Table of Contents State/Territory Name: State Plan Amendment (SPA) #: This file contains the following documents in the order listed: 1) Approval Letter UT-12-001 Utah 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages Effective Date 04/01/2012 Approval Date: 04/02/2012 TN: UT-12-001

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare &Medicaid Services 1600 Broadway, Suite 700 Denver, CO 802024967 Region VIII axrraa, amuaureneemsterxrJ April 2, 2012 W. David Patton. Ph.D. Utah Department of Health 288 North 1460 West PO Box 143102 Salt Lake City, UT 84114 RE: Utah # 12 -001 Dear Dr. Patton: We have reviewed the proposed State Plan Amendment (SPA) submitted under transmittal number (TN) 12 -001. This State Plan Amendment allows presumptive eligibility for individuals in Medicaid who are under 19 years of age if a qualified entity determines that they are eligible for Medicaid services. This expansion is one of 5 requirements necessary for the State to receive the Performance Bonus payments. Please be informed that this State Plan Amendment is approved effective April 1. 2012. We are enclosing the CMS -179 and the amended plan page(s). If you have any questions concerning this amendment, please contact Betty Strecker at 701) 540 -4118. Sincerely. s/ Richard C. Allen Associate Regional Administrator Division for Medicaid and Children's Health CC: Michael Hales, Medicaid Director. UT Craig Devashrayee, UT

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED HEALTHCARE FINANCING ADMINISTRATION OMB NO. 0938-0193 1. TRANSMITTAL NUMBER: 2. STATE: RANSMITTAL AND NOTICE OF APPROVAL OF f2- 001 -UT Utah STATE PLAN MATERIAL OR: HEALTHCARE FINANCING ADMINISTRATION 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) TO: REGIONAL ADMINISTRATOR 4. PROPOSED EFFECTIVE DATE HEALTHCARE FINANCING ADMINISTRATION April 1, 2012 DEPARTMENT OF HEALTH AND HUMAN SERVICES i. TYPE OF PLAN MATERIAL (Check One) NEW STATE PLAN AMENDMENT TO BE CONSIDERED AS NEW PLAN X AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate Transmittal foreach amendment i. FEDERAL STATUTE/REGULATION CITATION: 7. FEDERAL BUDGET IMPACT: a. FFY 2012 25,760 1920A of the Social Security Act b. IFFY 2 51,579 T. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable) Page 23d of ATTACHMENT 2.2 -A 10. SUBJECT OF AMENDMENT: Presumptive Eligibility for Children 11. GOVERNOR'S REVIEW (Check One): X GOVERNOR'S OFFICE REPORTED NO COMMENT OTHER, AS SPECIFIED: COMMENTS OF GOVERNOR'S OFFICE ENCLOSED NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL 12. 16. RETURN TO: Craig Devashrayee, Manager 13. TYPED ME: David Patton, Ph.D. Technical Writing Unit Utah Department of Heath 14. TITLE: Executive Director, Utah Department of Health P.O. Box 143102 Salt Lake City, UT 84114 -3102 15. DATE SUBMITTED: February 15, 2012 16. 17. DATE RECEIVED: 18. DATE APPROVEJO: . FOR REGIONAL USE ONLY. 19: EFF.ECTIVC E.OF APPROVED MATER'AL' AL OFFICIAL: M. TYPED NAME. T' C E: PLAN APPROVED -.ONE COPY ATTACHED 3. REMARKS

ATTACHMENT 2.2 -A Page 23d STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: UTAH COVERAGE AND CONDITIONS OF ELIGIBILITY Citation(s) Groups Covered B. Optional Coverage Other Than the Medically Needy (Continued) 1920A of the Act X 25. Presumptive Eligibility for Children Children under age 19 (no more than age 19) who are determined by a "qualified entity" (as defined in §1920A(b)( 3)( A) of the Act) based on preliminary information, to meet the highest applicable income criteria specified in this plan under ATTACHMENT 2.6 -A and are therefore determined to be presumptively eligible during a presumptive eligibility period in accordance with §1920A of the Act. The presumptive period begins on the day that the determination is made. If an application for Medicaid is filed on the child's behalf by the last day of the month following the month in which the determination of presumptive eligibility was made, the presumptive period ends on the day that the State agency makes a determination of eligibility based on that application. If an application is not filed on the child's behalf by the last day of the month following the month the determination of presumptive eligibility was made, the presumptive period ends on that last day. The following types of "qualified entities" are used to determine presumptive eligibility: Medicaid eligibility workers with the Divisions of Child and Family Services or Juvenile Justice Services. The State requires that a written application be completed and signed by the child's parent or other representative: X Yes No The written application requests the following identifying information: Names of children; birth date; gender; household members and relationship to children; state residency; household income; citizenship or legal alien status. T.N. # 12 -001 Approval Date Supersedes T.N. # New Effective Date 4 -1 -12

Table of Contents State/Territory Name: Utah State Plan Amendment (SPA) #: UT- 13- 021 This file contains the following documents in the order listed: 1) Approval Letter 2) 179 3) Approved SPA Pages TN: UT- 13- 021 Approval Date: 3/ 5/ 14 Effective Date: 7/ 1/ 13

DEPARTMENT OF HEALTH& HUMAN SERVICES Centers for Medicare& Medicaid Services momok 0= 1600 Broadway, Suite 700 Denver, CO 80202-4967 C N ERti t€ R MEC3WARE MFOIi AID Si itt I -`> Region VIII March 5, 2014 W. David Patton, Ph.D. Utah Department of Health 288 North 1460 West PO Box 143102 Salt Lake City, UT 84114 RE: Utah# 13- 021 Dear Dr. Patton: We have reviewed the proposed State Plan Amendment (SPA) submitted under transmittal number( TN) 13- 021. This SPA broadens access to podiatric services by including a provision that allows podiatrists along with physicians and osteopaths to perform podiatric services for categorically and medically needy clients. The agency also refers to the Podiatric Services Provider Manual for descriptions of service limitations. Please be informed that this State Plan Amendment was approved today with an effective date of July 1, 2013. We are enclosing the CMS- 179 and the amended plan page( s). If you have any questions concerning this amendment, please contact Mandy Strom at 303) 844- 7068. Sincerely, s/ Richard C. Allen Associate Regional Administrator Division for Medicaid and Children' s Health CC: Michael Hales, Medicaid Director, UT Craig Devashrayee, UT

FORM APPROVED 3EPARTMENT OF HEALTH AND HUMAN SERVICES OMB N0, 0938-0193 1EALTHCARE FINANCING ADMINISTRATION 1. TRANSMITTAL NUMBER: 2, STATE: RANSMITTAL AND NOTICE OF APPROVAL OF 13-021- UT Utah STATE PLAN MATERIAL 3, PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL OR: HEALTHCARE FINANCING ADMINISTRATION SECURITY ACT( MEDICAID) TO: REGIONAL ADMINISTRATOR 4. PROPOSED EFFECTIVE DATE HEALTHCARE FINANCING ADMINISTRATION July 1, 2013 DEPARTMENT OF HEALTH AND HUMAN SERVICES TYPE OF PLAN MATERIAL( Check One) NEW STATE PLAN AMENDMENT TO BE CONSIDERED AS NEW PLAN AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT( Separate Transmittal for each amendment 1. FEDERAL STATUTE/ REGULATION CITATION: 7. FEDaERFLYU BUDGET IMPACT: 42 CFR 440.50 b. IFFY 2014 $ 0 1. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: 9. OR ATTACHMENT( if HE Applicable) S RSEDED PLAN SECTION Page 1 of Attachment# 6a in ATTACHMENTS 3. 1- A and page 1 of Attachment# 6a in ATTACHMENTS 3. 1- A and ATTACHMENT 3. 1- B, ATTACHMENT 3. 1- B. Page 2 of Attachment# 6a in ATTACHMENTS 3. 1- A and Page 2 of Attachment# 6a in ATTACHMENTS 3. 1- A and ATTACHMENT 3. 1- 13 is removed. ATTACHMENT 3. 1- B is removed. 10. SUBJECT OF AMENDMENT: Podiatric Services 11, GOVERNOR' S REVIEW ( Check One): OTHER, AS SPECIFIED: GOVERNOR' S OFFICE REPORTED NO COMMENT COMMENTS OF GOVERNOR' S OFFICE ENCLOSED NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL 12. SIGNATUR OF TE GENCY OFFfCiAL: 16. RETURN TO: Craig Devashrayee, Manager 13. TY E AME: W. David Patton, Ph.D. Technical Writing Unit Utah Department of Heath 14. TITLE: Executive Director, Utah Department of Health PO Box 143102 Salt Lake City, UT 84114-3102 15, DATE SUBMITTED: May 31, 2013 a, zr 1. .)\ tfr' t) L•r:,.,,•y„ .,,. a a.. _ t R. ., 2• -- 1 a. .: v tp i. , w..,. L;;>?:: Y zf nr; t;; t c it : S z:: ie r=_ .. t.::LC: eik;L':..; r. s r SC:: ac;.., e:in f t f}. +• rFF:ii. , vti -+ {{' i'!' 3,{ c 4i1 . i V.LM W{{{ r ' tf T4 q'' },- , 4{ 3 c t , a i ? ISl'it I. R j r f t t L r\ r Ytf .. a y .) F{ r, 1. } t T' rf tt, T !! (-. 4rft'{`.,'. I < t ul j y s, Sf; . SyF. c: tr., sr,,.: ti. Iirj,Fs t c i> y. -• Y! ff , jiY fir 2.. v 7 f f..>. 0,.1.:_?. rT..:, ttc.c.' w..;,,• R;i.:, R i• rfcJ i: f9. 1 a -' t E t Iii S Y: 5F 1 t a :.:, L,:"::, vv. i, i;2h: •-- '. . 42. il:.si rn h. > s f 2` z`.. fix_ai L t Y ! cA i 1 t LFL Y1. q.- 7L?,{.. t{ 1 ,, y . 2`\ A 1 i C4 t , f ` t - i L is 3 } S y\ j f ctv!} xa.. d >! '.. i.. s L z, J A r x, c zFiS"r.1`S 7` l'YIk.1 f:f:. fx1' 1' 7'} f y # Y f{ 2y i. t '!. J. f} d 5 VL f. } ; f! t.. Y'fit 4 17 y f ff t t t t..:.j s t 4+IF,ii,t, fwf; r,iry;> r :, z• i.' r. >,: i y•.: f:x \` 4ztc J T f •.., t siu. z \ c , f r I,t z: !~ C t J.. h } i { i', ! L . r { S$ 4 : j i Y x N 7i++ Ii A xL yty{ Ti' T 5 t tif F fit t

42 CFR ATTACHMENT 4. 19- B 440. 60 Page 6 F. PODIATRISTS Except as otherwise noted in the plan, state developed fee schedule rates are the same for both governmental and private providers of podiatric services. The amount billed cannot exceed usual and customary charges. The agency's rates were set in accordance with the methodology described in Section D " Physicians," and are effective for services on or after the date noted in Section D. Payments for covered podiatric services are based on the established fee schedule unless a lower amount is billed. All rates are published on the agency's website at http://health. utah. gov/medicaid/. T.N. # 13-021 Approval Date Supersedes T.N. # 87-37 Effective Date 7- 1- 13

42 CFR ATTACHMENT 3. 1- A 440.60 Attachment# 6a Page 1 PODIATRIC SERVICES LIMITATIONS 1. A podiatrist is limited to the provision of podiatric services within the scope of professional licensure. 2. A person licensed to practice podiatry may not administer general anesthesia and may not amputate the foot. 3. Palliative care must include the specific service and must be billed by the specific service and not by using an evaluation and management (office call) procedure code. 4. Podiatry services for recipients residing in long term care facilities have the following limitations: a. Foot care performed by an employee of the facility is not covered. b. Visits are limited to one visit every 60 days. c. Debridement of mycotic toenails is limited to once every 60 days. d. Trimming corns, warts, calluses or nails is limited to once every 60 days. 5. The Agency may exceed the limitations on existing covered services to the extent allowed by law, if its medical staff determines: a. that the proposed services are medically appropriate; and b. that the proposed services are more cost effective than alternative services. T. N. # 13-021 Approval Date Supersedes T. N. # 02- 005 Effective Date 7- 1- 13

42 CFR ATTACHMENT 3. 1- A 440.60 Attachment# 6a Page 2 PODIATRIST SERVICES ( Continued) Deleted July 1, 2013 T. N. # 13- 021 Approval Date Supersedes T. N. # 02- 005 Effective Date 7- 1- 13

42 CFR ATTACHMENT 3. 1- B 440.60 Attachment# 6a Page 1 PODIATRIC SERVICES LIMITATIONS 1. A podiatrist is limited to the provision of podiatric services within the scope of professional licensure. 2. A person licensed to practice podiatry may not administer general anesthesia and may not amputate the foot. 3. Palliative care must include the specific service and must be billed by the specific service and not by using an evaluation and management( office call) procedure code. 4. Podiatry services for recipients residing in long term care facilities have the following limitations: a. Foot care performed by an employee of the facility is not covered. b. Visits are limited to one visit every 60 days. c. Debridement of mycotic toenails is limited to once every 60 days. d. Trimming corns, warts, calluses or nails is limited to once every 60 days. 5. The Agency may exceed the limitations on existing covered services to the extent allowed by law, if its medical staff determines: a. that the proposed services are medically appropriate; and b. that the proposed services are more cost effective than alternative services. T. N. # 13-021 Approval Date Supersedes T. N. # 02- 005 Effective Date 7- 1- 13

42 CFR ATTACHMENT 3. 1- B 440.60 Attachment# 6a Page 2 PODIATRIST SERVICES ( Continued) Deleted July 1, 2013 T. N. # 13- 021 Approval Date Supersedes T. N. # 02-005 Effective Date 7- 1- 13

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 1600 Broadway, Suite 700 Denver, CO 80202-4967

Region VIII

October 29, 2013

W. David Patton, Ph.D.

Utah Department of Health 288 North 1460 West PO Box 143102 Salt Lake City, UT 84114

RE: Utah #13-026

Dear Dr. Patton:

We have reviewed the proposed State Plan Amendment (SPA) submitted under transmittal number (TN) 13-026. This State Plan Amendment updates, clarifies and reorganizes physical therapy and occupational therapy services for eligible Medicaid recipients.

Please be informed that this State Plan Amendment was approved October 28, 2013 with an effective date of Julyu1, 2013. We are enclosing the CMS-179 and the amended plan page(s).

If you have any questions concerning this amendment, please contact Mandy Strom at (303) 844-7068.

Sincerely,

/s/

Richard C. Allen

Associate Regional Administrator

Division for Medicaid and Children’s Health

CC: Michael Hales, Medicaid Director, UT Craig Devashrayee, UT

42 CFR ATTACHMENT 3. 1- A 440. 110 Attachment# 11 a Page 1 PHYSICAL THERAPY SERVICES SERVICES Physical therapy services by independent provider, group practice, rehabilitation facility, outpatient facilities, and hospital include: The examination, evaluation, diagnosis, prognosis, and intervention under the direct supervision of a physical therapist of a client to prevent, correct, alleviate and limit physical disability, bodily malfunction, pain from injury, disease and other physical or mental disabilities. LIMITATIONS 1. Physical therapy requires a physician order. 2. Physical therapy requires the attending physician to certify the client's need for therapy services. 3. Physical therapy requires a written plan of care signed by the physician. 4. Physical therapy related to a stroke must be initiated within 60 days following the stroke and may continue only until the expected, reasonable level of function is restored. 5. Physical therapy is limited to 20 visits per calendar year. 6. The Agency may exceed the limitations on existing covered services to the extent allowed by law, if its medical staff determines: a. that the proposed services are medically appropriate; and b. that the proposed services are more cost effective than alternative services. T. N. # 13-026 Approval Date 3 Supersedes T. N. # 09- 003 Effective Date 7- 1- 13

42 CFR ATTACHMENT 3. 1- A 440. 110 Attachment# 11 b Page 1 OCCUPATIONAL THERAPY SERVICES SERVICES Outpatient occupational therapy services include: Program planning, consultation, evaluation, and intervention under the direct supervision of an occupational therapist to provide the therapeutic use of everyday activities to promote health and wellness for clients at risk for developing illness, injury, disease, disorder, condition, impairment, disability, activity limitation, or participation restriction. LIMITATIONS 1. Occupational therapy requires a physician order. 2. Occupational therapy requires the attending physician to certify the client's need for therapy services. 3. Occupational therapy requires a written plan of care signed by the physician. 4. Occupational therapy related to a stroke must be initiated within 90 days following the stroke and may continue only until the expected, reasonable level of function is restored. 5. Occupational therapy is limited to 20 visits per calendar year. 6. The Agency may exceed the limitations on existing covered services to the extent allowed by law, if its medical staff determines: a. that the proposed services are medically appropriate; and b. that the proposed services are more cost effective than alternative services. T. N. # 13- 026 Approval Date t0 >s Supersedes T.N. # 09-003 Effective Date 7- 1- 13

42 CFR ATTACHMENT 3. 1- 13 440. 110 Attachment# 11 a Page 1 PHYSICAL THERAPY SERVICES SERVICES Physical therapy services by independent provider, group practice, rehabilitation facility, outpatient facilities, and hospital include: The examination, evaluation, diagnosis, prognosis, and intervention under the direct supervision of a physical therapist of a client to prevent, correct, alleviate and limit physical disability, bodily malfunction, pain from injury, disease and other physical or mental disabilities. LIMITATIONS 1. Physical therapy requires a physician order. 2. Physical therapy requires the attending physician to certify the client's need for therapy services. 3. Physical therapy requires a written plan of care signed by the physician. 4. Physical therapy related to a stroke must be initiated within 60 days following the stroke and may continue only until the expected, reasonable level of function is restored. 5. Physical therapy is limited to 20 visits per calendar year. 6. The Agency may exceed the limitations on existing covered services to the extent allowed by law, if its medical staff determines: a. that the proposed services are medically appropriate; and b. that the proposed services are more cost effective than alternative services. T. N. # 13-026 Approval Date Supersedes T. N. # 09- 003 Effective Date 7- 1- 13

42 CFR ATTACHMENT 3. 1- 13 440. 110 Attachment# 11 b Page 1 OCCUPATIONAL THERAPY SERVICES SERVICES Outpatient occupational therapy services include: Program planning, consultation, evaluation, and intervention under the direct supervision of an occupational therapist to provide the therapeutic use of everyday activities to promote health and wellness for clients at risk for developing illness, injury, disease, disorder, condition, impairment, disability, activity limitation, or participation restriction. LIMITATIONS 1. Occupational therapy requires a physician order. 2. Occupational therapy requires the attending physician to certify the client's need for therapy services. 3. Occupational therapy requires a written plan of care signed by the physician. 4. Occupational therapy related to a stroke must be initiated within 90 days following the stroke and may continue only until the expected, reasonable level of function is restored. 5. Occupational therapy is limited to 20 visits per calendar year. 6. The Agency may exceed the limitations on existing covered services to the extent allowed by law, if its medical staff determines: a. that the proposed services are medically appropriate; and b. that the proposed services are more cost effective than alternative services. T. N. # 13- 026 Approval Date 41jw 1 13 Supersedes T. N. # 09-003 Effective Date 7- 1- 13

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED HEALTHCARE FINANCING ADMINISTRATION_ OMB NO. 0938- 0193 1. TRANSMITTAL NUMBER: 2. STATE: TRANSMITTAL AND NOTICE OF APPROVAL OF 13- 026- UT Utah STATE PLAN MATERIAL FOR: HEALTH CARE FINANCING ADMINISTRATION 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT( MEDICAID) TO: REGIONAL ADMINISTRATOR 4. PROPOSED EFFECTIVE DATE HEALTHCARE FINANCING ADMINISTRATION July 1, 2013 DEPARTMENT OF HEALTH AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL( Check One) NEW STATE PLAN _ AMENDMENT TO BE CONSIDERED AS NEW PLAN AMENDMENT COMPLETE BLOCKS 6 THRU 1d IF THIS IS AN AMENDMENT ( Separate Transmittal foreach amendment) 6, FEDERAL STATUTE/ REGULATION CITATION: 7. FEDERAL BUDGET IMPACT: a. FFY 2013 $ 0 42 CFR 440. 110 b. FFY 2014 $ 0 B. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT( IfApplicable) Page 1 of Attachment# 11 a in ATTACHMENTS 3. 1- A and 3. 1- B Page 1 of Attachment# 11 a in ATTACHMENTS 3. 1- A and 3. 1- B Page 1 of Attachment# 11 b in ATTACHMENTS 3. 1- A and 3. 1- 13 Page 1 of Attachment# 11 b in ATTACHMENTS 3. 1- A and 3. 1- B 10. SUBJECT OF AMENDMENT: Physical Thera py and Occupational Therapy 11. GOVERNOR' S REVIEW( Check One): GOVERNOR'S OFFICE REPORTED NO COMMENT OTHER, AS SPECIFIED: COMMENTS OF GOVERNOR' S OFFICE ENCLOSED NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL 12. SIGNATURE OF STATE AGENCY' OFFtC1AL:.: 16, RETURN TO: Craig Devashrayee, Manager 13. TYPED NAM Michael Hales Technical Writing Unit Utah Department of Heath 14. TITLE: Deputy Director, Utah Department of Health PO Box 143102 Salt Lake City, UT 84114- 3102 15. DATE SUBMITTED: September 30, 2013 1 r k dt v r E t E ; iFs I J a , h l n s i E -€ iJ RiitE Fri l I ' rrr' 1s; 4J Itl# 5-. T;' k 1, iI iLs

Table of Contents State/Territory Name: Utah State Plan Amendment (SPA) #: 14-0002-MM This file contains the following documents in the order listed: 1) Approval Letter 2) Additional Companion Letter 3) Summary Form (with 179-like data) 4) Superseding Pages Notice 5) Approved SPA Pages

ONO tanan

CMS

: CENTERS FOR MEDICARE & MEDICAID SERVICES Region VIII

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

1600 Broadway, Suite 700

Denver, CO 80202-4967

November 22, 2013

Michael Hales

State Medicaid Director

Division of Health Care Financing Utah Department of Health

P O Box 144102

Salt Lake City UT 84114- 4102

Dear Mr. Hales:

Enclosed is an approved copy of Utah’s state plan amendment (SPA) 14-0002-MM, which was submitted to CMS on August 27, 2013. SPA 14-0002-MM incorporates the MAGI-based eligibility process requirements, including the single streamlined application, into Utah’s Medicaid state plan in accordance with the Affordable Care Act. The effective date of this SPA is October 1, 2013.

Until June 30, 2014, the state is using an interim alternative single streamlined paper application and an interim alternative application used to apply for multiple human service programs. Until December 31, 2014, the state is using an interim alternative single streamlined online application. The state will implement revised applications that will address CMS concerns outlined in the companion letter issued with this SPA approval.

Enclosed is a copy of the following $94 state plan pages and attachments to be incorporated within a separate section at the end of Utah’s approved state plan:

e §94, pages S94-1 and S94-2

e Attachment 1 — Statement related to coordination of eligibility and enrollment

e Attachment 2— Statement of use with respect to the alternative single, streamlined online application

e Attachment 3 — Statement of use with respect to the alternative single, streamlined paper application

In addition, enclosed is a summary of the state plan pages which are superseded by SPA 14- 0002MM, which should also be incorporated into a separate section in the front of the state plan.

e Superseding pages of state plan material, SPA 14-0002-MM.

/s/

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

1600 Broadway, Suite 700

Denver, CO 80202-4967

Region VIII

CENTERS FOR MEDICARE & MEDICAID SERVICES

November 22, 2013

Michael Hales

State Medicaid Director

Division of Health Care Financing Utah Department of Health

P O Box 144102

Salt Lake City UT 84114- 4102

Dear Mr. Hales:

This letter is being sent as a companion to Centers for Medicare & Medicaid Services (CMS) approval of state plan amendment (SPA) UT 14-0002-MM, which was submitted to CMS on August 27, 2013. Our review of this submission included a review of the alternative single ~

streamlined paper and online applications developed by the state.

Until June 30, 2014 the state is using an interim alternative single streamlined paper application and an interim alternative application used to apply for multiple human service programs. Until December 31, 2014, the state is using an interim alternative single streamlined online application. These interim applications need to be revised to reflect the following changes.

Necessary changes:

Date by which changes will be completed:

programs):

Paper Application (including the application used to apply for multiple human service

The paper application will provide a space to indicate who in the household has each type and amount of income and deduction.

June 30, 2014

The paper application will remove language on the employer coverage form which states “This form MUST be completed by your employer or your company’s Human Resources representative. Any blanks left on this form may delay the process”, and replace it with language that will encourage people to apply who might not be able to gather this information easily.

June 30, 2014

We would like to note that in accordance with 42 CFR 435.907(c), questions needed for non-MAGI determinations of eligibility may be asked in supplemental forms. We recommend that in a future version of your 61-MED application you label the questions on page 6 as an attachment, with formatting similar to Attachments

(A)-(D).

Recommendation

Online Application:

The introductory language to the application should make clear that you can apply for APTC through MyCase, as well as through the federally facilitated Marketplace.

January 1, 2014

The online application must provide an opportunity for the application filer to indicate whether he or she is applying for benefits for him/herself early enough in the application so that if not applying, the household member is not asked for his/her citizenship, immigration status, or residency. An SSN requ.ct of non-applicants must be clearly optional in accordance with 42 CFR 435.907(e).

July 1, 2014

(By January 1, 2014, Utah will add language to clarify that non-applicants may skip questions on citizenship and immigration status.)

The online application will ask for the date that a household member joined the household only when there is an indication that there has been a recent move or change in household.

July 1, 2014

The following questions will not appear on applications for MAGI-based health coverage only:

e Questions regarding the amount of non-taxable income, such as income from child support and SSI

© Questions regarding assets and non-MAGI disregards

July 1, 2014

Applicants who do not appear eligible for Medicaid and CHIP based on income attestation will be asked whether they are offered health insurance from a job, and if so, will be asked additional details about that insurance offer, which they can submit in an online format.

December 31, 2014

/s/

COORDINATION OF ELIGIBILITY AND ENROLLMENT

TRANSMITTAL NUMBER:

14-0002 STATE:

Utah

Notwithstanding the final checked statement on page 2, the single state agency has not entered into an agreement with the Federally-facilitated Marketplace to date. The single state agency will make a good faith effort to enter into a memorandum of agreement with the Federally-facilitated Marketplace before 12/31/2013. At such time the agreement is signed, it will be incorporated by reference into this attachment

USE OF THE ALTERNATIVE SINGLE STREAMLINED APPLICATION

 Paper Application  Online Application

TRANSMITTAL NUMBER:

UT 14-0002-MM

STATE:

Utah

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

USE OF THE ALTERNATIVE SINGLE STREAMLINED APPLICATION

Paper Application Online Application

TRANSMITTAL NUMBER:

UT 14-0002 MM

STATE:

Utah

Through June 30, 2014, the state is using an interim alternative single streamlined paper application. After June 30, 2014, the state will use a revised alternative single streamlined paper application. The revised application will address the issues outlined in the CMS letter, which was issued with the approval of this state plan amendment, concerning the state’s application. The revised application will be incorporated by reference into the state plan.

State/Territory name: Utah Submitted By: Craig Devashrayee Last Revision Date: Nov 22, 2013 Submit Date: Aug 27, 2013 Medicaid State Plan Eligibility: Summary Page (CMS 179) Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. UT-14-0002 Proposed Effective Date 10/01/2013 (mm/dd/yyyy) Federal Statute/Regulation Citation Pub. L. No. 111-148 Federal Budget Impact Federal Fiscal Year Amount First Year 2014 $ 0.00 Second Year 2015 $ 0.00 Subject of Amendment Eligibility Process Governor's Office Review Governor's office reported no comment Comments of Governor's office received Describe:   No reply received within 45 days of submittal Other, as specified Describe:   Signature of State Agency Official Page 1 of 2 UT.0234.R00.00 - Oct 01, 2013 12/17/2013 http://157.199.113.99/MMDL/faces/protected/mac/c01/print/PrintSelector.jsp

SUPERSEDING PAGES OF STATE PLAN MATERIAL

TRANSMITTAL NUMBER:

14-0002 MM STATE:

Utah

PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:

S94 – Eligibility Process PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable):

Section 2, Page 10, section 2.1(a), TN 91-39 Effective date: 10/1/91, approved: 9/18/92 Section 2, Page 11a, section 2.1(d), TN 91-44 Effective date: 7/1/91 , approved: 10/8/91

Page 1 of 2 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 General Eligibility Requirements Eligibility Process S94 42 CFR 435, Subpart J and Subpart M Eligibility Process The state meets all the requirements of 42 CFR 435, Subpart J for processing applications, determining and verifying eligibility, and furnishing Medicaid. ✔ Application Processing Indicate which application the agency uses for individuals applying for coverage who may be eligible based on the applicable modified adjusted gross income standard. The single, streamlined application for all insurance affordability programs, developed by the Secretary in accordance with section 1413(b)(1)(A) of the Affordable Care Act An alternative single, streamlined application developed by the state in accordance with section 1413(b)(1)(B) of the Affordable Care Act and approved by the Secretary, which may be no more burdensome than the streamlined application developed by the Secretary. An attachment is submitted. An alternative application used to apply for multiple human service programs approved by the Secretary, provided that the agency makes readily available the single or alternative application used only for insurance affordability programs to individuals seeking assistance only through such programs. An attachment is submitted. Indicate which application the agency uses for individuals applying for coverage who may be eligible on a basis other than the applicable modified adjusted gross income standard: The single, streamlined application developed by the Secretary or one of the alternate forms developed by the state and approved by the Secretary, and supplemental forms to collect additional information needed to determine eligibility on such other basis, submitted to the Secretary. An attachment is submitted. An application designed specifically to determine eligibility on a basis other than the applicable MAGI standard which minimizes the burden on applicants, submitted to the Secretary. An attachment is submitted. The agency's procedures permit an individual, or authorized person acting on behalf of the individual, to submit an application via the internet website described in 42 CFR 435.1200(f), by telephone, via mail, and in person. The agency also accepts applications by other electronic means: Yes No TN: UT-14-0002-MM Utah Approval Date: 11/22/2013 S94, page 1 Effective Date: 1/1/14

Page 2 of 2 Medicaid Eligibility Indicate the other electronic means below: Name of Method Description + facsimile Individuals may complete a paper application form and transit the form via facsimile machine. x The agency has procedures to take applications, assist applicants and perform initial processing of applications for the eligibility groups listed below at locations other than those used for the receipt and processing of applications for the title IV-A program, including Federally-qualified health centers and disproportionate share hospitals. ✔ Parents and Other Caretaker Relatives Pregnant Women Infants and Children under Age 19 Redetermination Processing Redeterminations of eligibility for individuals whose financial eligibility is based on the applicable modified adjusted gross income standard are performed as follows, consistent with 42 CFR 435.916: ✔ Once every 12 months ■ Without requiring information from the individual if able to do so based on reliable information contained in the individual's account or other more current information available to the agency ■ If the agency cannot determine eligibility solely on the basis of the information available to it, or otherwise needs additional information to complete the redetermination, it provides the individual with a pre-populated renewal form containing the information already available. ■ Redeterminations of eligibility for individuals whose financial eligibility is not based on the applicable modified adjusted gross income standard are performed, consistent with 42 CFR 435.916 (check all that apply): ■ Once every 12 months Once every 6 months Other, more often than once every 12 months Once every 3 months Coordination of Eligibility and Enrollment The state meets all the requirements of 42 CFR 435, Subpart M relative to coordination of eligibility and enrollment between Medicaid, CHIP, Exchanges and other insurance affordability programs. The single state agency has entered into agreements with the Exchange and with other agencies administering insurance affordability programs. ✔ PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN: UT-14-0002-MM Utah Approval Date: 11/22/2013 S94, page 2 Effective Date: 1/1/14

Table of Contents State/Territory Name: Utah State Plan Amendment (SPA) #: UT-14- 0003-MM This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Superseding Pages Notice (delete if not applicable) 4) Approved SPA Pages

DEPARTMENT OF HEALTH& HUMAN SERVICES Centers for Medicare& Medicaid Services 1600 Broadway, Suite 700 Denver, CO 80202-4967 CMAN-W Region VIII CU'Nffk erA%ffl) 1( Akf,&) M 0K 1D SM K F December 10, 2013 W. David Patton, Ph. D. Utah Department of Health 288 North 1460 West PO Box 143102 Salt Lake City, UT 84114 RE: Utah# 14- 0003- MM Dear Dr. Patton: We have reviewed the proposed MAGI State Plan Amendment ( SPA) submitted under transmittal number UT- 14- 0003- MM. This SPA implements the new provision for MAGI Income Methodologies under the Affordable Care Act. Please be informed that this State Plan Amendment was approved today with an effective date of January 1, 2014. Enclosed is a copy of the new State Plan pages to be incorporated within a separate section at the back of Utah' s approved State Plan: S 10, pages S 10- 1 and S 10- 2 In addition, enclosed is a summary of State Plan pages that are superseded by SPA UT- 14- 0003- MM, which should also be incorporated into a separate section in the front of the State Plan: Superseding pages of State Plan Material, 13- 047 The enclosure incorporates the following statement into the Utah State Plan: Notwithstanding any other provisions of the Colorado Medicaid State Plan, the financial eligibility methodologies described in State Plan Amendment 14- 0003- MM will apply to all MAGI-based eligibility groups covered under Colorado' s Medicaid State Plan. The MAGI financial methodologies set forth in 42 CFR § 435. 603 apply to everyone except those individuals described at 42 CFR § 435. 6030) for whom MAGI-based methods do not apply. This State Plan Amendment supersedes the current financial eligibility provisions of the Medicaid State Plan only with respect to the MAGI-based eligibility groups." If you have any questions concerning this amendment, please contact Mandy Strom at 303) 844- 7068.

