of SPA: The purpose of this SPA is to demonstrate compliance with the American Rescue Plan Act provisions that require states to cover treatment (including treatment

of a condition that may seriously complicate COVID-19 treatment), testing and vaccinations for COVID-19 without cost sharing in CHIP

Proposed effective date: March 11, 2021

Proposed implementation date: March 11, 2021

1.4-TC Tribal Consultation. (Section 2107(e)(1)(C)) Describe the consultation process that occurred specifically for the development and submission of this State Plan Amendment, when it occurred and who was involved.

[State to describe the Tribal consultation that occurred for this SPA.]

[If the state did not follow their approved Tribal consultation policy, the state must submit a request for a waiver under section 1135 of the Act to modify its Tribal consultation process. The request for such waiver must be included in the cover letter submitted with this SPA.]

Tribal Consultation (Section 2107(e)(1)(C)) Describe the consultation process that occurred specifically for the development and submission of this State Plan Amendment, when it occurred and who was involved.

State Plan Amendments 10 & 11 was presented at the Indian Health Advisory Board meeting on October 7, 2011. There was no request for consultation.

State Plan Amendment 13 was presented at the Utah Indian Health Advisory Board meeting on August 3, 2012. Consultation was not requested.

State Plan Amendment 14 was presented at the Utah Indian Health Advisory Board meeting on 08/08/2014. Consultation was not requested.

State Plan Amendment 15 was presented at the Utah Indian Health Advisory Board meeting on 12/12/2014. Consultation was not requested.

State Plan Amendment 16 was presented at the Utah Indian Health Advisory Board meeting on 10/9/2015. Consultation was not requested.

State Plan Amendment 17 was presented at the Utah Indian Health Advisory Board meeting on 7/8/2016. Consultation was not requested.

State Plan Amendment 18 was presented at the Utah Indian Health Advisory Board meeting on 3/10/2017. Consultation was not requested.

State Plan Amendment 20 was presented at the Utah Indian Health Advisory Board meeting on June 7, 2018. Consultation was not requested.

State Plan Amendment 21 was presented at the Utah Indian Health Advisory Board meeting on June 7, 2019. Consultation was not requested.

State Plan Amendment 22 in concept was presented at the Utah Indian Health Advisory Board meeting on April 10, 2020. The final SPA was presented to the board on May 8, 2020, after the SPA was submitted to CMS. To address the Federal COVID-19 public health emergency, the State received waiver approval under section 1135(b)(5) of the Act, for flexibility to modify the timeframes associated with tribal consultation, including conducting consultation after submission of the SPA. Consultation was not requested.

State Plan Amendment 24 was presented to the Utah Indian Health Advisory Board meeting on February 12, 2021, again after CMS guidance on March 12, 2021, and a final status update on April 9, 2021. Consultation was not requested.

State Plan Amendment 25 was presented to the Utah Indian Health Advisory Board meeting on August 13, 2021. Consultation was not requested.

State Plan Amendment 26 was presented to the Utah Indian Health Advisory Board meeting on March 11, 2022. Consultation was not requested.

TN No: Approval Date Effective Date _____

6.2.28 Any other health care services or items specified by the Secretary and not included under this Section (Section 2110(a)(28))

Effective March 11, 2021 and through the last day of the first calendar quarter that begins one year after the last day of the COVID-19 emergency period described in section 1135(g)(1)(B) of the Act, and for all populations covered in the CHIP state child health plan:

COVID-19 Vaccine: • The state provides coverage of COVID-19 vaccines and their administration, in accordance with the requirements of section 2103(c)(11)(A) of the Act.

COVID-19 Testing:

• The state provides coverage of COVID-19 testing, in accordance with the requirements of section 2103(c)(11)(B) of the Act. • The state assures that coverage of COVID-19 testing is consistent with the Centers for Disease Control and Prevention (CDC) definitions of diagnostic and screening testing for COVID-19 and its recommendations for who should receive diagnostic and screening tests for COVID-19. • The state assures that coverage includes all types of FDA authorized COVID-19 tests.

COVID-19 Treatment: • The state assures that the following coverage of treatments for COVID-19 are provided without amount, duration, or scope limitations, in accordance with requirements of section 2103(c)(11)(B) of the Act: o The state provides coverage of treatments for COVID-19 including specialized equipment and therapies (including preventive therapies); o The state provides coverage of any non-pharmacological item or service described in section 2110(a) of the Act, that is medically necessary for treatment of COVID-19; and o The state provides coverage of any drug or biological that is approved (or licensed) by the U.S. Food & Drug Administration (FDA) or authorized by the FDA under an Emergency Use Authorization (EUA) to treat or prevent COVID-19, consistent with the applicable authorizations. Coverage for a Condition That May Seriously Complicate the Treatment of COVID-19: • The state provides coverage for treatment of a condition that may seriously complicate COVID-19 treatment without amount, duration, or scope limitations, during the period when a beneficiary is diagnosed with or is presumed to have COVID-19, in accordance with the requirements of section 2103(c)(11)(B) of the Act.

8.2.3. Coinsurance or copayments:

The following are the co-payment and co-insurance requirements for participation in CHIP. Levels of co-payments will be limited to the income groups identified in the federal enabling legislation 2103(e)(3)(A) & (B).

Plan B Co-Payment requirements:

Hospital Services:

$150 co-payment after deductible for inpatient services.

Co-insurance, 5% for surgeon and anesthesiologist services.

$5 co-payment for urgent care center services and emergency use of the emergency room.

$10 co-payment for non emergency use of the emergency room

Co-insurance, 5% after deductible for outpatient hospital services.

Ambulance (air and ground) for medical emergencies:

Co-insurance, 5% after deductible

Physician Office Visits (includes visits to a Specialist):

$5 co-payment per visit.

No co-payment for well-baby care, well-child care, and immunizations.

Prescription Drugs:

$5 co-payment per prescription for generics

Co-insurance, 5% per prescription for brand name drugs.

Laboratory and X-ray Services:

$0 co-payment for laboratory and x-ray services for minor diagnostic tests and x-rays

Co-insurance, 5% after deductible for major diagnostic tests and x-rays

Vision Screening Services:

$5 co-payment (limit of one exam per plan year).

Hearing Screening Services:

$5 co-payment (limit of one exam per plan year).

Dental Services :

Maximum benefit of $1,000 per person, per year

$0 co-payment for cleanings, exams, x-rays, fluoride, and sealants.

5% co-insurance for all other covered services.

Orthodontic benefits are only covered if the client scores 30 or greater on the Salzmann Index

Mental Health Services, Inpatient Facility:

$150 co-payment after deductible for each visit

Mental Health Services, Outpatient Office Visit and Urgent Care:

$0 co-payment for each visit

Residential Treatment:

$0 co-payment

Home Health and Hospice Care:

Co-insurance of 5% after deductible per visit.

Medical Equipment and Supplies:

Co-insurance of 5% after deductible

Physical, Occupational and Speech Therapy:

$5 co-payment, 20 visits combined limit per child, per plan year.

Applied Behavior Analysis for the Treatment of Autism Spectrum Disorder:

-$0 co-payment

Out- of-Pocket Maximum:

5% of a family’s annual gross countable income. Only out of pocket costs for covered services, deductibles, co-pays, and premiums will be used to calculate the maximum out of pocket limit.

Plan C Co-Insurance and Co-Payment requirements:

Hospital Services:

Co-insurance, 20% after deductible for inpatient services

$300 co-payment for emergency or non-emergency use of the emergency room, after deductible ; $300 per visit for non participating hospitals, after deductible

$40 co-payment each urgent care center visit

Co-insurance of 20% of total charges for surgeon and anesthesiologist services, after deductible.

Co-insurance, 20% after deductible for outpatient services.

Ambulance (air and ground) for medical emergencies:

Co-insurance, 20% after deductible

Physician office visits:

$25 co-payment per visit (excluding visits to a Specialist)

$40 co-payment per visit to a Specialist.

No co-payment for well-baby care, well-child care and immunizations.

Prescription Drugs:

$15 co-payment per prescription for generic drugs; Co-insurance 25% of total or brand name drugs on the approved list. Co-insurance 50% of total per prescription for brand name drugs not on the approved list.

Laboratory and X-Ray Services:

$0 co-payment for minor diagnostic tests and x-rays.

Co-insurance, 20% after deductible for major diagnostic tests and x-rays.

Vision Screening Services:

$25 co-payment, limit of one exam per plan year.

Hearing Screening Services:

$25 co-payment, limit of one exam per plan year.

Dental Services:

Maximum benefit of $1,000 per person, per year.

Plan pays 100% for cleanings, exams, x-rays, fluoride, and sealants.

Co-insurance, 20% after deductible for all other covered services.

Co-insurance, 50% after deductible for porcelain-fused crowns (not Covered for non- adult and back teeth).

Orthodontic benefits are only covered if the client scores 30 or greater on the Salzmann Index.

Mental Health Services In-Patient Facility

Co-insurance, 20% after deductible.

Mental Health Services Outpatient Office Visit and, Urgent Care:

$40 co-payment for each visit

Residential Treatment:

$0 co-payment

Home Health and Hospice Care:

Co-insurance, 20% after deductible

Medical Equipment and Supplies:

Co-insurance, 20% after deductible

Physical, Occupational and Speech Therapy:

$40 co-payment after deductible, 20 visits combined limit, per child, per plan year.

Out-of-Pocket Maximum

Applied Behavior Analysis for the Treatment of Autism Spectrum Disorder:

-$0 co-payment

The maximum out of pocket expense is 5% of a family's annual gross income. Only out of pocket costs for covered services, deductibles, co-pays, and premiums will be used to calculate the maximum out of pocket limit.

Co-Insurance and Co-payment requirements for CHIP clients/enrollees who are Native American.

No co-payments or premiums are charged to CHIP enrollees who are American Indian/Alaska Native

Co-Insurance and Co-payments requirements for COVID-19 Vaccines, Testing and Treatment under the American Rescue Plan Act of 2021 (ARP)

Effective March 11, 2021 and through the last day of the first calendar quarter that begins one year after the last day of the COVID-19 emergency period described in section 1135(g)(1)(B) of the Act, and for all populations covered in the CHIP state child health plan, the state assures the following:

COVID-19 Vaccine: • The state provides coverage of COVID-19 vaccines and their administration without cost sharing, in accordance with the requirements of section 2103(c)(11)(A) and 2013(e)(2) of the Act.

COVID-19 Testing: • The state provides coverage of COVID-19 testing without cost sharing, in accordance with the requirements of section 2103(c)(11)(B) and 2103(e)(2) of the Act.

COVID-19 Treatment: • The state provides coverage of COVID-19-related treatments without cost sharing, in accordance with the requirements of section 2103(c)(11)(B) and 2103(e)(2) of the Act.

Coverage for a Condition That May Seriously Complicate the Treatment of COVID-19: • The state provides coverage for treatment of a condition that may seriously complicate COVID-19 treatment without cost sharing, during the period when a beneficiary is diagnosed with or is presumed to have COVID-19, in accordance with the requirements of section 2103(c)(11)(B) and 2103(e)(2) of the Act. This coverage includes items and services, including drugs, that were covered by the state as of March 11, 2021.