UT- 14- 0003- MM Page 2 of 2 If you have any questions concerning this amendment, please contact Mandy Strom at 303) 844- 7068. Richard C. Allen Associate Regional Administrator Division for Medicaid and Children' s Health CC: Michael Hales, Medicaid Director, UT Craig Devashrayee, UT 2 /s/

UT.0235. R00. 00 - Jan 01, 2014 Page 1 of 2 7edic£i a state Nam, . l,,i i 1 9 i u 1arv - 0,e ((','MS 1, 79) State/Territory name: Utah Transmittal Number: Please enter the Transmittal Number( TN) in theformat ST-YY-0000 where ST= the state abbreviation, YY= the last two digits of the submission year, and 0000= afour digit number with leading zeros. The dashes must also be entered. UT- 14- 0003 Proposed Effective Date 01/ 01/ 2014 mm/ dd/ yyyy) Federal Statute/ Regulation Citation Pub. L. No. 111- 148 Federal Budget Impact Federal Fiscal Year Amount First Year 2014 0. 00 Second Year 2015 0. 00 Subject of Amendment MAGI Income Methodology- The fiscal impact for this SPA is included in the fiscal impact entered for the MAGI eligibility group SPA 14- 0001- MM. Governor' s Office Review Governor' s office reported no comment Comments of Governor' s office received Describe: No reply received within 45 days of submittal Other, as specified Describe: Signature of State Agency Official Submitted By: Craig Devashrayee Last Revision Date: Dee 6, 2013 Submit Date: Aug 27, 2013 httn•// 1 57 1 A9 1 VI 9A/ MMF)1 / fncPC/ nrntPCtPrI/ mac/ c01/ print/PrintCPIPCtnr icn 1?/ I()/?() I I

Medicaid Eligibility YVIB Control Number 0918- 1148 0\ 113 Expiration date: 10:31/ 2014 MAGI-Based Income Methodologies S10 1902( e)( 14) 42 CFR 435. 603 The state will a I. ' Modified Ad; usted Gross Income( MAGI)- based niethodolo a app IN ' f tics a5 described belixv, and consistent with 42 CFR 435. 603. In the case of determining ongoing eligibility for beneficiaries determined eligible for Medicaid on or before December 31, 3013, MAGI- based income methodologies will not be applied until March 31, 2014, or the next regularly- scheduled renewal of eligibility, whichever is later, if application of such methods results in a determination of ineligibility prior to such date. In determining family size for the eligibility determination of a pregnant woman, she is counted as herself plus each of the children she is expected to deliver. j In determining family size for the eligibility determination of the other individuals in a household that includes a pregnant woman: C 'The pregnant woman is counted just as herself. The pregnant wornan is counted as herself, plus one. The pregnant woman is counted as herself', plus the number of children she is expected to deliver. i Financial eligibility is determined consistent with the following provisions: 1Vhen determining eligibility for new applicants, financial eligibility is based on current monthly income and family size. I When determining, eligibility for current beneficiaries, financial eligibility is based on: i Current monthly household income and family size j C-" Projected annual household income and family size fbr the rernaining months of the current calendar year In determining current monthly or projected annual household income, the state will use reasonable methods to: 0 Include a prorated portion of a reasonably predictable increase in future income and/ or family size. 0 Account for a reasonably predictable decrease in future income and/ or family size. I Except as provided at 42 CFR 435. 603( d)( 2) through( d)( 4), household income is the sum of the MAGI- based income of every individual included in the individual' s household. i In determining eligibility for Medicaid, an amount equivalent to 5 percentage points of the FPE for the applicable family size will be deducted from household income in accordance with 42 CFR 435. 603( d). I Iousehold 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. i i' Yes (— No i TN: UT- 14-0003- MM Approval Date: 12/ 10/ 2013 Effective Date: 01/ 01/ 2014 Utah S10, page 1 pave I n#

Medicaid.~ 030 ° 0 0 N N/ Eligibility The age used f6r children . vith respect to 422 CTR 435. 603( t)(,)( iv) is: C Age 19 Age 19, or in the case of full- time students, age 21 PRA DiscICISLIN Statement ccuvJin& m the PupenvorkRcduohouAct o[| 99inupo»000mcmquiodm respond mncoUodionofin6/m o1ion unless i' dis1| uyso valid ON8 control number. The valid OMB control number for this information collection is093X-|| 48. Tlie time required wcomplete this information collection is estimated m average 4O hours per response, indudio hcdm/ oovicvinumction. cmd cxiuio data resources. gather the data needed, and complete and review the information collection. | f you have comments couccmio- the ocCumcyof dh timccmimoao( s) orwu c donoK`rimpm, in thi b/ rm. please", itcto: CMS, 750O Security Boulevard, Attn: [ IRA Reports O, umoce Officer. Mail Stop C4' 26' O5. Baltimore, Maryland 2) 244-| X0. TN: uT' 14- 0003- Mm Approval Date: 12n0/2013 Effective Date: 01m1o014 Utah n10, page u Po_)c2of

SUPERSEDING PAGES OF STATE PLAN MATERIAL TRANSMITTAL NUMBER: STATE: 14- 0003 Utah PAGE NUMBER OF THE PLAN SECTION OR PAGE NUMBER OF THE SUPERSEDED PLAN SECTION ATTACHMENT: OR ATTACHMENT( IfApplicable): Notwithstanding any other provisions of the Utah Medicaid State Plan, the financial eligibility methodologies described in State S10 - MAGI Income Methodology Plan Amendment 14- 0003 will apply to all MAGI- based eligibility groups covered under Utah' s Medicaid State Plan. The MAGI financial methodologies set forth in 42 CFR§ 435. 603 apply to everyone except those individuals described at 42 CFR§ 435. 6030) for whom MAGI- based methods do not apply. This State Plan Amendment supersedes the current financial eligibility provisions of the Medicaid State Plan only with respect to the MAGI- based eligibility groups. TN: UT- 14- 0003- MM Approval Date: 12/ 10/ 2013 Effective Date: 01/ 01/ 2014 Utah

Table of Contents State/Territory Name: Utah State Plan Amendment (SPA) #: UT- 14- 0004-MM This file contains the following documents in the order listed: 1) Approval Letter 2) Summary Form (with 179-like data) 3) Superseding Pages Notice (delete if not applicable) 4) Approved SPA Pages 5) Additional Attachments that are part of the state plan TN: UT-14- 0004-MM Approval Date: 02/ 28/ 2014 Effective Date: 01/ 01/ 2014

DEPARTMENT OF HEALTH& HUMAN SERVICES Centers for Medicare& Medicaid Services mom J 1600 Broadway, Suite 700 Denver, CO 80202-4967 cows OR MEDK ARE& b9i.OK 510 S£ Hb KB Region VIII March 6, 2014 W. David Patton, Ph.D. Utah Department of Health 288 North 1460 West PO Box 143102 Salt Lake City, UT 84114 RE: Utah# UT- 14- 0004-MM Dear Dr. Patton: We have reviewed the proposed State Plan Amendment ( SPA) submitted under transmittal number( TN) 14- 0004-MM. This SPA implements the Affordable Care Act' s provision for addressing the single state agencies delegation of appeals and determinations. Please be informed that this State Plan Amendment was approved on February 28, 2014 with an effective date of January 1, 2014. We are enclosing the summary sheet ( CMS- 179) and the amended plan page( s). If you have any questions concerning this amendment, please contact Mandy Strom at 303) 844- 7068. Sincerely, s/ Richard C. Allen Associate Regional Administrator Division for Medicaid and Children' s Health Operations CC: Michael Hales, Medicaid Director, UT Craig Devashrayee, UT

I.JT.0236. R00.00 - Jan 01, 2014 Page 1 of 12 Medicaid State I' Ian Eligjibifitv Medicaid Stete l" tan %

UT.0236A00.00 - Jon01. 2014 Page 2 of' | 2 Form Type of SPA Code I orm Naine/ Descrip( ion Uploaded? MAGI- Based S32 Mandatory: Individuals Below 133% of the FPL no Eligibility MAGI- Based Mandatory: Former Foster Care Children up to age Eligibility S33 no Groups 26 Eligibility S50 Optional: Individuals Above 133%) of the FPL 110 Groups Eligibility S51 Optional: Optional Parents an(] Caretakers 110 Groups Eligibility S52 Optional: Reasonable Classifications of Individuals no Groups Eligibility S53 Optional: Non IV- E Adoption Assistance 110 Groups Eligibility S54 Optional: Optional Targeted Low Income Children no Groups El igibility S55 Optional: Tuberculosis no Groups Groups Eligibility S59 Optional: Family Planning 110 Groups E'ligibility Single streamlined application or alternative, S94 Renewals, Coordination for enrollment and eligibility no Process agreements with Exchanges) Designates the income options the state is electing in MAGI Income S10 2014( e. g. how pregnant women are counted, no Methodology reasonably predietable changes in income, cash support, how full- time students are counted) Single State Addresses single state agencies delegation of appeals A.F-ency A 1- 3 and determinations yes Residency S88 State affirms residency regulations and addresses no interstalleagreements and temporary absence Citizenship& State affirms citizenship regulations, specifies Immigration S89 reasonable opportunity options, and specifies policy 110 Status options related to immigrant elicribili(y Ilospital State specifies options for presumptive eligibility Presumptive S21 conducted by hospitals no Eligibility Njle Ki icl State Phan TN: uT 4- 0004- wm Approval Date: 02/ 2814 Effective Date: 01m1n4 Utah Summary, page u hUp:A` l57.| q9.| | 3. 99/ MK1DL/ facou/ pro( ocicd/ nnoc/ c0)/ print/ PrintSdcctor ' sp 02/ 26/ 2014

t.'T.0236. ROO. 00 - Jan 01, 2014 Page 3 o1' 12 I. orm S 14: ' AFD ; I neoi e Slandarcls i Form Description: Uploaded Form: i Support Documents i Document F'or,m. S25 Elfigibility Groups - Mandafory Coverage: Parejits and Other Caretagker Relafives i'.W*•. w•. +,,, s' t-.. a: g i w s^av vs va, e a.'..:. n. a, e,,,.. x .:•> .> n ., a._ r Form Description: i tploaded Form: Support Documents 1 Document I°s, rm S2 Yibifilv Grot M art( izrtor°y " t,jver°a e I re iui ft t NVO FrI CTj 1 Form Description: Uploaded Form: Support Documents Document i F' ortrt M.): Eligibility groups - Mandatory Coverage: rs: Inf is and `flidren ttttrler age 19 1 Form Description: j 1 Uploaded Farm: i 1 Support Documents 1 Document 1 TN: UT- 14- 0004- MM Approval Date: 02/ 28/ 14 Effective Date: 01/ 01/ 14 Utah Summary, page 3 http:l' 157. 199. 1 13. 99/ M MDL/faces/ protected/ mac/ col 1print/Print4elector.jsp 02/ 26/ 2014

UT,0236, R00.00 - . Jan 01, 2014 Page 4 of 12 1 or in S32: Eligibility G'r°oups - Mandatory Coverage: Adult ' r°ouq) i Form Description: 1 Uploaded Dorm: 1 Support Documents 1 1 Document IFormrrr S33 Lli- ibility Groups lant.latory "over ge. ' ot°rrter Foster "111 i Children Farm Description: 1 t. ploaded Form: Support Documents l Document 3 3 For n-I S501, l; litxilrility ' r°orrps - Options for Coverage. I ndiN ideals aabovt, 133 fs, 1 i Form Description: 1 I ploaded Form: 3 Support Documents Document or rrr S51; " fifribilitV Gr°otrps - Options lrrrr, ` rry r° aru rtionarl Coverage of Parents anti Other Caretaker Relatives i Form Description: I ploaded Morro: j 1 Support Documents l TN: UT- 14- 0004- MM Approval Date: 02/ 28/ 14 Effective Date: 01/ 01/ 14 Utah Summary, page 4 littp:/ 157. 199, 113. 99/ MMDL/ faces/ protected/ mac/ e01/ prilit/ 13rintSelector.,jsp 02/ 76/ 2014

OT.O236. ROO. 00 - Jan O|, 20| 4 Page 5of (2 Document I'' orrn, S52, Elligibility Groups - Options foi. Coverace: Reasonable Classification of bidividuals unt.ler Age 21 Form Oescriptioll: Support Documents Form S53 Eligibility Groups - (.)pfions For C' ovei-age: ( Itildren with 7"() n 1\ 1"- F Adoption Assistarice Form Description: Support Documents Document Forin S54 Eligibility Groups - ) ptions for Coverage, Optional 'I' argetet.1 Low Income Children Form Description: Suppoi-t Documents Document Form. S,55: 1,. 1igibilitY Groups - Options for Covera,,,xe: Individuals with TN: uT- 14- 0004- mm Approval Date: 0212814 Effective Date: 01m1n4 umo Summary, page*

0T.0236R0O.00 - Jon01, 2014 Page 0 of' | 2 Vploaded Form: Support Docuntents Docunieul Forjti S,57. Eligibility Groups - Options for Coverage, Independeot Foster Cmry Adolescents Form Description: Uploaded Form: Support Docunients Document F'oriri S59: 11, Ifigibifity Groups - Optioris for ('..' overage, Individuals Eligible I`or i Form Description: Support Documents Document I orra S94; ( I'enwral Eligibility Requiretuienits-, Eligibility Process Form Description: ploaded Form: Support Documents Ln, ell Form Description: TN: UF14-000+ mM Approval Date: 02m8n4 Effective Date: 01m1n4 umn Summary, page n http: i,"| 57. l99.| | 3. 94/ 4MDL/ faccs/ prntcctcd/ xouc/ o0|/ print/ Print8c| co( nr.' sV 02/ 26/ 2014

L[ T. 0236. Ft00.00 - } un01, 2014 Page 7of | 2 11ploaded Form: Support Documents Document Form Description: Single State A,_4ency Support Documents Document Please provide a short description of this support document: Utah Department of I lealth Organization Chart Uploaded Document Name: Please providc a short description Of this Support docurnent: Uploaded Document Name: AG Certification.pdf Please provide a short description of this support document: This dOCLulleut updates information oil current and superseded State Plan pages, Uploade(I Document Name: Superseding Pages Sheel. p(If Please provide a short description of this support document: Utah Medicaid Oreanization Chart Uploaded Document Name: Please provide a short description Of this Support document: Response to RAI for SPA 14- 0004- MNI ploaded Document Name: T- 14- 0004- MM Response to RAI 12- 2- 1 3pdf Form S88: Non- Fimincial Eligibility: State Re.-SklerICY Forin Description: TN: uT14-0004- wM Approval Date: 02/28n* Effective Date: 01m1n4 Utah Summary, pager

I)T.0236. R00. 00 - Jan 01, 2014 13age 8 of 12 Uploaded Form: i Support Documents i l Document 13 I orm S89. Non- Financial Efigihility: t tlzens lt and o : iti i(, il tv t. 1 l' l Ali 3 5?..r p Nmcm a'.:.: sa , ,. 0 ,,,.... ne... .::: . t.,.'mzw.vw..,u.. ro• wr... a..... ir`. j Form Description: i Vploaded Form: 1 Support Documents Document orm S21. Presumptive Flioibilitv bv Hospitals Form Description: 1ploaded Form: 3 Support Documents i Docurent i Medicaid State Plan l-:ligibil t J'ribal Input State/Territory name: Utah Transmittal' Number: UT- I4-0004 One or more Indian Health Programs or Urban Indian Organizations furnish health care services in this State. This State Plan Amendment is likely to have a direct effect on Indians, Indian health programs or Urban Indian Organizations. The State has solicited advice from Indian Health Programs, Urban Indian Organizations, and/ or Tribal governments prior to submission of this State Plan Arnendrnent. Complete thefollowing information regarding any tribal consultation coniucted with resI)ect to this snbrni.ssion: Tribal consultation was conducted in the following manner. States are not required to consult with Indian tribal governments, but ifsuch consultation was conducted voltintarily, provide information aboat such consultation below: Indian Tribes Indian" Tribes IF TN: UT- 14-0004- MM Approval Date: 02128/ 14 Effective Date: 01/ 01/ 14 Utah Summary, page 8 http:/` 1 57. 199. 113. 99/ MMDL/ 1aces/ protected/ mac/ c01/ print/ PrintSelector.jsp 02/ 26/ 2014

lJU2i6.R00. 00 - Jan 01, 2014 Page 9 of 12 Indian Tribes Narne of Indian Tribe: Goshute Indian ' Tribe Date of consultation: 07,116/12013 Method,/Location of consultation: Meeting at the Utah Department of Health( I lighland Drive Bldg., SLC, U I Bridge line was available to access meeting by phone. Name of Indian' Tribe: Navajo Indian Tribe Date of consultation: 07%'16 112013 r,r;i 3 i; rlrrry Method/ Location of consultation: Meeting at the Utah Department of Health( Highland Drive Bldg., SLC, IJT). Bridge line was available to access meeting by phone. Name of Indian Tribe: Paitue Indian Tribe Date of consultation: 07/ 16/ 2013 Method,"Local ion of consultation: Meetine at the Utah Department of I lealth( highland Drive Bldg., SLC, U Bridge line was available to access mceting by phone. Name of Indian Tribe: Shoshone Indian" Tribe Date of consultation: 07/' 16/ 2013 Method/ Location of consultation: Meeting at the Utah Department of Health( Highland Drive Bldg., SLC, UT Bridge line was available to access meeting by phone. Name of Indian Tribe: Ute Indian I ribe Date of' consultation: 07/ 16/ 2013 ni z •., r;° Method/ Location of consultation: Meeting at the Utah Department of I lealth( I lighland Drive Bldg., SLC, UT). Bridge line was available to access meeting by phone. Indian health Programs Indian Health Programs Name of Indian I- lealth Programs: Fort Duchesne}- lealth Center Date of consultat ion: 07/ 16/ 2013 Method/ Location of consultation: Meeting at the Utah Department of Health( Highland Drive Bldg., SLC, UT Bridge line was available to access nneeting by phone. TN: UT- 14- 0004- MM Approval Date: 02/28/ 14 Effective Date: 01/ 01/ 14 Utah Summary, page 9 http:// 157. 199. 1 13. 99/ M MDL/faces/ protected/ rnac/ cO 1/ print./PrintSelector.jsp 02/ 26/ 2014

JT.0236. R00.00 - .Jan 01, 2014 Pa.ge 10 of 12 Indian Ilealth Programs Name of Indian Health Programs: Navajo Area Indian Health Service Date of consultation: 07,116/ 2013 Method/ Location of consultation: Meeting at the Utah Department of Health( I lighland Drive Bldg., SLC, L) F). Bridge line was available to access meeting by phone. Name of Indian I lealth Programs: Utah Navaio Indian ( lealth Systems, Inc. Date of consultation: 07/ 16/ 2013 Method/ Location of consultation: Meeting at the Utah Department of Health( Highland Drive Bldg., SI.,C, LIT), Bridge line was available to access meeting by phone. Urban Indian Organization Urban Indian Organizations Name of Urban Indian Organization: Urban Indian (' enter of Salt Lake Date of consultation: 07/ 16/ 20 1 J n.ir Met hodrLocatiOn of consultation: Meeting at the Utah Department of Health ( Highland Drive Bldg., SLC. UT). Bridge line was available to access meeting by phone. The state must upload copies of documents that support the solicitation of advice in accordance with statutory requirements, including any notices sent to Indian Health Programs and/or Urban Indian Organizations, as well as attendee lists if face- to- face meetings were held. Also upload documents with comments received from Indian Health Programs or Urban Indian Organizations and the state' s responses to any issues raised. Alternatively indicate the Ivey issues and summarize any comments received below and describe how the state incorporated them into the design of its program. Document Please provide a short description of this support document: Agenda for ACA Implementation Meeting Uploaded Document Name: Agenda for ACA Implementation Meetimnpdf Indicate the key issues raised in Indian consultative activities: Access Summarize Comments Summarize Response Quality Summarize Comments TN: UT- 14-0004- MM Approval Date: 02/ 28/ 14 Effective Date: 01/ 01/ 14 Utah Summary, page 10 http:8 157. 199. 1 13. 99/ MMDL,/faces/ protected/ rnac/ cO 1/ print/PrintSelector.jsp 02/ 20/2014

t.T.0236. R00.00 - . Jan 01, 2014 Page 1 1 of` 12 Summarize Response Cost Smnmarize Comments Summarize Response Payment methodology Summarize Comments Summarize Response Eligibility Summarize Comments Summarize Response Benefits Summarize Comments Summarize Response Service delivery Summarize Comments Summarize Response Other Issue Medicaid State Ilan f:jigibility. Summary ' all ( MIS I ) State/Territory name: Utah Transmittal Number: Please eater the Transmittal Number( TN) in the format.ST- YY-0000 where ST—the stater abbreviation, YY rite lost two digits of the,srtbnricsion pear. and ttIM0= afour digit nnnrber with leading_-eros. The dashes must also he entered. UT- 14- 0004 Proposed Effective Date 01/ 01/ 2014 TN: UT- 14-0004- MM Approval Date: 02/ 28/ 14 Effective Date: 01/ 01/ 14 Utah Summary, page 11 httti:,';'157. 199. 113. 99/ M MDL/faces/ protected/ iliac/ c01/ print/ PrintSelector.jsp 02/ 26/ 2014

YT, 0236. R00. 00 - Jan 01, 2014 Page 12 of 12 Federal Statute/Regulation Citation Pub. L. No. I I 1- 148 Federal Budget Impact Federal Fiscal Year Amount First Year 2014 0. 00 Second Year 2015 OM Subject of Amendment Single State Agency Governor' s Office Review Governor' s office reported no comment Comments of Governor' s office received Describe: No reply received within 45 days of submittal Other, as specified Describe: Signature of State Agency Official Submitted By: Craig Devashrayee Last Revision Date: Feb 25, 2014 Submit Date: Aug 27, 2013 TN: UT- 14-0004- MM Approval Date: 02/ 28/ 14 Effective Date: 01/ 01/ 14 Utah Summary, page 12 http:/,,,` I 57. 199. 11 3. 99/ MMDL,/1aces/ l) rotected/ iiiac/ c0 I/ print/PrintSelectorjsp 02/ 26/2014

SUPERSEDING PAGES OF STATE PIAN MATERIAL TRANSMITTAL NUMBER: STATE: 14- 0004MM Utah PAGE NUMBER OF TtlE, PLAN SECTION OR COMPLETE PAGES PARTIAL PAGES ATTACHMENT: SUPERSEDED: SUPERSEDED: Al 13 Page I Section 1. 4 ( page 9)( State Medical Care Advisory Section 1. 1 ( pages 2- 6) Committee only. Tribal Consultation will remain in the Section 1. 2( page 7) state plan.) C, Section 1. 3( page 9) Attachment 1. 1- A ( Attorney, General certification) Attachment 1. 2- A Attachment 1. 2- B ( Description of the functions of the single state agency) Attachment 1. 2- C`( Description of' professional medical and supporting staff) 1............................................. ........................... A I- A2 Notwithstanding any other provisions of the Medicaid State Plan, the agencies designated in Al and A2 will determine eligibility for 41 coverage to the extent specified in A I and A2' TN: UT- 14- 0004- MM Approval Date: 02/ 28/ 14 Effective Date: 01/ 01/ 14 Utah Superseding Pages, page 1

6 ms Medicaid Ad-ministration ONIB Control Number 0938- 1148 MOB Expiration date: 10/ 31/ 2014 State Plan Administration Designation and Authority Al 42 CFR 431. 10 Designation and Authority State Name: As a condition for receipt of Federal funds under title XIX of the Social Security Act. the single state agency named below submits the Ifollowing state plan for the medical assistance program, and hereby agrees to administer the program in accordance with the provisions of ithis state plan, the requirements of titles XI and XIX of the Act, and all applicable Federal regulations and other official issuances of the Department. Name of single state agency: Utah Department of Health Type of Agency: C Title IV-A Agency o Health r Yuman Resources Other Type of Agency The above named agency is the single state agency, designated to administer or supervise the administration of the Medicaid program Under title XIX of the Social Security Act.( All references in this plan to" the Medicaid agency" mean the agency named as the single state agency.) The state statutory citation for the legal authority under which the single state agency administers tile state plan is: UCA 26- 1- 18 J he single state agency supervises the administration of the state plan by local political subdivisions. C' Yes r:' No Fhe certification signed by the state Attorney General identifying the single state agency and citing the legal authority under Z> agency which it administers or supervises administration of the program has been provided. An attachment is submitted. The state plan may be administered solely by the single state agency, or some portions may be administered by other agencies. The single state agency administers the entire state plan under title XIX( i. e., no other agency or organization administers any portion of it). C Yes t No TN: UT- 14-0004- MM Approval Date: 02/28/ 14 Effective Date: 01/ 01/ 14 Utah AI- A3, page I Page I of'?

Medicaid .Administration. Waivers of the single state agency requirement have been granted under authority of the Intergovernmental Cooperation Act of FX 1968. The waivers are still in effect. Yes C No Enter the following information for each waiver: Date waiver granted( MM/DD/ YY): 1" 02, 19/ 14 The type of responsibility delegated is( check all that apply): F Determining eligibility Z Conducting fair hearings Other Name of state agency to which responsibility is delegated: Department of Workforce Services I Describe the organizational arrangement authorized, the nature and extent of for program n I administration delegated to the above named agency. and the resources and/for services of' such agency to be utilized in administration of the plan: The Department of lealth. Division of Medicaid and I lealth Financing( L) MI IF) delegates authority to the Department of Workforce Services( DWS), Office of Ad DW judications to conduct fair hearings. S conducts licarimts regarding all applicant and beneficiary appeals for medical assistance eligibility cases as defined in the Vlenwrandl.11n of Understanding with DNIIIF, except for decisions about disability Status, Issues regarding services or benefits, and foster care and subsidized adoption medical assistance eligibility. I) NN' S agrees to conduct hearings in compliance with 42 C. F. R. section 431, subpart E, and to comply with all applicable federal and state laws, rules, regulations, policies., and guidance governing the medical assistance programs. DMI IF' retains oversight of the fair hearing process, and can conduct a Superior Agency Review any time that the agency disagrees with the DWS recommended decision. I W IF retains oversight of the State Plan and has a process to monitor the entire appeals process, including the qUality and accuracy of the final decision,.,made by Department of Workforce Services. DMI If-'will ensure that every applicant and beneficiary is informed in writing of the fair hearing process, how if contact DWS, and how to obtain information about fair hearings from that aocncy. The DWS Adjudication Office conducts fair hearings when an applicant or recipient requests a hearing because the individual disagrees with the DWS decision about eligibility for medical assistance. I iearings are informal and most hearings are done via telephone, unless an individual requests to have an in- person hearing. Individuals have the opportunity to present their position, and can have someone assist them in the hearing process. DWS prepares a written recommended hearing decision which is sent to the applicant and recipient, the DWS eligibility worker and the Department of Health. Bureau Of Eligibility Policy( BEP). The recommended decision does not I become Final for 30 days, allowing either the applicant/ recipient or BEP to re(ILICSt a Superior Agency Review. The Superior Agency Review is conducted by the DMI-IF Office of Formal Hearings. The DMHF Office of Formal I learin- s conducts all fair hearings regarding denials of disability status, hearings TN: UT- 14- 0004- MM Approval Date: 02/ 28/ 14 Effective Date: 01/ 01/ 14 Utah Al- A3, page 2 Nie t of- 7

Medicaid Administration about ibster care or subsidized adoption Medicaid cases and hearings regarding services or cage its. Ali ofthese hearings are de novo hearings. Staff from 131- P and Department Off 11.1man Services attend hearings concernill:, foster care Or Subsidized adoption Medicaid cases to provide policy and regulation expertise, Or Case specific information. The methods for coordinating responsibilities among the agencies involved in administration of the plan under the alternate organizational arrangement are as follows: DWS' recommended hearing decisions are sent to the Department of Health, BEP office. The applicant or recipient receives a notice of the DWS hearing decision, and can request a Superior Agency Review from the Department ot' llealth. All hearing decisions on medical assistance cases made by the Adjudication Office at DWS are reviewed by the Department off lealth, which has the right of Superior Agency Review of those decisions before the decision is made final. BEP Program specialists review tair hearing decisions made by DWS Adjudications Officers for correct application and interpretation of' rules and policy to determine if a Superior Agency Review is necessary. The specialists also determine if the DWS hearing decision considered all file available information to make an accurate decision. The Office of Formal Hearings under the direction of the Medicaid Division Director conducts Superior Agency Reviews ot' decisions made by DWS. Be applicant Or recipient may request a Superior Agency Review or the BEP may request the Superior Agency Review. These reviews are not de novo hearings; they are a review of DWS' decision, but the applicant or beneficiary may submit a statement or additional information to the AL I for consideration. The Medicaid Division Director makes the final decision oil whether to uphold the decision made by the Administrative Law Judge under the Superior Agency Review Or whether to uphold the DWS decision. i File final decision under the Superior Agency Review is sent to the applicant/ recipient, DWS and BEP. Ilan applicant or recipient still disagrees with the decision, they may rile all appeal in court. Add The agency that administers or supervises the administration of the plan under Title X of the Act as of January 1. 1965, has been E] separately designated to administer Or supervise the administration ofthat portion of this plan related to blindindividuals. The entity or entities that have responsibility for determinations of eligibility for families, adults, and for individuals under 21 are: The Medicaid agency Single state agency under Title [ V- A ( in the 50 states or the District of Columbia) Or under Title I or XVI ( AABD) in Guam. Puerto Rico, or the Virgin Islands F An Exchange that is a governinent agency established under sections 131 1( b)( I) Or 13 2 1( c)( I) ot' llie Affordable Care Act The entity that has responsibility for determinations of eligibility for the aged, blind, and disabled are: The Medicaid agency Single state agency Under' l itle IV- A( in the 50 states or the District of Columbia) Or under"Title I or XVI (AABD) in Guam, Puerto Rico, or the Virgin Islands An Exchange that is a government agency established under sections 1311( b)( I) or 1 32 1( c)( I) of the Affordable Care Act The Federal agency administering the SSI program The entity or entities that have responsibility for conducting fair hearings with respect to denials of eligibility based on the applicable modified adjusted Gross incorne standard are: Medicaid agency An Exchange that is a government agency established under sections 1311( b)( I) or 1321( c)( I) of the Affordable Care Act Date. Utah Al- A3, page 3 PaLe 1 of 7

MS Medicaid Administration. An Exchange appeals entity, including an entity established under section 1411( 1) ofthe Affordable Care Act The agency has established a review process whereby the agency reviews appeals decisions made by the Exchange or Exchange appeals entity or other state agency, but only with respect to conclusions of law, including interpretations of state or federal policies. Yes C No State Plan Administration A2 Organization and Administration 42 CFR 431. 10 42 CFR 431. 1 I Organization and A(Injinistration Provide a description of the organization and functions of the Medicaid agency. 1 he Department of I lealth is organized into different divisions to carry out a wide variety Of public health functions. The Division of Medicaid and I lealth Financing is responsible for the administration of the Medicaid and CHIP programs. The Division is divided into several bureaus to carry Out the various functions of administering medical assistance programs. The bureaus include Eligibility Policy, Managed Health Care, Medicaid Operations. Financial Services, Coverage and Reimbursement I Policy, and Authorization and Community- Based Services. These bureaus manage the State Medicaid Plan, the State(' HIP Plan, eligibility policies, covered benefits. reimbursement rates, provider training, assurance of access to services. claims payments. reporting requirements, and coordination of long-term care services. Tile Bureau of Eligibility Policy is responsible for the State Plan provisions relating to eligibility coverage groups and eligibility criteria for Medicaid. It is also responsible for all the state administrative rules relating to eligibility for Medicaid and CHIP. It develops and publishes a Medicaid Eligibility Policy manual and a CHIP Eligibility Policy manual to lie used by the eligibility staff at the Department of Workforce Services as well as being available to the public. The Department of Health works closely with DWS ( Department of Workforce Set-vices) and the IT staff in charge of the client information computer System to make changes that support the eligibility determination process. The Bureau of Eligibility Policy( BEP) monitors eligibility decisions through its MEQC process. It also assures compliance with policies by reviewing DWS' training and procedure manuals. BEP also has a medical review board that makes disability determinations for Medicaid applicants. BEP Program specialists review fair hearing decisions made by F) WS Adjudications Officers for correct application and interpretation of rules and policy to determine d Superior Agency Review is necessary, which is conducted by Department ofFlealth Administrative Law Judges. The Bureau of Coverage and Reimbursement sets provider rates and reimbursement policies. It completes cost projeclions, establishes pricing strategies, policies and methodologies, as well as reviewing participant utilization, medical costs, inflationary factors and other risk factors affircting health care costs. The Bureau Of Managed Care develops and oversees contracts with Managed Health providers, determines areas of coverage for managed care, oversees the Children' s Health Insurance Stale Plan. and the EFISD,r requirements and service provision. It provides education to participants about their health care coverage under Medicaid and CHIP, and assists participants in selecting a managed care provider or other access issues. The Bureau Of Medicaid Operations is in charge of provider enrollment, processing provider claims on behalf of eligible beneficiaries. It provides training to providers about allow-able Medicaid expenditures in(] billing practices. It publishes providers 1 9 manuals and is the single point of phone contact for information about client cli6bility, claims processing and general Medicaid program questions. The Bureau of Financial Services monitors, coordinates and facilitates the Division' s efforts to operate economical and cost- effective medical assistance programs. It performs budget forecasting and preparation, appropriation requests, legislative reports, administration expenditures, and federal fiscal reports. TN. UT- 14- 0004- MM Approval Date: 02J28/ 14 Effective Date: 01/ 01/ 14 UT, h Al- A3, page 4 Nop 4 of 7

Medicaid Administration. he Bureau o Aut orizatnon ana Cornmunity- B asec 1,' crvices is responsible for the interpretation and implementation of quality. cost-effective long-term care services including the development and oversight of the Department' s several home and community based services waivers. The bureau is also responsible for the prior authorization process required for certain Medicaid- covered services. I There is an Office of Fornnal I learings under the direction of the Medicaid Division Director. " fhis office conducts Superior Agency Reviews of cases heard by DWS either at the request of the applicant or recipient or upon request of BEP. All hearing decisions on medical assistance eligibility cases made by the Adjudication Office at DWS are reviewed by the Department of Ilealth, which has the right of Superior Agency Review of those decisions before the decision becomes final. Individuals receive a notice of the DWS hearing decision, and can request a Superior Agency Review from the Department of 1 lealth. These reviews are not de novo j hearings, they are a review of DWS' decision. The Medicaid Division Director makes the final decision on whether to uphold the decision made by the Administrative Law Judge under the Superior Agency Review or whether to uphold the DWS decision. In addition, the DMHI' Office of Formal Hearings conducts hearings for the following issues: ( 1) disability determinations;( 2) safeguarding against unnecessary or inappropriate hospital admissions or lengths of stay;( 3) denying provider claims that fail to meet medically necessary criteria; ( 4) prepayment and postpayment review systems to determine if utilization is reasonable or necessary;( 5) preadmission certification of non- emergency admissions,( 6) long-term care physical and mental health certifications;! 7) alleged patient abuse in Medicare and Medicaid- certified nursing, facilities:( 4) issues regarding services or benefits. The Department of Health conducts fair hearings regarding denials of disability status, as well as hearings about foster care or subsidized adoption Medicaid eligibility cases. All of these hearings at the Department of Health are de novo hearings. Staff from Department of Health and Department of Human Services attend hearings concerning foster care or subsidized adoption Medicaid cases to provide policy and regulation expertise, or case specific information. Upload an organizational chart of the Medicaid agency. l ......... rini attachment is submitted. Provide a description ofthe.structure of the state' s executive branch which includes how the Medicaid agency fits in with other health, human service and public assistance agencies. The State Executive Branch is responsible for setting up Departments within the state government to carry out the various services and functions of the state government. The Executive Department designated the Department of Health as the Single State Medicaid Agency. As a department in the stage government, the Department of Health is responsible f'or producing and updating I the State Medicaid Plan, State Administrative Rules, and policies for the implementation of Medicaid and CHIP. The Department of Health is responsible for producing provider manuals, and managing the claims and reporting functions for Medicaid and CHIP. The Executive Director of the Department is appointed by the Governor of Utah, and is responsible for reporting to the Governor's office about the activities and responsibilities of the Department of t lealth. The Department of I lealth is also responsible for j working with other governmental departments providing social services and public assistance programs. This includes the Department of Human Services which is the Title IV- E agency, and the Department of Workforce Services which is the" Title 1V-,A agency. The Title IV-A Department. DWS, is the agency responsible for the TAN] and SNAP progrars, and is the agency which conducts j eligibility determinations for Medicaid and CIIIP programs. DWS completes medical assistance determinations for all Medicaid I eligibility groups including MAGI- based coverage groups, non- MAGI- based family, child and pregnant woman groups, aged, blind and disabled groups, breast and cervical cancer group, former foster care youth, and independent living foster care group. D' v'v' S also conducts fair hearings related to eligibility for these Medicaid groups, except for hearings concerning a denial of disability by the State Medical Review Board. All fair hearing recommended decisions are reviewed by the Single State "vedicaid Agency. DWS does not determine eligibility for foster care and subsidized adoption cases( both IV- E and non- IV- I .) The Department of Ihrman Services( the Title IV- E agency) conducts eligibility determinations for foster care and subsidized adoption medical assistance cases. Fair hearings for foster care and subsidized adoption coverage groups are conducted by the Single State Medicaid Agency. Entities that determine eligibility other than the Medicaid Agency( if entities are described under Designation and Authority) TN: UT- 14- 0004- MM _-- Approval Date: 02/28/ 1.4. Effective Date: 01/ 01/ 141 Remove Utah Al- A3, page 5 Pane* i raf 7

Medicaid Administration. Type of entity that determines eligibility: Single state agency under Title IV- A ( in the 50 states or the District of Columbia) or under Title 1 or XVI ( AABD) in Guam, Puerto Rico, or the Virgin Islands C" An Exchange that is a government agency established under sections 1311( b)( 1) or 1321( c)( I) of the Affordable Care Act C°` The Federal agency administering the SSI program Provide a description of the staff designated by the entity and the functions they perform in carrying out their responsibility. DWS, the Title IV- A Agency, has been designated by the Medicaid Agency under a written memorandum of agreernent to j determine eligibility for the.Medicaid and CHIP programs for all coverage groups except foster care and subsidized adoption. Dl S is the agency that does eligibility for TANF and SNAP programs, as well as Child Care Assistance. As the employment service i agency of the state. DWS also works to connect people with employment or educational resources to lead to employment. The i Department of Health has a Memorandurn of Agreement: with the Department of Workforce Services that delineates the i responsibilities and requirements ofcompleting the eligibility determinations fbr rnedical assistance programs, Front line staff, or Eligibility Workers. determine initial and ongoina eligibility for media ll assistance programs which includes answering questions and educating clients about the kledicaid and CHIP progrars. They accept and process applications for medical assistance, send notices of decision and conduct fair hearings, except for hearings concerning a denial of disability status or services and benefits. DWS has an Adjudication Office which conducts the fail- hearings. I learings are informal and most hearings are done via telephone, unless an individual requests to have an in- person hearing. Individuals have the opportunity to present their position, and can have someone assist them in the hearing process. The Department of Workforce Services has a training team which provides trainings statewide forprobtematic areas of eligibility, policy changes and the paining of new workers. In addition, they have program specialists that assist eligibility teams with policy and procedural questions. This allows for a consistent and concise message to all DWS workers. DWS also houses and maintains the eligibility determination computer system for all medical programs. It is an integrated system for public assistance programs. Add Entities that conduct fair hearings other than tite Medicaid Agency ( if are described under Designation and Authority) 1' Cn10Ve Type of entity that conducts fair hearings: C" An Exchange that is a government agency established under sections 131 1( b)( I) or 132I( c)( I) of the Affordable Care Act Cr' An Exchange appeals entity, including an entity established under section 1411( 1) of the Affordable Care Act Provide a description of the staff designated by the entity and the functions they perform in carrying out their responsibility. 1 _._.............................___________.............................._._..._................._..._......................... ...._............... i i Add Supervision of state plan administration by local political subdivisions( if described under Designation and Authority) Is the supervision of the administration done through a state-wide agency which uses local political subdivisions? C" Yes ' No State Flan Administration Assnranees TN: UT- 14- 0004- MM Approval Date: 02/28/ 14 Effective Date: 01/ 01/ 14 Utah Al- A3, page 6 Pae,e 6 of 7

Medicaid. ^ 0 0 01) 0 @ n ww ==` Disclosure 42 CFR 43 1. 10 42 CFR 411. 12 Assurances The state plan is in operation oil a statewide basis, in accordance with all the requirements of 42 CFR 43 1. 50, All requirements ol' 42 CTR 4.3 1. 10 are niet. There is a Medical Care Advisory Committee to the agency director oil health and medical set-vices established in accordance with ineeting all the requirements of 42 CFR 43 1. 121. The Medicaid a ency does not delegate. to other than its own officials, the authority to Supervise the plan or to develop or issue policies, rules. and regulations on prograin matters. Assurance for states that have delegated authority to determine eli ibiliq: 1 1 here is a written agreement between the Nledicaid a- ency and the I.-Achange or any other state or local agency that has been delcorated authority to deterinine eligibility for Medicaid eli- ibility in compliance with 42 CFR 43 1, 1 0( d), Assurances for states that have delegated authority to conduct fair hearings: I-here is a written agreement between the N'ledicaid agency and the Exchange or Exchange appeals entity that has been delegated authority to conduct Medicaid fair hearings in compliance with 4' CFR 43 1. 1 0( d). When authority is delegated to the Exchange oran Exchange appeals entity, individuals kho have requested a fair hearing are given the option to have their fair hearing conducted instead by the Medicaid a(yency. Assurance for states that have delegated authority to determine eligibility and/or to conduct fair hearings: The Medicaid a ency does not delegate authority to make eligibility determinations oi- to conduct fair hearings to entities other than ooverninent agencies which maintain personnel standards on a inerit basis, PRA 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. Thc valid OMB control xumhcr for this lo(bnnu/ ioo collection io0938-| | 4X. The/ imo required tocomplete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data eoouoes. gmhcrd`cdmtanoedcd. ondoomp| mcundnvic* tbcinfbnnmionc*|| cuioo. |[ you have comments concerning tile nocumcyv[ the timcc$ imuzc( o) o, suggestions for improving this f6nn. please write to: CMS. 7500 Security Boulevard, Attn: PRA Reports Clearance Offlc, r, Mail Stop C4- 2h- O5. Baltimore, Kimy|xod2) 244'| 850. TN: uT' 14- 0004- mm Approval Date: 02/28/ 14 Effective Date: 01m1/ 14 umm A1- Ao. page 7 Puzo7o[ 7

ATTACHMENT 1. 1 A STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM State: UTAH ATTORNEY GENERAL' S CERTIFICATION I certify that: THE UTAH STATE DEPARTMENT OF HEALTH is the single State agency responsible for: X administering the plan. The legal authority under which the agency administers the plan on a Statewide basis is Utah Code Annotated § 26- 1- 18 _ statutory citation) supervising the administration of the plan by local political subdivisions. The legal authority under which the agency supervises the administration of the plan on a Statewide basis is contained in statutory citation) The agency's legal authority to make rules and regulations that are binding on the political subdivisions administering the plan is statutory citation) July 21. 1997 Jan Graham 1sl Date Signature) JAN GRAHAM ATTORNEY GENERAL STATE OF UTAH Title) T. N. # 97- 008 Approval Date 9- 9- 97 Supersedes T. N. # 80-0106 Effective Date 7- 1- 97

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Table of Contents State/Territory Name: Utah State Plan Amendment (SPA) #: 14-0005-MM This file contains the following documents in the order listed: 1) Approval Letter 2) Summary Form (with 179-like data) 3) Superseding Pages Notice 4) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 1600 Broadway, Suite 700 Denver, CO 80202-4967

Region VIII

November 25, 2013

Michael Hales State Medicaid Director Division of Health Care Financing Utah Department of Health P O Box 144102 Salt Lake City UT 84114- 4102

Dear Mr. Hales:

Enclosed is an approved copy of Utah’s state plan amendment (SPA) 14-0005-MM, which was submitted to CMS on August 27, 2013. SPA 14-0005-MM incorporates the MAGI-based residency requirements into Utah’s Medicaid state plan in accordance with the Affordable Care Act. The effective date of this SPA is January 1, 2014.

Enclosed is a copy of the following S88 state plan pages and attachments to be incorporated within a separate section at the end of Utah’s approved state plan:

 S88, pages S88-1 through S88-4

In addition, enclosed is a summary of the state plan pages which are superseded by SPA 14- 0005-MM, which should also be incorporated into a separate section in the front of the state plan.

 Superseding pages of state plan material, SPA 14-0005-MM.

CMS appreciates the significant amount of work your staff dedicated to preparing this state plan amendment. If you have any questions concerning this SPA, please contact Mandy Strom of my staff at (303) 844-7068 or by email at Mandy.Strom@cms.hhs.gov.

Sincerely,

Richard C. Allen Associate Regional Administrator Divisions of Medicaid & Children’s Health Operations Cc: Gayle Six Jeff Nelson Craig Devashrayee

/s/

State/Territory name: Utah Submitted By: Craig Devashrayee Last Revision Date: Nov 20, 2013 Submit Date: Aug 27, 2013 Medicaid State Plan Eligibility: Summary Page (CMS 179) Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. UT-14-0005 Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation Pub L. No. 111-148 Federal Budget Impact Federal Fiscal Year Amount First Year 2014 $ 0.00 Second Year 2015 $ 0.00 Subject of Amendment State Residency Governor's Office Review Governor's office reported no comment Comments of Governor's office received Describe: No reply received within 45 days of submittal Other, as specified Describe: Signature of State Agency Official Page 1 of 2 UT.0237.R00.00 - Jan 01, 2014 11/25/2013 http://157.199.113.99/MMDL/faces/protected/mac/c01/print/PrintSelector.jsp

Page 2 of 2 UT.0237.R00.00 - Jan 01, 2014 11/25/2013 http://157.199.113.99/MMDL/faces/protected/mac/c01/print/PrintSelector.jsp

SUPERSEDING PAGES OF STATE PLAN MATERIAL TRANSMITTAL NUMBER: 14-0005-MM STATE: Utah PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: S88 Non-Financial Eligibility- State Residency PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable): Section 2.3: Page 13, TN 30-87 Attachment 2.6-A: Page 3, Item 4, TN 14-0006-MM

Page 1 of 4 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Non-Financial Eligibility State Residency S88 42 CFR 435.403 State Residency The state provides Medicaid to otherwise eligible residents of the state, including residents who are absent from the state under certain conditions. ✔ Individuals are considered to be residents of the state under the following conditions: Non-institutionalized individuals age 21 and over, or under age 21, capable of indicating intent and who are emancipated or married, if the individual is living in the state and: ■ Intends to reside in the state, including without a fixed address, or ■ Entered the state with a job commitment or seeking employment, whether or not currently employed. ■ Individuals age 21 and over, not living in an institution, who are not capable of indicating intent, are residents of the state in which they live. ■ Non-institutionalized individuals under 21 not described above and non IV-E beneficiary children: ■ Residing in the state, with or without a fixed address, or ■ The state of residency of the parent or caretaker, in accordance with 42 CFR 435.403(h)(1), with whom the individual resides. ■ Individuals living in institutions, as defined in 42 CFR 435.1010, including foster care homes, who became incapable of indicating intent before age 21 and individuals under age 21 who are not emancipated or married: ■ Regardless of which state the individual resides, if the parent or guardian applying for Medicaid on the individual's behalf resides in the state, or ■ Regardless of which state the individual resides, if the parent or guardian resides in the state at the time of the individual's placement, or ■ If the individual applying for Medicaid on the individual's behalf resides in the state and the parental rights of the institutionalized individual's parent(s) were terminated and no guardian has been appointed and the individual is institutionalized in the state. ■ Individuals living in institutions who became incapable of indicating intent at or after age 21, if physically present in the state, unless another state made the placement. ■ Individuals who have been placed in an out-of-state institution, including foster care homes, by an agency of the state. ■ Any other institutionalized individual age 21 or over when living in the state with the intent to reside there, and not placed in the institution by another state. ■ IV-E eligible children living in the state, or ■ TN: UT-14-0005-MM Utah Approval Date: 11/25/2013 S88, page 1 Effective Date: 01/01/2014

Page 2 of 4 Medicaid Eligibility Otherwise meet the requirements of 42 CFR 435.403. ■ TN: UT-14-0005-MM Utah Approval Date: 11/25/2013 S88, page 2 Effective Date: 01/01/2014

Page 3 of 4 Medicaid Eligibility Meet the criteria specified in an interstate agreement. Yes No The state has interstate agreements with the following selected states: ■ Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming The interstate agreement contains a procedure for providing Medicaid to individuals pending resolution of their residency status and criteria for resolving disputed residency of individuals who (select all that apply): ■ Are IV-E eligible Are in the state only for the purpose of attending school Are out of the state only for the purpose of attending school Retain addresses in both states Other type of individual Name of Type Description + State-Subsidized Adoption Children Utah is a reciprocal state and we provide Medicaid to children under state-subsidized adoption agreements with these other states. x The state has a policy related to individuals in the state only to attend school. Yes No Otherwise meet the criteria of resident, but who may be temporarily absent from the state. ■ TN: UT-14-0005-MM Utah Approval Date: 11/25/2013 S88, page 3 Effective Date: 01/01/2014

Page 4 of 4 Medicaid Eligibility The state has a definition of temporary absence, including treatment of individuals who attend school in another state. Yes No Provide a description of the definition: The State considers an individual who has established state residency to still be a state resident during a period of temporary absence which may include, but is not limited to, an absence for medical treatment, education, employment, military service, or for other religious or humanitarian purposes if the individual intends to return to the state when the the reason for the temporary absence ends. PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938‐1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4‐26‐05, Baltimore, Maryland 21244‐1850. TN: UT-14-0005-MM Utah Approval Date: 11/25/2013 S88, page 4 Effective Date: 01/01/2014

Table of Contents State/Territory Name: Utah State Plan Amendment (SPA) #: 14-0006-MM This file contains the following documents in the order listed: 1) Approval Letter 2) Summary Form (with 179-like data) 3) Superseding Pages Notice 4) Approved SPA Pages 5) Additional Attachments that are part of the state plan

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 1600 Broadway, Suite 700 Denver, CO 80202-4967

Region VIII

November 25, 2013

Michael Hales State Medicaid Director Division of Health Care Financing Utah Department of Health P O Box 144102 Salt Lake City UT 84114- 4102

Dear Mr. Hales:

Enclosed is an approved copy of Utah’s state plan amendment (SPA) 14-0006-MM, which was submitted to CMS on August 27, 2013. SPA 14-0006-MM incorporates the MAGI-based citizenship requirements into Utah’s Medicaid state plan in accordance with the Affordable Care Act. The effective date of this SPA is January 1, 2014.

Enclosed is a copy of the following S89 state plan pages and attachments to be incorporated within a separate section at the end of Utah’s approved state plan:

 S89, pages S89-1 through S89-3

In addition, enclosed is a summary of the state plan pages which are superseded by SPA 14- 0006-MM, which should also be incorporated into a separate section in the front of the state plan.

 Superseding pages of state plan material, SPA 14-0006-MM.

CMS appreciates the significant amount of work your staff dedicated to preparing this state plan amendment. If you have any questions concerning this SPA, please contact Mandy Strom of my staff at (303) 844-7068 or by email at Mandy.Strom@cms.hhs.gov.

Sincerely,

Richard C. Allen Associate Regional Administrator Divisions of Medicaid & Children’s Health Operations Cc: Gayle Six Jeff Nelson Craig Devashrayee

/s/

State/Territory name: Utah Submitted By: Craig Devashrayee Last Revision Date: Nov 6, 2013 Submit Date: Aug 27, 2013 Medicaid State Plan Eligibility: Summary Page (CMS 179) Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. UT-14-0006 Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation Pub L. No. 111-148 Federal Budget Impact Federal Fiscal Year Amount First Year 2014 $ 0.00 Second Year 2015 $ 0.00 Subject of Amendment Citizenship & Immigration Status Governor's Office Review Governor's office reported no comment Comments of Governor's office received Describe: No reply received within 45 days of submittal Other, as specified Describe: Signature of State Agency Official Page 1 of 2 UT.0238.R00.00 - Jan 01, 2014 11/25/2013 http://157.199.113.99/MMDL/faces/protected/mac/c01/print/PrintSelector.jsp

Page 2 of 2 UT.0238.R00.00 - Jan 01, 2014 11/25/2013 http://157.199.113.99/MMDL/faces/protected/mac/c01/print/PrintSelector.jsp

SUPERSEDING PAGES OF STATE PLAN MATERIAL TRANSMITTAL NUMBER: 14-0006 -MM STATE: Utah PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: S89 Non-Financial Eligibility- Citizenship and Non-citizen Eligibility PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable): Attachment 2.6-A: Page 2, item (3), subparagraphs (a) , (b), and (c), TN 92-01 Attachment 2.6-A: Page 3, item (3), paragraphs (d) and (e), TN 91-21

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

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

■ The reasonable opportunity period begins on and extends 90 days from the date the notice of reasonable opportunity is received by the individual. The agency provides for an extension of the reasonable opportunity period if the individual is making a good faith effort to resolve any inconsistencies or obtain any necessary documentation, or the agency needs more time to complete the verification process. Yes No The agency begins to furnish benefits to otherwise eligible individuals during the reasonable opportunity period on a date earlier than the date the notice is received by the individual. Yes No The date benefits are furnished is: The date of application containing the declaration of citizenship or immigration status. The date the reasonable opportunity notice is sent. Other date, as described: TN: UT-14-0006-MM Utah Approval Date: 11/25/2013 S89, page 1 Effective Date: 01/01/2014

Page 2 of 3 Medicaid Eligibility The state provides Medicaid coverage to all Qualified Non-Citizens whose eligibility is not prohibited by section 403 of PRWORA (8 U.S.C. §1613). Yes No The state elects the option to provide Medicaid coverage to otherwise eligible individuals under 21 and pregnant women, lawfully residing in the United States, as provided in section 1903(v)(4) of the Act. Yes No An individual is considered to be lawfully residing in the United States if he or she is lawfully present and otherwise meets the eligibility requirements in the state plan. ■ An individual is considered to be lawfully present in the United States if he or she: ■ 1. Is a qualified non-citizen as defined in 8 U.S.C. 1641(b) and (c); 2. Is a non-citizen in a valid nonimmigrant status, as defined in 8 U.S.C. 1101(a)(15) or otherwise under the immigration laws (as defined in 8 U.S.C. 1101(a)(17)); 3. Is a non-citizen who has been paroled into the United States in accordance with 8 U.S.C. 1182(d)(5) for less than 1 year, except for an individual paroled for prosecution, for deferred inspection or pending removal proceedings; 4. Is a non-citizen who belongs to one of the following classes: Granted temporary resident status in accordance with 8 U.S.C. 1160 or 1255a, respectively; ■ Granted Temporary Protected Status (TPS) in accordance with 8 U.S.C. §1254a, and individuals with pending applications for TPS who have been granted employment authorization; ■ Granted employment authorization under 8 CFR 274a.12(c); ■ Family Unity beneficiaries in accordance with section 301 of Pub. L. 101-649, as amended; ■ Under Deferred Enforced Departure (DED) in accordance with a decision made by the President; ■ Granted Deferred Action status; ■ Granted an administrative stay of removal under 8 CFR 241; ■ Beneficiary of approved visa petition who has a pending application for adjustment of status; ■ 5. Is an individual with a pending application for asylum under 8 U.S.C. 1158, or for withholding of removal under 8 U.S.C.1231, or under the Convention Against Torture who - Has been granted employment authorization; or ■ Is under the age of 14 and has had an application pending for at least 180 days; ■ 6. Has been granted withholding of removal under the Convention Against Torture; 7. Is a child who has a pending application for Special Immigrant Juvenile status as described in 8 U.S.C. 1101(a)(27)(J); 8. Is lawfully present in American Samoa under the immigration laws of American Samoa; or 9. Is a victim of severe trafficking in persons, in accordance with the Victims of Trafficking and Violence Protection Act of 2000, Pub. L. 106-386, as amended (22 U.S.C. 7105(b)); TN: UT-14-0006-MM Utah Approval Date: 11/25/2013 S89, page 2 Effective Date: 01/01/2014

Page 3 of 3 Medicaid Eligibility 10. Exception: An individual with deferred action under the Department of Homeland Security's deferred action for the childhood arrivals process, as described in the Secretary of Homeland Security's June 15, 2012 memorandum, shall not be considered to be lawfully present with respect to any of the above categories in paragraphs (1) through (9) of this definition. Other The state assures that it provides limited Medicaid services for treatment of an emergency medical condition, not related to an organ transplant procedure, as defined in 1903(v)(3) of the SSA and implemented at 42 CFR 440.255, to the following individuals who meet all Medicaid eligibility requirements, except documentation of citizenship or satisfactory immigration status and/or present an SSN: ✔ Qualified non-citizens subject to the 5 year waiting period described in 8 U.S.C. 1613; ■ Non-qualified non-citizens, unless covered as a lawfully residing child or pregnant woman by the state under the option in accordance with 1903(v)(4) and implemented at 435.406(b). ■ PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN: UT-14-0006-MM Utah Approval Date: 11/25/2013 S89, page 3 Effective Date: 01/01/2014

Non-Financial Eligibility: Citizenship and Non-citizen Eligibility TRANSMITTAL NUMBER: 14-0006-MM STATE: Utah Notwithstanding the checked assurance on page 1 that the State provides a reasonable opportunity period of 90 days for an individual pending verification of satisfactory immigration status or citizenship, the State currently provides a reasonable opportunity period of 10 days for an individual pending verification of satisfactory immigration status. Medicaid benefits are provided to individuals who have declared to have satisfactory immigration status pending verification of such status during the reasonable opportunity period.

Table of Contents State/Territory Name: Utah State Plan Amendment (SPA) #: Ut- 14- 0007-MM This file contains the following documents in the order listed: 1) Approval Letter 2) Additional Companion letter (delete if not if applicable) 3) Summary Form ( 179) 4) Superseding Pages Notice Approved SPA Pages 5) Additional Attachments that are part of the state plan TN: UT- 14-0007- MM Approval Date: 04/02/ 14 Effective Date: 01/ 01/ 14

DEPARTMENT OF HEALTH& HUMAN SERVICES Nam Centers for Medicare& Medicaid Services Denver Regional Office 1600 Broadway, Suite# 700 Denver, CO 80202-4967 g INN RS FOR WDICARF&) OFOR.:A") S[ R R IS REGION VIII- DENVER April 2, 2014 W. David Patton, Ph.D. Utah Department of Health 288 North 1460 West PO Box 143102 Salt Lake City, UT 84114 RE: Utah# 14- 0007-MM Dear Dr. Patton: We have reviewed the proposed State Plan Amendment( SPA) submitted under transmittal number( TN) 14- 0007- MM on January 3, 2014. This SPA implements presumptive eligibility by hospitals in accordance with the Affordable Care Act and 42 CFR 435. 1110. Please be informed this State Plan Amendment was approved April 2, 2014, with an effective date of January 1, 2014. We are enclosing the CMS- 179 and the amended plan page( s). In addition, Utah has agreed by July 2014 to incorporate changes to Utah' s single streamline application by providing better instructions to presumptive eligibility applicants on what question are required to be completed when applying for presumptive eligibility. In addition, the state will implement a paper form verifying an individual' s eligibility to be given to the applicant upon determination as well as work to train doctors and pharmacies to accept this paper documentation as proof in the interim until the applicant receives the actual medical card in the mail. If you have any questions regarding this letter, please contact Mandy Strom at( 303) 844-7068 or ri), mandv. stromcros.hhs. gov. Sincerely, Richard C. Allen Associate Regional Administrator Divisions of Medicaid& Children' s Health Operations CC: Michael Hales, Medicaid Director, UT Craig Devashrayee, UT Jeff Nelson, UT Gayle Six, UT

DEPARTMENT OF HEALTH& HUMAN SERVICES Centers for Medicare& Medicaid Services sombib- Denver Regional Office 1600 Broadway, Suite# 700 Denver, CO 80202-4967 CINTURs FOR MMICAltE MEDICAID SIRVICrs REGION VIII- DENVER April 2, 2014 W. David Patton, Ph. D. Utah Department of Health 288 North 1460 West PO Box 143102 Salt Lake City, UT 84114 RE: Utah# 14- 0007-MM Dear Dr. Patton: We have reviewed the proposed State Plan Amendment( SPA) submitted under transmittal number( TN) 14- 0007-MM on January 3, 2014. This SPA implements presumptive eligibility by hospitals in accordance with the Affordable Care Act and 42 CFR 435. 1110. Please be informed this State Plan Amendment was approved April 2, 2014, with an effective date of January 1, 2014. We are enclosing the CMS- 179 and the amended plan page( s). In addition, Utah has agreed by July 2014 to incorporate changes to Utah' s single streamline application by providing better instructions to presumptive eligibility applicants on what question are required to be completed when applying for presumptive eligibility. In addition, the state will implement a paper form verifying an individual' s eligibility to be given to the applicant upon determination as well as work to train doctors and pharmacies to accept this paper documentation as proof in the interim until the applicant receives the actual medical card in the mail. If you have any questions regarding this letter, please contact Mandy Strom at( 303) 844- 7068 or mandv, trom' ciscros. hhs. rcw. Sincerely, s/ Richard C. Allen Associate Regional Administrator Divisions of Medicaid& Children' s Health Operations CC: Michael Hales, Medicaid Director, UT Craig Devashrayee, UT Jeff Nelson, UT Gayle Six, UT

UT.0725. R00.00 - Jan 01, 2014 Page 1 of 2 State/Territory name: Utah Transmittal Number: Please enter the Transmittal Number( TN) in theformat ST-YY-0000 where ST= the state abbreviation, YY= the last two digits of the submission year, and 0000= afour digit number with leading zeros. The dashes must also be entered UT- 14- 0007 Proposed Effective Date 01/ 01/ 2014 mm/ ddiyyyy) Federal Statute/ Regulation Citation Pub. L. No. 111- 148 Federal Budget Impact Federal Fiscal Year Amount First Year 2014 0. 00 Second Year 2015 0. 00 Subject of Amendment Presumptive Eligibility by Hospitals- The fiscal impact for this SPA is included in the fiscal impact entered for the MAGI eligibility group SPA 14- 0001- MM. Governor' s Office Review Governor's office reported no comment Comments of Governor' s office received Describe: No reply received within 45 days of submittal Other, as specified Describe: Signature of State Agency Official Submitted By: Craig Devashrayee Last Revision Date: Apr 1, 2014 Submit Date: Jan 3, 2014 httn•// 1 57 100 1 VI 99/ MMnI./fa PS/ nrcitected/ mac/ c(ll/ nrint/PrintSe lector.isn 04/ 08/ 2014

Medicaid Eligibility ON-111 Control Number 0938- 1148 ONIB Expiration date: 10/ 31/ 2014 Presumptive Eligibility by flospitals S21 42 C FR 435. 11 10 One or more qualified hospitals are determining presumptive eligibility under 4' CH 43)5. 1 110, and the state is providing NIedicaid coverage for individuals determined presumptively eligible under this provision. 6 Yes No The state attests that presumptive eligibility by hospitals is administered in accordance with the following provisions: A qualified hospital is a hospital that: Participates as a provider under the Medicaid state plan or a Medicaid I I 15 Demonstration, notifies the Medicaid agency of m] its election to make preSLIrnptive eligibility deterniinalions and agrees to make presumptive eligibility determinations consistent with stale policies and procedures. I las not been disqualified by the Medicaid agency for klih-11V to make presumptive eligibility determinations in accordance with applicable state policies and procedures or for failure to meet any standards that rnay have been established by the Medicaid agency. Assists individuals in completing and submitting the full application and understanding any documentation requirements. i' Yes C No Ft The eligibility groups or populations for which hospitals determine eligibility presumptively are: Pregnant Women Infants and Children under Age 19 Parents and Other Caretaker Relatives F-] Adult Group, if covered by the state Individuals above 131% FI' I.., under Age 65, if covered by the slate Individuals Eligible for Family Planning Services. if covered by the state Former Foster Care Children Certain Individuals Needing Treatment for Breast or Cervical Cancer, if covered by the state Other Family/Adult groups: Eligibility groups for individuals age 65 and over Eligibility groups for individual,,;who are blind Eligibility groups for individuals with disabilities Other Medicaid state plan eligibility groups Demonstration populations covered under section 1 115 The state establishes standards for qualified hospitals making presumptive eligibility determinations. TN. UT- 14- 00ur-MM7 E ffecti ve-Date- iat/OV2014-- Utah S21, page I

Medicaid Eligibility Yes C' No Select one or both: I I lie state has standards that relate to the proportion of individuals determined presumptively eligible who submit a regular application, as described at 42 CI- R 435. 907, before the end of the presumptive eligibility period. The State has set a standard for hospitals to provide 100% of all PF applications completed by the hospital site to the Department of' Workfbrce Services( DWS). DWS enters the [ IF decision into the client eligibility system and issues medical assistance cards to eligible individuals. The hospital PIE application can be used to apply for ongoing assistance. Applicants only have to answer the questions required to make the PE decision and sign that paper application. The hospital staff' are expected to let individuals know that they can apply for ongoing assistance using the PE application, and must offer assistance to applicants in completing the application. Description of standards: Individuals are encouraged, but not required to complete the full application if they want to use the PE application to appIN, for ongoing assistance. Applicants for PE may choose not to submit a full application at the time they are doing the PE application. The applicant may also choose to apply later using a different application process.' I he hospital Pl". application includes a question about using the PE application to apply for ongoing medical assistance. Z DWS will accept the PE application as a full application for ongoing medical assistance when the applicant indicates lie wants to apply for ongoing assi sta nce. if client does not indicate lie wants to apply for ongoing assistance, DWS only enters the information about the PE decision. I and issues a medical card for presumptive eligibility only. The stale has standards that relate to the proportion of individuals Will) are determined eligible for Medicaid based oil the 1Z Z11 I submission of an application before the end of the presumptive eligibility period. The State has set a standard that the hospital will maintain all 851,6 accuracy rate for its presumptive eligibility decisions based on the information provided by the applicant. The State will conduct periodic reviews of PE applications received from the various sites, and randomly select a sample of cases to review to decide if the hospital made the correct PE decision based on the information provided by the applicant. The State will conduct additional training when a site has a lower accuracy rate, and take corrective actions if needed, which may include disqualifying i a site if improvement does not occur. The state will increase this standard as the hospitals have i had time to learn the process. and based on the findings ftorn reviews. For presumptively eligible individuals who SUbillit applications for OrlgOinlll medical assistance, the State has set a standard that 65410 ofthose will he determined eligible for ongoing Medicaid. Description of standards: We have set the standard based on eligibility statistics from our Presumptive Eligibility lot- Pregnant Women program. We will initially use a slightly lower standard for the hospitals than the average rate of eligibility the state has seen for Pregnant Women cases because this is a new process for hospitals and it includes different populations. The state will utilize data about the number ol' PF cases approved and denied ongoing medical assistance to decide if site is meeting this standard. ' File state may adjust the standard in the future based on its findings. from reviews. Based on the findings from reviews. the state will schedule additional training or take other corrective actions to improve the success rate of' hospitals that are not mecting these standards. If a hospital continues to be unable to meet the perf6miance standards after corrective actions have taken place, the state can disallow the hospital from continuing to make presumptive eligibility ii determinations. Fm The presumptive period begins on the date the determination is made. F- 1 The end date of the presumptive period is the earlier of: UUU I-MM App-r-ov--aT1TaM--T4= 2 EffeCtIve Date's - Utah S21, page 2

Medicaid | 0N 7 Eligibility 1 The date the eligibility determination Ior regular Medicaid is made, if an application ibr Medicaid is filed by the last day of' the month following the month in which the determination Of prCSUniptive eligibility is made: or The last day ol' the month fbilowing the month in which the determination of presumptive eligibility is inade, ifilo application f6r Medicaid is filed by that date. Periods ofpresumplive eligibility are limited as fbIlows: e— No more than one period vithin a calendar year, C' No more than one period within two calendar years. No more than one period within a twelve- nionth period. suirling Nvilh the effeclive date of the initial presumptive cligibilit\ Other reasonable limitation: The stale requires that a written application be signed by the applicant, parent or representative, as appropriale. Yes C No J he state uses a single application form for Tj\/ Iedicaid and presumptive eligibility, approved by (' MS. I he state uses a separate application lbrin for presumptive eligibility, approved by CAIS. A copy ol"the application lbrin it, C included. An attachment is submitted. L The presumptive eligibility determination is based On the fbilowing, filictors: The individual' s categorical or non- financial eligibility for the group R) r which the individual' s presumptive eligibility is Fm being deterinined( e. g.. based or) age, pregnancy status, status as a parent/caretaker relative, disability. or other reqUirernerns specified in the Medicaid state plan or a Medicaid I 115 dernonstration for that group) I louschold incorne must not exceed the applicable income standard for the group for which the individual' s presumptive Eml eligibility is being determined, ifan income standard is applicable for this group. State residency Citizenship, status as a national, or satisfactory immigration status The state assures that it has COMITILinicated the requirements for qualified hospitals, and has provided adequate training to the hospitals. A copy of' lhe training materials has been included. An attachment is submitted. According to the Paperwork Reduction Act of 1995, no persons are required to respond lo a collection ol' inforl"natiOn unless it displays a valid 0 8 control number. The valid OMB control number for this ioK` nnminx collection isU93X-} | 48 Thc time required mcon`p|,, c this io| 6unmion collection is estimated* average 4O hours per response. including the timem review instruct ions. search existing data resources, gather the data needed, and complete and review the intbrniation collection. | fyou have uommonu concerning the accuracy o[ the time emimam( v) or suggestions for impmvin this Knmi. please v, ri*: C 8. 7500Sooudty Boulevard, Axo: PRA KcponsOoomucc Officer, Mail Stop C4- 26- 05. 8n|6mnvx, Maryland 2\ 244- l85O. TN: uT' 14- 0007' Mm7 Approval Date: 04m2/ 2014 Effective Date: 01m1/ 2014 1 o° h n21 """° n Puoe] of']

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Table of Contents INTRODUCTION 2 PART 1 CONTACT INFORMATION 3 PART 2 POLICIES AND PROCEDURES Section 1: What is Hospital Presumptive Eligibility? 4 Section 2: Rules Hospitals Must Comply With 4 Section 3: Services and Payment 5 Section 4: Confidentiality 5 Section 5: Fraud, Waste and Abuse 6 Section 6: Eligibility Process 7 Section 7: Completing the HPE Application 8 Section 8: Hospital Presumptive Eligibility Medicaid Programs 9 Section 9: Determining Household Size 11 Section 10: Income 13 Section 11: What Happens Next After an Eligibility Determination? 14 Section 12: Application Process 15 Section 13: Check list 16 PART 3 APPENDIXES Income Chart 17

Introduction The Affordable Care Actl allows hospitals to play an increasingly important role in connecting patients to health care coverage. This new provision allows qualified hospitals to determine Presumptive Eligibility for Medicaid based on customers' preliminary information. This manual provides guidance for the administration of the Hospital Presumptive Eligibility HPE) program. It will outline the policy and procedures needed for an effective implementation. Thank you for your participation in ensuring the success of this important and effective resource for the citizens of Utah. Statute Authority and Related Federal Rules for PE Option Statutory Authority: Patient Protection and Affordable Care Act, Public Law 111- 148 ( March 23, 2010), as modified by the Health Care and Education Reconciliation Act or 2010, Public Law 111- 152 ( March 30, 2010), Title 2, Subtitle A, Section 2001( a) ( 4) ( B) and Title 2, Subtitle A, Section 2202. Federal Regulations: Eligibility in the States, District of Columbia, the Northern Mariana Islands, and American Samoa, 42 CFR 435.1110 ( 2013).

HOSPITAL PRESUMPTIVE ELIGIBILITY TRAINING MANUAL PART 1 CONTACT INFORMATION For Hospital Presumptive Eligibility policy or procedural questions, or to request training, contact: Laurie Ocobock Policy Specialist Phone: (801) 538- 9153 Fax: ( 801) 538- 6952 Utah Department of Health/ Medicaid Health Financing PO Box 143107 Salt Lake City, UT 84114- 3107 OR Laura Belgique (back up) Program Specialist Phone: (801) 538- 6241 Fax: ( 801) 538- 6952 Utah Department of Health/ Medicaid and Health Financing PO Box 143107 Salt Lake City, UT 84114- 3107 You may also e- mail questions to HPEpolicy@utah.gov To order Hospital Presumptive Eligibility applications, call ( 801) 538- 9153 or (801) 538- 6241. For questions regarding covered services, medical billing/ payment, call Medicaid at 801) 538- 6155 or 1- 800- 662- 9651. Email completed applications to DWS at hospitalPE @utah.gov

PART 2 POLICIES AND PROCEDURES Section 1: WHAT IS HOSPITAL PRESUMPTIVE ELIGIBILITY? With Hospital Presumptive Eligibility (HPE), an individual can temporarily enroll in Medicaid if it appears they are eligible based on preliminary information. Preliminary information includes information regarding the income and household size for the individual. The two departments that oversee the program are the Utah Department of Health ( UDOH) and the Department of Workforce Services ( DWS). UDOH oversees HPE policy and procedure. DWS oversees the ongoing Medicaid eligibility process. UDOH issues Memorandum of Agreements ( MOA) between UDOH and hospitals throughout the state to administer the HPE program. Hospital staff who are trained in the HPE process determine HPE eligibility. Section 3 describes information on the HPE process. Section 2: RULES HOSPITALS MUST COMPLY WITH A hospital must inform UDOH that it intends to make HPE determinations and that it agrees to follow the State' s policies and procedures. UDOH will provide hospitals with information on all policies and procedures related to HPE. A hospital must make HPE determinations in accordance with UDOH' s policies and procedures. If a hospital is not making HPE determinations in accordance with UDOH' s policies and procedures, UDOH will provide the hospital with additional training or other forms of corrective action before disqualifying the hospital. A hospital must also comply with the proficiency standards that UDOH developed for HPE. As of January 1, 2014, UDOH has established a standard of 85 percent accuracy rate on HPE decisions. Accuracy is measured by how accurate the hospital' s determination is based on the information provided by the applicant.

Section 3: SERVICES AND PAYMENT HPE covers an array of Medicaid eligible services including medication, lab work, inpatient and outpatient care. For questions regarding covered services, call Medicaid at 1- 800- 662- 9651. During the HPE period, the client will also be able to receive treatment from other Medicaid providers after they leave the hospital. Hospitals will be paid at regular Medicaid rates. Payment for covered services is guaranteed for a hospital during an individual' s presumptive eligibility period, even if the person fails to complete the full Medicaid application or is ultimately determined to be ineligible for ongoing Medicaid. If an HPE applicant is already covered under Medicaid, the Children' s Health Insurance Program (CHIP), the Primary Care Network (PCN) or the Utah Premium Partnership ( UPP) at the time of application, HPE cannot be authorized by DOH. States will not recoup money from the hospital for services rendered during the HPE period. Section 4: CONFIDENTIALITY All confidential information must be safeguarded from unauthorized disclosure and use. Staff who fail to safeguard confidential information may be subject to both civil and criminal penalties. Confidential information includes identifying information about applicants and recipients, such as names, addresses, telephone numbers, social security numbers, etc. Second, it includes information used to determine eligibility, such as income, assets, medical reports and data, names of persons obligated to provide financial and medical support, etc. Third, it includes information about benefits and medical services provided to individual recipients. Information that cannot be identified to particular applicants and recipients is not confidential information. For example, information stating the total number of HPE recipients is not confidential information because no one person can be identified by the general information.

Section 5: FRAUD, WASTE AND ABUSE To report suspected fraud, contact the DWS Information Fraud Hotline at 1- 800- 955- 2210 or via email at wsinv @utah.gov. What you need to know when reporting fraud, waste or abuse: It is helpful if you can provide any of the following information when reporting fraud, waste or abuse of the HPE Program: Provider or recipient name Date of birth Address Phone number Social security number Other details about what you suspect may be happening that appears to be wrong You may remain anonymous when reporting suspected fraud You may be requested to provide your name so that the investigator can contact you if there are questions regarding your referral. However, you may request that your name is not used in conjunction with the case. You may find more information on reporting fraud, waste or abuse at: http:// health. utah.goy/ mpi/ regiaient.html

Section 6: ELIGIBILITY PROCESS Applicants can apply for HPE through any qualified hospital site. The eligibility begins on the date the application is approved by the hospital. SELF- DECLARATION IS USED FOR ALL FACTORS OF ELIGIBILITY. If the applicant is a minor, the applicant' s parent, legal guardian, or representative must sign the application. If the minor is living independently, the minor may apply on his/ her own behalf. A representative for a child may be a relative or other responsible adult living with the child. An applicant may assign an authorized representative to apply on his/ her behalf. The applicant must sign application if possible. If the applicant is unable to sign, the authorized representative may sign the application. In general, the person who signs the application should be someone who can answer the questions on the application. If an applicant is unable to write, he/ she must make a mark on the application and have at least one witness to the signature. To qualify for all HPE programs, applicants must meet the following requirements based on preliminary information provided: Be a U. S. citizen or qualified alien. Qualified aliens are individuals who are not U. S. citizens but have received a lawful permanent residency ( LPR) status for at least five years. Ask for the month and year in which the applicant received the LPR status to determine if the applicant meets this requirement. Nationalized citizens and individuals born in any of the 50 states, the District of Columbia, Puerto Rico, Guam, the Virgin Islands, the Northern Mariana Islands, American Samoa, and Swain' s Island meet U. S. citizenship requirements. o Note: Individuals from the Marshall Islands are not considered U. S. Nationals. Be a Utah resident. Clients may only receive one HPE period within one calendar year and may only receive HPE once per pregnancy period. NOTE- There is no asset test. Clients must not currently receive Medicaid, CHIP, UPP, or PCN. Check the applicant's eligibility status by calling Medicaid at 80)538- 6155 or 1- 800- 662- 9651. Key in the client ID number and use the HPE determination date as the date of the medical service received. If the client is eligible, the system will give the medical program type, health plan, co- pay, mental health coverage information, and TPL information. If a client is open for Medicaid with a spenddown, the client is not eligible for HPE. Clients must not have received a denial for Medicaid, CHIP, UPP or PCN within the past 30 days, unless household circumstances have changed. For example, if the client was denied for Medicaid because his income is too high and now the client reports that his income has changed, determine if the client is eligible for HPE.