_____________________________________________________________________________ Table of Contents State/Territory Name: State Plan Amendment (SPA) #: This file contains the following documents in the order listed: 1) Approval Letter 2) State Plan Pages Utah UT-23-0028

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-01-16 Baltimore, MD 21244-1850 Children and Adults Health Programs Group April 26, 2023 Jennifer Strohecker Medicaid Director Director, Division of Integrated Healthcare P.O. Box 143101 Salt Lake City, UT 84114-3101 Dear Ms. Strohecker: Your title XXI Children’s Health Insurance Program (CHIP) State Plan Amendment (SPA), UT-23-0028, submitted on February 3, 2023, has been approved. Through SPA UT-23-0028, the state updates the CHIP out of pocket maximum member notification process. The state will use a new Provider Reimbursement Information System (PRISM) process that will track, calculate and inform members of when the 5 percent out of pocket maximum cost has been met. This approval relates only to the process for tracking cost sharing under the CHIP state plan; Medicaid processes will be analyzed separately. Additionally, this SPA clarifies Utah’s disenrollment policies for non-payment of premiums. This SPA has an effective date of April 1, 2023. Your Project Officer is Joyce Jordan. She is available to answer your questions concerning this amendment and other CHIP-related matters. Ms. Jordan’s contact information is as follows: Centers for Medicare & Medicaid Services Center for Medicaid and CHIP Services Mail Stop: S2-01-16 7500 Security Boulevard Baltimore, MD 21244-1850 Telephone: (410) 786-3413 E-mail: Joyce.Jordan@cms.hhs.gov If you have additional questions, please contact Meg Barry, Director, Division of State Coverage Programs, at (410) 786-1536. We look forward to continuing to work with you and your staff. Sincerely, Sarah deLone Director /Signed by Sarah deLone/

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

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

State/Territory: The State of Utah

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

________________________________________________________________________ (Signature of Governor, or designee, of State/Territory, Date Signed)

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

The following State officials are responsible for program administration and financial oversight (42 CFR 457.40(c)):

Name: Jennifer Strohecker Position/Title: Director, Medicaid and Health Financing Name: Jeff Nelson Position/Title: CHIP Director Name: Jennifer Wiser Position/Title: CHIP Program Manager

*Disclosure. 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 09380707. The time required to complete this information collection is estimated to average 160 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, write to: CMS, 7500 Security Blvd., Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

2 Introduction: Section 4901 of the Balanced Budget Act of 1997 (BBA), public law 1005-33 amended the Social Security Act (the Act) by adding a new title XXI, the Children’s Health Insurance Program (CHIP). In February 2009, the Children’s Health Insurance Program Reauthorization Act (CHIPRA) renewed the program. The Patient Protection and Affordable Care Act of 2010 further modified the program.

This template outlines the information that must be included in the state plans and the state plan amendments (SPAs). It reflects the regulatory requirements at 42 CFR Part 457 as well as the previously approved SPA templates that accompanied guidance issued to States through State Health Official (SHO) letters. Where applicable, we indicate the SHO number and the date it was issued for your reference. The CHIP SPA template includes the following changes: o Combined the instruction document with the CHIP SPA template to have a single document. Any modifications to previous instructions are for clarification only and do not reflect new policy guidance. o Incorporated the previously issued guidance and templates (see the Key following the template for information on the newly added templates), including: • Prenatal care and associated health care services (SHO #02-004, issued November 12, 2002) • Coverage of pregnant women (CHIPRA #2, SHO # 09-006, issued May 11, 2009) • Tribal consultation requirements (ARRA #2, CHIPRA #3, issued May 28, 2009) • Dental and supplemental dental benefits (CHIPRA # 7, SHO # #09-012, issued October 7, 2009) • Premium assistance (CHIPRA # 13, SHO # 10-002, issued February 2, 2010) • Express lane eligibility (CHIPRA # 14, SHO # 10-003, issued February 4, 2010) • Lawfully Residing requirements (CHIPRA # 17, SHO # 10-006, issued July 1, 2010) o Moved sections 2.2 and 2.3 into section 5 to eliminate redundancies between sections 2 and 5. o Removed crowd-out language that had been added by the August 17 letter that later was repealed. The Centers for Medicare & Medicaid Services (CMS) is developing regulations to implement the CHIPRA requirements. When final regulations are published in the Federal Register, this template will be modified to reflect those rules and States will be required to submit SPAs illustrating compliance with the new regulations. States are not required to resubmit their State plans based on the updated template. However, States must use the updated template when submitting a State Plan Amendment.

Federal Requirements for Submission and Review of a Proposed SPA. (42 CFR Part 457 Subpart A) In order to be eligible for payment under this statute, each State must submit a Title XXI plan for approval by the Secretary that details how the State intends to use the funds and fulfill other requirements under the law and regulations at

3 42 CFR Part 457. A SPA is approved in 90 days unless the Secretary notifies the State in writing that the plan is disapproved or that specified additional information is needed. Unlike Medicaid SPAs, there is only one 90 day review period, or clock for CHIP SPAs, that may be stopped by a request for additional information and restarted after a complete response is received. More information on the SPA review process is found at 42 CFR 457 Subpart A.

When submitting a State plan amendment, states should redline the changes that are being made to the existing State plan and provide a “clean” copy including changes that are being made to the existing state plan.

The template includes the following sections: 1. General Description and Purpose of the Children’s Health Insurance Plans and the Requirements- This section should describe how the State has designed their program. It also is the place in the template that a State updates to insert a short description and the proposed effective date of the SPA, and the proposed implementation date(s) if different from the effective date. (Section 2101); (42 CFR, 457.70) 2. General Background and Description of State Approach to Child Health Coverage and Coordination- This section should provide general information related to the special characteristics of each state’s program. The information should include the extent and manner to which children in the State currently have creditable health coverage, current State efforts to provide or obtain creditable health coverage for uninsured children and how the plan is designed to be coordinated with current health insurance, public health efforts, or other enrollment initiatives. This information provides a health insurance baseline in terms of the status of the children in a given State and the State programs currently in place. (Section 2103); (42 CFR 457.410(A)) 3. Methods of Delivery and Utilization Controls- This section requires a description that must include both proposed methods of delivery and proposed utilization control systems. This section should fully describe the delivery system of the Title XXI program including the proposed contracting standards, the proposed delivery systems and the plans for enrolling providers. (Section 2103); (42 CFR 457.410(A)) 4. Eligibility Standards and Methodology- The plan must include a description of the standards used to determine the eligibility of targeted low-income children for child health assistance under the plan. This section includes a list of potential eligibility standards the State can check off and provide a short description of how those standards will be applied. All eligibility standards must be consistent with the provisions of Title XXI and may not discriminate on the basis of diagnosis. In addition, if the standards vary within the state, the State should describe how they will be applied and under what circumstances they will be applied. In addition, this section provides information on income eligibility for Medicaid expansion programs (which are exempt from Section 4 of the State

4 plan template) if applicable. (Section 2102(b)); (42 CFR 457.305 and 457.320) 5. Outreach- This section is designed for the State to fully explain its outreach activities. Outreach is defined in law as outreach to families of children likely to be eligible for child health assistance under the plan or under other public or private health coverage programs. The purpose is to inform these families of the availability of, and to assist them in enrolling their children in, such a program. (Section 2102(c)(1)); (42CFR, 457.90) 6. Coverage Requirements for Children’s Health Insurance- Regarding the required scope of health insurance coverage in a State plan, the child health assistance provided must consist of any of the four types of coverage outlined in Section 2103(a) (specifically, benchmark coverage; benchmark-equivalent coverage; existing comprehensive state-based coverage; and/or Secretary- approved coverage). In this section States identify the scope of coverage and benefits offered under the plan including the categories under which that coverage is offered. The amount, scope, and duration of each offered service should be fully explained, as well as any corresponding limitations or exclusions. (Section 2103); (42 CFR 457.410(A)) 7. Quality and Appropriateness of Care- This section includes a description of the methods (including monitoring) to be used to assure the quality and appropriateness of care and to assure access to covered services. A variety of methods are available for State’s use in monitoring and evaluating the quality and appropriateness of care in its child health assistance program. The section lists some of the methods which states may consider using. In addition to methods, there are a variety of tools available for State adaptation and use with this program. The section lists some of these tools. States also have the option to choose who will conduct these activities. As an alternative to using staff of the State agency administering the program, states have the option to contract out with other organizations for this quality of care function. (Section 2107); (42 CFR 457.495) 8. Cost Sharing and Payment- This section addresses the requirement of a State child health plan to include a description of its proposed cost sharing for enrollees. Cost sharing is the amount (if any) of premiums, deductibles, coinsurance and other cost sharing imposed. The cost-sharing requirements provide protection for lower income children, ban cost sharing for preventive services, address the limitations on premiums and cost-sharing and address the treatment of pre-existing medical conditions. (Section 2103(e)); (42 CFR 457, Subpart E) 9. Strategic Objectives and Performance Goals and Plan Administration- The section addresses the strategic objectives, the performance goals, and the performance measures the State has established for providing child health assistance to targeted low income children under the plan for maximizing health benefits coverage for other low income children and children generally in the state. (Section 2107); (42 CFR 457.710) 10. Annual Reports and Evaluations- Section 2108(a) requires the State to assess

5 the operation of the Children’s Health Insurance Program plan and submit to the Secretary an annual report which includes the progress made in reducing the number of uninsured low income children. The report is due by January 1, following the end of the Federal fiscal year and should cover that Federal Fiscal Year. In this section, states are asked to assure that they will comply with these requirements, indicated by checking the box. (Section 2108); (42 CFR 457.750) 11. Program Integrity- In this section, the State assures that services are provided in an effective and efficient manner through free and open competition or through basing rates on other public and private rates that are actuarially sound. (Sections 2101(a) and 2107(e); (42 CFR 457, subpart I) 12. Applicant and Enrollee Protections- This section addresses the review process for eligibility and enrollment matters, health services matters (i.e., grievances), and for states that use premium assistance a description of how it will assure that applicants and enrollees are given the opportunity at initial enrollment and at each redetermination of eligibility to obtain health benefits coverage other than through that group health plan. (Section 2101(a)); (42 CFR 457.1120)

Program Options. As mentioned above, the law allows States to expand coverage for children through a separate child health insurance program, through a Medicaid expansion program, or through a combination of these programs. These options are described further below: o Option to Create a Separate Program- States may elect to establish a separate child health program that are in compliance with title XXI and applicable rules. These states must establish enrollment systems that are coordinated with Medicaid and other sources of health coverage for children and also must screen children during the application process to determine if they are eligible for Medicaid and, if they are, enroll these children promptly in Medicaid. o Option to Expand Medicaid- States may elect to expand coverage through Medicaid. This option for states would be available for children who do not qualify for Medicaid under State rules in effect as of March 31, 1997. Under this option, current Medicaid rules would apply.

Medicaid Expansion- CHIP SPA Requirements In order to expedite the SPA process, states choosing to expand coverage only through an expansion of Medicaid eligibility would be required to complete sections: • 1 (General Description) • 2 (General Background) They will also be required to complete the appropriate program sections, including: • 4 (Eligibility Standards and Methodology) • 5 (Outreach) • 9 (Strategic Objectives and Performance Goals and Plan Administration

6 including the budget) • 10 (Annual Reports and Evaluations).