Section 7: COMPLETING the HPE APPLICATION: UDOH will supply hospitals with HPE paper applications. General Instructions: Always use the most current application available. The application cover sheet will tell you which questions must be completed for HPE. Ensure the applicant signs the application. Application Clarification: Applicant' s name; this is the full, legal name of applicant. A hyphenated last name is acceptable. Question # 3: If anyone in your household is not a U. S. Citizen or U. S. National, does he or she have a Lawful Permanent Resident card ( Green Card) from U. S. Citizenship and Immigration Services? If an applicant indicates they are a Lawful Permanent Resident with a Green Card and the date that he/ she became a lawful permanent resident is at least five years, he/ she is considered a qualified alien. Question # 6 What is your total gross earned and unearned income ( before taxes) for your household this month? Indicate applicant' s total stated, gross monthly income. Make sure that educational and child support income are not included. Compare this information to the income limit assigned to the household size for the HPE program type. Income guidelines may change yearly. UDOH will e- mail HPE providers with an updated income chart each year. Please be sure you are using the most recent version. See Appendix 1 for the income chart. Page # 9: The applicant must sign the application. Without a signature, the application is incomplete.

Section 8: HOSPITAL PRESUMPTIVE ELIGIBILITY MEDICAID PROGRAMS The HPE Medicaid programs and eligibility components are as follows: Program Hierarchy: o When choosing an eligibility program to approve, choose using the following hierarchy starting with the Child Medicaid program category. Child Medicaid 0- 5 or Child Medicaid 6- 18 Parent/ Caretaker Relative Pregnant Woman Former Foster Care Individuals Child Medicaid Age 0- 5: o Eligibility requirements: Income limit: 139% of the Federal Poverty Level ( FPL). A child can receive eligibility through the month in which he turns age 6. A child does not have to live with a parent or specified relative. Child Medicaid Age 6- 18: o Eligibility requirements: Income limit: 133% of FPL. A child can receive eligibility through the month in which he/ she turns age 19. If an 18 year old lives with his/ her parents, the parents' income is countable. Pregnant Woman: o Eligibility requirements: Income limit: 139% of FPL. The woman must be pregnant. If a pregnant woman is age 19 or older and lives with her parent( s), her parent' s income is not countable. If she is under age 19 and living with her parent(s), her parents' income is countable. Former Foster Care Individuals o Eligibility requirements: Ages 18 to 26. Eligibility runs through the month he/ she turns 26. Individual was concurrently enrolled in Medicaid and Foster Care in Utah at age 18 or older when Foster Care ended. Individual was in the custody of DCFS, DHS or an American Indian Tribe when Foster Care ended. Persons in the custody of Juvenile Justice Services are not eligible.

There is no income test. Was not eligible for other categories of HPE. Parent/ Caretaker Relative ( PCR) o Eligibility requirements: Must have an eligible child. a. Household must include a child that is either under 18 or is age 18 and is a full time student and expected to graduate before the age of 19. Income test: See income chart in Appendix 1 Deprivation of Support must exist. a. Deprivation of support exists if the household has: A parent who is deceased. A parent who is incapacitated. A parent who is unemployed or employed less than 100 hours per month. A parent who is absent

Section 9: DETERMINING HOUSEHOLD SIZE Determine the household size using the following chart that applies to the coverage group: Include only people who live together. Child 0- 5 Applicant Applicant' s parent(s) and step- parent(s) Applicant' s sibling( s) and step- sibling(s) Child 6- 18 Applicant Parent(s) and step- parents) Legal spouse of applicant( s) ( not boyfriend) Applicant' s unborn child( ren) Sibling( s) and step- sibling( s) Note on Child Programs-Ifchild(ren) are living with a guardian who is not theirparent, their household size includes themselves and their sibling(s). For example, household consists of grandmother, grandfather and two grandchildren. The household size for each grandchild is two. Pregnant Woman if the applicant is under age 19 ( whether If the applicant is age 19 or older or not they are married) whether or not they are married) Applicant Applicant Legal spouse of applicant ( not boyfriend) Legal spouse of applicant ( not boyfriend) Applicant' s parent( s) Applicant' s unborn child( ren) Applicant' s unborn child( ren) Applicant' s child(ren) including step- children) under age 19 Applicant' s child( ren) including step- children) under age 19 Sibling( s) and step- sibling( s) that are under age 19 Former Foster Care (no income limit) Applicant

Parent Caretaker Relative Applicant Legal spouse of applicant(s) ( not boyfriend) Applicant' s unborn child( ren) if they are in the third trimester of pregnancy Applicant' s child( ren) including step- child( ren)

Section 10: INCOME Count the gross income ( before taxes) of everyone that is included in the household size for the specific program with the following exceptions: Do not count the income of a child to another child (sibling) Do not count the income of a child to a parent Do not count the income of a guardian to the child( ren) that the guardian is responsible for. Examples of whose income to count are as follows: Family consists of a father, mother, and two children. The child is approved for HPE. The parents' income counts toward the child' s HPE eligibility. The income of the sibling does not count toward the child approved for HPE. Family consists of a father, mother, and a child. The father is approved for HPE. Income of the mother counts toward the father's HPE eligibility. Income of the child doesn't count toward the father's HPE eligibility. Educational income and child support are not countable sources of income. Do not include the income when counting the household income. For the presumptive Former Foster Care program, there is no income limit for this program. Note: PAYCHECK STUBS ARE NOT REQUIRED. However, if an applicant provides you with paycheck stubs to help you determine their gross monthly income, use the following procedure to calculate their income: When paychecks are received twice a month, multiply the gross paycheck amount by 2. If paychecks are received every other week, multiply the gross paycheck amount by 2. 15. If received weekly, multiply the gross paycheck amount by 4.3. o Income calculation examples: Johnny provides you one $ 500 ( gross) paycheck stub and indicates he is paid every other Friday. Multiply $500 x 2. 15 to determine his gross monthly income ($500 x 2. 15 1075). Mary provides you one $200 (gross) paycheck stub and indicates she is paid every Wednesday. Multiply $200 x 4.3 to determine her gross monthly income ($200 x 4.3 = 860). Frankie provides you one $500 (gross) paycheck stub and indicates he is paid on the 1" and 15th of the month. Multiply $500 x 2 to determine his gross monthly income 500 x 2 = $ 1000).

Section 11: WHAT HAPPENS NEXT AFTER AN ELIGIBILITY DETERMINATION? Complete the cover sheet for presumptive eligibility. Make sure to complete all fields and include the denial reason if the decision is a denial. o Possible denial reasons are as follows: Already received HPE for the current pregnancy Current CHIP, UPP, or Medicaid recipient Issued HPE in the last calendar year Medicaid denial in the past 30 days No available HPE program No deprivation Not enough information to determine HPE Not a U. S. citizen or eligible alien Not a Utah resident Over the income limit Hospital scans in the application and a- mails it to DWS at hospital PE@utah. gov Send the application to DWS within 5 working days. IMPORTANT: If the application is incomplete and DWS contacts the hospital for additional information, the hospital must respond to DWS within 2 business days or HPE will not be issued. Shred the paper application. DWS will issue the HPE card for the current month and determine eligibility for ongoing Medicaid. DWS will send the approval/ denial notice and card. o The HPE Medicaid card is identical to a regular Medicaid card and provides the same medical coverage. Exception: For the presumptive eligibility program for pregnant women, the coverage is only for Medicaid covered ambulatory prenatal services. Delivery and inpatient services are not covered. HPE coverage will continue until DWS makes a decision for ongoing Medicaid. The following examples illustrate how the time frame for HPE eligibility is determined. Client is approved for HPE on Jan. 15th. Ongoing Medicaid eligibility is approved or denied on Jan. 16th. Jan. 161h is before the date Feb. cards are mailed. The HPE eligibility ends on Jan. 31St. The HPE card should not be used after Jan. 15tH Client is approved for HPE on Jan. 16th. Ongoing Medicaid eligibility is approved or denied on Feb. 15th. HPE eligibility continues until Feb. 28th. The HPE card should not be used after Feb. 15tH Client is approved for HPE on Jan. 16th. Ongoing Medicaid eligibility is approved or denied on Mar. 15th. HPE eligibility continues until Mar. 31st. The HPE card should not be th used after Mar. 15

Section 12: APPLICATION PROCESS Customer applies in Hospital Complete application will expedite eligibilityfar ongoing Medicaid) Qualified Hospital makes the HPE eligibility determination. z M n tray r LT pq D is ro Approve HPE application Deny HPE application and and indicate decision on indicate decision and denial the presumptive',eligibility reason on the presumptive cover page. eligibility cover page. Send application to DWS Send application to WS within S working days; within 5 working days Shred the application. Shred the application.

Section 13: CHECK LIST Make sure to do the following: Help the customer complete the application ( Note: Although the customer is only required to complete the questions for HPE, completing the entire Medicaid application may expedite eligibility for ongoing Medicaid coverage). Submit the HPE application by e- mail to hospitalPE @utah.gov and subsequently destroy application Educate the customer to stop using HPE card if she is approved or denied for ongoing Medicaid. If approved for ongoing Medicaid, the customer should use the new card for ongoing Medicaid.

Appendix 1: INCOME CHART (effective January 1, 2014) HH Size PCR Pregnant Child 6- Former Woman/ Child 18 Foster 0- 5 Care Individuals 139% FPL 133% No income FPL limit 1 438 1332 1274 2 544 1797 1720 3 678 2263 2165 4 797 2729 2611 5 912 3194 3056 6 1012 3660 3502 7 1072 4126 3947 8 1132 4591 4393 9 1196 5057 4838 10 1257 5522 5284

Please tear off this page and keep for your info Application Information CHIP PCN a UPP Medicaid • PE Private Health Insurance 9 APTC What Am I Applying For'? Health coverage is important for you and your family to get the medical care you need. When you submit this application, you will be considered for all medical programs that are now open for enrollment, including: CHIP( Children' s Health Insurance Program): Provides medical and dental insurance for uninsured children in families who qualify based on family size and income. For more information, visit: www.health. utah.gov/ chip PCN( Primary Care Network): Provides primary preventive health coverage for uninsured adults who qualify based on family size and income. For more information, visit: www.health. utah. gov/ pcn UPP( Utah' s Premium Partnership for Health Insurance): Provides a monthly premium reimbursement when a previously uninsured individual or family enrolls in their employer' s health plan or COBRA. For more information, visit: www.health. utah. gov/ upp Medicaid: Provides medical assistance for low-income families, children, pregnant women, and disabled, blind and elderly individuals. For more information, visit: www.health. utah.gov/ bep Presumptive Eligibility( PE) for Medicaid: Presumptive Eligibility is a program that provides temporary coverage for individuals who qualify based on preliminary information. Private Health Insurance: Provides comprehensive coverage to help you stay well. This is offered through the Federally Facilitated Marketplace( FFM). For more information, visit: www.healthcare.2ov Advanced Premium Tax Credit( APTC): This is a tax credit that can immediately help pay your premiums for health coverage in the Federally Facilitated Marketplace( FFM). For more information, visit: www. healthcare. P-ov x:% What Do I Need to Do Next? On your application, tell us about all of your family Page 7: Section K- All Questions members who live with you. If you file taxes, we need Page 9: Section L- Signature you to tell us about everyone on your tax return. ( You don' t • The hospital will determine PE eligibility and will forward need to file taxes to get health coverage). The program you your application to the Department of Workforce Services qualify for depends on the number of people in your family DWS) to determine continued medical benefits. DWS will and their income. This information helps us make sure notify you of your eligibility decision. everyone gets the best coverage they can. If more information is needed to determine your eligibility We can best determine your eligibility if all questions are for benefits, an eligibility worker from DWS will contact you. answered. However, for Presumptive Eligibility( PE), at a If you have not heard from DWS within 10 days, please minimum you must fill out the following questions on call toll-free 1-866-435-7414. the four pages listed below: Applying for continued medical benefits is not a Page 1: Section A- Name, Address, Phone Number requirement for presumptive eligibility. You may choose to Section B- Question 1 Only opt out of applying for continued medical benefits by Student and marital statuses are optional. responding to question 9 on page 7 of the application. Page 3: Section D- Questions 4 and 7 Where Can I Get More Information? For questions about how to complete the application, your application status, or to find out if you qualify, please access your information online at www.mobs. utah. gov/ mycase. If you have questions about how to complete the application or you are unable to access the website, please call DWS at 1-866-435-7414. For general questions about the health care services covered by Medicaid or PCN, call the Medicaid hotline at 1-800-662-9651. For general questions about CHIP, PCN or UPP, call the Health Information Hotline at 1-888-222-2542. 0 Information Medicaid, CHIP, UPP, and PCN recipients are automatically enrolled in the Utah Clinical Healt Information Exchange( cHIE). The cHIE provides a safe place for participating healthcare providers to share and view patient medical information. Recipients have the right to not participate in the cHIE or to change their participation status at any time. For more information or to opt out of the cHIE participation, visit www.mychie. org or talk to a healthcare provider.

For Presumptive Eligibility (PE) Worker Only: Please complete this page for each presumptive eligibility application. Name of PE Hospital: PE Worker Name: PE Decision Date: Name of Individual(s) PE Program Approved/ Denied Denial Reason

DOH/ 1/ 2014 Case#: Application CHIP * PCN * UPP * Medicaid * PE * Private Health Insurance APTC 0 Applicant Information Name: first start with yourself) middle initial maiden last E- mail: optional) Home Address: Leave blank if you don' t have one) street apt.# city state zip Mailing Address: If different from home address) street apt. city state zip Home Phone: ( ) Cell/ Other Phone: ( ) Primary Language Spoken in Your Home: Would you like to receive notices in English or Spanish? English Spanish 0 Household Information 1. List everyone who is living in your household and applying for benefits. Social Security Birth Marital Fulltime Utah Resident Name Relation Number Date Sex Race Ethnicity Status Student U. S. Citizen/ first, m. i., last) to You mm/ dd/ yy M/ F ** *** **** Y/ N National* Utah Resident U. S. Citizen/ National Utah Resident U. S. Citizen/ National Utah Resident U. S. Citizen/ National Utah Resident U. S. Citizen/ National Utah Resident U. S. Citizen/ National Social Security Number& Social Security Number( SSN) and citizenship information are only needed for people applying for ongoing benefits. You are not required to Citizenship provide SSN for presumptive eligibility, however, providing it may expedite your benefits. If someone needs help getting a SSN, call 1-800-772- 1213 or visit socialsecurity.gov. TTY users should call 1-800-325-0778. Race Codes WH: White, BL: Slack/ African American, Al: American Indian/ Alaska Native, ASI: Asian Indian, CH: Chinese, FI: Filipino, Optional) JA: Japanese, K0: Korean, VI: Vietnamese, OA: Other Asian, NH: Native Hawaiian, SA: Samoan, GC: Guamanian/ Chamorro, OPI: Other Pacific Islander, OT: Other Ethnicity Codes N: Not Hispanic/ Latino, M: Mexican, MA: Mexican American, CH: Chicano/ a, PR: Puerto Rican, CU: Cuban, Optional) AH: Another Hispanic, Latino, or Spanish Origin, OT: Other Martial Status Single, Married, Divorced, Widowed 2. If you mark that you are an American Indian or Alaska Native above, please complete Attachment A. Yes No 3. If you are not a U. S. Citizen or U. S. National, do you have an eligible immigration status? ( Only answer this question for individuals who are applying for benefits.) If yes, please complete all columns: Document ID Lived in the Has a spouse or parent who is a veteran or Immigration Number U. S. Since an active-duty member of the U. S. military, Document Alien if different 1996? or is himself a veteran or an active-duty Name Type Number from Alien #) ( Yes/ No) member of the U. S. military. ( Yes/ No) 1

Tax Filer Information Please answer the following questions to help us select the program for your household. In addition to the questions below, please complete Attachment B of this application for all dependents that are not living with you, but are claimedon your tax return. Yes No 1. Do you plan to file a federal income tax return next year or will you be claimed as a dependent on someone's tax return next year? If yes, please complete the chart* below. Note: If you are claiming more than 6 dependents on your tax return, please make a copy of this page and attach it to your application. Check one: Filing Jointly with Spouse: Dependents Listed on Your Tax Return: Tax Filer - or- Tax Dependent Applicable to Tax Filer Only) Applicable to Tax Filer Only) First& Last Name: Are you filing jointly with your Dependent# 1 spouse? Yes No Name: Living with tax filer: Yes No Will you be claimed as a dependent on If yes, name of spouse: Dependent# 2 someone' s tax return? Name: Yes No Living with tax filer: Yes No If yes, list name of tax filer and your Dependent# 3 relationship to the tax filer: Name: Living with tax filer: Yes No Name: Dependent# 4 Name: Relationship: Living with tax filer: Yes No Dependent# 5 Name: Living with tax filer: Yes No Dependent# 6 Name: Living with tax filer: Yes No Check one: Filing Jointly with Spouse: Dependents Listed on Your Tax Return: El Tax Filer - or- Tax Dependent Applicable to Tax Filer Only) Applicable to Tax Filer Only) First& Last Name: Are you filing jointly with your Dependent# 1 spouse? Yes No Name: Living with tax filer: Yes No Will you be claimed as a dependent on If yes, name of spouse: Dependent# 2 someone' s tax return? Name: Yes No Living with tax filer: Yes No If yes, list name of tax filer and your Dependent# 3 Name: relationship to the tax filer: Living with tax filer: Yes No Name: Dependent# 4 Name: Living with tax filer: Yes No Relationship: Dependent# 5 Name: Living with tax filer: [] Yes No Dependent# 6 Name: Living with tax filer: Yes No 2

0 General Information Please answer the following questions for anyone in your household that is applying for benefits. This will help us select the right medical program. Yes No 1. Do you want help paying any medical bills from the last 3 months? If yes, for who: For which months: Yes No 2. Does anyone in your household have a major medical need? This includes pregnancy, cancer, kidney disease, etc. ( Answering this question mayget you extra help.) If yes, who: What is the medical need? Yes No 3 Do you live with at least one child under the age of 19, and are you the primary person taking care of this child? Yes No 4. Was anyone in your household in foster care on or after his/ her 18th birthday? If yes, who: OYes No 5. Does anyone in your household have a disability( a physical, mental, or emotional health condition that causes limitations in activities like bathing, dressing, daily chores, etc.)? If yes, who: Yes No 6. Has anyone in your household been in a jail, medical facility/ hospital, or nursing home for 30 days or more within the last 3 months? Ifyes, explain: Yes ONo 7. Is anyone in your household currently pregnant or has been pregnant in the last 3 months? If yes, who: Due date: How many babies are expected during the pregnancy? Has she smoked or used tobacco in the past 6 months? Yes No This question is for survey purposes only and does not affect eligibility.) Income Yes No 1. Does anyone in your household have earned income? If yes, list any earned income received by all people who live in your home. Pay Rate Hours How Employed Person Employer Name, Address and Phone Before Taxes Worked Often Paid Name) Number 900/ mo.,$ 6/ hr.) Weekly weekly, monthly) Yes No 2. Does anyone in your household have self-employment income? If yes, list any self-employment income received by all people who live in your home. Type of Net Income This Business Month Self-Employed Ex. LLC, Business Percent of Gross Income ( profit once business' Person ( name) Company Name S-Corp, etc.)' Start Date Company Owned This Month expenses are paid) 3

Yes No 3. If employed, do you expect any changes in earnings or in the number of hours worked? If yes, explain: Yes No 4. In the past year, did anyone in your household change jobs, stop working or start working fewer hours? If yes, who: Yes No 5. Do you or anyone in your household have/ receive any of the following? Check all that apply Name of Individual(s) below: Amount How Often Date Income Started Receiving the Income Unemployment Pensions Social Security Retirement Accts. Alimony Received Net farming/ fishing Net rental/ royalty Other Income Type Deductions Check all that apply. List the amount paid and how often you get it. If you pay for certain things that can be deducted on a federal income tax return, telling us about them could make the cost of health coverage a little lower. Note: You shouldn' t include a cost already considered in your answer to net self-employment.) Name of Individual(s) Check all that apply below: Amount Paid How Often Paying Alimony Paid Student Loan Interest Paid Other deductions: Type: Yearly Complete only if your income changes from month to month. If you don' t expect changes from month to month, skip to the next question. Name Total Income This Year Total Income Next Year if you think it would be different) 4

0 Health Insurance Information Yes No 1. Does anyone in your household currently have Medicaid, CHIP, or Medicare? If yes, check the type of coverage and write the person( s) name(s) next to the coverage they have. Medicaid: CHIP: Medicare: Yes No 2. Has anyone in your household been injured in an accident or been a victim of assault in the last 12 months? Yes No 3. Is someone outside your home required to pay for medical services? Yes No 4. Is anyone in your household enrolled or eligible for COBRA coverage or continued health insurance through an employer? Yes No 5. Does anyone in your household currently have health insurance( including VA Health Care System benefits, Tricare, or Peace Corps), have insurance available but not enrolled, or has had insurance in the past 6 months? 6. If you answer yes to questions 4 or 5, please complete the chart below regarding the insurance(s). Do not list Medicaid, Medicare, CHIP, or PCN.) Insurance 1 Enrolled, start date: Not enrolled, but available Ended, date ended: If you check that your insurance status is Not enrolled, but avallable and this insurance is offered through either your job or someone else's job, such as a parent or spouse, please also complete Attachment C- Employer's Health Insurance Information Form attached to this application.) Name(s) of individual(s) covered: Name of insurance company: Phone#: Address of insurance company: Group#: Policyholder name: Policy#: Policyholder birth date: Policyholder SS#: If insurance is through an employer, list employer' s name and phone#: Premium cost: $ Date due: How often: Type of Coverage: comprehensive limited Yes No Is this a retiree plan? Insurance 2 Enrolled, start date: Not enrolled, but available Ended, date ended: If you check that your insurance status is Not enrolled, but available and this insurance is offered through either yourjob or someone else's job, such as a parent or spouse, please also complete Attachment C- Employer's Health Insurance Information Form attached to this application.) Name(s) of individual(s) covered: Name of insurance company: Phone#: Address of insurance company: Group#: Policyholder name: Policy#: Policyholder birth date: Policyholder SS#: If insurance is through an employer, list employer's name and phone#: Premium cost: $ Date due: How often: Type of Coverage: comprehensive limited Yes [] No Is this a retiree plan? 5

Aged, Blind, Disabled, Nursing Home, Waiver, or Spenddown Medicaid, Medicare Cost Sharing, Refugee Medical You are only required to answer the questions on this page if there is anyone in your household who is applying for Aged( 65+), Blind, Disabled Medicaid, Nursing Home, Waiver, or Spenddown Medicaid, Medicare Cost Sharing, and/ or Refugee Medical. 0 Other Benefits, Expenses Yes No 1. Has anyone in your household applied for, received, or been denied Social Security Income, VA, Unemployment or Worker's Compensation? If yes, explain: Yes [] No 2. Has anyone in your household been determined disabled by Social Security? If yes, who: Yes No 3. Does anyone in your household that has been determined disabled by Social Security pay child support or alimony? If yes, list name and amount paid: Yes No 4. If employed, do you expect any changes in earnings or in the number of hours worked? If yes, explain: Yes [] No 5. Does anyone help you pay mortgage/ rent, food, or utility bills? If yes, explain: Yes No 6. Does anyone in the household work in exchange for mortgage/ rent, food, or utility bills? If yes, explain: Yes No 7. Does anyone in the household pay for dependent care so he/ she can go to work? If yes, list name and amount paid: Assets Yes No 1. Do you or anyone in your household have any of the following financial assets? Check all that apply) Annuities 401K/ Retirement Checking Account$ IRA Money Market Funds Savings Account$ Stocks Trust Funds Other: Bonds Time Certificates Yes [] No 2. Do you or anyone in your household have any of the following assets? Check all that apply) Land Cemetery Plots Mineral or Timber Rights Life Estate Home Life Insurance Rental/ Investment Property Time Shares Tools Campers/ Trailers Burial Plans/ Funds Livestock Other: Yes No 3. Do you own any vehicles? If yes, using the chart below, list any vehicles that are owned by you and anyone who lives with you. Type of vehicle includes all cars, trucks, vans, snowmobiles, motorcycles, motor homes, boats/ motors, ATV' s or other vehicles. Licensed License Owner/ Joint Amount Make Model Year Y/ N Plate # State Owners Owed 6

Additional Presumptive Eligibility Questions If there is anyone in your household who is applying for presumptive eligibility( PE) for Medicaid, you are also required to answer questions on this page in addition to the specified questions on page 1 and 3. Please refer to the application coversheet to identify which specific questions on page 1 and 3 you must answer for PE. Make sure to sign the application on page 9. 0 Presumptive OYes ONo 1. If anyone in your household is not a U. S. Citizen or U. S. National, does he or she have a Lawful Permanent Resident card ( Green Card) from U. S. Citizenship and Immigration Services? If yes, please complete the chart below: Name Date the Individual Became a Lawful Permanent Resident month/ year) OYes ONo 2. Is anyone in the household currently on Utah Medicaid, CHIP( Children Health Insurance Program), PCN ( Pri- mary Care Network), or UPP( Utah' s Premium Partnership Program) or has been approved for Utah Medicaid with a spenddown? If yes, who: OYes ONo 3. Has anyone in your household been denied Utah Medicaid, CHIP, PCN, or UPP in the last 30 days? If yes, who: OYes ONo 4. If you answered yes to question 3, has the reason changed since the denial? If yes, explain OYes ONo 5. Has anyone in your household been approved for presumptive eligibility in the last calendar year, or if there is anyone pregnant, has she been approved for presumptive eligibility for pregnant women ( Baby Your Baby) during this pregnancy? If yes, who: 6. What is your total gross earned and unearned income( before taxes) for your household this month? Do not include child support or educational income.) OYes ONo 7. Is there any child in the household who has any of the following? ( Check all that apply and list the child(ren)'s name(s) below.) a parent who is absent from the home a parent who is incapacitated (meaning unable to work due to injury or illness)? a parent who is deceased a parent who receives unemployment or works less than 100 hours per month. If yes, list the name(s) of the child( ren): OYes ONo 8. Does anyone in your household currently have health insurance?( This information is optional.) If yes, complete the chart below: Insurance Name(s) of individual(s) covered: Name of insurance company: Phone#: Address of insurance company: Group#: Policyholder name: Policy#: 9. Applying for continued medical benefits is not a requirement for presumptive eligibility. You may choose to opt out of applying for continued medical benefits by checking the box and placing your initials below: 1 opt out from applying for continued medical benefits. Client Initial: 7

Understand The State of Utah( the State) references below include the Utah Department of Health, the Department of Workforce Services and/ or the Office of Recovery Services. 1 know that under federal law, discrimination isn' t permitted on the basis of race, color, national origin, sex, age, sexual orientation, gender identity, or disability. I can file a complaint of discrimination by visiting www.hhs. gov/ ocr/-office/ file My benefits may be reduced, denied or stopped because • The Utah Statewide Immunization Information System of reported information. I understand that giving any USIIS) is a registry that keeps complete up to date false information or failing to report changes may result records of your child' s immunization history. For more in prosecution for fraud. If I receive benefits that I am information, or to withdraw your child from USIIS, call the not eligible to receive, I will be responsible for repaying Immunization Hot Line at 1-800-275-0659. the benefits received. If the State pays for my medical care, I assign to it my In the event of my death and my spouse' s death, the rights to payments from any third party and to benefits State has the right to recover from my estate all money for medical services. I will give to the State any money spent to pay my medical bills if I receive PCN and/ I collect from an insurance policy or from someone or Medicaid at anytime while I am 55 years of age or required to pay for my medical expenses. I authorize older. The state does not have the right to recover from payment directly to the State and will hold harmless any my estate those costs paid as a benefit of eligibility for a party making payment to them. Medicare cost-sharing program ( QMB, SLMB, QI). 1 must report any changes in my address, phone 1 give permission for any information provided to be number, household size and access to coverage by verified when I apply and after I receive benefits. another health insurance program within 10 days. The Utah Clinical Health Information Exchange( cHIE) 1 authorize the State to give health care providers is an electronic system that gathers my medical history information about my eligibility for medical benefits. from participating cHIE healthcare providers. The cHIE The State may exchange information with my health provides a safe place for my healthcare providers to insurance carrier and/ or my employer for the period share my medical information. For more information or I receive benefits from the program. to opt out of the cHIE participation, visit www. mychie.org or contact your health care provider. The benefits I am eligible to receive may be changed The medical benefits I receive are limited to those without my knowledge or consent. I understand that I described in the Provider Manual established for the am responsible for any co-pays to providers at the time program, as applicable. I understand that these manuals of medical service unless I am exempt from those may be amended without my consent or consideration. co-pays. If I receive a medical card, I will allow only the people 1 may ask for a fair hearing if I disagree with the decision named on the medical card to use the card. made on this application. 1 must follow the medical assistance program rules. My • 1 have been given a copy of the Rights and spouse and/ or children, as applicable, also must follow Responsibilities and Change Reporting Requirements. these rules. 1 assure that all household members applying for 1 must cooperate with the State in medical coverage or reimbursement are U. S. citizens pursuing any third party responsible or aliens in lawful immigration status, unless I am for medical expense. I must cooperate requesting emergency medical assistance only. I with the State to establish medical understand that I do not have to report citizenship support for my family, if required, information for household members who are not unless I have good cause to not cooperate. applying for coverage or reimbursement. The State will verify alien registration numbers with the U. S. Citizenship and Immigration Services( USCIS). The State will not report undocumented household members to USCIS. 8

I understand that my Social Security number will be used with the State Income and Eligiblity Verification System to make sure that my household is eligible for federal assistance programs. Computer matching, program reviews, and audits will be done with the Department of Workforce Services, Department of Health, Department of Human Services, Department of Homeland Security, Social Security, Internal Revenue Service, and/ or a consumer reporting agency. These agencies may also do inquiries to banking and loan institutions and any other organizations or individuals who may have eligibility information about my household. I must provide proof showing that my household is eligible for assistance. I,( print name) have read or had someone read to me the statements on this page. I understand and agree to those statements. Under penalty of perjury, I swear that the answers I give on this application are complete and correct. I am the person represented by the signature on this document. I know that I may be subject to penalties under federal law if I provide false or untrue information. Signature( check one): Applicant Authorized Representative Date Yes No Would you like someone to act as an authorized representative and have access to the information regarding your case? If yes, please complete Attachment D- Authorization to Disclose Medical Eligibility Information form attached to this application. 0 Renewal To make it easier to determine my eligibility for help paying for health coverage in future years, I agree to allow the Marketplace to use income data, including information from tax returns. I also agree to allow the Department of Workforce Services, the Department of Human Services and the Department of Health to use information from tax returns. I can opt out at any time. The Marketplace will send me a notice and let me make changes. Yes, renew my eligibility automatically for the next 5 years( the maximum number of years allowed), or for a shorter number of years: 4 years 3 years 2 years 1 year Don' t use information from tax returns to renew my coverage. 0 Voter Registration Information Yes No If you are not registered to vote where you live now, would you like to apply to register to vote here today? If you do not check either of these boxes, we will assume you have decided not to register to vote at this time. You may fill out the application form in private. If you would like help in filling out the voter registration application form, we will help you. The decision to seek or accept help is yours. Choosing to register or declining to register to vote will not affect the amount of assistance that you will be provided by this agency. If you believe that someone has interfered with your right to register, your right to decline to register to vote, your right to privacy in deciding whether to register or in applying to register to vote, or your right to choose your own political party or other political preference, you may file a complaint with the Lt. Governor, State of Utah, PO Box 142220, SLC, UT 84114. 0 Return completed I You have now completed the application. For more information please review the" Application Information" cover sheet. Please return this completed application form to: Department of Workforce Services PO Box 143245 SLC, UT 84114-3245 Fax: 1-801-526-9505 Toll-free Fax: 1-888-522-9505 9

Please tear off this page and keep it for your information. Your Rights & Responsibilities You Have the Right to: Apply or re-apply any time you wish for any medical program. Some programs are only available during open enrollment periods. If you need help, someone will help you apply. Receive a notice that we have either approved or denied your application and the reasons for the decision. For medical assistance, we have 30 days to process your application. We have 90 days, if you claim to be disabled, unless you need more time. Be notified explaining why we reduce, stop or hold your assistance. In most instances, we must mail the notice 10 days before we do this. Do the following things if you do not agree with decisions made regarding your case: A. Talk to your worker. Make sure you are not misunderstanding each other. B. Talk to your worker's supervisor. C. Talk to Constituent Services: 1-801-526-4390 or call toll-free 1-800-331-4341 D. Request a Fair Hearing within 90 days of the decision; 10 days to get benefits while the hearing is held. If you were denied disability status, you may also ask for a reconsideration as part of the fair hearing. If SSA denied your disability, you would have to go through their appeal process. Note: There are not any fair hearings for presumptive eligibility programs. E. Request legal representation regarding your fair hearing. You may be entitled to free legal assistance from Utah Legal Services. In Ogden, 1-801-394-9431 or Salt Lake, 1-801-328-8891. The toll-free number is 1-800-662-2538. You may also receive a referral for legal advice from the Salt Lake Lawyer Referral at 1-801-531-9075. Look at information in your case. Information about you and your case is confidential. We may give information to other agencies to administer a program to help you. Your Responsibilities.- Verify Information. The Social Security Act( U. S.C. 1320 b- 7 ( a)( 1) requires that you give us a Social Security number for each household member who wants medical assistance. If you are applying only for emergency Medicaid, you do not have to provide a Social Security number. If you do not have a number, you must prove you have applied. You may be eligible for assistance while you are waiting to receive a number. Your Social Security number will be used with the State Income and Eligibility Verification System to make sure that your household is eligible for federal assistance programs. Computer matching, program reviews, and audits will be done with the Department of Workforce Services, Department of Health, Department of Human Services, Department of Homeland Security, Social Security, Internal Revenue Service, and/ or a consumer reporting agency. These agencies may also do inquiries to banking and loan institutions and any other organizations or individuals who may have eligibility information about my household. I must provide proof showing that my household is eligible for assistance. Children enrolled in Medicaid are automatically enrolled in the Utah Statewide Immunization Information System USIIS). If you do not want your children enrolled in this system, you must call the USIIS Help Line at 1-801-538-6872 or the Immunization Hot Line at 1-800-275-0659. You must cooperate in any review of your case by Quality Control, Recovery Services, and the Bureau of Eligibility Policy. You must also cooperate in providing information about any other sources of medical payments and obtaining medical support. If you feel you could be harmed by giving this information, you can request a ' good cause' claim. Your worker can explain this procedure. Medical assistance( Medicaid, CHIP, UPP, PCN) recipients are automatically enrolled in the Utah Clinical Health Information Exchange( cHIE). For more information or to opt out of the cHIE participation, visit www.mychie. org or contact your health care provider. You and your household must also follow the medical assistance program rules. 10

Please tear off this! sage and keep for your information. Changes You Must Report Remember that YOU are required to report changes in your situation WITHIN 10 DAYS of the day you learn of the change. Do not delay reporting changes. Changes can affect your eligibility. If you receive benefits which you are not eligible to receive, you will have to repay that amount. To report changes, contact DWS online at www.mobs. utah. gov/ mycase or call 1-866-435-7414. If you receive CHIP, PCN, UPP, or Medicaid Benefits, you must Change in Marital Status or Living Arrangements Getting married, separated, or divorced; moving in with a roommate; change of address or phone number; absent parent moves in; birth of a baby or end of a pregnancy; household member moves in or out; death of a household member; hospital stays for more than 30 days; or if anyone in your household goes to jail or prison; receiving help with your household expenses, etc. Change in Insurance Coverage Changes in access to insurance, coverage, or enrollment in any health coverage plan ( including Medicare or VA Health Care System benefits) for anyone in the household. You must also report accidents or injuries which may be payable by a third party. Medicaid, If you receive you must also Change in Source of Income Getting a job, terminating a job, changingjobs, working for temporary services, obtaining educational income, SSI, SSA, or unemployment compensation, etc. Receiving a lump sum. Going on strike. Change in Amount of Earned or Unearned Gross Monthly Income Working more OR less hours, overtime, getting a raise, etc. Change in the amount of SSI, SSA, Unemployment Compensation, etc. Change in the Legal Obligation to Pay Child Support Gain or Loss of a Vehicle (Licensed or Unlicensed) Car, truck, van, motorcycle, camper, trailer, recreational vehicle, etc. Change in Any Asset(s) Report changes in ownership or value of stocks, bonds, property, vehicles, life insurance, trust funds, burial plans, cash, opening and closing of bank accounts, etc. for all household members. ( Includes joint ownership of any asset with spouse, parents, children, etc.) Change in Allowable Deductions Child care expenses, health insurance expenses, etc. If you are age 65 or over, blind, or disabled, you must also report changes in alimony or child support paid by a spouse or parent and work related expenses. 11