Medicaid Expansion- Medicaid SPA Requirements States expanding through Medicaid-only will also be required to submit a Medicaid State Plan Amendment to modify their Title XIX State plans. These states may complete the first check-off and indicate that the descriptions of the requirements for these sections are incorporated by reference through their State Medicaid plans for sections: • 3 (Methods of Delivery and Utilization Controls) • 4 (Eligibility Standards and Methodology) • 6 (Coverage Requirements for Children's Health Insurance) • 7 (Quality and Appropriateness of Care) • 8 (Cost Sharing and Payment) • 11 (Program Integrity) • 12 (Applicant and Enrollee Protections) indicating State

• Combination of Options- CHIP allows states to elect to use a combination of the Medicaid program and a separate child health program to increase health coverage for children. For example, a State may cover optional targeted-low income children in families with incomes of up to 133 percent of poverty through Medicaid and a targeted group of children above that level through a separate child health program. For the children the State chooses to cover under an expansion of Medicaid, the description provided under “Option to Expand Medicaid” would apply. Similarly, for children the State chooses to cover under a separate program, the provisions outlined above in “Option to Create a Separate Program” would apply. States wishing to use a combination of approaches will be required to complete the Title XXI State plan and the necessary State plan amendment under Title XIX.

Proposed State plan amendments should be submitted electronically and one signed hard copy to the Centers for Medicare & Medicaid Services at the following address: Amy Lutzky Centers for Medicare & Medicaid Services 7500 Security Blvd Baltimore, Maryland 21244 Attn: Children and Adults Health Programs Group Center for Medicaid, CHIP and Survey & Certification Mail Stop - S2-01-16

1.4 Provide the effective (date costs begin to be incurred) and implementation (date services begin to be provided) dates for this SPA (42 CFR 457.65). A SPA may only have one effective date, but provisions within the SPA

7 may have different implementation dates that must be after the effective date.

Original Plan Effective Date: July 10, 1998

Implementation Date: August 1, 1998

SPA #_10_, Purpose of SPA: Rebenchmark CHIP benefits Proposed effective date: November 19, 2011

Proposed implementation date: November 19, 2011

SPA #_11_, Purpose of SPA:_ Express Lane Eligibility and Presumptive Eligibility -pending Proposed effective date: ELE- September 1, 2011; Presumptive Eligibility- April 1, 2012

Proposed implementation date: ELE- September 1, 2011; PE- April 1, 2012

SPA #_12_, Purpose of SPA: Rebenchmark CHIP benefits Proposed effective date: July 1, 2012

Proposed implementation date: July 1, 2012 Withdrawn

SPA #_13_, Purpose of SPA: Rebenchmark CHIP benefits Proposed effective date: July 1, 2012

Proposed implementation date: July 1, 2012

SPA #_14_, Purpose of SPA: Eliminate Presumptive Eligibility for children that meet the requirements of section 1920A of the Act. (Section 2107 (e)(1)(L)); (42 CFR 457.355) Removing references to Plan A. Proposed effective date: November 1, 2014

Proposed implementation date: November 1, 2014

SPA# 15, Purpose of SPA: Ex Parte Reviews Proposed effective date: February 1, 2015

Proposed implementation date: February 1, 2015

8

SPA# 16, Purpose of SPA: Change Reports Proposed effective date: November 1, 2015

Proposed implementation date: November 1, 2015

SPA# 17, Purpose of SPA: Rebenchmark CHIP dental benefits Proposed effective date: July 1, 2016

Proposed implementation date: July 1, 2016 SPA# 18, Purpose of SPA: FQHC Payment Methodology Proposed effective date: July 1, 2016

Proposed implementation date: July 1, 2016

SPA #20 Purpose of SPA: CHIP Mental Health Parity and Addiction Equity Act Analysis, Removal of Co-Payment Requirements for Residential Treatment and the Removal of Co-payment Requirements for Mental Health and Substance Use Disorder Services in an Urgent Care Clinic Proposed effective date: July 1, 2021

Proposed implementation date: July 1, 2021

SPA# 21, Purpose of SPA: Update CHIP benefits Proposed effective date: July 1, 2019

Proposed implementation date: July 1, 2019

SPA# 22, Purpose of SPA: Add CHIP Disaster Relief Plan Proposed effective date: March 1, 2020

Proposed implementation date: March 1, 2020

SPA# 24, Delay timeliness requirements on ex parte renewals.

Proposed implementation date: February 1, 2021

SPA# 25, Purpose of SPA: Update CHIP Benefits

Proposed implementation date: July 1, 2021

Proposed Implementation date: July 1, 2021

9

SPA# UT-21-0026, Purpose of SPA: The purpose of this SPA is to demonstrate compliance with the American Rescue Plan Act provisions that require states to cover treatment (including treatment of a condition that may seriously complicate COVID-19 treatment), testing and vaccinations for COVID-19 without cost sharing in CHIP.

Proposed effective date: March 11, 2021

Proposed implementation date: March 11, 2021

SPA# UT-23-0028, Purpose of SPA: The purpose of this SPA is to update the CHIP out of pocket maximum member notification process.

Proposed effective date: April 1, 2023

Proposed implementation date: April 1, 2023

1.4- TC Tribal Consultation (Section 2107(e)(1)(C)) Describe the consultation process that occurred specifically for the development and submission of this State Plan Amendment, when it occurred and who was involved.

State Plan Amendments 10 & 11 was presented at the Indian Health Advisory Board meeting on October 7, 2011. There was no request for consultation.

State Plan Amendment 13 was presented at the Utah Indian Health Advisory Board meeting on August 3, 2012. Consultation was not requested.

State Plan Amendment 14 was presented at the Utah Indian Health Advisory Board meeting on 08/08/2014. Consultation was not requested.

State Plan Amendment 15 was presented at the Utah Indian Health Advisory Board meeting on 12/12/2014. Consultation was not requested.

State Plan Amendment 16 was presented at the Utah Indian Health Advisory Board meeting on 10/9/2015. Consultation was not requested.

State Plan Amendment 17 was presented at the Utah Indian Health Advisory Board meeting on 7/8/2016. Consultation was not requested.

State Plan Amendment 18 was presented at the Utah Indian Health Advisory Board meeting on 3/10/2017. Consultation was not requested.

10

State Plan Amendment 20 was presented at the Utah Indian Health Advisory Board meeting on June 7, 2018. Consultation was not requested.

State Plan Amendment 21 was presented at the Utah Indian Health Advisory Board meeting on June 7, 2019. Consultation was not requested.

State Plan Amendment 22 in concept was presented at the Utah Indian Health Advisory Board meeting on April 10, 2020. The final SPA was presented to the board on May 8, 2020, after the SPA was submitted to CMS. To address the Federal COVID-19 public health emergency, the State received waiver approval under section 1135(b)(5) of the Act, for flexibility to modify the timeframes associated with tribal consultation, including conducting consultation after submission of the SPA. Consultation was not requested.

State Plan Amendment 24 was presented to the Utah Indian Health Advisory Board meeting on February 12, 2021, again after CMS guidance on March 12, 2021, and finally a status update on April 9, 2021. Consultation was not requested.

State Plan Amendment 25 was presented to the Utah Indian Health Advisory Board meeting on August 13, 2021. Consultation was not requested.

State Plan Amendment 26 was presented to the Utah Indian Health Advisory Board meeting on March 11, 2022. Consultation was not requested.

State Plan Amendment UT-23-0028 was presented to the Utah Indian Health Advisory Board meeting on January 13, 2023. Consultation was not requested.

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

At application and renewal families are sent an approval notice telling them what their 5% out of pocket maximum amount will be for that certification period. Enrollees who have been verified as American Indian or Alaska Native are

11 exempt from the 5% out of pocket maximum cost sharing requirement, as they are not charged any cost sharing.

All new CHIP enrollee’s will receive a letter with information about their CHIP benefits and instructions on how to access the CHIP Member Guide. The letter instructs the member to call the Medicaid and CHIP office to learn about their medical, pharmacy, dental and mental health benefits. The office may also provide information about how co-pays and deductibles will be tracked and applied toward their out-of-pocket maximum.

The cost sharing from premiums, and eligible medical, pharmacy and dental expenses contribute toward the 5% out of pocket maximum. The state’s Provider Reimbursement Information System (PRISM) will use premiums, medical, pharmacy and dental encounters to track when the household has met their 5% maximum out of pocket. When the 5% has been met the enrollee no longer has a cost share for that certification period. PRISM will use the date the encounter was received to calculate when the out-of-pocket maximum will be met.

Once the maximum out of pocket is met, the health and dental plans will end the cost sharing requirement and the Enrollee will not billed any additional co- payments, coinsurance or deductibles for the rest of the certification period . The managed care plan will notify the enrollee that they no longer have cost sharing for the certification period and they will be sent a new identification card. Until the new card is received, the Enrollee may use the letter to show the provider that co-pays are not owed. Cost sharing paid over the 5% maximum will be refunded.

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

Consequences for an enrollee or applicant who does not pay copayments or coinsurance will be handled between the enrollee or applicant and the health care provider who has rendered the services.

The invoice regarding the quarterly premium is mailed to enrollees on the 1st day of the first month of the quarter.”

The invoice regarding the premium notifies families when termination of coverage will occur if the family fails to pay the quarterly premium.

A family who does not pay their premium balance on time will be terminated from CHIP. The termination notice informs enrollees of their right to challenge a proposed termination of coverage for failure to pay premiums, consistent with

12 regulatory requirements for disenrollment protections at 42 CFR 457.570.

Approval notices sent at application and renewal inform enrollees of the amount of their quarterly premium, that they will receive a premium invoice when a premium is due, and that they will be terminated from CHIP if they do not pay the premium on time.

An invoice for payment is sent the 1st day of the 1st month of the quarter giving the enrollee until the 1st working day after the 10th of the following month to pay the premium. The family must pay the premium to keep their children enrolled. The family has a minimum grace period of at least 30 days after the beginning of the new coverage period to pay their quarterly premium. If the premium is not paid by the due date a $15.00 late fee is assessed, enrollment is terminated effective the last day of the 2nd month, and a termination notice is sent. The termination notice tells the family coverage may be reinstated if they pay the past due premium balance by the last day of the following month. Any termination notice sent to the family would be mailed out 10 days before the end of the month.

Coverage may be reinstated without a break in coverage when any of the following events occur:

• The family pays the premium balance by the last day of the 3rd month of the quarter (the month immediately following the termination. • The family’s countable income decreased to below 133% of the federal poverty level. The family will be considered for Medicaid coverage instead. • The family’s countable income decreases prior to the first month of the quarter and the family owes a lower premium amount. The new premium must be paid within 30 days.

A family who was terminated from CHIP, who reapplies within 90 days of the termination date, must pay any outstanding premium balance before the children can be re-enrolled.

_____________________________________________________________________________ Table of Contents State/Territory Name: State Plan Amendment (SPA) #: This file contains the following documents in the order listed: 1) Approval Letter 2) State Plan Pages Utah UT-23-0029

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-01-16 Baltimore, MD 21244-1850 Children and Adults Health Programs Group June 10, 2024 Jennifer Strohecker State Medicaid and CHIP Director Director, Division of Integrated Healthcare P.O. Box 143101 Salt Lake City, UT 84114-3101 Dear Jennifer Strohecker: Your title XXI Children’s Health Insurance Program (CHIP) State Plan Amendment (SPA), UT-23-0029, submitted on August 16, 2023, with additional information submitted on May 31, 2024, has been approved. This SPA has an effective date of July 1, 2023. Utah continues to provide dental services under CHIP through a benchmark plan as permitted under Section 2103(c)(6) of title XXI of the Social Security Act. The state is making several dental code modifications through UT-23-0029 because the benchmark plan, the HMO with the largest commercial enrollment, has changed. For example, the state provided teledentistry during the public health emergency and this SPA will make it a permanent modality under the CHIP state plan. The state is also eliminating some codes, such as those previously covered that are not applicable to children, or codes that have been retired from the Code on Dental Procedures and Nomenclature (CDT Code). Your Project Officer is Joyce Jordan. She is available to answer your questions concerning this amendment and other CHIP-related matters. Her contact information is as follows: Centers for Medicare & Medicaid Services Center for Medicaid and CHIP Services Mail Stop: S2-01-16 7500 Security Boulevard Baltimore, MD 21244-1850 Telephone: (410) 786-3413 E-mail: Joyce.Jordan@cms.hhs.gov If you have additional questions, please contact Meg Barry, Director, Division of State Coverage Programs, at (410) 786-1536. We look forward to continuing to work with you and your staff. Sincerely, Sarah deLone Director /Signed by Sarah deLone/

1

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

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

State/Territory: The State of Utah

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

________________________________________________________________________ (Signature of Governor, or designee, of State/Territory, Date Signed)

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

The following State officials are responsible for program administration and financial oversight (42 CFR 457.40(c)):

Name: Jennifer Strohecker Position/Title: Medicaid Director, Director of Integrated Healthcare Name: Jennifer Wiser Position/Title: CHIP Director Name: Position/Title:

*Disclosure. 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 09380707. The time required to complete this information collection is estimated to average 160 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, write to: CMS, 7500 Security Blvd., Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

2

Guidance: The effective date as specified below is defined as the date on which the State begins to incur costs to implement its State plan or amendment. (42 CFR 457.65) The implementation date is defined as the date the State begins to provide services; or, the date on which the State puts into practice the new policy described in the State plan or amendment. For example, in a State that has increased eligibility, this is the date on which the State begins to provide coverage to enrollees (and not the date the State begins outreach or accepting applications).

1.4. Provide the effective (date costs begin to be incurred) and implementation (date services begin to be provided) dates for this SPA (42 CFR 457.65). A SPA may only have one effective date, but provisions within the SPA may have different implementation dates that must be after the effective date.

Original Plan Effective Date: July 10, 1998

Implementation Date: August 1, 1998

SPA #UT-23-0029 Purpose of SPA: The purpose of this SPA is to update the CHIP dental benchmark plan and benefits. Proposed effective date: July 1, 2023

Proposed implementation date: July 1, 2023

1.4- TC Tribal Consultation (Section 2107(e)(1)(C)) Describe the consultation process that occurred specifically for the development and submission of this State Plan Amendment, when it occurred and who was involved. State Plan Amendment UT-23-0029 was presented to the Utah Indian Health Advisory Board meeting on June 9, 2023. Consultation was not requested. TN No: Approval Date Effective Date

3 Section 6. Coverage Requirements for Children’s Health Insurance

Check here if the State elects to use funds provided under Title XXI only to provide expanded eligibility under the State’s Medicaid plan and proceed to Section 7 since children covered under a Medicaid expansion program will receive all Medicaid covered services including EPSDT.

6.1. The State elects to provide the following forms of coverage to children: (Check all that apply.) (Section 2103(c)); (42CFR 457.410(a))

Guidance: Benchmark coverage is substantially equal to the benefits coverage in a benchmark benefit package (FEHBP-equivalent coverage, State employee coverage, and/or the HMO coverage plan that has the largest insured commercial, non-Medicaid enrollment in the state). If box below is checked, either 6.1.1.1., 6.1.1.2., or 6.1.1.3. must also be checked. (Section 2103(a)(1))

6.1.1.

Benchmark coverage; (Section 2103(a)(1) and 42 CFR 457.420)

Guidance: Check box below if the benchmark benefit package to be offered by the State is the standard Blue Cross/Blue Shield preferred provider option service benefit plan, as described in and offered under Section 8903(1) of Title 5, United States Code. (Section 2103(b)(1) (42 CFR 457.420(b))

6.1.1.1.

FEHBP-equivalent coverage; (Section 2103(b)(1) (42 CFR 457.420(a)) (If checked, attach copy of the plan.)

Guidance: Check box below if the benchmark benefit package to be offered by the State is State employee coverage, meaning a coverage plan that is offered and generally available to State employees in the state. (Section 2103(b)(2))

6.1.1.2.

State employee coverage; (Section 2103(b)(2)) (If checked, identify the plan and attach a copy of the benefits description.)

Guidance: Check box below if the benchmark benefit package to be offered by the State is offered by a health maintenance organization (as defined in Section 2791(b)(3) of the Public Health Services Act) and has the largest insured commercial, non-Medicaid enrollment of covered lives of such coverage plans offered by an HMO in the state. (Section 2103(b)(3) (42 CFR 457.420(c)))

6.1.1.3.

HMO with largest insured commercial enrollment (Section 2103(b)(3)) (If checked, identify the plan and attach a copy of the benefits description.)

4 Guidance: States choosing Benchmark-equivalent coverage must check the box below and ensure that the coverage meets the following requirements:  the coverage includes benefits for items and services within each of the categories of basic services described in 42 CFR 457.430: • dental services • inpatient and outpatient hospital services, • physicians’ services, • surgical and medical services, • laboratory and x-ray services, • well-baby and well-child care, including age-appropriate immunizations, and • emergency services;  the coverage has an aggregate actuarial value that is at least actuarially equivalent to one of the benchmark benefit packages (FEHBP-equivalent coverage, State employee coverage, or coverage offered through an HMO coverage plan that has the largest insured commercial enrollment in the state); and  the coverage has an actuarial value that is equal to at least 75 percent of the actuarial value of the additional categories in such package, if offered, as described in 42 CFR 457.430: • coverage of prescription drugs, • mental health services, • vision services and • hearing services.

If 6.1.2. is checked, a signed actuarial memorandum must be attached. The actuary who prepares the opinion must select and specify the standardized set and population to be used under paragraphs (b)(3) and (b)(4) of 42 CFR 457.431. The State must provide sufficient detail to explain the basis of the methodologies used to estimate the actuarial value or, if requested by CMS, to replicate the State results.

The actuarial report must be prepared by an individual who is a member of the American Academy of Actuaries. This report must be prepared in accordance with the principles and standards of the American Academy of Actuaries. In preparing the report, the actuary must use generally accepted actuarial principles and methodologies, use a standardized set of utilization and price factors, use a standardized population that is representative of privately insured children of the age of children who are expected to be covered under the State child health plan, apply the same principles and factors in comparing the value of different coverage (or categories of services), without taking into account any differences in coverage based on the method of delivery or means of cost control or utilization used, and take into account the ability of a State to reduce benefits by taking into account the increase in actuarial value of benefits coverage offered

5 under the State child health plan that results from the limitations on cost sharing under such coverage. (Section 2103(a)(2))

6.1.2.

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

Guidance: A State approved under the provision below, may modify its program from time to time so long as it continues to provide coverage at least equal to the lower of the actuarial value of the coverage under the program as of August 5, 1997, or one of the benchmark programs. If “existing comprehensive state-based coverage” is modified, an actuarial opinion documenting that the actuarial value of the modification is greater than the value as of August 5, 1997, or one of the benchmark plans must be attached. Also, the fiscal year 1996 State expenditures for “existing comprehensive state-based coverage” must be described in the space provided for all states. (Section 2103(a)(3))

6.1.3.

Existing Comprehensive State-Based Coverage; (Section 2103(a)(3) and 42 CFR 457.440) This option is only applicable to New York, Florida, and Pennsylvania. Attach a description of the benefits package, administration, and date of enactment. If existing comprehensive State-based coverage is modified, provide an actuarial opinion documenting that the actuarial value of the modification is greater than the value as of August 5, 1997 or one of the benchmark plans. Describe the fiscal year 1996 State expenditures for existing comprehensive state- based coverage.

Guidance: Secretary-approved coverage refers to any other health benefits coverage deemed appropriate and acceptable by the Secretary upon application by a state. (Section 2103(a)(4)) (42 CFR 457.250)

6.1.4.

Secretary-approved Coverage. (Section 2103(a)(4)) (42 CFR 457.450) Guidance: Section 1905(r) of the Act defines EPSDT to require coverage of (1) any medically necessary screening, and diagnostic services, including vision, hearing, and dental screening and diagnostic services, consistent with a periodicity schedule based on current and reasonable medical practice standards or the health needs of an individual child to determine if a suspected condition or illness exists; and (2) all services listed in section 1905(a) of the Act that are necessary to correct or ameliorate any defects and mental and physical illnesses or conditions discovered by the screening services, whether or not those services are covered under the Medicaid state plan. Section 1902(a)(43) of the Act requires that the State (1) provide and arrange for all necessary services, including supportive services, such as transportation, needed to receive medical care included

6 within the scope of the EPSDT benefit and (2) inform eligible beneficiaries about the services available under the EPSDT benefit.

If the coverage provided does not meet all of the statutory requirements for EPSDT contained in sections 1902(a)(43) and 1905(r) of the Act, do not check this box.

6.1.4.1.

Coverage of all benefits that are provided to children under the the same as Medicaid State plan, including Early Periodic Screening Diagnosis and Treatment (EPSDT)

6.1.4.2.

Comprehensive coverage for children under a Medicaid Section 1115 demonstration waiver

6.1.4.3.

Coverage that the State has extended to the entire Medicaid population

Guidance: Check below if the coverage offered includes benchmark coverage, as specified in 457.420, plus additional coverage. Under this option, the State must clearly demonstrate that the coverage it provides includes the same coverage as the benchmark package, and also describes the services that are being added to the benchmark package.

6.1.4.4.

Coverage that includes benchmark coverage plus additional coverage

6.1.4.5.

Coverage that is the same as defined by existing comprehensive state- based coverage applicable only New York, Pennsylvania, or Florida (under 457.440)

Guidance: Check below if the State is purchasing coverage through a group health plan, and intends to demonstrate that the group health plan is substantially equivalent to or greater than to coverage under one of the benchmark plans specified in 457.420, through use of a benefit-by-benefit comparison of the coverage. Provide a sample of the comparison format that will be used. Under this option, if coverage for any benefit does not meet or exceed the coverage for that benefit under the benchmark, the State must provide an actuarial analysis as described in 457.431 to determine actuarial equivalence.

6.1.4.6.

Coverage under a group health plan that is substantially equivalent to or greater than benchmark coverage through a benefit by benefit comparison (Provide a sample of how the comparison will be done)

Guidance: Check below if the State elects to provide a source of coverage that is not

7 described above. Describe the coverage that will be offered, including any benefit limitations or exclusions.

6.1.4.7.

Other (Describe)

Guidance: All forms of coverage that the State elects to provide to children in its plan must be checked. The State should also describe the scope, amount and duration of services covered under its plan, as well as any exclusions or limitations. States that choose to cover unborn children under the State plan should include a separate section 6.2 that specifies benefits for the unborn child population. (Section 2110(a)) (42CFR, 457.490)

If the state elects to cover the new option of targeted low income pregnant women, but chooses to provide a different benefit package for these pregnant women under the CHIP plan, the state must include a separate section 6.2 describing the benefit package for pregnant women. (Section 2112)

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

6.2.1.

Inpatient services (Section 2110(a)(1))

6.2.2.

Outpatient services (Section 2110(a)(2))

6.2.3.

Physician services (Section 2110(a)(3))

6.2.4.

Surgical services (Section 2110(a)(4))

6.2.5.

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

6.2.6.

Prescription drugs (Section 2110(a)(6))

6.2.7.

Over-the-counter medications (Section 2110(a)(7))

6.2.8.

Laboratory and radiological services (Section 2110(a)(8))

6.2.9.

Prenatal care and pre-pregnancy family services and supplies (Section 2110(a)(9))

6.2.10.

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

8

6.2.11.

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

6.2.12.

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

6.2.13.