Attachment A American Indian or Alaska Native Family Member (AVAN) Complete this attachment if you or a family member are American Indian or Alaska Native. Submit this with your application. If you have more people to include, make a copy of this page and attach it to your application. Tell us about your American Indian or Alaska Native family American Indians and Alaska Natives can get services from the Indian Health Services, tribal health programs, or urban Indian Health programs. They also may not have to pay cost sharing and may get special monthly enrollment periods. Answer the following questions to make sure your family gets the most help possible. AI/ AN Person 1 AI/ AN Person 2 1. Name First Middle First Middle Last Last 2. Member of a federally recognized Yes _ Yes tribe? If yes, tribe name If yes, tribe name No No 3. Has this person ever received a service from the Yes Yes Indian Health Service, a tribal health program, or urban Indian Health program, or through a referral No No from one of these programs? If no, is this person eligible to If no, is this person eligible to get services from the Indian get services from the Indian Health Service, tribal health Health Service, tribal health programs, or urban Indian programs, or urban Indian Health programs, or through a Health programs, or through a referral from one of these referral from one of these programs? Yes No programs? Yes No 4. Certain money received may not be counted for Medicaid or the Children' s Health Insurance Amount:$ Amount: $ Program (CHIP). List any income( amount and how often) reported on your application that How often? How often? includes money from these sources: Per capita payments from a tribe that come from natural resources, usage rights, leases, or royalties Payments from natural resources, farming, ranching, fishing, leases, or royalties from land designated as Indian Trust Land by the Department of Interior( including reservations and former reservations) Money from selling things that have cultural significance 12

Attachment B Information on Your Dependents that are Not Living With You Complete this attachment for all dependents that ARE NOT living with you, but are claimed on your tax return. If you have more dependents that are not living with you, but are claimed on your tax return, please make a copy of this page and attach it to your application. 3 General Information Complete the following chart for your dependent: Name of Dependent Sex SSN# first, m. i., last) Relationship to You Date of Birth M/ F optional) Yes No 1. Is your dependent currently pregnant or has been pregnant in the last 3 months? If yes, due date: How many babies are expected during the pregnancy? 0 Income Yes No 1. Does your dependent have earned income? If yes, complete the chart below: Pay Rate Before Taxes Hours Worked How Often Paid Employer Name, Address and Phone Number ($ 900/ mo., $ 6/ hr.) Weekly weekly, monthly) Yes No 2. Does your dependent have self-employment income? If yes, list any self-employed income received. Type of Percent Company Name Business Business Company Net income this month Ex. LLC, S-Corp, etc.) ;, Start Date Owned ( profit once business expenses are paid) Yes No 3. In the past year, did your dependent change jobs, stop working or start working few hours? Yes No 4. Does your dependent have/ receive any of the following?( Check all that apply.) Unemployment $ How often: Net farming/ fishing $ How often: Pensions How often: Net rental/ royalty $ How often: Social Security $ How often: Other Income How often: Pensions How often: Type: Retirement Accts. $ How often: Alimony Received $ How often: 0 Deductions 1. Check all that apply, and give the amount and how often your dependent gets it. If your dependent pay for certain things that can be deducted on a federal income tax return, telling us about them could make the cost of health coverage a little lower. Note: You shouldn' t include a cost already considered in your answer to net self- employment. Alimony Paid How often: Other deductions $ How often: Student Loan Interest $ How often: Type: Yearly Income 1. Complete only if your dependent's income changes from month to month. Total income THIS year: Total income NEXT year: If you think it will be different) 13

DOH/ Form 116M 1/ 2014 Case#: Attachment C Employer's Health Insurance Information You will need your employer or company's Human Resources representative to complete this form. Complete this form for each employed household member. You may copy this form. If you need more time to finish this form, please send us the rest of the application so that we can look at your application as soon as possible. However, in some situations, we will need the information from this form to help determine your eligibility. If you have questions regarding this form, please call 1-866-435-7414. General Information Employee Information Employee name Employee SSN# first, m. i., last) Employer Information Employer Name: EIN#: Phone#: Address: street apt.# city state zip Who can we contact about employee health coverage at this job? Contact Name: Phone#: E- mail Address: Yes No 1. Does your company offer health insurance? If no, skip to section D. Sign and return the form. Yes No 2. Is your health insurance a state employee benefit plan? Yes No 3. Is your health insurance offered through Avenue H? Yes ONO 4. Is the employee eligible to enroll in any insurance plan offered? If no, please explain: If yes, when is/ was the employee eligible to enroll?( mm/ dd/ yy) Yes No 5. Is the employee or any family member enrolled in any insurance plan offered? If yes, name(s) of person(s) enrolled: Yes No 6. Has this employee or any family member dropped/ changed coverage in the last six months? If yes, name(s): If yes, when did coverage end/ change?( mm/ dd/ yy) Yes No 7. Does the employer offer a health plan that meets the * minimum value standard? 8. For the lowest-cost plan that meets the* minimum value standard offered only to employee( don' t include family plans): If the employer has wellness programs, provide the premium that the employee would pay if he/ she received the maximum discount for any tobacco cessation programs, and did not receive any other discounts based on the wellness programs: a. How much would the employee have to pay in premiums for that plan? $ b. How often? weekly every 2 weeks twice a month quarterly yearly Yes No 9. Do you know what change the employer will make for the new plan year? If yes, complete the following: Employer won' t offer health insurance Employer will start offering health coverage to employees or change the premium for the lowest-cost plan available only to the employee that meets the * minimum value standard. Premium should not reflect the discount for wellness programs. See question 8. a. How much will the employee have to pay in premiums for that plan? b. How often? weekly every 2 weeks twice a month quarterly yearly An employer-sponsored health plan meets the" minimum value standard" if the plan' s share of the total allowed benefit costs covered by the plan is no less than 60% of such costs( Section 36B(c)( 2)( C)( 11) of the Internal Revenue Code of 1986) 14

0 Employer's Least Expensive Plan or Avenue H Default Plan Questions below refer to the employer's least expensive plan or the Avenue H Default Plan. Yes ONO 1. Does the employee have to enroll in order to add their dependent(s)? 2. When will/ did coverage begin?( mm/ dd/ yy) 3. When does the company' s next open enrollment begin?( mm/ dd/ yy) 4. Complete the chart below. Do not include the cost of dental, vision or other coverage if it is separate. Monthly Premium Employee' s Portion Company's Portion Employee Employee+ spouse . $ Employee+ child Family Employee's h Plan Choice Questions below refer to the plan that the employee has selected. Questions 3- 7 refer to" in- network" benefits. 1. Insurance company and plan name: 2. Policy number, if known: Yes [] No 3. Is the deductible$ 2, 500 or less per individual? Yes ONO 4. Is the lifetime maximum benefit$ 1,000,000 or more? Yes No 5. Does the plan pay at least 70% of an inpatient stay( after the deductible)? 6. What benefits are covered under this plan?( Check all that apply.) Physician visits Hospital inpatient services Pharmacy/ Rx Yes No 7. Does the plan cover abortion services? If yes, under what circumstances: Only in the case where the life of the mother would be endangered if the fetus were carried to term or in the case of incest or rape Other, please describe: 8. Complete this chart only if it is different from the chart on the front page( section B). Do not include the cost of dental, vision or other coverage if it is separate. Monthly Premium Employee' s Portion Company's Portion Employee Employee+ spouse $ Employee+ child Family Yes No 9. Are the employee' s children currently enrolled or do they plan to enroll in your company's 0 dental plan? If yes, name(s): Signature I certify that I am a representative of the Human Resource Department, or that I am the health insurance contact person. The information on this form is true and correct to the best of my knowledge. Signature: Date: Name( please print): Title: Phone: Please returns completed fora o: Department of Workforce Services, PO Box 143245, SLC, UT 84114-3245 Fax: 1-801-526-9500 Toll-free Fax: 1-877-313-4717 15

DOH/ Form 114AR 10/ 2013 Attachment D Authorization to Disclose Medical Information You can choose an authorized representative. You can give a trusted person permission to talk about this application with us, see your information, and act for you on matters related to this application, including getting information about your application and signing your application on your behalf. This person is called an authorized representative." Ifyou're a legally appointment representative for someone on this application, submit proof with this application. I hereby give the authority to: Name of Customer or Authorized Representative) Name of individual or Organization) check only one box) Receive Medicaid, CHIP, UPP, PCN or Buyout eligibility information regarding my current application, ongoing case or a recent case denial or closure. This authorization is effective from the date this form is signed to whichever of the following occurs first: The following date: or The medical application is denied*; or 30 days from the month the medical program is closed*. if the application is denied or the case is closed, information disclosure will continue throughout the fair hearing process. p Speak or act on my behalf as an authorized representative, which includes receiving Medicaid, CHIP, UPP, PCN or Buyout eligibility information regarding my current application, ongoing case or a recent case denial or closure. This authorization is effective from the date this form is signed until a written notification to revoke the authorization is received by the Department of Workforce Services. Name of Authorized Representative: Address of Authorized Representative: 1 understand that I may revoke this authorization at any time by sending a written notification to the Department of Workforce Services( DWS). I understand that a revocation is not effective to the extent that the Utah Department of Health, through its Division of Medicaid and Health Financing( DMHF) or the DWS has relied on the disclosed health information. I understand my rights and responsibilities described in the Notice of Privacy Practices. For a duplicate Notice of Privacy Practices, access the following URL- http:// health. utah. gov/ hipaa/ privacy.htm. I understand that I may refuse to sign this authorization. I also understand that the DWS cannot deny eligibility for benefits if I refuse to sign this authorization. I understand that giving an individual authorized representative power allows them to act on my behalf, which includes making changes to my medical case and any changes that they make, I may be liable for if an overpayment is incurred. I understand that, once information is disclosed pursuant to this authorization, it is possible that it will no longer be protected by medical privacy laws and could be disclosed by the person or agency that receives it. Note: DMHF and DWS will not disclose controlled documents without the consent of their Legal Departments. By signing this form, I acknowledge I have been provided a copy of this signed authorization. Signature of Customer, Legal Guardian, or Authorized Representative) Date) If signed by other than the customer, description of authority to serve: Equal Opportunity Employer Program Auxiliary aids and services are available upon request to individuals with disabilities by calling( 801) 526-9240. Individuals with speech and/ or hearing impairments may call Relay Utah by dialing 711. Spanish Relay Utah: 1-888-346-3162 16

Strom, Mandy L. ( CMS/ CMCHO) From: Hollis, Annie R. ( CMS/ CMCS) Sent: Tuesday, April 01, 2014 12:02 PM To: Strom, Mandy L. ( CMS/ CMCHO) Cc: Kress, Marielle I (CMS/ CMCS) Subject: RE: PLEASE REPLY ASAP: UT 14- 0007 Submitted Thank you. I was out all last week so my email is a mess, No feedback to note, it looks great! From: Strom, Mandy L. ( CMS/ CMCHO) Sent: Tuesday, April 01, 2014 1: 58 PM To: Hollis, Annie R. ( CMS/ CMCS); Kress, Marielle]. ( CMS/ CMCS) Cc: Marchioni, Mary A. ( CMS/ WC) Subject: RE: PLEASE REPLY ASAP: UT 14- 0007 Submitted The draft approval letter email is attached. Mandy Strom 303) 844- 7068 Mandy. Strom @cros. hhs. gov From: Hollis, Annie R. ( CMS/ CMCS) Sent: Tuesday, April 01, 2014 11: 58 AM To: Strom, Mandy L. ( CMS/ CMCHO); Kress, Marielle 1. ( CMS/ CMCS) Cc: Marchioni, Mary A. ( CMS/ WC) Subject: RE: PLEASE REPLY ASAP: UT 14-0007 Submitted Since I haven' t been too tuned in to this SPA I defer to Marielle on final approval,.. I can' t find the draft approval letter in my email, do you mind resending? Thanks From: Strom, Mandy L. ( CMS/ CMCHO) Sent: Tuesday, April 01, 2014 1: 44 PM To: Hollis, Annie R. ( CMS/ CMCS); Kress, Marielle J. ( CMS/ CMCS) Cc: Marchioni, Mary A. ( CMS/ WC) Subject: RE: PLEASE REPLY ASAP: UT 14- 0007 Submitted I just got off the phone from the state and now I understand what they did. You are correct it is still there, They removed the opt out box and initials section from the cover page( see attached older version) because the state does not always get the cover page when an application is submitted. They added the language referring them to question 9 in appendix K regarding opting out so it is still there. Based on this last piece of information from the state, I think we are good and ready to approve. Please let me know your concurrence. Also, any feedback on the draft approval letter, I shared with Marielle yesterday afternoon? Mandy Strom 303) 844- 7068 Mandy.Strom@Cms. hhs. gov 1

From: Hollis, Annie R. ( CMS/ CMCS) Sent: Tuesday, April 01, 2014 11: 32 AM To: Strom, Mandy L. ( CMS/ CMCHO); Kress, Marielle J. ( CMS/ CMCS) Cc: Marchioni, Mary A. ( CMS/ WC) Subject: RE: PLEASE REPLY ASAP: UT 14- 0007 Submitted It looks like the apt out language is still there to me, according to these attachments... where do you see that? Thanks! From: Strom, Mandy L. ( CMS/ CMCHO) Sent: Tuesday, April 01, 2014 1: 29 PM To: Kress, Marielle J. ( CMS/ CMCS); Hollis, Annie R. ( CMS/ CMCS) Cc: Marchioni, Mary A. ( CMS/ WC) Subject: PLEASE REPLY ASAP: UT 14- 0007 Submitted Hi Marielle and Annie, Utah has submitted its revisions in MMDL and they are attached. They have made all the required changes, but I have one question for you. They removed the opt out language from the cover page of the application, which they had added in the version Jeff shared with us on Friday. Can will still approve without that language or does it need to be added back in? Let me know ASAP. Thanks, Mandy Attut4 StwmI Division of Medicaid and Children' s Health Operations I Denver Regional Office I Centers for Medicare& Medicaid Services 11600 Broadway, Suite 700, Denver, CO 80202 19:( 303) 844- 70681 ( 443) 380- 60911,': Mandy.5trom@cros.hhs. gov bA I' h, a- e> rean ides, I h hel; n, prinii) g thi, e- mail, 2

Strom, Mandy L. ( CMS/ CMCHO) From: Strom, Mandy L. ( CMS/ CMCHO) Sent: Tuesday, April 01, 2014 10:24 AM To: Craig Devashrayee'; Gayle M. Six( gaylesix @utah.gov) Cc: Jeff Nelson Jeffnelson @utah.gov); Michelle Smith (michellesmith @utah.gov); Kress, Marielle J. ( CMS/ CMCS); Hollis, Annie R.( CMS/ CMCS); Marchioni, Mary A. (CMS/ WC) Subject: ACTION REQUESTED ASAP RE: SPA 14- 0007- MM Presumptive Eligibility by Hospitals Attachments: S21- hospital presumptive. pdf Categories: Follow- up Fli Craig, I have quickly reviewed the documents uploaded in the system and we need two revisions. 1. S21 Template: The State had submitted a revised S21 ternplate on March 21 ( attached) that included more information regarding the standards. set( 100%, 85%, and 65%). The new uploaded version does not reflect these revisions. Please update the March 2: 1" version to reflect the one PE period per calendar year and upload into MMDL. 2, Training Slide Deck: The state needs to update the " Next Steps" slide to indicate the paper receipt given to the client by the hospital once PE is determined. If you could make these two quick changes and get them uploaded into MMDL then we should be good to go. I am unlocking the system right now. Mandy Mandy Strom 303) 844-7068 Mandy. Strom @cros.hhs. gov From: Craig Devashrayee [ mailto: cdevashrayee a utah.gov] Sent: Tuesday, April 01, 2014 9: 31 AM To: Strom, Mandy L. ( CMS/ CMCHO) Subject: QAZ: SPA 14- 0007- MM Presumptive Eligibility by Hospitals Hi Mandy: All these items have been uploaded for CMS approval. Thanks. Strom, Mandy L.( CMS/CMCHO) x. . M.. One more it.e= rr): Please indicate on the subject line for fiscal impact that this SPA' s fiscal irnpact is incorporated with 14- 0001_MM. Mandy Strom 1

303) 844-7068 Mandy.Strom2cros.hhs.gov From: Strom, Mandy L. ( CMS/ CMCHO) Sent: Monday, March 31, 2014 2: 49 PM To: ' Jeff Nelson'; ' Craig Devashrayee( cdevashrayeeOdutah. gov)' Cc: Six, Gayle M.; Yoshida, Amanda; Smith, Michelle; Laura Belgique; Jennifer Meyer-Smart; Kress, Marielle J. CMS/ CMCS); Marchioni, Mary A. ( CMS/ WC) Subject: ACTION REQUIRED ASAP: RE: Utah - HPE Next Steps - SPA 14- 0007- MM Importance: High Hi Jeff and Craig, Thanks for making the changes and sending the updated documents. We need you to do the following by noon tomorrow at the very latest so we can approve by COB to meet.the 90th day, which is Wednesday. Change S21 template PE Eligibility Limit Description box to 1 PE period per calendar year and upload revised in MMDL Modify training slide deck " Next Step" slide to indicate=a paper receipt will be provided by the hospital and upload revised version in MMDL Upload revised training manual Upload revised application Please let me know if you have any questions or can' t make the noon deadline. Thanks, Mandy IMPORTANT MESSAGE ********** This message, including any attachments, may contain confidential information intended for a specific individual and purpose, and is protected by law. If you are not the intended recipient, delete this message, including from trash, and notify me by telephone or email. If you are not the intended recipient, any distribution or copying of this message, or the taking of any action based on its content is strictly prohibited. 2

Strom, Mandy L. ( CMS/ CMCHO) From: Strom, Mandy L (CMS/ CMCH0 Sent: Monday, March 31, 20l44/4OPK4 To: Kress, MaheUe1 ( CMS/ CM[ 8 Cc: K4aohioni. Mary A. ([ K4S/ VV[); AUen' Richard C. ([ K4S/[ K4[ H[); Hollis, Annie Pi CMS/IM[ S); Cash, Judith ( CMS/ CM[ S) Subject RE: LIT SPA 14' 0007' k4K4 DRAFT RAl Attachments: LIT I4' 0O07RAlORAFTdocx Follow 0p Flag: Follow up Flag Status: Completed K4arieUe' In case the state cannot get the information submitted tomorrow, I want to make sure we have a RAI ready to go. Please review the draft and let me know any suggested changes, Mandy Strom 303) 844- 7068 Fromm: Strom, Mandy L. ( CMS/ CMCHO) Sent: Monday, March 31, 20143: 22 PM To: Kress MaheUe]. ( CMS/ CM[ S) Cc: Marchioni, Mary A. ( CMS/ WC); Allen, Richard C. ([ MS/ CM[ HO); Hollis, Annie R. ( CMS/ CMCS); Cash, Judith CMS/ CMCS) Subject: LIT SPA 14' UOO7- MMDRAFT APPROVAL LETTER Importance: High Attached ismy draft approval letter. Please review and let me know what changes, Thanks, Mandy Mandy Strom 3O3) 844' 7068 From: Kress Mohe||e]. ( OqS/ CMCS) Sent: Monday, March 31, 30142: 3O PM To: Strom, Mandy L. ([ MS/ CM[ HO) Cc: Manchinni, Mary A. ( CMS/ WC); Allen, Richard C. ( CMS/ CM[ HO); Hollis, Annie R. ( CMS/ CM[ S); Cash, Judith CMS/ CMCS) Subject: RE: NEED RESPONSE ASAP: FW: Utah HPE Next Steps SPA 14' 0007- MM Perfect. From: Strom, Mandy L. ( CMS/[ MCHO) Sent: Monday, March 31, 2014 4: 30 PM To: Kress, Marie||o]. ( CMS/ CMCS) Cm: Manchiuni, Mary A. ( CMS/ WC); Allen, Richard C. ( CMS/ CMCHO); Hollis, Annie R. ( CMS/[ MCS); Cash, Judith

CMS/ CMCS) Subject: RE: NEED RESPONSE ASAP: FW: Utah - HPE Next Steps - SPA 14- 0007- MM Great. I will contact the state and send you a draft approval letter for review and edit. Mandy Strom 303) 844-7068 Mandy.Strom @cros. hhs.gov From: Kress, Marielle J. ( CMS/ CMCS) Sent: Monday, March 31, 2014 2: 27 PM To: Strom, Mandy L. ( CMS/ CMCHO) Cc: Marchioni, Mary A. ( CMS/ WC); Allen, Richard C. ( CMS/ CMCHO); Hollis, Annie R. ( CMS/ CMCS); Cash, Judith CMS/ CMCS) Subject: RE: NEED RESPONSE ASAP: FW: Utah - HPE Next Steps - SPA 14- 0007- MM Thank you for this, Mandy. I agree with the next steps, can you get back to the state on these? They will need to upload the new training materials and application to MMDL, as well as amend the SPA page, but not necessarily the word document with the next steps. I think those we will need to reflect on the approval letter. Can you start crafting the approval letter? The paper receipt does not need to be uploaded to MMDL, either. Do you need any other guidance? Thanks very very much for pushing this forward today! From: Strom, Mandy L. ( CMS/ CMCHO) Sent: Monday, March 31, 2014 1: 50 PM To: Kress, Marielle J. ( CMS/ CMCS) Cc: Marchioni, Mary A. ( CMS/ WC); Allen, Richard C. ( CMS/ CMCHO); Hollis, Annie R. ( CMS/ CMCS) Subject: NEED RESPONSE ASAP: FW: Utah - HPE Next Steps - SPA 14- 0007- MM Hi Marielle, I have reviewed the materials submitted by Utah on Friday afternoon. Here is my analysis: They updated slide 12 to reflect ambulatory prenatal care coverage. Good They have agreed to just 1 PE period in a calendar year. This has been updated in the training manual and slide presentation. Good, but they need to update the SPA template and submit revised versions of the template and training materials in MMDL. They submitted a PE receipt for individuals to use to show proof of coverage during the lag of getting their actual eligibility card. The state has committed in writing to use the receipt as well as working with the pharmacy community to honor the receipt as proof of coverage. Good, but the state did not update the" next steps" Aide to indicate the paper receipt. The State updated the opening language in Section K of the application to indicate the other sections that need to be completed and also referring back to the cover page with instructions, The State also updated the cove=r page to include an opt out for continuing medical benefits. I know some of the recon-(Trended changes to make the application more user friendly were not deal breakers, but I a m not sure= the revisions clarified much, In addition, are you ok with the new " opt out" piece for continuing medical benefits? Next steps for approval: Update training slide deck " Next Step" slide with the paper receipt and upload revised version in MMDL Upload revised training manual Change template to 1 PE period per calendar year and upload revised in MMDL Are we good with the application? If so, then the state needs to upload the revised into MMDL Do we need the document with the state' s commitment to make all the changes uploaded into MMDL? Does the paper receipt need to be uploaded in to MMDL? 2

Thanks, Mandy Mandy Strom 303) 844-7068 Mand . Strom cros. hhs. ov From: Jeff Nelson [ mai Ito:jeffnelsonC' utah.gov] Sent: Friday, March 28, 2014 4: 58 PM To: Kress, Marielle J. ( CMS/ CMCS); Strom, Mandy L. ( CMS/ CMCHO) Cc: Six, Gayle M.; Yoshida, Amanda; Smith, Michelle; Laura Belgique; Jennifer Meyer-Smart Subject: QAZ: Utah - HPE Next Steps - SPA 14- 0007- MM Hello - Thank you for all of the technical assistance you have provided for Utah on the Hospital Presumptive Eligibility SPA. We appreciate the open dialogue to discuss our concerns and explain our thoughts on how to implement the program in Utah. We made several changes today and have included updated documents and a description of all the changes we have or will make for HPE. We tried to call out specific dates of when we think we could make those changes. Again we thank you for your help and we look forward to approval of this outstanding SPA. Jeff Nelson Bureau Director of Eligibility Policy Medicaid and Health Financing Utah Department of Health 801) 538- 6471 PS. We plan to move the " opt out" bullet into the last position in the same section but had a computer glitch this afternoon. IMPORTANT MESSAGE ********** This message, including any attachments, may contain confidential information intended for a specific individual and purpose, and is protected by law. If you are not the intended recipient, delete this message, including from trash, and notify me by telephone or email. If you are not the intended recipient, any distribution or copying of this message, or the taking of any action based on its content is strictly prohibited. 3

DEPARTMENT OF HEALTH& HUMAN SERVICES Centers for Medicare& Medicaid Services 1600 Broadway, Suite 700 Denver, CO 80202-4967 CMS r, Region VIII April 1, 2014 Michael Hales State Medicaid Director Division of Health Care Financing Utah Department of Health P O Box 144102 Salt Lake City, UT 84114- 4102 Dear Mr. Hales: We are reviewing the Utah State Plan Amendment( SPA) 14- 0007, received in the Denver Regional Office on January 3, 2014. This MAGI SPA addresses hospital presumptive eligibility. Before we continue processing the SPA, we need additional clarifying information. 1. The state needs to explain in the subject line of the 179 that its fiscal impact is included in the fiscal impact entered for MAGI eligibility group SPA 14- 0001- MM. 2. The state needs to revise the S21 template on page 3 for the Presumptive Eligibility Limit. The description box should reflect one presumptive eligibility period per calendar year. The State will need to upload the revised S21 template in MMDL with that change. 3. The State will need to revise the training slide deck attachment with the following changes and upload to MMDL: i) Slide 5: Modify to reflect the one presumptive eligibility period per calendar year; ii) Slide 12: Modify to reflect" ambulatory prenatal care" instead of" outpatient prenatal care" as the benefits available to pregnant women during the presumptive eligibility period; and iii) Slide 23 " Next Steps": Modify to reflect a paper receipt will be provided by the hospital to the applicant upon presumptive eligibility determination. 4. The State will need to revise the training manual with the following changes and upload to MMDL: i) Page 7: Modify to reflect the one presumptive eligibility period per calendar year, and ii) Page 14: Modify to reflect " ambulatory prenatal care" instead of" outpatient prenatal care" as the benefits available to pregnant women during the presumptive eligibility period.

5. By July 2014, Utah should incorporate changes to Utah' s single streamline application by providing better instructions to presumptive eligibility applicants on what question are required to be completed when applying for presumptive eligibility. In addition, the state will implement a paper form verifying an individual' s eligibility to be given to the applicant upon determination as well as work to train doctors and pharmacies to accept this paper documentation as proof in the interim until the applicant receives the actual medical card in the mail. Under § 1915( f) of the Social Security Act, a State plan amendment must be approved, disapproved or a request for additional information must be issued within the first 90 days of submittal; if not, a State plan amendment will be deemed approved. The 90- day period for SPA 14- 0007- MM was scheduled to end on April 2, 2014. This request for additional information will stop this 90-day clock. A new 90- day time frame will start on the day when we receive your response. In accordance with our guidelines to all State Medicaid directors dated January 2, 2001, if we have not received the State' s response to our request for additional information within 90 days from the date of this letter, we will initiate disapproval action on the amendment. In addition, because this amendment was submitted after January 2, 2001 and is effective after January 1, 2001, please be advised that we will continue to defer Federal financial participation ( FFP) for State payments made in accordance with this amendment until it is approved. Upon approval, FFP will be available for the period beginning with the effective date through the date of approval. We appreciate our continued dialogue as we work together to resolve the aforementioned outstanding questions. If you or your staff has questions regarding this request please contact Mandy Strom of my staff at ( 303) 844- 7068 or by email at Njandy. StromLta.)cros. hhs. gov. Sincerely, Richard C. Allen Associate Regional Administrator Divisions of Medicaid & Children' s Health Operations 2

Strom, Mandy L. ( CMS/ CMCHO) From: Strom, Mandy L. ( CMS/ CMCHO) Sent: Monday, March 31, 2014 3:22 PM To: Kress, Marielle J. ( CMS/ CMCS) Cc: Marchioni, Mary A. (CMS/ WC); Allen, Richard C. ( CMS/ CMCHO); Hollis, Annie R. CMS/ CMCS); Cash, Judith ( CMS/ CMCS) Subject: UT SPA 14- 0007- MM DRAFT APPROVAL LETTER Attachments: UT 14- 0007- MM Draft Approval letter.docx Importance: High Follow Up Flag: Follow up Flag Status: Completed Attached is my draft approval letter. Please review and let me know what changes. Thanks, Mandy Mandy Strom 303) 844- 7068 Mandy.Strom @cros. hhs. gov From: Kress, Marielle J. ( CMS/ CMCS) Sent: Monday, March 31, 2014 2: 30 PM To: Strom, Mandy L. ( CMS/ CMCHO) Cc: Marchioni, Mary A. ( CMS/ WC); Allen, Richard C. ( CMS/ CMCHO); Hollis, Annie R. ( CMS/ CMCS); Cash, Judith CMS/ CMCS) Subject: RE: NEED RESPONSE ASAP: FW: Utah - HPE Next Steps - SPA 14- 0007- MM Perfect. From: Strom, Mandy L. ( CMS/ CMCHO) Sent: Monday, March 31, 2014 4: 30 PM To: Kress, Marielle J. ( CMS/ CMCS) Cc: Marchioni, Mary A. ( CMS/ WC); Allen, Richard C. ( CMS/ CMCHO); Hollis, Annie R. ( CMS/ CMCS); Cash, Judith CMS/ CMCS) Subject: RE: NEED RESPONSE ASAP: FW: Utah - HPE Next Steps- SPA 14-0007- MM Great. I will contact the state and send you a draft approval letter for review and edit, Mandy Strom 303) 844- 7068 Mandy.Strom @cros. hhs.gov From: Kress, Marielle J. ( CMS/ CMCS) Sent: Monday, March 31, 2014 2: 27 PM To: Strom, Mandy L. ( CMS/ CMCHO) Cc: Marchioni, Mary A. ( CMS/ WC); Allen, Richard C. ( CMS/ CMCHO); Hollis, Annie R. ( CMS/ CMCS); Cash, Judith CMS/ CMCS) Subject: RE: NEED RESPONSE ASAP: FW: Utah - HPE Next Steps- SPA 14-0007- MM 1

Thank you for this, Mandy. I agree with the next steps, can you get back to the state on these? They will need to upload the new training materials and application to MMDL, as well as amend the SPA page, but not necessarily the word document with the next steps. I think those we will need to reflect on the approval letter. Can you start crafting the approval letter? The paper receipt does not need to be uploaded to MMDL, either. Do you need any other guidance? Thanks very very much for pushing this forward today! From: Strom, Mandy L. ( CMS/ CMCHO) Sent: Monday, March 31, 2014 1: 50 PM To: Kress, Marielle J. ( CMS/ CMCS) Cc: Marchioni, Mary A. ( CMS/ WC); Allen, Richard C. ( CMS/ CMCHO); Hollis, Annie R. ( CMS/ CMCS) Subject: NEED RESPONSE ASAP: FW: Utah - HPE Next Steps - SPA 14- 0007- MM Hi Marielle, I have reviewed the materials submitted by Utah on Friday afternoon. Here is my analysis: They updated slide 12 to reflect ambulatory prenatal care coverage. Good They have agreed to just 1 PE period in a calendar year. This has been updated in the training manual and slid e presentation. Good, but they need to update the SPA template and submit revised versions of the template and training materials in MMDL. They submitted a PE receipt for individuals to use to show proof of coverage during the lag of getting their actual eligibility card. The state has committed in writing to use the receipt as well as working with the pharmacy community to honor the receipt as proof of coverage. Good, but the state did not update the " next steps" slide to indicate the paper receipt. The State updated the opening language in Section K of the application to indicate the other sections that need to be completed and also referring back to the cover page with instructions. The State also updated the cover page to include an opt out for continuing medical benefits. I know some of the recommended changes to make the application more user friendly were not deal breakers, but I am not scare the revisions clarified much. In addition, are you ok with the new " opt out" piece for corrtinUing medical benefits' Next steps for approval: Update training slide deck " Next Step„ slide with the paper receipt and upload revised version in MMDL Upload revised training manual Change template to 1 PE period per calendar year and upload revised in MMDL Are we good with the application? If so, then the state needs to upload the revised Into MMDL Do we need the document with the state' s commitment to make all the changes uploaded into MMDL? Does the paper receipt need to be uploaded in to MMDL? Thanks, Mandy Mandy Strom 303) 844-7068 Mandy. Strom@cms.hhs. gov cros.hhs. gov From: Jeff Nelson [ mailto jeffnelson@utah. gov] Sent: Friday, March 28, 2014 4: 58 PM To: Kress, Marielle J. ( CMS/ CMCS); Strom, Mandy L. ( CMS/ CMCHO) Cc: Six, Gayle M.; Yoshida, Amanda; Smith, Michelle; Laura Belgique; Jennifer Meyer-Smart Subject: QAZ: Utah - HPE Next Steps - SPA 14- 0007-MM Hello - 2

Thank you for all of the technical assistance you have provided for Utah on the Hospital Presumptive Eligibility SPA. We appreciate the open dialogue to discuss our concerns and explain our thoughts on how to implement the program in Utah. We made several changes today and have included updated documents and a description of all the changes we have or will make for HPE. We tried to call out specific dates of when we think we could make those changes. Again we thank you for your help and we look forward to approval of this outstanding SPA. Jeff Nelson Bureau Director of Eligibility Policy Medicaid and Health Financing Utah Department of Health 801) 538- 6471 PS. We plan to move the " opt out" bullet into the last position in the same section but had a computer glitch this afternoon. IMPORTANT MESSAGE ********** This message, including any attachments, may contain confidential information intended for a specific individual and purpose, and is protected by law. If you are not the intended recipient, delete this message, including from trash, and notify me by telephone or email. If you are not the intended recipient, any distribution or copying of this message, or the taking of any action based on its content is strictly prohibited. 3

DEPARTMENT OF HEALTH& HUMAN SERVICES Centers for Medicare& Medicaid Services Denver Regional Office 1600 Broadway, Suite# 700 Denver, CO 80202-4967 CENTERS FOR MEDI nett&; MIDIcAID SERI IC£5 REGION VIII- DENVER April 1, 2014 W. David Patton, Ph. D. Utah Department of Health 288 North 1460 West PO Box 143102 Salt Lake City, UT 84114 RE: Utah# 14- 0007- MM Dear Dr. Patton: We have reviewed the proposed State Plan Amendment( SPA) submitted under transmittal Number( TN) 14- 0007- MM on January 3, 2014. This SPA implements presumptive eligibility by hospitals in accordance with the Affordable Care Act and 42 CFR 435. 1110. Please be informed this State Plan Amendment was approved April 1, 2014, with an effective date of January 1, 2014. We are enclosing the CMS- 179 and the amended plan page( s). In addition, Utah has agreed by July 2014 to incorporate changes to Utah' s single streamline application by providing better instructions to presumptive eligibility applicants on what question are required to be completed when applying for presumptive eligibility. In addition, the state will implement a paper form verifying an individual' s eligibility to be given to the applicant upon determination as well as work to train doctors and pharmacies to accept this paper documentation as proof in the interim until the applicant receives the actual medical card in the mail. If you have any questions regarding this letter, please contact Mandy Strom at( 303) 844- 7068 or mandv. strom' ci,cros. lihs.« ov. Sincerely, Richard C. Allen Associate Regional Administrator Divisions of Medicaid& Children' s Health Operations

Page 2- Suzanne Brennan, State Medicaid Director CC: Michael Hales, Medicaid Director, UT Craig Devashrayee, UT Jeff Nelson, UT Gayle Six, UT

Strom, Mandy L. ( CMS/ CMCHO) From: StmmMandyLACMS/ CM[ H0 Sent Monday, March 31, 2Ul42:SIPK4 To: Jeff Nelson'; ' Craig Deva» hrayee( cdevashrayee@utah.gmv)' Cc; Six. Gayle M.'; ' Yoshida. Amanda'; ' Smith' Michelle'; ' Laura Belgique'; ' Jennifer Meyer- Smart'; Kress, K4aheUe1 ( CM5/[ K4[ 6); Marchioni. Mary A. ([ MS/ VV[) Subject: REVISED: ACTION REQUIRED ASAP: RE: Utah HPE Next Steps SPAI4' OOU7' Mk4 FmUUom/ 0p Flag: Follow up Flag Status: Completed One more item: Please indicate on the subject line for fiscal impact that this SPA' sfisca| impact is incorporated with 14- 0001- K4k1. Mandy Strom 303) 844- 7068 From: Strom, Mandy L. ( CMS/[ MCHO) Sent: Monday March 31, 20142: 49RM To: ' Jeff Nelson'; ' Craig Devashrayea Cc: Six, Gavle M.; Yoshida, Amanda; Smith Michelle; Laura Jennifer Meyer Smart Kress Mahel|e]. MS/ CMCS); Marchioni, Mary A. ( CMS/ VV[) Subject: ACTION REQUIRED ASAP: RE: Utah HPE Next Steps ' SPA 14' 0007' MM Importance: High Hi Jeff and Craig, Thanks for making the changes and sending the updated documents. VVe need you todo the following bynoon tomorrow at the very latest so we can approve by COB to meet the 90th day, which is Wednesday. Change S21 template PE Eligibility Limit Description box to 1 PE period per calendar year and upload revised in MMDL K4odifytrainin8didedeck ° NextStep^ a| idetoindicateapaperreceiptvviUbepnovidedbythehospita| and upload revised version in K4K8DL Upload revised training manual Upload revised application Please let me know if you have any questions or can' t make the noon deadline. Thanks, Mandy Mandy Strom 303) 844- 7068 From: Jeff Nelson Sent: Friday, March 28, 2014 4: 58 PM To: Kress, Marie||e]. ( CMS/ CMCS); Strom, Mandy L. ( CMS/ CMCHO) Cc: Six, Gayle M.; Yoshida, Amanda; Smith, Michelle; Laura Belgique; Jennifer Meyer-Smart Subject: OAZ: Utah - HPE Next Steps ' SPA 14' 0007' MM z