Disposable medical supplies (Section 2110(a)(13))

Guidance: Home and community based services may include supportive services such as home health nursing services, home health aide services, personal care, assistance with activities of daily living, chore services, day care services, respite care services, training for family members, and minor modifications to the home.

6.2.14.

Home and community-based health care services (Section 2110(a)(14))

Guidance: Nursing services may include nurse practitioner services, nurse midwife services, advanced practice nurse services, private duty nursing care, pediatric nurse services, and respiratory care services in a home, school or other setting.

6.2.15.

Nursing care services (Section 2110(a)(15))

6.2.16.

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

6.2.17.

Dental services (Section 2110(a)(17)) States updating their dental benefits must complete 6.2-DC (CHIPRA # 7, SHO # #09-012 issued October 7, 2009)

6.2.18.

Vision screenings and services (Section 2110(a)(24))

6.2.19.

Hearing screenings and services (Section 2110(a)(24))

6.2.20.

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

6.2.21.

Outpatient substance abuse treatment services (Section 2110(a)(19))

6.2.22.

Case management services (Section 2110(a)(20))

6.2.23.

Care coordination services (Section 2110(a)(21))

6.2.24.

Physical therapy, occupational therapy, and services for individuals with speech,

9 hearing, and language disorders (Section 2110(a)(22))

6.2.25.

Hospice care (Section 2110(a)(23))

Guidance: See guidance for section 6.1.4.1 for a guidance on the statutory requirements for EPSDT under sections 1905(r) and 1902(a)(43) of the Act. If the benefit being provided does not meet the EPSDT statutory requirements, do not check this box.

6.2.26.

EPSDT consistent with requirements of sections 1905(r) and 1902(a)(43) of the Act

Guidance: Any other medical, diagnostic, screening, preventive, restorative, remedial, therapeutic or rehabilitative service may be provided, whether in a facility, home, school, or other setting, if recognized by State law and only if the service is: 1) prescribed by or furnished by a physician or other licensed or registered practitioner within the scope of practice as prescribed by State law; 2) performed under the general supervision or at the direction of a physician; or 3) furnished by a health care facility that is operated by a State or local government or is licensed under State law and operating within the scope of the license.

6.2.27.

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

6.2.28.

Premiums for private health care insurance coverage (Section 2110(a)(25))

6.2.29.

Medical transportation (Section 2110(a)(26))

Guidance: Enabling services, such as transportation, translation, and outreach services, may be offered only if designed to increase the accessibility of primary and preventive health care services for eligible low-income individuals.

6.2.30.

Enabling services (such as transportation, translation, and outreach services) (Section 2110(a)(27))

6.2.31.

Any other health care services or items specified by the Secretary and not included under this Section (Section 2110(a)(28))

6.2-DC Dental Coverage (CHIPRA # 7, SHO # #09-012 issued October 7, 2009) The State will provide dental coverage to children through one of the following. Please update Sections 9.10 and 10.3-DC when electing this option. Dental services provided to children eligible for dental-only supplemental services must receive the same dental services as provided to otherwise eligible CHIP children (Section 2103(a)(5)):

10 6.2.1-DC State Specific Dental Benefit Package. The State assures dental services represented by the following categories of common dental terminology (CDT0F1) codes are included in the dental benefits: 1. Diagnostic (i.e., clinical exams, x-rays) (CDT codes: D0100-D0999) (must follow periodicity schedule) 2. Preventive (i.e., dental prophylaxis, topical fluoride treatments, sealants) (CDT codes: D1000-D1999) (must follow periodicity schedule) 3. Restorative (i.e., fillings, crowns) (CDT codes: D2000-D2999) 4. Endodontic (i.e., root canals) (CDT codes: D3000-D3999) 5. Periodontic (treatment of gum disease) (CDT codes: D4000-D4999) 6. Prosthodontic (dentures) (CDT codes: D5000-D5899, D5900-D5999, and D6200-D6999) 7. Oral and Maxillofacial Surgery (i.e., extractions of teeth and other oral surgical procedures) (CDT codes: D7000-D7999) 8. Orthodontics (i.e., braces) (CDT codes: D8000-D8999) 9. Emergency Dental Services

6.2.1.1-DC Periodicity Schedule. The State has adopted the following periodicity schedule: State-developed Medicaid-specific American Academy of Pediatric Dentistry Other Nationally recognized periodicity schedule Other (description attached)

6.2.2-DC Benchmark coverage; (Section 2103(c)(5), 42 CFR 457.410, and 42 CFR 457.420)

6.2.2.1-DC FEHBP-equivalent coverage; (Section 2103(c)(5)(C)(i)) (If checked, attach copy of the dental supplemental plan benefits description and the applicable CDT1F2 codes. If the State chooses to provide supplemental services, also attach a description of the services and applicable CDT codes)

6.2.2.2-DC State employee coverage; (Section 2103(c)(5)(C)(ii)) (If checked, identify the plan and attach a copy of the benefits description and the applicable CDT codes. If the State chooses to provide supplemental services, also attach a description of the services and applicable CDT codes)

6.2.2.3-DC HMO with largest insured commercial enrollment (Section 2103(c)(5)(C)(iii)) (If checked, identify the plan and attach a copy of the benefits description and the applicable CDT codes. If the State chooses to provide supplemental services, also attach a description of the services and

Current Dental Terminology, © 2010 American Dental Association. All rights reserved. Current Dental Terminology, © 2010 American Dental Association. All rights reserved.

11 applicable CDT codes)

Premier Access/Avesis has the largest insured commercial enrollment and is the current benchmark.

Reference: D0100-D0999 – Diagnostic D1000-D1999 – Preventive D2000-D2999 – Restorative D3000-D3999 – Endodontics D4000-D4999 – Periodontics D5000-D5999 – Prosthodontics (Removable) D6000-D6199 – Implant Services D6200-D6999 – Prosthodontics, Fixed D7000-D7999 – Oral and Maxillofacial Surgery D8000-D8999 – Orthodontics D9000-D9999 – Adjunctive General Services

Specifically, only the following dental services based on American Dental Association (ADA) codes are covered:

D0120 D1206 D2393 D3351 D5511 D6740 D7461 D7970 D0140 D1208 D2394 D3352 D5512 D6752 D7465 D7971 D0145 D1351 D2740 D3353 D5520 D7111 D7471 D7980 D0150 D1352 D2750 D3410 D5611 D7140 D7472 D7981 D0170 D1353 D2751 D3421 D5612 D7210 D7473 D7982 D0171 D1354 D2752 D3425 D5621 D7220 D7509 D7983 D0190 D1510 D2920 D3426 D5622 D7230 D7510 D8010 D0191 D1516 D2930 D3430 D5630 D7240 D7511 D7999 D0210 D1517 D2931 D3450 D5640 D7241 D7520 D8020 D0220 D1520 D2932 D3920 D5650 D7250 D7530 D8030 D0230 D1526 D2933 D4210 D5660 D7260 D7540 D8070 D0240 D1527 D2940 D4211 D5710 D7261 D7550 D8080 D0270 D1551 D2950 D4341 D5711 D7270 D7560 D8210 D0272 D1552 D2951 D4342 D5720 D7280 D7610 D8220 D0273 D1553 D2952 D4355 D5721 D7282 D7620 D8680 D0274 D1556 D2954 D4910 D5730 D7283 D7630 D8703 D0277 D1557 D2980 D5110 D5731 D7285 D7640 D8704 D0330 D1558 D3220 D5120 D5740 D7286 D7670 D8999 D0340 D1575 D3221 D5130 D5741 D7290 D7710 D9110 D0350 D2140 D3222 D5140 D5750 D7291 D7720 D9222 D0391 D2150 D3230 D5211 D5751 D7410 D7730 D9223 D0470 D2160 D3240 D5212 D5760 D7411 D7740 D9239

12

Applicable Notes from Benchmark Plan Schedule of Allowances Procedures D3230 through D3920 include all test x-rays taken as part of the complete root canal procedure.

The following applies to D5000 – D5899 Prosthodontics (Removable). Dentures and partial dentures include relines. Allowances for dentures, partial dentures and relines include all adjustments for six-months. Fee for specialized techniques involving precision dentures, personalization or characterizations must be paid by the patient.

The following applies to D6200 – D6999 Prosthodontics, Fixed. Each retainer and each pontic constitutes a unit in a fixed partial denture.

The following applies to D7000 – D7999 oral and Maxillofacial Surgery. Extractions include local anesthesia, suturing, if needed, and routine postoperative care.

The following applies to D8000 – D8999 Orthodontics. Allowances include all appliances, adjustments, insertion, removal and post treatment stabilization (retention).

Additional Coverage Notes

a. When an Enrollee is pregnant, CHIP will pay for additional services to help improve the oral health of the Enrollee during pregnancy. The additional services each contract year include: i. one (1) additional oral exam and either one (1) additional routing cleaning or one (1) additional periodontal scaling and root planning per quadrant. b. Written confirmation of the pregnancy must be provided by the Enrollee or her dentist when the claim is submitted.

6.2-DS

Supplemental Dental Coverage- The State will provide dental coverage to children eligible for dental-only supplemental services. Children eligible for this option must receive the same dental services as provided to otherwise eligible CHIP children (Section 2110(b)(5)(C)(ii)). Please update Sections 1.1-DS, 4.1-DS, 4.2-DS, and 9.10 when electing this option.

D0604 D2161 D3310 D5213 D5761 D7412 D7910 D9243 D0605 D2330 D3320 D5214 D5899 D7413 D7911 D9248 D0701 D2331 D3330 D5225 D5931 D7950 D7912 D9310 D0707 D2332 D3332 D5226 D5932 D7955 D7920 D9420 D0708 D2335 D3333 D5410 D7414 D7451 D9930 D9440 D0709 D2390 D3346 D5411 D7450 D7460 D9951 D9999 D1110 D2391 D3347 D5421 D5954 D7961 D9995 D1120 D2392 D3348 D5422 D5955 D7962 D9996

13 Guidance: Under Title XXI, pre-existing condition exclusions are not allowed, with the only exception being in relation to another law in existence (HIPAA/ERISA). Indicate that the plan adheres to this requirement by checking the applicable description.

In the event that the State provides benefits through a group health plan or group health coverage, or provides family coverage through a group health plan under a waiver (see Section 6.4.2.), pre-existing condition limits are allowed to the extent permitted by HIPAA/ERISA. If the State is contracting with a group health plan or provides benefits through group health coverage, describe briefly any limitations on pre-existing conditions. (Formerly 8.6.)

6.2.15.

Dental services (Section 2110(a)(17)) States updating their dental benefits must complete 6.2-DC (CHIPRA # 7, SHO # #09-012 issued October 7, 2009)

Scope of Coverage

Oral examinations, diagnostic services, preventive services, oral surgery that is dental in nature, restorative services, orthodontic and endodontic services are covered benefits. Oral examinations and other preventive services including cleaning and fluoride applications are limited to two per plan year.

Covered dental procedures under the Dental Plan are payable in an outpatient surgical facility for children five years of age and younger or a child who is at high risk due to other medical diagnosis.

Dental Anesthesia (as covered by the Health Plan)

Services including local, regional, general, and/or intravenous sedation anesthesia, are covered at participating facilities by the Health Plan when members meet one of the following criteria:

i. The member has a global development or intellectual disability, regardless of the chronological age of the member:

ii. The member, regardless of age, has a congenital cardiac or neurological condition and provides documentation that the dental anesthesia is needed to closely monitor the condition; or

iii. The member is younger than five years of age and: a. The proposed dental treatment involves three or more teeth; and b. The diagnosis is nursing bottle-mouth syndrome or extreme enamel hypoplasia.