Hello - Thank you for all of the technical assistance you have provided for Utah on the Hospital Presumptive Eligibility SPA. We appreciate the open dialogue to discuss our concerns and explain our thoughts on how to implement the program in Utah. We made several changes today and have included updated documents and a description of all the changes we have or will make for HPE. We tried to call out specific dates of when we think we could make those changes. Again we thank you for your help and we look forward to approval of this outstanding SPA. Jeff Nelson Bureau Director of Eligibility Policy Medicaid and Health Financing Utah Department of Health 801) 538- 6471 PS. We plan to move the " opt out" bullet into the last position in the same section but had a computer glitch this afternoon. IMPORTANT MESSAGE ********** This message, including any attachments, may contain confidential information intended for a specific individual and purpose, and is protected by law. If you are not the intended recipient, delete this message, including from trash, and notify me by telephone or email. If you are not the intended recipient, any distribution or copying of this message, or the taking of any action based on its content is strictly prohibited. 2

Strom, Mandy L. ( CMS/ CMCHO) From: Kress, Marielle J. ( CMS/ CMCS) Sent: Monday, March 31, 2014 2: 30 PM To: Strom, Mandy L. ( CMS/ CMCHO) Cc: Marchioni, Mary A. (CMS/ WC); Allen, Richard C. ( CMS/ CMCHO); Hollis, Annie R. CMS/ CMCS); Cash, Judith ( CMS/ CMCS) Subject: RE: NEED RESPONSE ASAP: FW: Utah - HPE Next Steps - SPA 14- 0007- MM Perfect. From: Strom, Mandy L. ( CMS/ CMCHO) Sent: Monday, March 31, 2014 4: 30 PM To: Kress, Marielle J. ( CMS/ CMCS) Cc: Marchioni, Mary A. ( CMS/ WC); Allen, Richard C. ( CMS/ CMCHO); Hollis, Annie R. ( CMS/ CMCS); Cash, Judith CMS/ CMCS) Subject: RE: NEED RESPONSE ASAP: FW: Utah - HPE Next Steps - SPA 14- 0007- MM Great. I will contact the state and send you to draft approval letter for review and edit. Mandy Strom 303) 844- 7068 Mandy.Strom@cms. hhs.gov From: Kress, Marielle J. ( CMS/ CMCS) Sent: Monday, March 31, 2014 2: 27 PM To: Strom, Mandy L. ( CMS/ CMCHO) Cc: Marchioni, Mary A. ( CMS/ WC); Allen, Richard C. ( CMS/ CMCHO); Hollis, Annie R. ( CMS/ CMCS); Cash, Judith CMS/ CMCS) Subject: RE: NEED RESPONSE ASAP: FW: Utah - HPE Next Steps - SPA 14- 0007- MM Thank you for this, Mandy. I agree with the next steps, can you get back to the state on these? They will need to upload the new training materials and application to MMDL, as well as amend the SPA page, but not necessarily the word document with the next steps. I think those we will need to reflect on the approval letter. Can you start crafting the approval letter? The paper receipt does not need to be uploaded to MMDL, either. Do you need any other guidance? Thanks very very much for pushing this forward today! From: Strom, Mandy L. ( CMS/ CMCHO) Sent: Monday, March 31, 2014 1: 50 PM To: Kress, Marielle J. ( CMS/ CMCS) Cc: Marchioni, Mary A. ( CMS/ WC); Allen, Richard C. ( CMS/ CMCHO); Hollis, Annie R. ( CMS/ CMCS) Subject: NEED RESPONSE ASAP: FW: Utah - HPE Next Steps - SPA 14- 0007- MM Hi Marielle, I have reviewed the materials submitted by Utah on Friday afternoon. Mere is my analysis; They updated slide 12 to reflect ambulatory prenatal care coverage. Good They have agreed to just 1 PE period in a calendar year. This has been updated in the training manual and slide presentation. Good, but they need to update the SPA template and submit revised versions of the template and training materials in MMDL. 1

They submitted a PIT receipt for individuals to use to show proof of coverage during the lag of getting their actual eligibility card. The state has committed in writing to use the receipt as well as working with the pharmacy community to honor the receipt as proof of coverage. Good, but the state did not update the " next steps" slide to indicate the paper receipt. The State updated the opening language in Section K of the application to indicate the other sections that need to be completed and also referring back to the cover page with instructions. The State also updated the cover page to include an opt out for continuing medical benefits. I know some of the recommended changes to make the application more user friendly were not deal breakers, but I am not sure the revisions clarified much. In addition, are you ok with the new " opt out" piece for continuing medical benefits"? Next steps for approval: Update training slide deck " Next Step" slide with the pape=r receipt and upload revised version in MMDL Upload revised training manual Change template to 1 PE period per calendar year and upload revised in MIVIDL Are we good with the application? If so, then the state needs to upload the revised into MMDL Cho we need the document with the state' s commitment to make all the changes uploaded into MIVIDL? Goes the paper receipt need to be uploaded in to MMDL? Thanks, Mandy Mandy Strom 303) 844- 7068 Mandy.Strom @cros. hhs. gov From: Jeff Nelson ( mailto:jeffnelson5utah.gov] Sent: Friday, March 28, 2014 4: 58 PM To: Kress, Marielle J. ( CMS/ CMCS); Strom, Mandy L. ( CMS/ CMCHO) Cc: Six, Gayle M.; Yoshida, Amanda; Smith, Michelle; Laura Belgique; Jennifer Meyer-Smart Subject: QAZ: Utah - HIDE Next Steps - SPA 14- 0007- MM Hello - Thank you for all of the technical assistance you have provided for Utah on the Hospital Presumptive Eligibility SPA. We appreciate the open dialogue to discuss our concerns and explain our thoughts on how to implement the program in Utah. We made several changes today and have included updated documents and a description of all the changes we have or will make for HPE. We tried to call out specific dates of when we think we could make those changes. Again we thank you for your help and we look forward to approval of this outstanding SPA. Jeff Nelson Bureau Director of Eligibility Policy Medicaid and Health Financing Utah Department of Health 801) 538- 6471 PS. We plan to move the " opt out" bullet into the last position in the same section but had a computer glitch this afternoon. 2

IMPORTANT MESSAGE ********** This message, including any attachments, may contain confidential information intended for a specific individual and purpose, and is protected by law. If you are not the intended recipient, delete this message, including from trash, and notify me by telephone or email. If you are not the intended recipient, any distribution or copying of this message, or the taking of any action based on its content is strictly prohibited. 3

Strom, Mandy L. ( CMS/ CMCHO) From: Jeff Nelson <jeffnelson @utah.gov> Sent: Friday, March 28, 2014 4:58 PM To: Kress, Marielle J. ( CMS/ CMCS); Strom, Mandy L. ( CMS/ CMCHO) Cc: Six, Gayle M.; Yoshida, Amanda; Smith, Michelle; Laura Belgique; Jennifer Meyer- Smart Subject: QAZ: Utah - HPE Next Steps - SPA 14- 0007- MM Attachments: Hospital SPA- Next steps- 3- 28- 14.docx; HPE Powerpoint updated based on CMS' feedback.pptx; HPE TRAINING MANUAL updated per CMS feedback.docx; PE Receipt.docx; HPE App with CMS' Feedback.pdf Hello - Thank you for all of the technical assistance you have provided for Utah on the Hospital Presumptive Eligibility SPA. We appreciate the open dialogue to discuss our concerns and explain our thoughts on how to implement the program in Utah. We made several changes today and have included updated documents and a description of all the changes we have or will make for HPE. We tried to call out specific dates of when we think we could make those changes. Again we thank you for your help and we look forward to approval of this outstanding SPA. Jeff Nelson Bureau Director of Eligibility Policy Medicaid and Health Financing Utah Department of Health 801) 538- 6471 PS. We plan to move the " opt out" bullet into the last position in the same section but had a computer glitch this afternoon. IMPORTANT MESSAGE ********** This message, including any attachments, may contain confidential information intended for a specific individual and purpose, and is protected by law. If you are not the intended recipient, delete this message, including from trash, and notify me by telephone or email. If you are not the intended recipient, any distribution or copying of this message, or the taking of any action based on its content is strictly prohibited. i

1.71AH OF PAN IN1 INT OF HEALTH Presumptive Eligibility Receipt Important: Any attempt to change any information can this receipt will invalidate the receipt. ATTENTION PROVIDERS: The Medicaid presumptive eligibility program provides temporary medical coverage for members based on preliminary information. This receipt serves as proof that the following number of members have been approved for Medicaid: of Members: The eligibility decision was sent to the Department of Workforce Services to enter into the eligibility system. Each member will receive a medical card with an activated medical ID# in the mail. Eligibility Start Date M M/ DD/ YY) Member Name( Last, First, M. l.) Date of Birth (MM/ DD/ YY) Important: Worker must complete all information below in order for this receipt to be valid. Presumptive Eligibility Worker Information Worker Office: Phone#: Address: Worker Signature: Date:

March 28, 2014 Hospital SPA 14-0007- MM Utah' s Response to CMS on Next Steps Needed From today' s discussion with Marielle Kress and Mandy Strom, Utah has outlined the next steps needed to finalize the HIDE SPA. 1. Policy a. Utah will change the limit on presumptive eligibility periods from once every 6 months to one period during the calendar year on the hospital SPA template. Pregnant women will remain as one period per pregnancy. ( We will also seek to amend our SPA for children to be consistent with this policy.) 2. Training a. Modify the training to reflect the eligibility period as mentioned above. ( See p. 7 training manual, & PowerPoint slide 5) b. Modify the training material language to say " ambulatory prenatal care" instead of" outpatient prenatal care" as the benefits available to pregnant women during the presumptive eligibility period. ( See p. 14 training manual, slide 12) 3. Application & forms a. Utah made proposed changes to the applications with better directions for HIDE applicants. We will incorporate these changes in the next iteration expected for July 2014. ( See cover and p. 7) b. Utah created a proposed form for hospitals to give to the applicant upon determination. It verifies the individual' s eligibility for presumptive Medicaid benefits. i. Utah will work with the pharmacy team to train pharmacies and others to accept this letter as proof of eligibility in the few days before the applicant receives their medical card by mail. Expected completion date is July 2014. ii. Utah will follow up with already approved hospital providers to inform them of these changes. 4. Consistency a. Utah will continue its work to align the presumptive processes for all PE programs. Specifically, Utah will seek to automate the eligibility system to allow for PE extensions while the actual eligibility is being determined. Until such a time that it can be automated, an interim solution will be found to extend presumptive pregnant women who apply through the clinic setting.

Strom, Mandy L. ( CMS/ CMCHO) From: Allen, Richard C. ( CMS/ CMCHO) Sent: Friday, March 28, 2014 10:56 AM To: Strom, Mandy L. ( CMS/ CMCHO) Cc: Marchioni, Mary A. (CMS/ WC) Subject: Utah PE Jeff was asking about other states successfully using portals with hospitals and feeds into the MMIS. Colorado has had a lot of success in this area. You may want to let Jeff know a good state contact is Antoinette Taranto. Her email address is antoinette.taranto @ state. co. us Richard C. Allen Associate Regional Administrator Centers for Medicare& Medicaid Services Division of Medicaid & Children' s Health Operations, Region VIII Tel: 303- 844- 1370 Fax: 303- 844- 3753 Take health care into your cAvn hands 1

Strom, Mandy L. ( CMS/ CMCHO) From: Kress, Marielle J. ( CMS/ CMCS) Sent: Friday, March 28, 2014 8:00 AM To: Strom, Mandy L. ( CMS/ CMCHO) Cc: Allen, Richard C. ( CMS/ CMCHO); Marchioni, Mary A. (CMS/ WC) Subject: RE: Can you do 12:00 Eastern for a Utah on Hospital PE That works perfectly. Thank you very much, Mandy! From: Strom, Mandy L. ( CMS/ CMCHO) Sent: Friday, March 28, 2014 9: 59 AM To: Kress, Marielle 1. ( CMS/ CMCS) Cc: Allen, Richard C. ( CMS/ CMCHO); Marchioni, Mary A. ( CMS/ WC) Subject: Can you do 12: 00 Eastern for a Utah on Hospital PE Hi Marielle, Gayle and Jeff can do 10Mountain/ 12 Eastern. Jeff alone might be able to meet with us later today, but Gayle is leaving early. They are both off Monday. twtdy StwmI Division of Medicaid and Children's Health Operations I Denver Regional Office I Centers for Medicare& Medicaid Services 11600 Broadway, Suite 700, Denver, CO 80202 1 Q:( 303) 844- 70681 ( 443) 380- 6091. Mandy.5trom@cros. hhs.. oy ii. 5 l' 1. s= r eF: aa icier rhi, i, nvirmlitw.W 1} el`M' o, pr€niiu l this v- mod. 1

Strom, Mandy L. ( CMS/ CMCHO) From: Kress, Marielle J. ( CMS/ CMCS) Sent: Thursday, March 27, 2014 11:46 AM To: Marchioni, Mary A. (CMS/ WC); Strom, Mandy L. ( CMS/ CMCHO); Kress, Marielle J. CMS/ CMCS); Hollis, Annie R. ( CMS/ CMCS); Cash, Judith ( CMS/ CMCS) Cc: Allen, Richard C. ( CMS/ CMCHO) Subject: Re: UT 14- 0007- MM= Next Step RAI Follow Up Flag: Follow up Flag Status: Completed It sounds like we do need to talk, but we are all unavailable today. We can regroup tomorrow morning, what time works on your end? Thanks. From: Marchioni, Mary A. ( CMS/ WC) Sent: Thursday, March 27, 2014 09: 28 AM To: Strom, Mandy L. ( CMS/ CMCHO); Kress, Marielle J. ( CMS/ CMCS); Hollis, Annie R. ( CMS/ CMCS) Cc: Allen, Richard C. ( CMS/ CMCHO) Subject: Re: UT 14- 0007- MM= Next Step RAI We may need to talk. Neither myself nor Richard Allen, our ARA are not supporting an RAI. Let me know if you would like a call to discuss. We can also issue a Companion letter, assuring formal notice to the state that changes may be needed for future. From: Strom, Mandy L. ( CMS/ CMCHO) Sent: Thursday, March 27, 2014 08: 23 AM To: Kress, Marielle J. ( CMS/ CMCS); Hollis, Annie R. ( CMS/ CMCS) Cc: Marchioni, Mary A. ( CMS/ WC) Subject: RE: UT 14- 0007- MM= Next Step RAI Thanks Marielle. I just want to make sure I understand. Utah has indicated they will make changes, but they need some time. Are you saying that you need the changes made before you can approve the SPA or you need some type of agreement that they will make them in the future to approve the SPA? If it is the later, then what type of agreement do you need? Mandy Mandy Strom 303) 844-7068 Mandy. Strom @cros. hhs.gov From: Kress, Marielle J. ( CMS/ CMCS) Sent: Thursday, March 27, 2014 5: 26 AM To: Strom, Mandy L. ( CMS/ CMCHO); Kress, Marielle J. ( CMS/ CMCS); Hollis, Annie R. ( CMS/ CMCS) Cc: Marchioni, Mary A. ( CMS/ WC) Subject: Re: UT 14- 0007- MM= Next Step RAI 1

Thanks so much Mandy. Both Annie and I have been out of the office this week and I will get you questions tomorrow so the RAI can go out by the end of the week. We cannot approve the SPA since we do not have agreement that the state will make the changes. Best, Marielle From: Strom, Mandy L. ( CMS/ CMCHO) Sent: Wednesday, March 26, 2014 07: 09 PM To: Kress, Marielle 1. ( CMS/ CMCS); Hollis, Annie R. ( CMS/ CMCS) Cc: Marchioni, Mary A. ( CMS/ WC) Subject: RE: UT 14- 0007-MM= Next Step RAI Marielle and Annie, I have re- reviewed everything submitted as well as spoke with the State today. Here is my analysis: The actual SPA template looks approvable. It does not look like the state made edits to the training manual or slide presentation based on our informal comments. As for the additional questions you sent to the state, but the state had already submitted its revisions to CMS so those changes were not incorporated. I was able to speak with Gayle today frorn Utah and she indicated the following: The alternative single streamline application does have a * indicating below that SSN is not required for PE. The rate and ethnicity fields also have * and show optional so not sure what more you want on this piece. She indicated the state is willing to make changes to the application such as adding gt:est.ion 3 in section D for PE, but they will not be printing revised applications to July. They are okay with some type of conditional approval requiring them to make changes. I recommend approval for this SPA and then require changes to the training manual and application in the approval letter. Please let me know your thoughts ASAP. Mandy Mandy Strom 303) 844- 7068 Mandy.Strom@cms. hhs. gov From: Strom, Mandy L. ( CMS/ CMCHO) Sent: Wednesday, March 26, 2014 11: 08 AM To: Kress, Marielle J. ( CMS/ CMCS); Hollis, Annie R. ( CMS/ CMCS) Cc: Marchioni, Mary A. ( CMS/ WC) Subject: RE: UT 14- 0007-MM= Next Step RAI Hey Marielle, I just a left you a voicemail. Just trying to connect to discuss next steps on this SPA. We are at day 82 on the clock and my management has requested to know the status. Thanks. Mandy Strom 303) 844- 7068 Mandy.Strom @c..ms. hhs.gov_ From: Strom, Mandy L. ( CMS/ CMCHO) Sent: Monday, March 24, 2014 8: 10 AM To: Kress, Marielle J. ( CMS/ CMCS); Hollis, Annie R. ( CMS/ CMCS) 2

Cc: Marchioni, Mary A. ( CMS/ WC) Subject: RE: UT 14- 0007- MM= Next Step RAI Hi Annie and Marielle, I just wanted to check back in with you on any outstanding issues you may have for the RAI for this SPA. I know Marielle had sent some comments on the application ( attached) that were not addressed with Utah' s latest submission of attachments. At this point, I have the following outstanding items: 1. The first page of the application indicates the questions required to be answered, but it may be easier on folks to denote the required questions on the questions themselves. 2. SSN and Race/ Ethnicity cannot be required fields. 3. In section D, question 3 should also be required. 4. In section K, it appears these are PE questions while you also require other questions for PE in the rest of the application. We think the header of this section could be refined to make it clearer. Let me know. Thanks, Mandy Mandy Strom 303) 844- 7068 Mandy.Strom @cros. hhs.gov From: Strom, Mandy L. ( CMS/ CMCHO) Sent: Tuesday, March 18, 2014 10: 16 AM To: Kress, Marielle J. ( CMS/ CMCS) Cc: Hollis, Annie R. ( CMS/ CMCS); Marchioni, Mary A. ( CMS/ WC) Subject: UT 14- 0007- MM= Next Step RAI Hi Marielle, Regional management has directed staff to not go down to the wire on issuing RAls close to day 90 and align with the dates in our SOP. Since we are approaching clay 76 or) Thursday, I think we should go the RAI route. I can draft the RAI if you send me your outstanding issues. Thanks, Mandy Mandy Strom 303) 844- 7068 Mandy.Strom@cros. hhs.gov From: Kress, Marielle J. ( CMS/ CMCS) Sent: Wednesday, March 12, 2014 1: 37 PM To: Strom, Mandy L. ( CMS/ CMCHO) Cc: Hollis, Annie R. ( CMS/ CMCS) Subject: RE: Another time I think it makes sense for us to try to provide another round of informal comments for the state to try to address before day 90. 1 will get those to you before the end of the week. Thanks for following up! Marielle From: Strom, Mandy L. ( CMS/ CMCHO) Sent: Wednesday, March 12, 2014 1: 57 PM To: Kress, Marielle J. ( CMS/ CMCS) 3

Cc: Hollis, Annie R. ( CMS/ CMCS) Subject: RE: Another time Hey Marielle, I forwarded Gayle your original email to Jeff letting her know those items were not addressed with the latest submission, I told her we would send a compiled list of outstanding items after reviewing everything and possibly have a call. In looking at where we are on the clock, I noticed day 76 is next week, Do you anticipate providing another round of informal comments for the state to try to address before day 90 or issuing a RAI? Just trying to see what direction you would like to go since we are getting late on the clock. Thanks, Mandy Mandy Strom 303) 844-7068 Mandy.Strom@crns. hhs. gov From: Kress, Marielle J. ( CMS/ CMCS) Sent: Monday, March 10, 2014 11: 18 AM To: Strom, Mandy L. ( CMS/ CMCHO) Cc: Hollis, Annie R. ( CMS/ CMCS) Subject: FW: Another time Hi Mandy, I wanted to flag this email for you since Gayle just sent us back their materials. I provided some high level feedback on the application and it appears the changes were not made. I think we will need another follow up call once we are able to re- review their submission. Just wanted to make sure you flagged this email for Gayle in case Jeff didn't get it or did not pass it along to her. Thanks! From: Kress, Marielle J. ( CMS/ CMCS) Sent: Wednesday, March 05, 2014 4: 06 PM To: ' Jeff Nelson'; Hollis, Annie R. ( CMS/ CMCS) Cc: Strom, Mandy L. ( CMS/ CMCHO) Subject: RE: Another time Hi Jeff, We had a chance to take a look at the application and we had some questions and comments for you. While we like the notation of which questions are required on the first page, it might make it easier on folks to denote the required questions on the questions themselves. In addition, we wanted to flag that SSN and race/ethnicity cannot be required fields. In section D, question 3 should also be required. Finally, in section K, it appears these are PE questions while you also require other questions for PE in the rest of the application. We think the header of this section could be refined to make it clearer. think we are waiting for updated materials from you to re- review, but we wanted to get you some topline thoughts on the application as we are winding down our 90 days. Please let me know if you need questions answered, and we look forward to hearing from you shortly. Best, Marielle From: Jeff Nelson [ mailto:ieffnelson@utah. aov] Sent: Friday, February 21, 2014 2: 28 PM 4

To: Kress, Marielle J. ( CMS/ CMCS); Hollis, Annie R. ( CMS/ CMCS) Subject: QAZ: Another time JeffNelson Bureau Director of Eligibility Policy Medicaid and Health Financing Utah Department of Health 801) 538- 6471 IMPORTANT MESSAGE ********** This message, including any attachments, may contain confidential information intended for a specific individual and purpose, and is protected by law. If you are not the intended recipient, delete this message, including from trash, and notify me by telephone or email. If you are not the intended recipient, any distribution or copying of this message, or the taking of any action based on its content is strictly prohibited. 5

Strom, Mandy L. ( CMS/ CMCHO) From: Manchioni Mary A. ACMS/ W0 Sent: Thuraby, March Z7, 2Ol48:0SAM To: Strom, Mandy L (CMS/ CM[ H0; Hin josa' SophiaA. ([ MS/ CMCH0; Clemens, Ann [. CMS/ CMCH0 Cc Allen, Richard [. ([ M5/[ K4[ H{) Subject: RE: UTl4-0O07' K4K4 - Late onClock VVe need to discuss asanRA| doesn' t seem appropriate, | o there a federal law or regulation that is being challenged via the SPA in its current form? From: Strom, Mandy L Sent: Thursday, March 27, 20146: 50 AM To: Hinujosa, Sophia A. ( CMS/ CMCHO); Marchioni, Mary A. ( CMS/ VV[); Clemens, Ann C. ( CMS/[ MCHO) Cc: Allen, Richard C ( CMS/ CMCHO) Subject: RE: UT 14- 0007- MM - Late on Clock Marielle emailed and said they want to issue a RAI and I will have the questions to issue by the end of the week, See Attached. Mandy Strom O3) 844- 7068 From: Strom, Mandy L. ([ ME/ CMCHO) Sent: Wednesday, March 26, 3O145: OSPM To: Hinojosa, Sophia & ( CMS/ CMCH0; Marchioni, Mary A. ( Clemens, Ann C ( CMS/ CMCHO) Cc: Allen, Richard C. Subject: RE: UT 14' 0007' MM - Late on Clock Hereismysummaryofuutstandin8issuesbasedonmyre-reviewoFeve/ ythin8: The actual SPA temp|ate looks appnovab| e. It does not look like the state made edits to the training manual or slide presentation based on our informal comments, As for the additional questions I had listed below, the state had already submitted its revisions to CMS when they saw the additional items come via email, | was able to speak with Gayle today and she indicated the following: o The alternative single streamline application does have * indicating below that 5SN is not required for PE. The rate and ethnicity fields also have * and show optional so not sure what more central office wants onthis piece. o The state is willing to make changes to the application such as adding question 3 in section D for PE, but they will not be printing revised applications toJuly, They are okay with some type ofconditional approval requiring them to make changes, This isaP2 SPA so the region does not have approval authority, | think we could approve the SPA and have inthe approval letter the requirement for changes to the training materials and application, This is what | am going to recommend to MarieUevia email. Mandy Mandy Strom 3O3) 8447088

Mandy.Strom@cros. hhs.gov From: Hinojosa, Sophia A. ( CMS/ CMCHO) Sent: Wednesday, March 26, 2014 10: 56 AM To: Marchioni, Mary A. ( CMS/ WC); Clemens, Ann C. ( CMS/ CMCHO); Strom, Mandy L. ( CMS/ CMCHO) Cc: Allen, Richard C. ( CMS/ CMCHO) Subject: RE: UT 14- 0007-MM - Late on Clock Mandy, can you please send copies of this SPA? If the PE application is not an actual part of the SPA, I think the RO could move with approval noting in the approval letter of the SPA that CMS approves the amendment with the understanding that the state will revise the PE application to meet Federal requirements, If the application questions are part of the actual SPA, I think it would be problematic for the RO to approve it as the application questions are not in line with our require=ments ( i. e, asking for SSN and r=ace/ ethnicity), Mandy: have you heard from Gayle or Jeff about their reasons for not making the CMS requested changes in their hospital PE application? Was it a matter of not having time to do so or is the state really apposed to making these changes? Perhaps the state can make the requested changes before the end of the week as well and that would really address the pending questions to allow CMS to move forward with approval. Thanks, From: Marchioni, Mary A. ( CMS/ WC) Sent: Wednesday, March 26, 2014 10: 21 AM To: Clemens, Ann C. ( CMS/ CMCHO); Strom, Mandy L. ( CMS/ CMCHO); Hinojosa, Sophia A. ( CMS/ CMCHO) Cc: Allen, Richard C. ( CMS/ CMCHO) Subject: RE: UT 14- 0007- MM - Late on Clock Thanks Ann, I am not convinced that we should RAI the SPA. This is another one of those circumstances where we are late on the clock, and sending the RAI out on the 85'''— 90'" day is not a recommended practice ( at least it did riot used to be). Mandy, just let me know if you have success in talking with Marieile today. If not, we may just push this one through to approval. Thanks again everyone. Mary From: Clemens, Ann C. ( CMS/ CMCHO) Sent: Wednesday, March 26, 2014 9: 58 AM To: Marchioni, Mary A. ( CMS/ WC); Strom, Mandy L. ( CMS/ CMCHO); Hinojosa, Sophia A. ( CMS/ CMCHO) Cc: Allen, Richard C. ( CMS/ CMCHO) Subject: RE: UT 14- 0007- MM - Late on Clock Not to shirk, because you know I' ll help, but I also haven't been working directly with this team and am not exactly sure what they want for final materials. Mandy's suggestions are sound, but I' m unsure if they'd want more. I just spoke with Marielle yesterday, so maybe try her again. Last time I was dealing with this type of delay with a MAGI team, I wrote the RAI, sent them the letter and said the day I'd be sending it out with a request for input before then. Luckily they responded, but it might be a tactic if they're unresponsive. Ann Clemens/ Health Insurance Specialist/ Centers for Medicare& Med/caid Services, Region VIII 11600 Broadway, Suite 700 I Denver CO/ 303.844.2125/ 443 380.7042 fax I Ann.Clemensfo?cros.hhs.gov 2

From: Marchloni, Mary A. ( CMS/ WC) Sent: Wednesday, March 26, 2014 9: 49 AM To: Clemens, Ann C. ( CMS/ CMCHO); Strom, Mandy L. ( CMS/ CMCHO); Hinojosa, Sophia A. ( CMS/ CMCHO) Cc: Allen, Richard C. ( CMS/ CMCHO) Subject: FW: UT 14- 0007- MM - Late on Clock Mandy, Thanks for informing. This may be one of those events where we consult at RO and draw upon our own expertise, and then move without Central Office. Ann and Sophia, I know I promised riot to pull you into more tasks at this time, but do you have any expertise for the PE Hospital PE SPAS which we may be able to access? Please let me know ASAP, and I can schedule some time for us to review together. Thank you, Mary From: Strom, Mandy L. ( CMS/ CMCHO) Sent: Wednesday, March 26, 2014 9: 20 AM To: Marchioni, Mary A. ( CMS/ WC) Subject: UT 14- 0007- MM - Late on Clock Hi Mary, We are on day 82 of the clock for the PE Hospital MAGI SPA. I tried to ping my CO counterparts last Tuesday before day 76 and then again Monday. Annie is out all week and she is usually responsive. I am not sure what to do. I don' t have the expertise to identify all the problem issues for the RAI. I guess we can include the issues I am aware of in the RAI and then address any additional items while off the clock informally or when it is back on the clock. I will try Marielle again this week by phone and email, but wanted to make you aware. Mandy Strom 303) 844- 7068 Mandy.Strom@cms. hhs. gov From: Strom, Mandy L. ( CMS/ CMCHO) Sent: Monday, March 24, 2014 8: 10 AM To: Kress, Marielle J. ( CMS/ CMCS); Hollis, Annie R. ( CMS/ CMCS) Cc: Marchioni, Mary A. ( CMS/ WC) Subject: RE: UT 14-0007- MM= Next Step RAI Hi Annie and Marielle, I just wanted to check back in with you on any outstanding issues you may have for the RAI for this SPA. I know Marielle had sent some comments on the application (attached) that were not addressed with Utah' s latest submission of attachments. At this point, I have the following outstanding items: 1. The first page of the application indicates the questions required to be answered, but it may be easier on folks to denote the required questions on the questions themselves. 2. SSN and Race/ Ethnicity cannot be required fields. 3. In section D, question 3 should also be required. 4. In section K, it appears these are PE questions while you also require other questions for PE in the rest of the application. We think the header of this section could be refined to make it clearer. Let me know. 3

Thanks, Mandy Mandy Strom 303) 844- 7068 From: Strom, Mandy L. ( CMS/ CMCHO) Sent: Tuesday, March 18, 3014 10: 16 AM To: Kress, Marie||e]. ( CMS/ CMCS) Cc: Hollis, Annie R. ( CMS/ CMCS); Mavchioni, Mary A. ( CMS/ WC) Subject: UT14-O0O7' MM= Next Step RAl HiMa/ ieUe' Regional management has directed staff tonot go down tw the wire on issuing RA| o close 1u day 9O and align with the dates in our SOP. Since we are approaching day 76 on Thursday, I think we should go the RAI route. | can draft the RA| if you send me your outstanding issues. Thanks' Mandy Mandy Strom 303) 844- 7068 From: Kress, Mahe||e]. ( CMS/ CMCS) Sent: Wednesday, March 12, 3014 1: 37 PM To: Strom, Mandy L. ( CMS/[ MCHO) Cc: Hollis, Annie R. ( CMS/[ MCS) Subject: RE: Another time I think it makes sense for us to try to provide another round of informal comments for the state to try to address before day 90. | will get those to you before the end cf the week. Thanks for following up! K8aheUe From: Strom, Mandy L. ( CMS/ CMCHO) Sent: Wednesday, March 12, 20141: 57PM To: Kress, Marie|(e]. ([ MS/ CMCS) Cc: Hollis, Annie R. ( CMS/[ MCS) Subject: RE: Another time Hey K4a/ ie|| e' I forwarded Gayle your original email to Jeff letting her know those items were not addressed with the latest submission, | told her we would send a compiled list of outstanding items after reviewing everything and possibly have aoa||. n looking at where vve are on the clock, | noticed day 7Gis next week. Do you anticipate providing another round of informal comments for the state to try to address before day 90 or issuing a RAI? Just trying to see what direction you would like tugn since vve are getting late mn the clock. Thanks' Mandy 4

Mandy Strom 303) 844-7068 Mandy.Strom @cros. hhs.gov From: Kress, Marielle J. ( CMS/ CMCS) Sent: Monday, March 10, 2014 11: 18 AM To: Strom, Mandy L. ( CMS/ CMCHO) Cc: Hollis, Annie R. ( CMS/ CMCS) Subject: FW: Another time Hi Mandy, I wanted to flag this email for you since Gayle just sent us back their materials. I provided some high level feedback on the application and it appears the changes were not made. I think we will need another follow up call once we are able to re- review their submission. Just wanted to make sure you flagged this email for Gayle in case Jeff didn' t get it or did not pass it along to her. Thanks! From: Kress, Marielle J. ( CMS/ CMCS) Sent: Wednesday, March 05, 2014 4: 06 PM To: ' Jeff Nelson'; Hollis, Annie R. ( CMS/ CMCS) Cc: Strom, Mandy L. ( CMS/ CMCHO) Subject: RE: Another time Hi Jeff, We had a chance to take a look at the application and we had some questions and comments for you. While we like the notation of which questions are required on the first page, it might make it easier on folks to denote the required questions on the questions themselves. In addition, we wanted to flag that SSN and race/ethnicity cannot be required fields. In section D, question 3 should also be required. Finally, in section K, it appears these are PE questions while you also require other questions for PE in the rest of the application. We think the header of this section could be refined to make it clearer. I think we are waiting for updated materials from you to re-review, but we wanted to get you some topline thoughts on the application as we are winding down our 90 days. Please let me know if you need questions answered, and we look forward to hearing from you shortly. Best, Marielle From: Jeff Nelson [ mai Ito: jeffnelson a utah. gov] Sent: Friday, February 21, 2014 2: 28 PM To: Kress, Marielle J. ( CMS/ CMCS); Hollis, Annie R. ( CMS/ CMCS) Subject: QAZ: Another time Jeff Nelson Bureau Director of Eligibility Policy Medicaid and Health Financing Utah Department of Health 801) 538- 6471 5

IMPORTANT MESSAGE ********** This message, including any attachments, may contain confidential information intended for a specific individual and purpose, and is protected by law. If you are not the intended recipient, delete this message, including from trash, and notify me by telephone or email. If you are not the intended recipient, any distribution or copying of this message, or the taking of any action based on its content is strictly prohibited. 6

Strom, Mandy L. ( CMS/ CMCHO) From: Strom, Mandy L. ( CMS/ CMCHO) Sent: Monday, March 24, 2014 8:10 AM To: Kress, Marielle J. ( CMS/ CMCS); Hollis, Annie R. ( CMS/ CMCS) Cc: Marchioni, Mary A. (CMS/ WC) Subject: RE: UT 14- 0007- MM= Next Step RAI Attachments: RE: Another time Follow Up Flag: Follow up Flag Status: Completed Hi Annie and Marielle, I just wanted to check back in with you on any outstanding issues you may have for the RAI for this SPA. I know Marielle had sent some comments on the application (attached) that were not addressed with Utah' s latest submission of attachments. At this point, I have the following outstanding items: 1. The first page of the application indicates the questions required to be answered, but it may be easier on folks to denote the required questions on the questions themselves. 2. SSN and Race/ Ethnicity cannot be required fields. 3. In section D, question 3 should also be required. 4. In section K, it appears these are PE questions while you also require other questions for PE in the rest of the application. We think the header of this section could be refined to make it clearer. Let me know. Thanks, Mandy Mandy Strom 303) 844- 7068 Mandy.Strom @cros. hhs. gov From: Strom, Mandy L. ( CMS/ CMCHO) Sent: Tuesday, March 18, 2014 10: 16 AM To: Kress, Marielle]. ( CMS/ CMCS) Cc: Hollis, Annie R. ( CMS/ CMCS); Marchioni, Mary A. ( CMS/ WC) Subject: UT 14- 0007- MM= Next Step RAI Hi Marielle, Regional management has directed staff to not go down to the wire on issuing RAIs close to day 90 and align with the dates in our SOP. Since we are approaching day 76 on Thursday, I think we should go the RAI route, I can draft the RAI if you send me your outstanding issues. Thanks, Mandy Mandy Strom 303) 844- 7068 Mandy.Strom @cros. hhs. gov From: Kress, Marielle J. ( CMS/ CMCS) Sent: Wednesday, March 12, 2014 1: 37 PM To: Strom, Mandy L. ( CMS/ CMCHO) 1