Cardiac/Neurologic Conditions

14 i. Consideration of coverage will be given to members, regardless of age, with congenital cardiac or neurological conditions. The member must provide documentation describing that the need for dental anesthesia is due to an underlying medical condition and the associated requirement to closely monitor this condition.

ii. Dental anesthesia for conditions such as ADHD, situational anxiety, or fear of dentists is not covered by the Health Plan.

Limitations on Diagnostic and Preventative Benefits:

i. Routine oral examinations and cleanings (including periodontal cleanings) are provided no more than twice in any Contract Year. Note that periodontal cleanings are covered as a Basic Benefit and routine cleanings are covered as a Diagnostic and Preventative Benefit. See note on additional benefits during pregnancy.

ii. Full-mouth x-rays and panoramic x-rays are limited to once every five years

iii. Bitewing x-rays are provided for enrollees twice each contract year.

iv. Space maintainers are limited to the initial appliance only and to enrollees under age 14.

Limitations on Basic Benefits

i. Sealants are limited as follows: ii. Sealant Benefits are available only to Enrollees through age 15. iii. Sealants are limited to application to permanent molars with no caries (decay), without restorations and with the occlusal surface intact. iv. Sealant Benefits do not include the repair or replacement of a sealant on any tooth within two (2) years of its application.

v. CHIP will not pay to replace an amalgam, composite, synthetic porcelain or plastic fillings or prefabricated stainless steel restorations within 24 months of treatment if the service is provided by the same Dentist.

vi. CHIP limits payment for stainless steel and porcelain crowns under this section to services on baby teeth. However, after consultant’s review, CHIP may allow stainless steel and porcelain crowns on permanent teeth as a Major Benefit.

vii. Benefits for periodontal scaling and root planning in the same quadrant are limited to once in every 24-month period. See note on additional benefits during

15 pregnancy.

Limitations on Major Benefits:

i. CHIP will not pay to replace any crowns, inlays/onlays or cast restorations which the Enrollee received in the previous five (5) years under any CHIP program or any program of the Contract holder.

ii. Prosthodontic appliances that were provided under any CHIP program will be replaced only after five (5) years have passed, except when CHIP determines that there is such extensive loss of remaining teeth or change in supporting tissue that the existing fixed bridge or denture cannot be made satisfactory. Replacement of a prosthodontic appliance not provided under a CHIP program will be made if CHIP determines it is unsatisfactory and cannot be made satisfactory.

iii. CHIP limits payment for dentures to a standard partial or denture (coinsurances apply). A standard denture means a removable appliance to replace missing natural, permanent teeth that is made from acceptable materials by conventional means.

iv. CHIP will not pay for implants (artificial teeth implanted into or on bone or gums), their removal or other associated procedures, but CHIP will credit the cost of a crown or standard complete or partial denture toward the cost of the implant associated appliance, i.e. the implant supported crown or denture.

Limitations on Orthodontic Benefits:

i. Payment for orthodontics is provided for a proportion of the upfront costs and then monthly thereafter.

ii. Orthodontic Benefits begin with the first payment due after the person becomes covered if treatment has begun.

iii. Benefits end with the loss of eligibility. Benefits end immediately if treatment stops or if the dental plan Contract is terminated, whichever occurs first. If a CHIP enrollee loses eligibility before the orthodontic treatment has been completed, the dental plan provider shall not increase the total amount owed for the service. The dental plan shall contractually obligate its provider network to follow this requirement.

iv. Benefits are not paid to repair or replace any Orthodontic appliance furnished, in whole or in part, under this program.

v. X-rays or extractions are not subject to the Orthodontic maximum.

16

vi. Surgical procedures are not subject to the Orthodontic maximum.

vii. Orthodontic benefits are only covered if the client scores 30 or greater on the Salzmann Index.

Limitations on All Benefits - Optional Services

a. Optional Services that are more expensive than the form of treatment customarily provided under accepted dental practice standards are called “Optional Services”. Optional Services also include the use of specialized techniques instead of standard procedures. For example: i. A crown where a filing would restore the tooth; ii. A precision denture/partial where a standard denture/partial could be used; iii. An inlay/onlay instead of an amalgam restoration; or iv. A composite restoration instead of an amalgam restoration on posterior teeth.

b. If an enrollee receives Optional Services, Benefits will be based on the lower cost of the customary service or standard practice instead of the higher cost of the Optional Service. The enrollee will be responsible for the difference between the higher cost of the Optional Service and the lower cost of the customary service or standard procedure.

Excluded Benefits

i. Services and supplies not listed in the scope of coverage, not recognized as essential for the treatment of the condition according to accepted standards of practice or considered experimental.

ii. Charges for cosmetic procedures, including but not limited to veneers and bleaching of teeth and procedures performed primarily for cosmetic reasons.

iii. Charges for services related to, performed in conjunction with, or resulting from a non-covered procedure.

iv. Charges for crowns, inlays and onlays on teeth that can be restored by direct placement materials.

v. Charges for replacement of crowns, bridges, inlays, onlays or prosthetic appliance within 5 years from the date of last placement.

17

vi. Charges for services that are applied toward the satisfaction of a deductible, if any.

vii. Charges for services subject to a waiting period.

viii. Charges for implants; myofunctional therapy; athletic mouthguards; precision or semiprecision attachments; treatment of fractures, cysts, tumors, or lesions; maxillofacial prosthesis; orthognathic surgery; TMJ dysfunction; cleft palate; or anodontia.

ix. Charges for orthodontia, unless included within the scope of coverage.

x. Charges for composite, resin or white fillings on posterior primary teeth. Benefit will be reduced to that of an amalgam or silver filling.

xi. Charges for the replacement of a filling within 24 months of placement, unless for specific health reasons.

xii. Charges for the replacement of retainers.

xiii. Charges for sealants not applied to permanent bicuspid or molar; applied at age 15 or older; applied 3 years from a previous sealant application; applied to a decayed tooth.

xiv. Charges for lab fees for higher metals or porcelain crowns, bridges, inlays or onlays.

General Exclusions

i. Charges in excess of the contracted Fee-for-Service schedule or the Reasonable and Customary rate, whichever applies.

ii. Charges for any treatment program which began prior to the date the Insured is covered under the policy.

iii. Services or supplies payable under any medical expense, auto or no-fault plan.

iv. Conditions covered under any Worker’s Compensation Act or similar law.

18 v. Charges for services applied without cost by any municipality, county or other political subdivision or for which there would be no charge in the absence of insurance.

vi. Charges resulting from changing from one provider to another while receiving treatment, or from receiving treatment from more than one provider for one dental procedure to the extent that the total charges billed exceed the amount incurred if one provider had performed all services.

vii. Hospital facility charges for any dental procedure, including but not limited to emergency room charges, surgical facility charges, hospital confinement.

viii. Charges for drugs or the dispensing of drugs.

ix. Charges for oral hygiene instruction; plaque control; acid etch; prescription or take home fluoride; broken appointments; completion of a claim form; OSHA/Sterilization fees (Occupational Safety & Health Agency); or diagnostic photographs (except for orthodontic purposes).

x. Charges for services to replace teeth that were missing (extracted or congenitally) prior to the effective date of coverage on the Plan. This limitation ends after 36 months of continuous coverage on the Plan. Abutment teeth will be reviewed for eligibility of prosthetic benefits. This exclusion does not apply if the device covers one or more natural teeth lost or extracted while covered under the Plan, or if the prosthetic device was in place when the policy became effective.

xi. Services incurred during travel or activity outside the United States.

9.10. Provide a 1-year projected budget. A suggested financial form for the budget is below. The budget must describe: (Section 2107(d)) (42CFR 457.140)

• Planned use of funds, including: • Projected amount to be spent on health services; • Projected amount to be spent on administrative costs, such as outreach, child health initiatives, and evaluation; and • Assumptions on which the budget is based, including cost per child and expected enrollment. • Projected expenditures for the separate child health plan, including but not limited to expenditures for targeted low income children, the optional coverage of the unborn, lawfully residing eligibles, dental services, etc. • All cost sharing, benefit, payment, eligibility need to be reflected in the budget.

19

• Projected sources of non-Federal plan expenditures, including any requirements for cost-sharing by enrollees. • Include a separate budget line to indicate the cost of providing coverage to pregnant women. • States must include a separate budget line item to indicate the cost of providing coverage to premium assistance children. • Include a separate budget line to indicate the cost of providing dental-only supplemental coverage. • Include a separate budget line to indicate the cost of implementing Express Lane Eligibility. • Provide a 1-year projected budget for all targeted low-income children covered under the state plan using the attached form. Additionally, provide the following: - Total 1-year cost of adding prenatal coverage - Estimate of unborn children covered in year 1

CHIP Budget STATE: FFY Budget Federal Fiscal Year 2023 State’s enhanced FMAP rate 23.87%

Benefit Costs

Insurance payments $0 Managed care $21,939,400

Managed Care Payments (MCHIP) $108,845,600 per member/per month rate $197.27

Fee for Service $0 Total Benefit Costs $130,859,500

(Offsetting beneficiary cost sharing payments)

Net Benefit Costs $122,282,900

Cost of Proposed SPA Changes – Benefit $74,500

Administration Costs

Personnel $566,300

General administration $1,143,600

Contractors/Brokers $2,800,000

20 STATE: FFY Budget $0 Claims Processing $0 Outreach/marketing costs

Health Services Initiatives

Other $1,994,200 Total Administration Costs $6,504,100

10% Administrative Cap $13,587,000

Cost of Proposed SPA Changes

Federal Share $98,045,500

State Share $30,741,500

Total Costs of Approved CHIP Plan $128,787,000

NOTE: Include the costs associated with the current SPA.

The Source of State Share Funds: State General Funds/Tobacco Settlement Funds

_____________________________________________________________________________ Table of Contents State/Territory Name: State Plan Amendment (SPA) #: This file contains the following documents in the order listed: 1) Approval Letter 2) State Plan Pages Utah UT-23-0030

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-01-16 Baltimore, MD 21244-1850 Children and Adults Health Programs Group March 8, 2024 Jennifer Strohecker State Medicaid and CHIP Director Director, Division of Integrated Healthcare P.O. Box 143101 Salt Lake City, UT 84114-3101 Dear Director Strohecker: Your title XXI Children’s Health Insurance Program (CHIP) State Plan Amendment (SPA) UT-23- 0030, submitted on December 28, 2023, has been approved. Through this SPA, Utah provides 12 months of continuous postpartum coverage to individuals enrolled in its separate CHIP, pursuant to section 9822 of the American Rescue Plan Act of 2021 (ARP). This SPA is a companion to the Medicaid continuous postpartum coverage Medicaid SPA, UT-23-0017. In addition, SPA UT-23- 0030 also demonstrates compliance with the requirement in the Consolidated Appropriations Act, 2023 (CAA, 2023) to provide continuous eligibility for children. The SPA has an effective date of January 1, 2024. Section 9822 of the ARP added section 2107(e)(1)(J) to the Social Security Act, which requires states to provide continuous eligibility throughout an individual’s pregnancy and 12-month postpartum period in CHIP if the state has elected this option in Medicaid. In Utah, this provision applies to targeted low-income children who are pregnant. Section 5112 of the CAA, 2023 amended section 1902(e)(12) and added a new paragraph (K) to section 2017(e)(1) of the Social Security Act (the Act) to require that states provide 12 months of continuous eligibility for children under the age of 19 in Medicaid and CHIP effective January 1, 2024. Prior to January 1, 2024, states that elected to provide continuous eligibility to children enrolled in a separate CHIP were permitted to disenroll such children during a continuous eligibility period due to failure to pay premiums. However, under section 2107(e)(1)(K) of the Act, effective January 1, 2024, states are no longer permitted to do so. Utah had elected in its state plan to provide continuous eligibility to children enrolled in CHIP, and to disenroll children during a continuous eligibility period due to failure to pay premiums. Utah confirmed that it no longer disenrolls children from coverage due to late premium payments during or after the continuous eligibility period and no longer institutes a premium lock-out policy. Utah must effectuate these changes by amending Section 8 of its CHIP state plan and the CS21 form in MMDL no later than the end of its fiscal year.