Cc: Hollis, Annie R. ( CMS/ CMCS) Subject: RE: Another time I think it makes sense for us to try to provide another round of informal comments for the state to try to address before day 90. 1 will get those to you before the end of the week. Thanks for following up! Marielle From: Strom, Mandy L. ( CMS/ CMCHO) Sent: Wednesday, March 12, 2014 1: 57 PM To: Kress, Marielle J. ( CMS/ CMCS) Cc: Hollis, Annie R. ( CMS/ CMCS) Subject: RE: Another time Hey Marielle, I forwarded Gayle your original email to Jeff letting her know those items were not addressed with the latest submission. I told her we would send a compiled list of outstanding items after reviewing everything and possibly have a call. In looking at where we are on the clock, I noticed day 76 is next week. Do you anticipate providing another round of informal comments for the state to try to address before day 90 or issuing a RAI? Just trying to see what direction you would like to go since we are getting late can the clock. Thanks, Mandy Mandy Strom 303) 844- 7068 Mandy.Strom cros. hhs. gov From: Kress, Marielle J. ( CMS/ CMCS) Sent: Monday, March 10, 2014 11: 18 AM To: Strom, Mandy L. ( CMS/ CMCHO) Cc: Hollis, Annie R. ( CMS/ CMCS) Subject: FW: Another time Hi Mandy, I wanted to flag this email for you since Gayle just sent us back their materials. I provided some high level feedback on the application and it appears the changes were not made. I think we will need another follow up call once we are able to re- review their submission. Just wanted to make sure you flagged this email for Gayle in case Jeff didn' t get it or did not pass it along to her. Thanks! From: Kress, Marielle J. ( CMS/ CMCS) Sent: Wednesday, March 05, 2014 4: 06 PM To: ' Jeff Nelson'; Hollis, Annie R. ( CMS/ CMCS) Cc: Strom, Mandy L. ( CMS/ CMCHO) Subject: RE: Another time Hi Jeff, We had a chance to take a look at the application and we had some questions and comments for you. While we like the notation of which questions are required on the first page, it might make it easier on folks to denote the required questions on the questions themselves. In addition, we wanted to flag that SSN and race/ethnicity cannot be required fields. 2

In section D, question 3 should also be required. Finally, in section K, it appears these are PE questions while you also require other questions for PE in the rest of the application. We think the header of this section could be refined to make it clearer. I think we are waiting for updated materials from you to re-review, but we wanted to get you some topline thoughts on the application as we are winding down our 90 days. Please let me know if you need questions answered, and we look forward to hearing from you shortly. Best, Marielle From: Jeff Nelson [ ma i Ito:Jeffnelson@utah. gov] Sent: Friday, February 21, 2014 2: 28 PM To: Kress, Marielle J. ( CMS/ CIVICS); Hollis, Annie R. ( CMS/ CIVICS) Subject: QAZ: Another time Jeff Nelson Bureau Director of Eligibility Policy Medicaid and Health Financing Utah Department of Health 801) 538- 6471 IMPORTANT MESSAGE ********** This message, including any attachments, may contain confidential information intended for a specific individual and purpose, and is protected by law. If you are not the intended recipient, delete this message, including from trash, and notify me by telephone or email. If you are not the intended recipient, any distribution or copying of this message, or the taking of any action based on its content is strictly prohibited. 3

Strom, Mandy L. ( CMS/ CMCHO) From: Kress, Marielle J. ( CMS/ CMCS) Sent: Wednesday, March 12, 2014 1:37 PM To: Strom, Mandy L. ( CMS/ CMCHO) Cc: Hollis, Annie R. ( CMS/ CMCS) Subject: RE: Another time Follow Up Flag: Follow up Flag Status: Completed I think it makes sense for us to try to provide another round of informal comments for the state to try to address before day 90. 1 will get those to you before the end of the week. Thanks for following up! Marielle From: Strom, Mandy L. ( CMS/ CMCHO) Sent: Wednesday, March 12, 2014 1: 57 PM To: Kress, Marielle J. ( CMS/ CMCS) Cc: Hollis, Annie R. ( CMS/ CMCS) Subject: RE: Another time Hey Marielle, I forwarded Gayle your original email to Jeff letting her know those items were not addressed with the latest submission, I told her we would send a compiled list of outstanding items after reviewing everything and possibly have a call. In looking at where we are on the clock, I noticed day 76 is next week. Do you anticipate providing another, round of informal comments for the state to try to address before day 90 or issuing a RAI? Just trying to see whet direction you would like to go since we are getting late on the clock. Thanks, Mandy Mandy Strom 303) 844- 7068 Mandy. Strom@cros. hhs. gov From: Kress, Marielle J. ( CMS/ CMCS) Sent: Monday, March 10, 2014 11: 18 AM To: Strom, Mandy L. ( CMS/ CMCHO) Cc: Hollis, Annie R. ( CMS/ CMCS) Subject: FW: Another time Hi Mandy, I wanted to flag this email for you since Gayle just sent us back their materials. I provided some high level feedback on the application and it appears the changes were not made. I think we will need another follow up call once we are able to re- review their submission. Just wanted to make sure you flagged this email for Gayle in case Jeff didn't get it or did not pass it along to her. Thanks! 1

From: Kress, Marielle J. ( CMS/ CMCS) Sent: Wednesday, March 05, 2014 4:06 PM To: ' Jeff Nelson'; Hollis, Annie R. ( CMS/ CMCS) Cc: Strom, Mandy L. ( CMS/ CMCHO) Subject: RE: Another time Hi Jeff, We had a chance to take a look at the application and we had some questions and comments for you. While we like the notation of which questions are required on the first page, it might make it easier on folks to denote the required questions on the questions themselves. In addition, we wanted to flag that SSN and race/ethnicity cannot be required fields. In section D, question 3 should also be required. Finally, in section K, it appears these are PE questions while you also require other questions for PE in the rest of the application. We think the header of this section could be refined to make it clearer. I think we are waiting for updated materials from you to re-review, but we wanted to get you some topline thoughts on the application as we are winding down our 90 days. Please let me know if you need questions answered, and we look forward to hearing from you shortly. Best, Marielle From: Jeff Nelson [ mai Ito:jeffnelson(cbutah. gov] Sent: Friday, February 21, 2014 2: 28 PM To: Kress, Marielle J. ( CMS/ CMCS); Hollis, Annie R. ( CMS/ CMCS) Subject: QAZ: Another time Jeff Nelson Bureau Director of Eligibility Policy Medicaid and Health Financing Utah Department of Health 801) 538- 6471 IMPORTANT MESSAGE ********** This message, including any attachments, may contain confidential information intended for a specific individual and purpose, and is protected by law. If you are not the intended recipient, delete this message, including from trash, and notify me by telephone or email. If you are not the intended recipient, any distribution or copying of this message, or the taking of any action based on its content is strictly prohibited. 2

Strom, Mandy L. ( CMS/ CMCHO) From: Strom, Mandy L. ( CMS/ CMCHO) Sent: Wednesday, March 12, 2014 11:54 AM To: Gayle M. Six( gaylesix@utah.gov) Subject: FW: Utah Hospital PE SPA materials Attachments: RE: Another time Hey Gayle, I have forwarded the materials to Marielle and Annie knack in Baltimore. They did alert me that the items in the attached email were not addressed. You may not have received the email since it was only addressed to. Jeff. CMS will re- review your submission and follow-up on what is outstanding. Stay tuned.... Mandy Strom 303) 844- 7068 Mandy.Strom@cros. hhs.gov From: Strom, Mandy L. ( CMS/ CMCHO) Sent: Monday, March 10, 2014 7: 14 AM To: Kress, Marielle J. ( CMS/ CMCS); Hollis, Annie R. ( CMS/ CMCS) Subject: FW: Utah Hospital PE SPA materials FYI: Mandy Strom 303) 844- 7068 Mandy.Strc)m@cms. hhs.gov From: Gayle M. Six [ mailto: gaylesixC@utah. gov] Sent: Friday, March 07, 2014 11: 02 AM To: Strom, Mandy L. ( CMS/ CMCHO); Jeff Nelson Subject: QAZ: Hospital SPA materials Mandy, after our phone call, we were asked to send the packet of materials for the Hospital PE SPA to CMS. Here it is. I am not clear on who else to send this to. Can you forward the appropriate people? Let me know if anything is missing. I included the SPA as well, just in case. Thanks, Gayle IMPORTANT MESSAGE ********** This message, including any attachments, may contain confidential information intended for a specific individual and purpose, and is protected by law. If you are not the intended recipient, delete this message, including from trash, and notify me by telephone or email. 1

If you are not the intended recipient, any distribution or copying of this message, or the taking of any action based on its content is strictly prohibited. 2

Strom, Mandy L. ( CMS/ CMCHO) From: Kress, Marielle J. ( CMS/ CMCS) Sent: Monday, March 10, 2014 11: 18 AM To: Strom, Mandy L. ( CMS/ CMCHO) Cc: Hollis, Annie R. ( CMS/ CMCS) Subject: FW: Another time Attachments: 11- 12- 2013 HPE English eDOCs.pdf Hi Mandy, I wanted to flag this email for you since Gayle just sent us back their materials. I provided some high level feedback on the application and it appears the changes were not made. I think we will need another follow up call once we are able to re-review their submission. Just wanted to make sure you flagged this email for Gayle in case Jeff didn't get it or did not pass it along to her. Thanks! From: Kress, Marielle J. ( CMS/ CMCS) Sent: Wednesday, March 05, 2014 4:06 PM To: ' Jeff Nelson'; Hollis, Annie R. ( CMS/ CMCS) Cc: Strom, Mandy L. ( CMS/ CMCHO) Subject: RE: Another time Hi Jeff, We had a chance to take a look at the application and we had some questions and comments for you. While we like the notation of which questions are required on the first page, it might make it easier on folks to denote the required questions on the questions themselves. In addition, we wanted to flag that SSN and race/ethnicity cannot be required fields. In section D, question 3 should also be required. Finally, in section K, it appears these are PE questions while you also require other questions for PE in the rest of the application. We think the header of this section could be refined to make it clearer. I think we are waiting for updated materials from you to re- review, but we wanted to get you some topline thoughts on the application as we are winding down our 90 days. Please let me know if you need questions answered, and we look forward to hearing from you shortly. Best, Marielle From: Jeff Nelson [ mailto: teffnelson(autah.aov] Sent: Friday, February 21, 2014 2: 28 PM To: Kress, Marielle J. ( CMS/ CMCS); Hollis, Annie R. ( CMS/ CMCS) Subject: QAZ: Another time Jeff Nelson Bureau Director of Eligibility Policy Medicaid and Health Financing Utah Department of Health 801) 538- 6471 i

IMPORTANT MESSAGE ********** This message, including any attachments, may contain confidential information intended for a specific individual and purpose, and is protected by law. If you are not the intended recipient, delete this message, including from trash, and notify me by telephone or email. If you are not the intended recipient, any distribution or copying of this message, or the taking of any action based on its content is strictly prohibited. 2

Strom, Mandy L. ( CMS/ CMCHO) From: Strom, Mandy L. ( CMS/ CMCHO) Sent: Monday, March 10, 2014 7:14 AM To: Kress, Marielle J. ( CMS/ CMCS); Hollis, Annie R. ( CMS/ CMCS) Subject: FW: Utah Hospital PE SPA materials Attachments: 61HPE appl.pdf; HPE Powerpoint.pptx; HPE_Manual.pdf, S21- hospital presumptive.pdf FYI: Mandy Strom 303) 844- 7068 Mandy. Strom @cros. hhs.gov From: Gayle M. Six [ mailto: gaylesixCalutah. gov] Sent: Friday, March 07, 2014 11: 02 AM To: Strom, Mandy L. ( CMS/ CMCHO); Jeff Nelson Subject: QAZ: Hospital SPA materials Mandy, after our phone call, we were asked to send the packet of materials for the Hospital PE SPA to CMS. Here it is. I am not clear on who else to send this to. Can you forward the appropriate people? Let me know if anything is missing. I included the SPA as well, just in case. Thanks, Gayle IMPORTANT MESSAGE ********** This message, including any attachments, may contain confidential information intended for a specific individual and purpose, and is protected by law. If you are not the intended recipient, delete this message, including from trash, and notify me by telephone or email. If you are not the intended recipient, any distribution or copying of this message, or the taking of any action based on its content is strictly prohibited. i

C 1 o f 3 1 w F`., fit N,{` 2 ri,, xi`5 A s r " a a 1Y I"f".9fd Ula i 112 C} fw;" y' 23j T A" fi a HEALTH n n, y IN MEDICAID 1 Y.. u'u. n. ( SP. U iw'. t:• d_ y.^,^.,,..,,., , rC a. GN

Table of Contents INTRODUCTION 2 PART 1 CONTACT INFORMATION 3 PART 2 POLICIES AND PROCEDURES Section 1: What is Hospital Presumptive Eligibility? 4 Section 2: Rules Hospitals Must Comply With 4 Section 3: Services and Payment 5 Section 4: Confidentiality 5 Section 5: Fraud, Waste and Abuse 6 Section 6: Eligibility Process 7 Section 7: Completing the HPE Application 8 Section 8: Hospital Presumptive Eligibility Medicaid Programs 9 Section 9: Determining Household Size 11 Section 10: Income 13 Section 11: What Happens Next After an Eligibility Determination? 14 Section 12: Application Process 15 Section 13: Check list 16 PART 3 APPENDIXES Income Chart 17

Introduction The Affordable Care Act' allows hospitals to play an increasingly important role in connecting patients to health care coverage. This new provision allows qualified hospitals to determine Presumptive Eligibility for Medicaid based on customers' preliminary information. This manual provides guidance for the administration of the Hospital Presumptive Eligibility HPE) program. It will outline the policy and procedures needed for an effective implementation. Thank you for your participation in ensuring the success of this important and effective resource for the citizens of Utah. Statute Authority and Related Federal Rules for PE Option Statutory Authority: Patient Protection and Affordable Care Act, Public Law 111- 148 ( March 23, 2010), as modified by the Health Care and Education Reconciliation Act or 2010, Public Law 111- 152 ( March 30, 2010), Title 2, Subtitle A, Section 2001( a) ( 4) ( B) and Title 2, Subtitle A, Section 2202. Federal Regulations: Eligibility in the States, District of Columbia, the Northern Mariana Islands, and American Samoa, 42 CFR 435. 1110 ( 2013).

HOSPITAL PRESUMPTIVE ELIGIBILITY TRAINING MANUAL PART 1 CONTACT INFORMATION For Hospital Presumptive Eligibility policy or procedural questions, or to request training, contact: Laurie Ocobock Policy Specialist Phone: (801) 538- 9153 Fax: ( 801) 538- 6952 Utah Department of Health/ Medicaid Health Financing PO Box 143107 Salt Lake City, UT 84114- 3107 OR Laura Belgique (back up) Program Specialist Phone: (801) 538- 6241 Fax: ( 801) 538- 6952 Utah Department of Health/ Medicaid and Health Financing PO Box 143107 Salt Lake City, UT 84114- 3107 You may also e- mail questions to.HPEpolicy@utah.gov To order Hospital Presumptive Eligibility applications, call (801) 538- 9153 or (801) 538- 6241. For questions regarding covered services, medical billing/ payment, call Medicaid at 801) 538- 6155 or 1- 800- 662- 9651. Email completed applications to DWS at hospital PE @utah.gov

PART 2 POLICIES AND PROCEDURES Section 1: WHAT IS HOSPITAL PRESUMPTIVE ELIGIBILITY? With Hospital Presumptive Eligibility (HPE), an individual can temporarily enroll in Medicaid if it appears they are eligible based on preliminary information. Preliminary information includes information regarding the income and household size for the individual. The two departments that oversee the program are the Utah Department of Health (UDOH) and the Department of Workforce Services ( DWS). UDOH oversees HPE policy and procedure. DWS oversees the ongoing Medicaid eligibility process. UDOH issues Memorandum of Agreements ( MOA) between UDOH and hospitals throughout the state to administer the HPE program. Hospital staff who are trained in the HPE process determine HPE eligibility. Section 3 describes information on the HPE process. Section 2: RULES HOSPITALS MUST COMPLY WITH A hospital must inform UDOH that it intends to make HPE determinations and that it agrees to follow the State' s policies and procedures. UDOH will provide hospitals with information on all policies and procedures related to HPE. A hospital must make HPE determinations in accordance with UDOH' s policies and procedures. If a hospital is not making HPE determinations in accordance with UDOH' s policies and procedures, UDOH will provide the hospital with additional training or other forms of corrective action before disqualifying the hospital. A hospital must also comply with the proficiency standards that UDOH developed for HPE. As of January 1, 2014, UDOH has established a standard of 85 percent accuracy rate on HPE decisions. Accuracy is measured by how accurate the hospital' s determination is based on the information provided by the applicant. V1, 11 7i> i#_ iii

Section 3: SERVICES AND PAYMENT HPE covers an array of Medicaid eligible services including medication, lab work, inpatient and outpatient care. For questions regarding covered services, call Medicaid at 1- 800- 662- 9651. During the HPE period, the client will also be able to receive treatment from other Medicaid providers after they leave the hospital. Hospitals will be paid at regular Medicaid rates. Payment for covered services is guaranteed for a hospital during an individual' s presumptive eligibility period, even if the person fails to complete the full Medicaid application or is ultimately determined to be ineligible for ongoing Medicaid. If an HPE applicant is already covered under Medicaid, the Children' s Health Insurance Program (CHIP), the Primary Care Network (PCN) or the Utah Premium Partnership ( UPP) at the time of application, HPE cannot be authorized by DOH. States will not recoup money from the hospital for services rendered during the HPE period. Section 4: CONFIDENTIALITY All confidential information must be safeguarded from unauthorized disclosure and use. Staff who fail to safeguard confidential information may be subject to both civil and criminal penalties. Confidential information includes identifying information about applicants and recipients, such as names, addresses, telephone numbers, social security numbers, etc. Second, it includes information used to determine eligibility, such as income, assets, medical reports and data, names of persons obligated to provide financial and medical support, etc. Third, it includes information about benefits and medical services provided to individual recipients. Information that cannot be identified to particular applicants and recipients is not confidential information. For example, information stating the total number of HPE recipients is not confidential information because no one person can be identified by the general information.

Section 5: FRAUD, WASTE AND ABUSE To report suspected fraud, contact the DWS Information Fraud Hotline at 1- 800- 955- 2210 or via email at wsinv2utah.gov. What you need to know when reporting fraud, waste or abuse: It is helpful if you can provide any of the following information when reporting fraud, waste or abuse of the HPE Program: Provider or recipient name Date of birth Address Phone number Social security number Other details about what you suspect may be happening that appears to be wrong You may remain anonymous when reporting suspected fraud You may be requested to provide your name so that the investigator can contact you if there are questions regarding your referral. However, you may request that your name is not used in conjunction with the case. You may find more information on reporting fraud, waste or abuse at: http:// health. utah. o v/ mpi recipient.html

Section 6: ELIGIBILITY PROCESS Applicants can apply for HPE through any qualified hospital site. The eligibility begins on the date the application is approved by the hospital. SELF- DECLARATION IS USED FOR ALL FACTORS OF ELIGIBILITY. If the applicant is a minor, the applicant' s parent, legal guardian, or representative must sign the application. If the minor is living independently, the minor may apply on his/ her own behalf. A representative for a child may be a relative or other responsible adult living with the child. An applicant may assign an authorized representative to apply on his/ her behalf. The applicant must sign application if possible. If the applicant is unable to sign, the authorized representative may sign the application. In general, the person who signs the application should be someone who can answer the questions on the application. If an applicant is unable to write, he/ she must make a mark on the application and have at least one witness to the signature. To qualify for all HPE programs, applicants must meet the following requirements based on preliminary information provided: Be a U. S. citizen or qualified alien. Qualified aliens are individuals who are not U. S. citizens but have received a lawful permanent residency (LPR) status for at least five years. Ask for the month and year in which the applicant received the LPR status to determine if the applicant meets this requirement. Nationalized citizens and individuals born in any of the 50 states, the District of Columbia, Puerto Rico, Guam, the Virgin Islands, the Northern Mariana Islands, American Samoa, and Swain' s Island meet U. S. citizenship requirements. o Note: Individuals from the Marshall Islands are not considered U. S. Nationals. Be a Utah resident. Clients may only receive one HPE period within a six- month period and may only receive HPE once per pregnancy period. NOTE- There is no asset test. Clients must not currently receive Medicaid, CHIP, UPP, or PCN. Check the applicant's eligibility status by calling Medicaid at 80)538- 6155 or 1- 800- 662- 9651. Key in the client ID number and use the HPE determination date as the date of the medical service received. If the client is eligible, the system will give the medical program type, health plan, co- pay, mental health coverage information, and TPL information. If a client is open for Medicaid with a spenddown, the client is not eligible for HPE. Clients must not have received a denial for Medicaid, CHIP, UPP or PCN within the past 30 days, unless household circumstances have changed. For example, if the client was denied for Medicaid because his income is too high and now the client reports that his income has changed, determine if the client is eligible for HPE.

Section 7: COMPLETING the HPE APPLICATION: UDOH will supply hospitals with HPE paper applications. General Instructions: Always use the most current application available. The application cover sheet will tell you which questions must be completed for HPE. Ensure the applicant signs the application. Application Clarification: o Applicant' s name; this is the full, legal name of applicant. A hyphenated last name is acceptable. o Question # 3: If anyone in your household is not a U. S. Citizen or U.S. National, does he or she have a Lawful Permanent Resident card (Green Card) from U. S. Citizenship and Immigration Services? If an applicant indicates they are a Lawful Permanent Resident with a Green Card and the date that he/ she became a lawful permanent resident is at least five years, he/ she is considered a qualified alien. Question # 6 What is your total gross earned and unearned income (before taxes) for your household this month? Indicate applicant' s total stated, gross monthly income. Make sure that educational and child support income are not included. Compare this information to the income limit assigned to the household size for the HPE program type. Income guidelines may change yearly. UDOH will e- mail HPE providers with an updated income chart each year. Please be sure you are using the most recent version. See Appendix 1 for the income chart. Page # 9: The applicant must sign the application. Without a signature, the application is incomplete.

Section 8: HOSPITAL PRESUMPTIVE ELIGIBILITY MEDICAID PROGRAMS The HPE Medicaid programs and eligibility components are as follows: Program Hierarchy: o When choosing an eligibility program to approve, choose using the following hierarchy starting with the Child Medicaid program category. Child Medicaid 0- 5 or Child Medicaid 6- 18 Parent/ Caretaker Relative Pregnant Woman Former Foster Care Individuals Child Medicaid Age 0- 5: o Eligibility requirements: Income limit: 139% of the Federal Poverty Level ( FPL). A child can receive eligibility through the month in which he turns age 6. A child does not have to live with a parent or specified relative. Child Medicaid Age 6- 18: o Eligibility requirements: Income limit: 133% of FPL. A child can receive eligibility through the month in which he/ she turns age 19. If an 18 year old lives with his/ her parents, the parents' income is countable. Pregnant Woman: o Eligibility requirements: Income limit: 139% of FPL. The woman must be pregnant. If a pregnant woman is age 19 or older and lives with her parent(s), her parent's income is not countable. If she is under age 19 and living with her parent(s), her parents' income is countable. Former Foster Care Individuals o Eligibility requirements: Ages 18 to 26. Eligibility runs through the month he/ she turns 26. Individual was concurrently enrolled in Medicaid and Foster Care in Utah at age 18 or older when Foster Care ended. Individual was in the custody of DCFS, DHS or an American Indian Tribe when Foster Care ended. Persons in the custody of Juvenile Justice Services are not eligible.

There is no income test. Was not eligible for other categories of HPE. Parent/ Caretaker Relative ( PCR) o Eligibility requirements: Must have an eligible child. a. Household must include a child that is either under 18 or is age 18 and is a full time student and expected to graduate before the age of 19. Income test: See income chart in Appendix 1 Deprivation of Support must exist. a. Deprivation of support exists if the household has: A parent who is deceased. A parent who is incapacitated. A parent who is unemployed or employed less than 100 hours per month. A parent who is absent

Section 9: DETERMINING HOUSEHOLD SIZE Determine the household size using the following chart that applies to the coverage group: Include only people who live together. Child 0- 5 Applicant Applicant' s parent(s) and step- parent(s) Applicant' s sibling(s) and step- sibling(s) Child 6- 18 Applicant Parent(s) and step- parent(s) Legal spouse of applicant(s) ( not boyfriend) Applicant' s unborn child( ren) Sibling( s) and step- sibling(s) Note on Child Programs. Ifchildren) are living with a guardian who is not theirparent, their household size includes themselves and their sibling(s). For example, household consists of grandmother, grandfather and two grandchildren. The household size for each grandchild is two. Pregnant Woman If the applicant is under age 19 ( whether If the applicant is age 19 or older or not they are married) whether or not they are married) Applicant Applicant Legal spouse of applicant (not boyfriend) Legal spouse of applicant (not boyfriend) Applicant' s parent( s) Applicant' s unborn child( ren) Applicant' s unborn child( ren) Applicant' s child(ren) including step- children) under age 19 Applicant' s child(ren) including step- child( ren) under age 19 Sibling( s) and step- sibling(s) that are under age 19 Former Foster Care (no income limit) Applicant

Parent Caretaker Relative Applicant Legal spouse of applicant(s) ( not boyfriend) Applicant' s unborn child( ren) if they are in the third trimester of pregnancy Applicant' s children) including step- child( ren)

Section 10: INCOME Count the gross income ( before taxes) of everyone that is included in the household size for the specific program with the following exceptions: Do not count the income of a child to another child ( sibling) Do not count the income of a child to a parent Do not count the income of a guardian to the child( ren) that the guardian is responsible for. Examples of whose income to count are as follows: Family consists of a father, mother, and two children. The child is approved for HPE. The parents' income counts toward the child' s HPE eligibility. The income of the sibling does not count toward the child approved for HPE. Family consists of a father, mother, and a child. The father is approved for HPE. Income of the mother counts toward the father's HPE eligibility. Income of the child doesn't count toward the father's HPE eligibility. Educational income and child support are not countable sources of income. Do not include the income when counting the household income. For the presumptive Former Foster Care program, there is no income limit for this program. Note: PAYCHECK STUBS ARE NOT REQUIRED. However, if an applicant provides you with paycheck stubs to help you determine their gross monthly income, use the following procedure to calculate their income: When paychecks are received twice a month, multiply the gross paycheck amount by 2. If paychecks are received every other week, multiply the gross paycheck amount by 2. 15. If received weekly, multiply the gross paycheck amount by 4.3. o Income calculation examples: Johnny provides you one $500 (gross) paycheck stub and indicates he is paid every other Friday. Multiply $500 x 2. 15 to determine his gross monthly income ($500 x 2. 15 1075). Mary provides you one $ 200 (gross) paycheck stub and indicates she is paid every Wednesday. Multiply $200 x 4.3 to determine her gross monthly income ($200 x 4.3 = 860). Frankie provides you one $ 500 ( gross) paycheck stub and indicates he is paid on the 1s' and 15th of the month. Multiply $500 x 2 to determine his gross monthly income 500 x 2 = $ 1000).

Section 11: WHAT HAPPENS NEXT AFTER AN ELIGIBILITY DETERMINATION? Complete the cover sheet for presumptive eligibility. Make sure to complete all fields and include the denial reason if the decision is a denial. o Possible denial reasons are as follows: Already received HPE for the current pregnancy Current CHIP, UPP, or Medicaid recipient Issued HPE in the last 6 months Medicaid denial in the past 30 days No available HPE program No deprivation Not enough information to determine HPE Not a U. S. citizen or eligible alien Not a Utah resident Over the income limit Hospital scans in the application and a- mails it to DWS at hospitalPE@utah.gov Send the application to DWS within 5 working days. IMPORTANT: If the application is incomplete and DWS contacts the hospital for additional information, the hospital must respond to DWS within 2 business days or HPE will not be issued. Shred the paper application. DWS will issue the HPE card for the current month and determine eligibility for ongoing Medicaid. DWS will send the approval/ denial notice and card. o The HPE Medicaid card is identical to a regular Medicaid card and provides the same medical coverage. Exception: For the presumptive eligibility program for pregnant women, the coverage is only for Medicaid covered pregnancy related outpatient services. Delivery and inpatient services are not covered. HPE coverage will continue until DWS makes a decision for ongoing Medicaid. The following examples illustrate how the time frame for HPE eligibility is determined. Client is approved for HPE on Jan. 15th. Ongoing Medicaid eligibility is approved or denied on Jan. 16tH. Jan. 16tH is before the date Feb. cards are mailed. The HPE eligibility ends on Jan. 31St. The HPE card should not be used after Jan. 15tH Client is approved for HPE on Jan. 16th. Ongoing Medicaid eligibility is approved or denied on Feb. 15th. HPE eligibility continues until Feb. 28th. The HPE card should not be used after Feb. 15tH Client is approved for HPE on Jan. 16th. Ongoing Medicaid eligibility is approved or denied on Mar. 15th. HPE eligibility continues until Mar. 31st. The HPE card should not be used after Mar. 15th

Section 12: APPLICATION PROCESS Customer applies in Hospital Complete application will expedite eligibilityfor ongoing Medicaid) Qualified Hospital makes the HPE eligibility determination. z m_ O tau a` as is Approve HPE application Deny HPE application and and indicate decision on indicate decision and denial the presumptive eligibility reason on the presumptive cover page. eligibility cover page. Send application to DWS Send application to DWS within 5' working days within 5 working days Shred the application. Shred the application.

Section 13: CHECK LIST Make sure to do the following: Help the customer complete the application ( Note.-Although the customer is only required to complete the questions for HPE, completing the entire Medicaid application may expedite eligibility for ongoing Medicaid coverage). Submit the HPE application by e- mail to hospital PE@ tah.gov and subsequently destroy application Educate the customer to stop using HPE card if she is approved or denied for ongoing Medicaid. If approved for ongoing Medicaid, the customer should use the new card for ongoing Medicaid.

Appendix 1: INCOME CHART ( effective January 1, 2014) HH Size PCR Pregnant Child 6- Former Woman/ Child 18 Foster 0- 5 Care Individuals 139% FPL 133% No income FPL Limit 1 438 1332 1274 2 544 1797 1720 3 678 2263 2165 4 797 2729 2611 5 912 3194 3056 6 1012 3660 3502 7 1072 4126 3947 8 1132 4591 4393 9 1196 5057 4838 10 1257 5522 5284

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Please tear off this page and keep for your information. Application Information CHIP * PCN . UPP • Medicaid PE * Private Health Insurance * APTC What Am I Applying For' Health coverage is important for you and your family to get the medical care you need. When you submit this application, you will be considered for all medical programs that are now open for enrollment, including: CHIP( Children' s Health Insurance Program): Provides medical and dental insurance for uninsured children in families who qualify based on family size and income. For more information, visit: www.health. utah.gov/ chip PCN( Primary Care Network): Provides primary preventive health coverage for uninsured adults who qualify based on family size and income. For more information, visit: www health utah 9-ov/ pcn UPP( Utah' s Premium Partnership for Health Insurance): Provides a monthly premium reimbursement when a previously uninsured individual or family enrolls in their employer' s health plan or COBRA. For more information, visit: www.health. utah. gov/ upp Medicaid: Provides medical assistance for low-income families, children, pregnant women, and disabled, blind and elderly individuals. For more information, visit: www.health. utah.gov/ bep Presumptive Eligibility( PE) for Medicaid: Presumptive Eligibility is a program that provides temporary coverage for individuals who qualify based on preliminary information. Private Health Insurance: Provides comprehensive coverage to help you stay well. This is offered through the Federally Facilitated Marketplace( FFM). For more information, visit: www.healthcare. F-ov Advanced Premium Tax Credit( APTC): This is a tax credit that can immediately help pay your premiums for health coverage in the Federally Facilitated Marketplace( FFM). For more information, visit: www.healthcare.gov s What Do I Need to Do Next? On your application, tell us about all of your family Page 3: Section D- Questions 4 and 7 members who live with you. If you file taxes, we need Page 7: Section K- All Questions you to tell us about everyone on your tax return. ( You don' t Page 9: Section L- Signature need to file taxes to get health coverage). The program you • Return this application to a qualified hospital that qualify for depends on the number of people in your family determines PE eligibility. The hospital will determine and their income. This information helps us make sure PE eligibility and will also forward your application to the everyone gets the best coverage they can. Department of Workforce Services( DWS) to determine We can best determine your eligibility if all questions are continued medical benefits. DWS will notify you of your answered. However, for Presumptive Eligibility( PE), at a eligibility decision. minimum you must fill out the following questions on If more information is needed to determine your eligibility the four pages listed below: for benefits, an eligibility worker from DWS will contact you. Page 1: Section A- Name, Address, Phone Number If you have not heard from DWS within 10 days, please Section B- Question 10nly call toll-free 1-866-435-7414. Student and marital statuses are optional.) 0 Where Can I Get More Information? For questions about how to complete the application, your application status, or to find out if you qualify, please access your information online at www.iobs.utah. gov/ mycase. If you have questions about how to complete the application or you are unable to access the website, please call DWS at 1-866-435-7414. For general questions about the health care services covered by Medicaid or PCN, call the Medicaid hotline at 1-800-662-9651. For general questions about CHIP, PCN or UPP, call the Health Information Hotline at 1-888-222-2542. t Information on the cHIE Medical assistance( Medicaid, CHIP, UPP, PCN) recipients are automatically enrolled in the Utah Clinical Health Information Exchange( cHIE). The cHIE provides a safe place for participating healthcare providers to share and view patient medical information. Once your consent status has been set to PARTICIPATE, it will remain in effect for five years or until a minor turns 18. Recipients have the right to not participate in the cHIE or to change their consent status at any time. For more information or to opt out of the cHIE participation, visit www.mychie.orp-or talk to a healthcare provider.