Page 2 – Jennifer Strohecker

Your Project Officer is Joyce Jordan. She is available to answer your questions concerning this amendment and other CHIP-related matters. Her contact information is as follows:

Centers for Medicare & Medicaid Services

Center for Medicaid and CHIP Services

7500 Security Boulevard, Mail Stop: S2-01-16

Baltimore, MD 21244-1850

Telephone: (410) 786-3413

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

If you have additional questions, please contact Meg Barry, Director, Division of State Coverage Programs, at (410) 786-1536. We look forward to continuing to work with you and your staff.

Sincerely,

Sarah deLone Director /Signed by Sarah deLone/

Page 1 of 2 CHIP Eligibility State Name: Utah OMB Control Number: 0938-1148 Transmittal Number: UT - 23 - 0030 Separate Child Health Insurance Program General Eligibility - Continuous Eligibility CS27 2107(e)(1)(K) of the SSA and 42 CFR 457.342 and 435.926; 2107(e)(1)(J) and 1902(e)(16) of the SSA Mandatory 12-Month Postpartum Continuous Eligibility in CHIP for States Electing This Option in Medicaid

At state option in Medicaid, states may elect to provide continuous eligibility for an individual’s 12-month postpartum period consistent with section 1902(e)(16) of the SSA. If elected under Medicaid, states are required to provide the same continuous eligibility and extended postpartum period for pregnant individuals in its separate CHIP. A separate CHIP cannot implement this option if not also elected under the Medicaid state plan. State elected the Medicaid option to provide continuous eligibility through the 12- month postpartum period Yes The state assures the extended postpartum period available to pregnant targeted low-income children or targeted low- income pregnant women under section 2107(e)(1)(J) of the SSA is provided consistent with the following provisions: Individuals who, while pregnant, were eligible and received services under the state child health plan or waiver shall remain eligible throughout the duration of the pregnancy (including any period of retroactive eligibility) and the 12- month postpartum period, beginning on the day the pregnancy ends and ending on the last day of the 12th month consistent with paragraphs (5) and (16) of section 1902(e) of the SSA Continuous eligibility is provided to targeted low-income children who are pregnant or targeted low-income pregnant women (if applicable) who are eligible for and enrolled under the state child health plan through the end of the 12-month postpartum period who would otherwise lose eligibility because of a change in circumstances, unless: The individual or representative requests voluntary disenrollment. ■ The individual is no longer a resident of the state. ■ The Agency determines that eligibility was erroneously granted at the most recent determination or renewal of eligibility because of Agency error or fraud, abuse, or perjury attributed to the individual. ■ The individual dies. ■ Unlike continuous eligibility for children, states providing the 12-month postpartum period may not end an individual’s continuous eligibility due to becoming eligible for Medicaid. Consistent with section 2107(e)(1)(J) of the SSA, the state assures that continuous eligibility is provided through an individual’s pregnancy and 12-month postpartum period regardless of an individual becoming eligible for Medicaid. Benefits provided during the 12-month postpartum period must be the same scope of comprehensive services consistent with the benefit package elected by the state under section 2103(a) of the SSA that is available to targeted low-income children and/or targeted low-income pregnant women and may include additional benefits as described in Section 6 of the CHIP state plan.

Page 2 of 2 CHIP Eligibility Mandatory Continuous Eligibility for Children

The CHIP Agency must provide that children who have been determined eligible under the state plan shall remain eligible, regardless of any changes in the family’s circumstances, for a 12-month continuous eligibility period. Consistent with section 2107(e)(1)(K) of the SSA, the state assures that continuous eligibility is provided to its targeted low-income children for a duration of 12 months, regardless of any changes in circumstances, unless: The child attains age 19. ■ The child or child's representative requests voluntary disenrollment. ■ The child is no longer a resident of the state. ■ The Agency determines that eligibility was erroneously granted at the most recent determination or renewal of eligibility because of Agency error or fraud, abuse, or perjury attributed to child or child's representative. ■ The child dies. ■ The child becomes eligible for Medicaid. ■ The state elects to provide coverage to the from-conception-to-end-of-pregnancy (FCEP) population (otherwise known as the "unborn"). No PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. V.20240112

_____________________________________________________________________________ Table of Contents State/Territory Name: State Plan Amendment (SPA) #: This file contains the following documents in the order listed: 1) Approval Letter 2) State Plan Pages Utah UT-24-0014

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-01-16 Baltimore, MD 21244-1850

Children and Adults Health Programs Group

September 16, 2024

Jennifer Strohecker State Medicaid and CHIP Director Director, Division of Integrated Healthcare P.O. Box 143101 Salt Lake City, UT 84114-3101

Dear Director Jennifer Strohecker:

Your title XXI Children’s Health Insurance Program (CHIP) State Plan Amendments (SPA) UT-24- 0014, submitted on June 27, 2024, have been approved. The effective date of this SPA is January 1, 2024.

Utah received approval for continuous eligibility for children under UT-23-0030. Through SPA UT-24-0014, Utah amends its CS21 state plan page to demonstrate that it no longer disenrolls children from coverage due to non-payment of premiums during, or at the end of the continuous eligibility period. In addition, the SPA eliminates the state’s premium lock-out period.

Your Project Officer is Joyce Jordan. She is available to answer your questions concerning this amendment and other CHIP-related matters. Her contact information is as follows:

Centers for Medicare & Medicaid Services

Center for Medicaid and CHIP Services

7500 Security Boulevard, Mail Stop: S2-01-16

Baltimore, MD 21244-1850

Telephone: (410) 786-3413

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

If you have additional questions, please contact Meg Barry, Director, Division of State Coverage Programs, at (410) 786-1536. We look forward to continuing to work with you and your staff.

Sincerely,

Sarah deLone Director /Signed by Sarah deLone/

‐

_____________________________________________________________________________ Table of Contents State/Territory Name: State Plan Amendment (SPA) #: This file contains the following documents in the order listed: 1) Approval Letter 2) State Plan Pages Utah UT-25-0014 and UT-25-0033

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-01-16 Baltimore, MD 21244-1850 Children and Adults Health Programs Group September 12, 2025 Jennifer Strohecker Medicaid Director Director, Division of Integrated Healthcare P.O. Box 143101 Salt Lake City, UT 84114-3101 Dear Director Strohecker: Your Title XXI Children’s Health Insurance Program (CHIP) State Plan Amendments (SPAs), UT-25-0033 and UT-25-0014, submitted on June 19, 2025, and June 27, 2025, respectively, have been approved. The effective date for these SPAs is July 1, 2024. Through SPA UT-25-0033, Utah updates the CHIP State Plan to indicate that the State permanently eliminates premiums and adds a new managed care vendor, Healthy U. SPA UT- 25-0014 updates the CS21 to reflect the removal of the CHIP premiums. Your Project Officer is Joyce Jordan. She is available to answer your questions concerning this amendment and other CHIP-related matters and can be reached at Joyce.Jordan@cms.hhs.gov. If you have additional questions, please contact Mary Beth Hance, Acting Director, Division of State Coverage Programs, at (410) 786-4299. We look forward to continuing to work with you and your staff. Sincerely, Acting Director on Behalf of Sarah deLone, Director /Signed by Alice Weiss/

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

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

State/Territory: The State of Utah

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

________________________________________________________________________ (Signature of Governor, or designee, of State/Territory, Date Signed)

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

The following State officials are responsible for program administration and financial oversight (42 CFR 457.40(c)):

Name: Jennifer Strohecker Position/Title: Medicaid Director, Director of Integrated Healthcare Name: Jennifer Wiser Position/Title: CHIP Director Name: Position/Title:

*Disclosure. 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 09380707. The time required to complete this information collection is estimated to average 160 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, write to: CMS, 7500 Security Blvd., Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

2 Introduction: Section 4901 of the Balanced Budget Act of 1997 (BBA), public law 1005-33 amended the Social Security Act (the Act) by adding a new title XXI, the Children’s Health Insurance Program (CHIP). In February 2009, the Children’s Health Insurance Program Reauthorization Act (CHIPRA) renewed the program. The Patient Protection and Affordable Care Act of 2010 further modified the program.

This template outlines the information that must be included in the state plans and the state plan amendments (SPAs). It reflects the regulatory requirements at 42 CFR Part 457 as well as the previously approved SPA templates that accompanied guidance issued to States through State Health Official (SHO) letters. Where applicable, we indicate the SHO number and the date it was issued for your reference. The CHIP SPA template includes the following changes: o Combined the instruction document with the CHIP SPA template to have a single document. Any modifications to previous instructions are for clarification only and do not reflect new policy guidance. o Incorporated the previously issued guidance and templates (see the Key following the template for information on the newly added templates), including: • Prenatal care and associated health care services (SHO #02-004, issued November 12, 2002) • Coverage of pregnant women (CHIPRA #2, SHO # 09-006, issued May 11, 2009) • Tribal consultation requirements (ARRA #2, CHIPRA #3, issued May 28, 2009) • Dental and supplemental dental benefits (CHIPRA # 7, SHO # #09-012, issued October 7, 2009) • Premium assistance (CHIPRA # 13, SHO # 10-002, issued February 2, 2010) • Express lane eligibility (CHIPRA # 14, SHO # 10-003, issued February 4, 2010) • Lawfully Residing requirements (CHIPRA # 17, SHO # 10-006, issued July 1, 2010) o Moved sections 2.2 and 2.3 into section 5 to eliminate redundancies between sections 2 and 5. o Removed crowd-out language that had been added by the August 17 letter that later was repealed. The Centers for Medicare & Medicaid Services (CMS) is developing regulations to implement the CHIPRA requirements. When final regulations are published in the Federal Register, this template will be modified to reflect those rules and States will be required to submit SPAs illustrating compliance with the new regulations. States are not required to resubmit their State plans based on the updated template. However, States must use the updated template when submitting a State Plan Amendment.

Federal Requirements for Submission and Review of a Proposed SPA. (42 CFR Part 457 Subpart A) In order to be eligible for payment under this statute, each State must submit a Title XXI plan for approval by the Secretary that details how the State intends to use the funds and fulfill other requirements under the law and regulations at

3 42 CFR Part 457. A SPA is approved in 90 days unless the Secretary notifies the State in writing that the plan is disapproved or that specified additional information is needed. Unlike Medicaid SPAs, there is only one 90 day review period, or clock for CHIP SPAs, that may be stopped by a request for additional information and restarted after a complete response is received. More information on the SPA review process is found at 42 CFR 457 Subpart A.

When submitting a State plan amendment, states should redline the changes that are being made to the existing State plan and provide a “clean” copy including changes that are being made to the existing state plan.

The template includes the following sections: 1. General Description and Purpose of the Children’s Health Insurance Plans and the Requirements- This section should describe how the State has designed their program. It also is the place in the template that a State updates to insert a short description and the proposed effective date of the SPA, and the proposed implementation date(s) if different from the effective date. (Section 2101); (42 CFR, 457.70) 2. General Background and Description of State Approach to Child Health Coverage and Coordination- This section should provide general information related to the special characteristics of each state’s program. The information should include the extent and manner to which children in the State currently have creditable health coverage, current State efforts to provide or obtain creditable health coverage for uninsured children and how the plan is designed to be coordinated with current health insurance, public health efforts, or other enrollment initiatives. This information provides a health insurance baseline in terms of the status of the children in a given State and the State programs currently in place. (Section 2103); (42 CFR 457.410(A)) 3. Methods of Delivery and Utilization Controls- This section requires a description that must include both proposed methods of delivery and proposed utilization control systems. This section should fully describe the delivery system of the Title XXI program including the proposed contracting standards, the proposed delivery systems and the plans for enrolling providers. (Section 2103); (42 CFR 457.410(A)) 4. Eligibility Standards and Methodology- The plan must include a description of the standards used to determine the eligibility of targeted low-income children for child health assistance under the plan. This section includes a list of potential eligibility standards the State can check off and provide a short description of how those standards will be applied. All eligibility standards must be consistent with the provisions of Title XXI and may not discriminate on the basis of diagnosis. In addition, if the standards vary within the state, the State should describe how they will be applied and under what circumstances they will be applied. In addition, this section provides information on income eligibility for Medicaid expansion programs (which are exempt from Section 4 of the State

4 plan template) if applicable. (Section 2102(b)); (42 CFR 457.305 and 457.320) 5. Outreach- This section is designed for the State to fully explain its outreach activities. Outreach is defined in law as outreach to families of children likely to be eligible for child health assistance under the plan or under other public or private health coverage programs. The purpose is to inform these families of the availability of, and to assist them in enrolling their children in, such a program. (Section 2102(c)(1)); (42CFR, 457.90) 6. Coverage Requirements for Children’s Health Insurance- Regarding the required scope of health insurance coverage in a State plan, the child health assistance provided must consist of any of the four types of coverage outlined in Section 2103(a) (specifically, benchmark coverage; benchmark-equivalent coverage; existing comprehensive state-based coverage; and/or Secretary- approved coverage). In this section States identify the scope of coverage and benefits offered under the plan including the categories under which that coverage is offered. The amount, scope, and duration of each offered service should be fully explained, as well as any corresponding limitations or exclusions. (Section 2103); (42 CFR 457.410(A)) 7. Quality and Appropriateness of Care- This section includes a description of the methods (including monitoring) to be used to assure the quality and appropriateness of care and to assure access to covered services. A variety of methods are available for State’s use in monitoring and evaluating the quality and appropriateness of care in its child health assistance program. The section lists some of the methods which states may consider using. In addition to methods, there are a variety of tools available for State adaptation and use with this program. The section lists some of these tools. States also have the option to choose who will conduct these activities. As an alternative to using staff of the State agency administering the program, states have the option to contract out with other organizations for this quality of care function. (Section 2107); (42 CFR 457.495) 8. Cost Sharing and Payment- This section addresses the requirement of a State child health plan to include a description of its proposed cost sharing for enrollees. Cost sharing is the amount (if any) of premiums, deductibles, coinsurance and other cost sharing imposed. The cost-sharing requirements provide protection for lower income children, ban cost sharing for preventive services, address the limitations on premiums and cost-sharing and address the treatment of pre-existing medical conditions. (Section 2103(e)); (42 CFR 457, Subpart E) 9. Strategic Objectives and Performance Goals and Plan Administration- The section addresses the strategic objectives, the performance goals, and the performance measures the State has established for providing child health assistance to targeted low income children under the plan for maximizing health benefits coverage for other low income children and children generally in the state. (Section 2107); (42 CFR 457.710) 10. Annual Reports and Evaluations- Section 2108(a) requires the State to assess

5 the operation of the Children’s Health Insurance Program plan and submit to the Secretary an annual report which includes the progress made in reducing the number of uninsured low income children. The report is due by January 1, following the end of the Federal fiscal year and should cover that Federal Fiscal Year. In this section, states are asked to assure that they will comply with these requirements, indicated by checking the box. (Section 2108); (42 CFR 457.750) 11. Program Integrity- In this section, the State assures that services are provided in an effective and efficient manner through free and open competition or through basing rates on other public and private rates that are actuarially sound. (Sections 2101(a) and 2107(e); (42 CFR 457, subpart I) 12. Applicant and Enrollee Protections- This section addresses the review process for eligibility and enrollment matters, health services matters (i.e., grievances), and for states that use premium assistance a description of how it will assure that applicants and enrollees are given the opportunity at initial enrollment and at each redetermination of eligibility to obtain health benefits coverage other than through that group health plan. (Section 2101(a)); (42 CFR 457.1120)

Program Options. As mentioned above, the law allows States to expand coverage for children through a separate child health insurance program, through a Medicaid expansion program, or through a combination of these programs. These options are described further below: o Option to Create a Separate Program- States may elect to establish a separate child health program that are in compliance with title XXI and applicable rules. These states must establish enrollment systems that are coordinated with Medicaid and other sources of health coverage for children and also must screen children during the application process to determine if they are eligible for Medicaid and, if they are, enroll these children promptly in Medicaid. o Option to Expand Medicaid- States may elect to expand coverage through Medicaid. This option for states would be available for children who do not qualify for Medicaid under State rules in effect as of March 31, 1997. Under this option, current Medicaid rules would apply.

Medicaid Expansion- CHIP SPA Requirements In order to expedite the SPA process, states choosing to expand coverage only through an expansion of Medicaid eligibility would be required to complete sections: • 1 (General Description) • 2 (General Background) They will also be required to complete the appropriate program sections, including: • 4 (Eligibility Standards and Methodology) • 5 (Outreach) • 9 (Strategic Objectives and Performance Goals and Plan Administration

6 including the budget) • 10 (Annual Reports and Evaluations).

Medicaid Expansion- Medicaid SPA Requirements States expanding through Medicaid-only will also be required to submit a Medicaid State Plan Amendment to modify their Title XIX State plans. These states may complete the first check-off and indicate that the descriptions of the requirements for these sections are incorporated by reference through their State Medicaid plans for sections: • 3 (Methods of Delivery and Utilization Controls) • 4 (Eligibility Standards and Methodology) • 6 (Coverage Requirements for Children's Health Insurance) • 7 (Quality and Appropriateness of Care) • 8 (Cost Sharing and Payment) • 11 (Program Integrity) • 12 (Applicant and Enrollee Protections) indicating State

• Combination of Options- CHIP allows states to elect to use a combination of the Medicaid program and a separate child health program to increase health coverage for children. For example, a State may cover optional targeted-low income children in families with incomes of up to 133 percent of poverty through Medicaid and a targeted group of children above that level through a separate child health program. For the children the State chooses to cover under an expansion of Medicaid, the description provided under “Option to Expand Medicaid” would apply. Similarly, for children the State chooses to cover under a separate program, the provisions outlined above in “Option to Create a Separate Program” would apply. States wishing to use a combination of approaches will be required to complete the Title XXI State plan and the necessary State plan amendment under Title XIX.

Proposed State plan amendments should be submitted electronically and one signed hard copy to the Centers for Medicare & Medicaid Services at the following address: Amy Lutzky Centers for Medicare & Medicaid Services 7500 Security Blvd Baltimore, Maryland 21244 Attn: Children and Adults Health Programs Group Center for Medicaid, CHIP and Survey & Certification Mail Stop - S2-01-16

7 Section 1. General Description and Purpose of the Children’s Health Insurance Plans and the Requirements 1.1. The state will use funds provided under Title XXI primarily for (Check appropriate box) (Section 2101)(a)( 1)); (42 CFR 457.70):

Guidance: Check below if child health assistance shall be provided primarily through the development of a separate program that meets the requirements of Section 2101, which details coverage requirements and the other applicable requirements of Title XXI.

1.1.1 Obtaining coverage that meets the requirements for a separate child health program (Sections 2101(a)(1) and 2103); OR

Guidance: Check below if child health assistance shall be provided primarily through providing expanded eligibility under the State’s Medicaid program (Title XIX). Note that if this is selected the State must also submit a corresponding Medicaid SPA to CMS for review and approval.

1.1.2. Providing expanded benefits under the State’s Medicaid plan (Title XIX) (Section 2101(a)(2)); OR

Guidance: Check below if child health assistance shall be provided through a combination of both 1.1. and 1.2. (Coverage that meets the requirements of Title XXI, in conjunction with an expansion in the State’s Medicaid program). Note that if this is selected the state must also submit a corresponding Medicaid state plan amendment to CMS for review and approval.

1.1.3.

A combination of both of the above. (Section 2101(a)(2))

1.1-DS

The State will provide dental-only supplemental coverage. Only States operating a separate CHIP program are eligible for this option. States choosing this option must also complete sections 4.1-DS, 4.2-DS, 6.2-DS, 8.2-DS, and 9.10 of this SPA template. (Section 2110(b)(5)) 1.2

Check to provide an assurance that expenditures for child health assistance will not be claimed prior to the time that the State has legislative authority to operate the State plan or plan amendment as approved by CMS. (42 CFR 457.40(d)) 1.3

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

8

Guidance: The effective date as specified below is defined as the date on which the State begins to incur costs to implement its State plan or amendment. (42 CFR 457.65) The implementation date is defined as the date the State begins to provide services; or, the date on which the State puts into practice the new policy described in the State plan or amendment. For example, in a State that has increased eligibility, this is the date on which the State begins to provide coverage to enrollees (and not the date the State begins outreach or accepting applications).

1.4 Provide the effective (date costs begin to be incurred) and implementation (date services begin to be provided) dates for this SPA (42 CFR 457.65). A SPA may only have one effective date, but provisions within the SPA may have different implementation dates that must be after the effective date.

Original Plan

Effective Date: July 10, 1998

Implementation Date: August 1, 1998

SPA #_10_, Purpose of SPA: Rebenchmark CHIP benefits

Proposed effective date: November 19, 2011

Proposed implementation date: November 19, 2011

SPA #_11_, Purpose of SPA:_ Express Lane Eligibility and Presumptive Eligibility -pending

Proposed effective date: ELE- September 1, 2011; Presumptive Eligibility- April 1, 2012

Proposed implementation date: ELE- September 1, 2011; PE- April 1, 2012

SPA #_12_, Purpose of SPA: Rebenchmark CHIP benefits

Proposed effective date: July 1, 2012

Proposed implementation date: July 1, 2012 Withdrawn

9 SPA #_13_, Purpose of SPA: Rebenchmark CHIP benefits

Proposed effective date: July 1, 2012

Proposed implementation date: July 1, 2012

SPA #_14_, Purpose of SPA: Eliminate Presumptive Eligibility for children that meet the requirements of section 1920A of the Act. (Section 2107 (e)(1)(L)); (42 CFR 457.355) Removing references to Plan A.

Proposed effective date: November 1, 2014

Proposed implementation date: November 1, 2014

SPA# 15, Purpose of SPA: Ex Parte Reviews

Proposed effective date: February 1, 2015

Proposed implementation date: February 1, 2015

SPA# 16, Purpose of SPA: Change Reports

Proposed effective date: November 1, 2015

Proposed implementation date: November 1, 2015

SPA# 17, Purpose of SPA: Rebenchmark CHIP dental benefits

Proposed effective date: July 1, 2016

Proposed implementation date: July 1, 2016

Proposed implementation date: July 1, 2016 SPA# 18, Purpose of SPA: FQHC Payment Methodology

Proposed effective date: July 1, 2016