0 For Presumptive Eligibility Worker Only: Please complete this page for each presumptive eligibility application. Name of PE Hospital: PE Worker Name: PE Decision Date: Name of Individual(s): PE Medical Program Approved/ Denied

Case#: HPE 1/ 2014 Application Case#: CHIP a PCN a UPP Medicaid PE # Private Health Insurance # APTC 0 Applicant Information Name: first start with yourself) middle initial maiden last E- mail: D05914000500116 optional) Home Address: Leave blank if you don' t have one) street apt.# city state zip Mailing Address: If different from home address) street apt. city state zip Home Phone: ( ) Cell/ Other Phone: ( ) Primary Language Spoken in Your Home: Would you like to receive notices in English or Spanish? English Spanish 0 Household Information 1. List everyone who is living in your household and applying for benefits. Social Security Birth Marital Fulltime Utah Resident Name Relation Number` Date Sex Race' Ethnicity Status Student U. S. Citizen/ first, m. i., last) to You mm/ dd/ yy M/ F ** *** **** f Y/ N National* Utah Resident U. S. Citizen/ National Utah Resident U. S. Citizen/ National Utah Resident U. S. Citizen/ National Utah Resident U. S. Citizen/ National Utah Resident U. S. Citizen/ National Social Security Number& Social Security Number( SSN) and citizenship information are only needed for people applying for ongoing benefits. You are not required to Citizenship provide SSN for presumptive eligibility, however, providing it may expedite your benefits. If someone needs help getting a SSN, call 1- 800-772- 1213 or visit sociaisecurity.gov. TTY users should call 1-800-325-0778. Race Codes WH: White, BL: Slack/ African American, Al: American Indian/ Alaska Native, ASI: Asian Indian, CH: Chinese, FI: Filipino, Optional) JIA: Japanese, KO: Korean, VI: Vietnamese, OA: Other Asian, NH: Native Hawaiian, SA: Samoan, GC: Guamanian/ Chamorro, OPh Other Pacific Islander, OT: Other Ethnicity Codes N: Not Hispanic/ Latino, M: Mexican, MA: Mexican American, CH: Chicano/ a, PR: Puerto Rican, CU: Cuban, Optional) AH: Another Hispanic, Latino, or Spanish Origin; OT: Other Marital Status Single, Married, Divorced, Widowed 2. If you mark that you are an American Indian or Alaska Native above, please complete Attachment A. Yes No 3. If you are not a U. S. Citizen or U. S. National, do you have an eligible immigration status? ( Only answer this question for individuals who are applying for benefits.) If yes, please complete all columns: Document ID Lived in the Has a spouse or parent who is a veteran or Immigration Number U. S. Since an active-duty member of the U.S. military, Document Alien if different 1996? or is himself a veteran or an active-duty Name Type Number from Alien #) ( Yes/ No) member of the U. S. military. ( Yes/ No)

Tax Filer Please answer the following questions to help us select the program for your household. In addition to the questions below, please complete Attachment 8 of this application for all dependents that are not living with you, but are claimedon your tax return. Yes No 1. Do you plan to file a federal income tax return next year or will you be claimed as a Ed dependent on someone's tax return next year? D05914000500216 If yes, please complete the chart* below. Note: If you are claiming more than 6 dependents on your tax return, please make a copy of this page and attach it to your application. Check one: Filing Jointly with Spouse: Dependents Listed on Your Tax Return: Tax Filer - or- Tax Dependent Applicable to Tax Filer Only) Applicable to Tax Filer Only) First& Last Name: Are you filingjointly with your Dependent# 1 spouse? [] Yes No Name: Living with tax filer: Yes [] No Will you be claimed as a dependent on If yes, name of spouse: Dependent# 2 someone' s tax return? Name: Yes No Living with tax filer: Yes No If yes, list name of tax filer and your Dependent# 3 relationship to the tax filer: Name: Living with tax filer: Yes No Name: Dependent# 4 Name: Relationship: Living with tax filer: Yes [] No Dependent# 5 Name: Living with tax filer: Yes No Dependent# 6 Name: Living with tax filer: Yes No Check one: Filing Jointly with Spouse: Dependents Listed on Your Tax Return: Tax Filer - or- Tax Dependent Applicable to Tax Filer Only) Applicable to Tax Filer Only) First& Last Name: Are you filing jointly with your Dependent# 1 spouse? Yes No Name: Living with tax filer: Yes No Will you be claimed as a dependent on if yes, name of spouse: Dependent# 2 someone' s tax return? Name: Yes No Living with tax filer: Yes No If yes, list name of tax filer and your Dependent# 3 Name: relationship to the tax filer: Living with tax filer: [] Yes [] No Name: Dependent# 4 Name: Living with tax filer: Yes No Relationship: Dependent# 5 Name: Living with tax filer: Yes [] No Dependent# 6 Name: Living with tax filer: Yes No 2

General Information Please answer the following questions for anyone in your household that is applying for benefits. This will help us select the right medical program. Yes No 1. Do you want help paying any medical bills from the last 3 months? If yes, for who: For which months: Yes No 2. Does anyone in your household have a major medical need? This includes pregnancy, D05914000500316 cancer, kidney disease, etc. ( Answering this question may get you extra help.) If yes, who: What is the medical need? Yes No 3 Do you live with at least one child under the age of 19, and are you the primary person taking care of this child? Yes No 4. Was anyone in your household in foster care on or after his/ her 18th birthday? If yes, who: Yes [] No 5. Does anyone in your household have a disability( a physical, mental, or emotional health condition that causes limitations in activities like bathing, dressing, daily chores, etc.)? If yes, who: Yes No 6. Has anyone in your household been in a jail, medical facility/ hospital, or nursing home for 30 days or more within the last 3 months? Ifyes, explain: Yes No 7. Is anyone in your household currently pregnant or has been pregnant in the last 3 months? If yes, who: Due date: How many babies are expected during the pregnancy? Has she smoked or used tobacco in the past 6 months? Yes No This question is for survey purposes only and does not affect eligibility.) 0 Income Yes No 1. Does anyone in your household have earned income? If yes, list any earned income received by all people who live in your home. Pay Rate Hours How Employed Person Employer Name, Address and Phone Before Taxes Worked Often Paid Name) Number 900/ mo.,$ 6/ hr.) Weekly weekly, monthly) Yes [--] No 2. Does anyone in your household have self-employment income? If yes, list any self-employment income received by all people who live in your home. Type of Net Income This Business Month Self-Employed Ex. LLC, Business Percent of Gross Income ( profit once business' Person ( name) Company Name ` S-Corp, etc.) Start Date Company Owned This Month expenses are paid) 3

Yes ONO 3. If employed, do you expect any changes in earnings or in the number of hours worked? If yes, explain: Yes ONO 4. In the past year, did anyone in your household change jobs, stop working or start working fewer hours? RE If yes, who: D05914000500416 Yes ONO 5. Do you or anyone in your household have/ receive any of the following? Check all that apply.) Unemployment $ How often: Date Income Started Pensions How often: Date Income Started Social Security $ How often: Date Income Started Retirement Accts. $ How often: Date Income Started Alimony Received $ How often: Date Income Started Net farming/ fishing$ How often: Date Income Started Net rental/ royalty $ How often: Date Income Started Other Income $ How often: Date Income Started Type 0 Deductions Check all that apply. List the amount paid and how often you get it. If you pay for certain things that can be deducted on a federal income tax return, telling us about them could make the cost of health coverage a little lower. Note: You shouldn' t include a cost already considered in your answer to net self- employment.) Alimony Paid How often: Student Loan Interest Paid $ How often: Other deductions: How often: Type: GYearly Income Complete only if your income changes from month to month. If you don' t expect changes from month to month, skip to the next question. Total income THIS year: Total income NEXT year: If you think it will be different) 4

Health Insurance Information Yes No 1. Does anyone in your household currently have Medicaid, CHIP, or Medicare? If yes, check the type of coverage and write the person(s) name(s) next to the coverage they have. 12 Medicaid: CHIP: D05914000500516 Medicare: Yes No 2. Has anyone in your household been injured in an accident or been a victim of assault in the last 12 months? Yes No 3. Is someone outside your home required to pay for medical services? Yes No 4. Is anyone in your household enrolled or eligible for COBRA coverage or continued health insurance through an employer? Yes [] No 5. Does anyone in your household currently have health insurance( including VA Health Care System benefits, Tricare, or Peace Corps), have insurance available but not enrolled, or has had insurance in the past 6 months? 6. If you answer yes to questions 4 or 5, please complete the chart below regarding the insurance(s). Do not list Medicaid, Medicare, CHIP, or PCN.) Insurance 1 Enrolled, start date: Not enrolled, but available Ended, date ended: If you check that your insurance status is Not enrolled, but available and this insurance is offered through either yourjob or someone else's job, such as a parent or spouse, please also complete Attachment C- Employer's Health Insurance Information Form attached to this application.) Name(s) of individual(s) covered: Name of insurance company: Phone#: Address of insurance company: Group#: Policyholder name: Policy#: Policyholder birth date: Policyholder SS#: If insurance is through an employer, list employer's name and phone#: Premium cost: $ Date due: How often: Type of Coverage: comprehensive limited Yes No Is this a retiree plan? Insurance 2 Enrolled, start date: Not enrolled, but available [--] Ended, date ended: If you check that your insurance status is Not enrolled, but available and this insurance is offered through either your job or someone else's job, such as a parent or spouse, please also complete Attachment C- Employer's Health Insurance Information Form attached to this application.) Name(s) of individual(s) covered: Name of insurance company: Phone#: Address of insurance company: Group#: Policyholder name: Policy#: Policyholder birth date: Policyholder SS#: If insurance is through an employer, list employer's name and phone#: Premium cost: $ Date due: How often: Type of Coverage: comprehensive limited Yes No Is this a retiree plan? 5

Aged, Blind, Disabled, Nursing Home, Waiver, or Spenddown Medicaid, Medicare Cost Sharing, Refugee Medical You are only required to answer the questions on this page if there is anyone in your household who is applying for Aged( 65+), Blind, Disabled Medicaid, Nursing Home, Waiver, or Spenddown Medicaid, Medicare Cost Sharing, and/ or Refugee Medical. 1E 0 Other D05914000500616 Benefits, Yes No 1. Has anyone in your household applied for, received, or been denied Social Security Income, VA, Unemployment or Worker' s Compensation? If yes, explain: Yes [] No 2. Has anyone in your household been determined disabled by Social Security? If yes, who: Yes No 3. Does anyone in your household that has been determined disabled by Social Security pay child support or alimony? If yes, list name and amount paid: Yes No 4. If employed, do you expect any changes in earnings or in the number of hours worked? If yes, explain: Yes No 5. Does anyone help you pay mortgage/ rent, food, or utility bills? If yes, explain: Yes No 6. Does anyone in the household work in exchange for mortgage/ rent, food, or utility bills? If yes, explain: Yes No 7. Does anyone in the household pay for dependent care so he/ she can go to work? If yes, list name and amount paid: 0 Assets Yes No 1. Do you or anyone in your household have any of the following financial assets? Check all that apply) Annuities 401K/ Retirement Checking Account$ IRA Money Market Funds Savings Account$ Stocks Trust Funds Other: Bonds Time Certificates Yes No 2. Do you or anyone in your household have any of the following assets? Check all that apply) Land Cemetery Plots Mineral or Timber Rights Life Estate Home Life Insurance Rental/ Investment Property Time Shares Tools Campers/ Trailers Burial Plans/ Funds Livestock Other: Yes No 3. Do you own any vehicles? If yes, using the chart below, list any vehicles that are owned by you and anyone who lives with you. Type of vehicle includes all cars, trucks, vans, snowmobiles, motorcycles, motor homes, boats/ motors, ATV' s or other vehicles. Licensed License Owner/ Joint Amount Make Model Year Y/ N Plate # State Owners Owed 6

Presumptive Eligibility You are only required to answer the questions on this page if there is anyone in your household who is applying for presumptive eligibility( PE) for Medicaid. 0 Presumptive Eligibility Questions: Yes No 1. If anyone in your household is not a U. S. Citizen or U. S. National, does he or she have a Lawful Permanent Resident card ( Green Card) from U. S. Citizenship and Immigration D05914000500716 Services? If yes, please complete the chart below: Name Date the Individual Became a Lawful Permanent Resident month/ year) Yes No 2. Is anyone in the household currently on Utah Medicaid, CHIP( Children Health Insurance Program), PCN ( Pri- mary Care Network), or UPP( Utah's Premium Partnership Program) or has been approved for Utah Medicaid with a spenddown? If yes, who: Yes No 3. Has anyone in your household been denied Utah Medicaid, CHIP, PCN, or UPP in the last 30 days? If yes, who: Yes No 4. If you answered yes to question 3, has the reason changed since the denial? If yes, explain Yes No 5. Has anyone in your household been approved for presumptive eligibility in the last 6 months, or if there is anyone pregnant, has she been approved for presumptive eligibility for pregnant women( Baby Your Baby) during this pregnancy? If yes, who: 6. What is your total gross earned and unearned income( before taxes) for your household this month? Do not include child support or educational income.) Yes No 7. Is there any child in the household who has any of the following? ( Check all that apply and list the child(ren)'s name(s) below.) a parent who is absent from the home a parent who is incapacitated (meaning unable to work due to injury or illness)? a parent who is deceased a parent who receives unemployment or works less than 100 hours per month. If yes, list the name(s) of the child( ren): Yes No 8. Does anyone in your household currently have health insurance?( This information is optional.) If yes, complete the chart below: Insurance Name(s) of individual(s) covered: Name of insurance company: Phone#: Address of insurance company: Group#: Policyholder name: Policy#: 7

0 1 Understand a The State of Utah( the State) references below include the Utah Department of Health, the Department of Workforce Services and/ or the Office of Recovery Services. 1 know that under federal law, discrimination isn' t Em permitted on the basis of race, color, national origin, sex, D05914000500816 age, sexual orientation, gender identity, or disability. I can file a complaint of discrimination by visiting www.hhs. gov/ ocr/ office/ file My benefits may be reduced, denied or stopped because • The Utah Statewide Immunization Information System of reported information. I understand that giving any USIIS) is a registry that keeps complete up to date false information or failing to report changes may result records of your child' s immunization history. For more in prosecution for fraud. If I receive benefits that I am information, or to withdraw your child from USIIS, call the not eligible to receive, I will be responsible for repaying Immunization Hot Line at 1-800-275-0659. the benefits received. If the State pays for my medical care, I assign to it my In the event of my death and my spouse' s death, the rights to payments from any third party and to benefits State has the right to recover from my estate all money for medical services. I will give to the State any money spent to pay my medical bills if I receive PCN and/ I collect from an insurance policy or from someone or Medicaid at any time while I am 55 years of age or required to pay for my medical expenses. I authorize older. The state does not have the right to recover from payment directly to the State and will hold harmless any my estate those costs paid as a benefit of eligibility for a party making payment to them. Medicare cost-sharing program ( QMB, SLMB, QI). 1 must report any changes in my address, phone 0 1 give permission for any information provided to be number, household size and access to coverage by verified when I apply and after I receive benefits. another health insurance program within 10 days. The Utah Clinical Health Information Exchange( cHIE) 1 authorize the State to give health care providers is an electronic system that gathers my medical history information about my eligibility for medical benefits. from participating cHIE healthcare providers. The cHIE The State may exchange information with my health provides a safe place for my healthcare providers to insurance carrier and/ or my employer for the period share my medical information. For more information or I receive benefits from the program. to opt out of the cHIE participation, visit www. mychie.org or contact your health care provider. 0 The benefits I am eligible to receive may be changed The medical benefits I receive are limited to those without my knowledge or consent. I understand that I described in the Provider Manual established for the am responsible for any co-pays to providers at the time program, as applicable. I understand that these manuals of medical service unless I am exempt from those may be amended without my consent or consideration. co-pays. If I receive a medical card, I will allow only the people 1 may ask for a fair hearing if I disagree with the decision named on the medical card to use the card. made on this application. 1 must follow the medical assistance program rules. My • 1 have been given a copy of the Rights and spouse and/ or children, as applicable, also must follow Responsibilities and Change Reporting Requirements. these rules. 1 assure that all household members applying for 1 must cooperate with the State in medical coverage or reimbursement are U. S. citizens pursuing any third party responsible or aliens in lawful immigration status, unless I am for medical expense. I must cooperate requesting emergency medical assistance only. I with the State to establish medical understand that I do not have to report citizenship support for my family, if required, information for household members who are not unless I have good cause to not cooperate. applying for coverage or reimbursement. The State will verify alien registration numbers with the U. S. Citizenship and Immigration Services( USCIS). The State will not report undocumented household members to USCIS. 8

I understand that my Social Security number will be used with the State Income and Eligiblity Verification System to make sure that my household is eligible for federal assistance programs. Computer matching, program reviews, and audits will be done with the Department of Workforce Services, Department of Health, Department of Human Services, Department of Homeland Security, Social Security, Internal Revenue Service, and/ or a consumer reporting agency. These agencies may also do inquiries to banking and loan institutions and any other organizations or individuals who may have eligibility information about my household. I must provide proof showing that my household is eligible for assistance. IN D05914000500916 I, ( print name) have read or had someone read to me the statements on this page. I understand and agree to those statements. Under penalty of perjury, I swear that the answers I give on this application are complete and correct. I am the person represented by the signature on this document. I know that I may be subject to penalties under federal law if I provide false or untrue information. Signature( check one): Applicant Authorized Representative Date Yes No Would you like someone to act as an authorized representative and have access to the information regarding your case? If yes, please complete Attachment D- Authorization to Disclose Medical Eligibility Information form attached to this application. Renewal of Coverage in Future Years To make it easier to determine my eligibility for help paying for health coverage in future years, I agree to allow the Marketplace to use income data, including information from tax returns. I also agree to allow the Department of Workforce Services, the Department of Human Services and the Department of Health to use information from tax returns. I can opt out at any time. The Marketplace will send me a notice and let me make changes. Yes, renew my eligibility automatically for the next 5 years( the maximum number of years allowed), or for a shorter number of years: 4 years 3 years 2 years 1 year Don't use information from tax returns to renew my coverage. 0 Voter Registration Information Yes No If you are not registered to vote where you live now, would you like to apply to register to vote here today? If you do not check either of these boxes, we will assume you have decided not to register to vote at this time. You may fill out the application form in private. If you would like help in filling out the voter registration application form, we will help you. The decision to seek or accept help is yours. Choosing to register or declining to register to vote will not affect the amount of assistance that you will be provided by this agency. If you believe that someone has interfered with your right to register, your right to decline to register to vote, your right to privacy in deciding whether to register or in applying to register to vote, or your right to choose your own political party or other political preference, you may file a complaint with the Lt. Governor, State of Utah, PO Box 142220, SLC, UT 84114. GReturn completed form to: You have now completed the application. For more information please review the" Application Information" cover sheet. Please return this completed application form to: Department of Workforce Services PO Box 143245 SLC, UT 84114-3245 Fax: 1-801-526-9505 Toll-free Fax: 1-888-522-9505 9

Please tear off this page and keep it for your information. Your Rights & Responsibilities 51 D05914000501016 You Have the Right o Apply or re-apply any time you wish for any medical program. Some programs are only available during open enrollment periods. If you need help, someone will help you apply. Receive a notice that we have either approved or denied your application and the reasons for the decision. For medical assistance, we have 30 days to process your application. We have 90 days, if you claim to be disabled, unless you need more time. Be notified explaining why we reduce, stop or hold your assistance. In most instances, we must mail the notice 10 days before we do this. Do the following things if you do not agree with decisions made regarding your case: A. Talk to your worker. Make sure you are not misunderstanding each other. B. Talk to your worker's supervisor. C. Talk to Constituent Services: 1-801-526-4390 or call toll-free 1-800-331-4341 D. Request a Fair Hearing within 90 days of the decision; 10 days to get benefits while the hearing is held. If you were denied disability status, you may also ask for a reconsideration as part of the fair hearing. If SSA denied your disability, you would have to go through their appeal process. Note: There are not any fair hearings for presumptive eligibility programs. E. Request legal representation regarding your fair hearing. You may be entitled to free legal assistance from Utah Legal Services. In Ogden, 1-801-394-9431 or Salt Lake, 1-801-328-8891. The toll-free number is 1-800-662-2538. You may also receive a referral for legal advice from the Salt Lake Lawyer Referral at 1-801-531-9075. Look at information in your case. Information about you and your case is confidential. We may give information to other agencies to administer a program to help you. Your Verify Information. The Social Security Act( U. S. C. 1320 b- 7 ( a) ( 1) requires that you give us a Social Security number for each household member who wants medical assistance. If you are applying only for emergency Medicaid, you do not have to provide a Social Security number. If you do not have a number, you must prove you have applied. You may be eligible for assistance while you are waiting to receive a number. Your Social Security number will be used with the State Income and Eligibility Verification System to make sure that your household is eligible for federal assistance programs. Computer matching, program reviews, and audits will be done with the Department of Workforce Services, Department of Health, Department of Human Services, Department of Homeland Security, Social Security, Internal Revenue Service, and/ or a consumer reporting agency. These agencies may also do inquiries to banking and loan institutions and any other organizations or individuals who may have eligibility information about my household. I must provide proof showing that my household is eligible for assistance. Children enrolled in Medicaid are automatically enrolled in the Utah Statewide Immunization Information System USIIS). If you do not want your children enrolled in this system, you must call the USIIS Help Line at 1-801-538-6872 or the Immunization Hot Line at 1-800-275-0659. You must cooperate in any review of your case by Quality Control, Recovery Services, and the Bureau of Eligibility Policy. You must also cooperate in providing information about any other sources of medical payments and obtaining medical support. If you feel you could be harmed by giving this information, you can request a ' good cause' claim. Your worker can explain this procedure. Medical assistance( Medicaid, CHIP, UPP, PCN) recipients are automatically enrolled in the Utah Clinical Health Information Exchange( cHIE). For more information or to opt out of the cHIE participation, visit www.mychie. org or contact your health care provider. You and your household must also follow the medical assistance program rules. 10

Mease tear off this page and keep for your information. Changes You 8i Must Report D05914000501116 Remember that YOU are required to report changes in your situation WITHIN 10 DAYS of the day you learn of the change. Do not delay reporting changes. Changes can affect your eligibility. If you receive benefits which you are not eligible to receive, you will have to repay that amount. To report changes, contact DWS online atwww.'obs. utah. gov/ mycase or call 1-866-435-7414. If you receive CHIP, I UPP, or Medicaid Benefits, you must report: Change in Marital Status or Living Arrangements Getting married, separated, or divorced; moving in with a roommate; change of address or phone number; absent parent moves in; birth of a baby or end of a pregnancy; household member moves in or out; death of a household member; hospital stays for more than 30 days; or if anyone in your household goes to jail or prison; receiving help with your household expenses, etc. Change in Insurance Coverage Changes in access to insurance, coverage, or enrollment in any health coverage plan ( including Medicare or VA Health Care System benefits) for anyone in the household. You must also report accidents or injuries which may be payable by a third party. If you receive Medicaidg you must also report: Change in Source of Income Getting a job, terminating a job, changingjobs, working for temporary services, obtaining educational income, SSI, SSA, or unemployment compensation, etc. Receiving a lump sum. Going on strike. Change in Amount of Earned or Unearned Gross Monthly Income Working more OR less hours, overtime, getting a raise, etc. Change in the amount of SSI, SSA, Unemployment Compensation, etc. Change in the Legal Obligation to Pay Child Support Gain or Loss of a Vehicle (Licensed or Unlicensed) Car, truck, van, motorcycle, camper, trailer, recreational vehicle, etc. Change in Any Asset(s) Report changes in ownership or value of stocks, bonds, property, vehicles, life insurance, trust funds, burial plans, cash, opening and closing of bank accounts, etc. for all household members. ( Includes joint ownership of any asset with spouse, parents, children, etc.) Change in Allowable Deductions Child care expenses, health insurance expenses, etc. If you are age 65 or over, blind, or disabled, you must also report changes in alimony or child support paid by a spouse or parent and work related expenses. it

Attachment A American Indian or Alaska Native Family Member (AVAN) Complete this attachment ifyou or a family member are American Indian or Alaska Native. Submit this with your application. If you have more people to include, make a copy of this page and attach it to your D05914000501216 application. ell us about your American Indian or Alaska Native family s . American Indians and Alaska Natives can get services from the Indian Health Services, tribal health programs, or urban Indian Health programs. They also may not have to pay cost sharing and may get special monthly enrollment periods. Answer the following questions to make sure your family gets the most help possible. AI/ AN Person 1 AI/ AN Person 2 1. Name First Middle First Middle Last Last 2. Member of a federally recognized Yes Yes tribe? If yes, tribe name If yes, tribe name No No 3. Has this person ever received a service from the Yes Yes Indian Health Service, a tribal health program, or urban Indian Health program, or through a referral No No from one of these programs? If no, is this person eligible to If no, is this person eligible to get services from the Indian get services from the Indian Health Service, tribal health Health Service, tribal health programs, or urban Indian programs, or urban Indian Health programs, or through a Health programs, or through a referral from one of these referral from one of these programs? programs? Yes No Yes No 4. Certain money received may not be counted for Medicaid or the Children' s Health Insurance Amount: $ Amount: $ Program ( CHIP). List any income( amount and how often) reported on your application that How often? How often? includes money from these sources: Per capita payments from a tribe that come from natural resources, usage rights, leases, or royalties Payments from natural resources, farming, ranching, fishing, leases, or royalties from land designated as Indian Trust Land by the Department of Interior( including reservations and former reservations) Money from selling things that have cultural significance 12

Attachment B Information on Your Dependents that are Not Living With You Complete this attachment for all dependents that ARE NOT living with you, but are claimed on your tax return. If you have more dependents that are not living with you, but are claimed on your tax return, D05914000501316 please make a copy of this page and attach it to your application. A General Complete the following chart for your dependent: Name of Dependent Sex SSN# first, m. i., last) Relationship to You Date of Birth M/ F optional) Yes No 1. Is your dependent currently pregnant or has been pregnant in the last 3 months? If yes, due date: How many babies are expected during the pregnancy? income Yes No 1. Does your dependent have earned income? If yes, complete the chart below: Pay Rate Before Taxes Hours Worked How Often Paid Employer Name, Address and Phone Number ($ 900/ mo., $ 6/ hr.) Weekly weekly, monthly) Yes No 2. Does your dependent have self-employment income? If yes, list any self-employed income received. Type of Percent Company Name Business Business Company) Net income this month Ex. LLC, S-Corp, etc.) Start Date Owned ( profit once business expenses are paid)' Yes No 3. In the past year, did your dependent change jobs, stop working or start working few hours? Yes No 4. Does your dependent have/ receive any of the following?( Check all that apply.) Unemployment $ How often: Net farming/fishing $ How often: Pensions How often: Net rental/ royalty $ How often: Social Security $ How often: Other Income How often: Pensions How often: Type: Retirement Accts. $ How often: Alimony Received $ How often: Deductions( a 1. Check all that apply, and give the amount and how often your dependent gets it. If your dependent pay for certain things that can be deducted on a federal income tax return, telling us about them could make the cost of health coverage a little lower. Note: You shouldn' t include a cost already considered in your answer to net self- employment. Alimony Paid How often: Other deductions $ How often: Student Loan Interest $ How often: Type: 49Yearly Income 1. Complete only if your dependent's income changes from month to month. Total income THIS year: Total income NEXT year: If you think it will be different) 13

DOH/ Form 116M 10/ 2013 Case#: Attachment C Employer's Health Insurance Information This form MUST be completed byyour employer or your company's Human Resources representative. Any blanks left on this form may delay the process. A form must be completed for each employed household member. You may copy this form. If you have general questions about this form or the medical programs, please call D05914000501416 1-866-435-7414. General Information Employee Information Employee name Employee SSN# first, m. i., last) Employer Information Employer Name: EIN#: Phone#: Address: street apt.# city state zip Who can we contact about employee health coverage at this job? Contact Name: Phone#: E- mail Address: OYes No 1. Does your company offer health insurance? If no, skip to section D. Sign and return the form. OYes No 2. Is your health insurance a state employee benefit plan? OYes No 3. Is your health insurance offered through Avenue H? OYes ONo 4. Is the employee eligible to enroll in any insurance plan offered? If no, please explain: If yes, when is/ was the employee eligible to enroll? (mm/ dd/ yy) Yes ONO 5. Is the employee or any family member enrolled in any insurance plan offered? If yes, name(s) of person(s) enrolled: OYes ONo 6. Has this employee or any family member dropped/ changed coverage in the last six months? If yes, name(s): If yes, when did coverage end/ change?( mm/ dd/ yy) OYes ONo 7. Does the employer offer a health plan that meets the * minimum value standard? 8. For the lowest-cost plan that meets the * minimum value standard offered only to employee( don' t include family plans): If the employer has wellness programs, provide the premium that the employee would pay if he/ she received the maximum discount for any tobacco cessation programs, and did not receive any other discounts based on the wellness programs: a. How much would the employee have to pay in premiums for that plan? $ b. How often? O weekly every 2 weeks twice a month quarterly yearly Yes ONO 9. Do you know what change the employer will make for the new plan year? If yes, complete the following: Employer won' t offer health insurance O Employer will start offering health coverage to employees or change the premium for the lowest-cost plan available only to the employee that meets the * minimum value standard. Premium should not reflect the discount for wellness programs. See question 8. a. How much will the employee have to pay in premiums for that plan? b. How often? O weekly O every 2 weeks O twice a month O quarterly O yearly An employer-sponsored health plan meets the" minimum value standard" if the plan' s share of the total allowed benefit costs covered by the plan is no less than 60% of such costs( Section 36B(c)( 2)( C)( ii) of the Internal Revenue Code of 1986) 14

0 Employer's t Expensive Plan or Avenue H Default Plan Questions below refer to the employer's least expensive plan or the Avenue H Default Plan. Yes No 1. Does the employee have to enroll in order to add their dependent(s)? 2. When will/ did coverage begin?( mm/ dd/ yy) 3. When does the company' s next open enrollment begin?( mm/ dd/ yy) 4. Complete the chart below. Do not include the cost of dental, vision or other coverage D05914000501516 if it is separate. Monthly Premium Employee' s Portion Company' s Portion Employee Employee+ spouse $ Employee+ child Family Health Questions below refer to the plan that the employee has selected. Questions 3- 7 refer to" in- network" benefits. 1. Insurance company and plan name: 2. Policy number, if known: Yes ONO 3. Is the deductible$ 2,500 or less per individual? Yes No 4. Is the lifetime maximum benefit$ 1,000,000 or more? Yes ONO 5. Does the plan pay at least 70% of an inpatient stay( after the deductible)? 6. What benefits are covered under this plan?( Check all that apply.) Physician visits Hospital inpatient services Pharmacy/ Rx Yes ONO 7. Does the plan cover abortion services? If yes, under what circumstances: Only in the case where the life of the mother would be endangered if the fetus were carried to term or in the case of incest or rape Other, please describe: 8. Complete this chart only if it is different from the chart on the front page( section B). Do not include the cost of dental, vision or other coverage if it is separate. Monthly Premium Employee' s Portion Company' s Portion Employee Employee+ spouse $ ee x Employee+ child Family Oyes ONO 9. Are the employee' s children currently enrolled or do they plan to enroll in your company's dental plan? If yes, name(s): Signature certify that I am a representative of the Human Resource Department, or that I am the health insurance contact person. The information on this form is true and correct to the best of my knowledge. Signature: Date: Name( please print): Title: Phone: Please return completed form s Department of Workforce Services, PO Box 143245, SLC, LIT 84114-3245 Fax: 1-801-526-9500 Toll-free Fax: 1-877-313-4717 15

DOH/ Form 114AR 10/ 2013 Attachment D Authorization to Disclose Medical Information You can choose an authorized representative. You can give a trusted person permission to talk about this application with us, see your information, and act for you on matters related to this application, including getting information about your D05914000501616 application and signing your application on your behalf. This person is called an authorized representative." Ifyou're a legally appointment representative for someone on this application, submit proof with this application. I hereby give the authority to: Name of Customer or Authorized Representative) Name of individual or Organization) check only one box) p Receive Medicaid, CHIP, UPP, PCN or Buyout eligibility information regarding my current application, ongoing case or a recent case denial or closure. This authorization is effective from the date this form is signed to whichever of the following occurs first: The following date: or The medical application is denied*; or 30 days from the month the medical program is closed*. If the application is denied or the case is closed, information disclosure will continue throughout the fair hearing process. Speak or act on my behalf as an authorized representative, which includes receiving Medicaid, CHIP, UPP, PCN or Buyout eligibility information regarding my current application, ongoing case or a recent case denial or closure. This authorization is effective from the date this form is signed until a written notification to revoke the authorization is received by the Department of Workforce Services. Name of Authorized Representative: Address of Authorized Representative: I understand that I may revoke this authorization at any time by sending a written notification to the Department of Workforce Services( DWS). I understand that a revocation is not effective to the extent that the Utah Department of Health, through its Division of Medicaid and Health Financing( DMHF) or the DWS has relied on the disclosed health information. I understand my rights and responsibilities described in the Notice of Privacy Practices. For a duplicate Notice of Privacy Practices, access the following URL- http:// health. utah. gov/ hipaa/ privacy.htm. I understand that I may refuse to sign this authorization. I also understand that the DWS cannot deny eligibility for benefits if I refuse to sign this authorization. I understand that giving an individual authorized representative power allows them to act on my behalf, which includes making changes to my medical case and any changes that they make, I may be liable for if an overpayment is incurred. I understand that, once information is disclosed pursuant to this authorization, it is possible that it will no longer be protected by medical privacy laws and could be disclosed by the person or agency that receives it. Note: DMHF and DWS will not disclose controlled documents without the consent of their Legal Departments. By signing this form, I acknowledge I have been provided a copy of this signed authorization. Signature of Customer, Legal Guardian, or Authorized Representative) Date) If signed by other than the customer, description of authority to serve: Equal Opportunity Employer Program Auxiliary aids and services are available upon request to individuals with disabilities by calling( 801) 526-9240. Individuals with speech and/ or hearing impairments may call Relay Utah by dialing 711. Spanish Relay Utah: 1-888-346-3162 16

Strom, Mandy L. ( CMS/ CMCHO) From: Hollis, Annie R. ( CMS/ CK4[ S) Sent: Tuesday, February 2S, 20l46:3OAM To: Strom, Mandy L ([ MS/ CM[ H0 Cc: Kress, MaheUe1 ([ MS/ CMCS) Subject: RE: UTl4' O0O7' K4K4 Hi Mandy! Thanks for checking in. The call went well in that they were very nice and understanding about the issues that we raised, Unfortunately, we are running into some systems issues with them automating a full Medicaid app whether nr not the person is willing and able to or not... Marielle, correct me if I' m wrong, but I think we are waiting to hear back from them on some sort of mitigation ,)Ian for that issue— Thanks! From: Strom, Mandy L. Sent: Monday, February 24, 3O143: S6PM To: Hollis, Annie R. ( CMS/[ M[ S) Cc: Kress, Mariel|e]. ( CMS/ OMCS) Subject: LIT 14OOO7' MM Hey Annie, How did the call Qo with Utah onFriday? J& m4 & m*| Division u Medicaid and Children' s Health Operations| Denver Regional Office| Centers for Medicare o ameuxomSe" wm|/ mm o"oau" mv Suite mv Denver, CO 8020219:$ 0$ 844- 70681 x:( 443) 38* 60911 dr, mip.u, u, u/ I^ u, n- p, iuuupdhi,~- omiL

Strom, Mandy L. ( CMS/ CMCHO) From: Repasch, Lee A.(CMS/ CMCHO) Sent: Thursday, February 20, 2014 11:58 AM To: Frandson, Renee L.( CMS/ CMCS); Jones, Lisa Y. ( CMS/ CMCS); Mills, Michelle CMS/ CMCS); Ryan, Jennifer( CMS/ CMCS); Costello, Anne Marie (CMS/ CMCS); Kress, Marielle J. ( CMS/ CMCS) Cc: Sheer, Jennifer L. ( CMS/ CMCS); Burch Mack, Rebecca M.( CMS/ CMCHO); Strom, Mandy L. ( CMS/ CMCHO) Subject: RE: [ SOTA- UT] SOTA Call Good afternoon, while on this hospital PE call, I was reminded that Utah asked me to report that they began hospital presumptive eligibility yesterday. As of today, 50% of hospitals are on board, and many more contracts are currently in process. They will have the majority of hospitals on by month' s find, They wanted to note this on the SOTA call yesterday but forgot and asked if I could send on word. Thanks, Lee Original Appointment----- From: Frandson, Renee L.( CMS/ CMCS) Sent: Tuesday, August 27, 2013 8: 16 PM To: Frandson, Renee L.( CMS/ CMCS); Allen, Richard C. ( CMS/ CMCHO); Anderson, Alvin F. ( CMS/ CMCS); Aretakis, Nicolas J. ( CMS/ CMCHO); Calhoun, Yolande M. ( CMS/ OIS); Cash, Judith ( CMS/ CMCS); Cohen Ross, Donna ( CMS/ CMCS); Cummins, Susan K. ( CMS/ CMCHO); Curry, Elliot M. ( CMS/ CMCHO); Greene, Deanna K. ( CMS/ CMCS); Holmes, William J. CMS/ WC); Hughes, Ruth A. ( CMS/ CMCHO); Jones, Lisa Y. ( CMS/ CMCS); Kress, Marielle J. ( CMS/ CMCS); Lutzky, Amy CMS/ CMCS); Maiden, Diana ( CMS/ CMCHO); Manning, Scott( CMS/ CMCS); Matthews, Elizabeth A. ( CMS/ CMCS); Melendez, Ricardo ( CMS/ CMCHO); Mills, Michelle ( CMS/ CMCS); Pedneau, Emily S. ( CMS/ CCIIO); Preston, Robin A. CMS/ CMCS); Repasch, Lee A.( CMS/ CMCHO); Richards, Barbara K. ( CMS/ CMCS); Schmidt, Donna W. ( CMS/ OIS); Strecker, Betty L. ( CMS/ WC); Sweet, Jocelyn A. ( CMS/ CCIIO); Tibbals, Erica ( CMS/ CCIIO); Strom, Mandy L. CMS/ CMCHO) Cc: Sheer, Jennifer L. ( CMS/ CMCS); Burch Mack, Rebecca M.( CMS/ CMCHO); Kahn, Jessica ( CMS/ CMCS); Hollis, Annie R. CMS/ CMCS) Subject: [ SOTA- UT] SOTA Call When: Wednesday, February 19, 2014 1: 30 PM- 2: 00 PM ( UTC- 05: 00) Eastern Time ( US& Canada). Where: Jen' s Office and Call- in Below File: UT_ SOTA_ Agenda_ 21 Call 2- 19- 14.doc>> Please contact Lisa Jones ( Lisa. Jones@cros. hhs.gov) if you have any questions. Renee Frandson invites you to an online meeting using WebEx. Meeting Number: 994 751 267 Meeting Password: This meeting does not require a password. 1

Audio conference information 1. Please call the following number: WebEx: 1- 877- 267- 1577 2. Follow the instructions you hear on the phone. Your WebEx Meeting Number: 994 751 267 To join from a Cisco VoIP enabled CMS Region or from CMS Central Office 1. Dial ext. 63100 2. Enter the Meeting Number: 994 751 267 To join this meeting online 1. Go to https:// cros.webex.com/ cros/j.php?J= 994751267 2. If requested, enter your name and email address. 3. If a password is required, enter the meeting password: This meeting does not require a password. 4. Click" Join". 5. Follow the instructions that appear on your screen. 2

Strom, Mandy L. ( CMS/ CMCHO) From: Strom, Mandy L. ( CMS/ CMCHO) Sent: Wednesday, February 19, 2014 6:53 AM To: Hollis, Annie R. ( CMS/ CMCS) Cc: Kress, Marielle J. ( CMS/ CMCS) Subject: RE: UT 14- 0007- MM PE Hospital SPA= CMS Informal Comments Hi Annie, I have sent an appointment with a call- in line for Friday from 2- 2: 30 Eastern. As I mentioned, I am off on Friday so I will not be able to make the call. I am going to give you some Utah contact information in case you need to cancel the call on Friday or need to get in touch with the State and I am out. Gayle Six: gaylesix@utah. gov or 801- 538-6895 Jeff Nelson: jeffnelson @utah. gov or 801- 538- 6471 Thanks, Mandy Mandy Strom 303) 844- 7068 Mandy. Strom@cros. hhs. gov From: Hollis, Annie R. ( CMS/ CMCS) Sent: Wednesday, February 19, 2014 6: 16 AM To: Strom, Mandy L. ( CMS/ CMCHO) Cc: Kress, Marielle 1. ( CMS/ CMCS) Subject: RE: UT 14- 0007- MM PE Hospital SPA= CMS Informal Comments Hi Mandy, Let' s try for Friday from 2- 2: 30... Marielle, not sure if that works for you, but Monday looked worse for you than Friday does. Thanks much. Annie From: Strom, Mandy L. ( CMS/ CMCHO) Sent: Tuesday, February 18, 2014 5: 57 PM To: Hollis, Annie R. ( CMS/ CMCS) Cc: Kress, Marielle J. ( CMS/ CMCS) Subject: RE: UT 14-0007- MM PE Hospital SPA= CMS Informal Comments Hi Annie, I spoke with Utah. They are struggling to find a time for the three critical people that need to be on this call, Gayle, Jeff, and Amanda. They have just a few times that currently work. Tomorrow-Wednesday, 2/ 19 from :1: 00- 2: 30 Eastern Friday, 2121. from 2- 2: 30 Eastern Monday, 2/ 24 from 11: 30- 12 or 12- 12: 30 Eastern 1

Do any of these times work for you? I am out of the office tomorrow and Friday at those times so I will not be able to make them, but I am fine with you meeting with the state without me since everyone is so busy and time is critical at this point. Let me know. Mandy Mandy Strom 343) 844- 7068 Mandy.Strom@cms. hhs.gov From: Hollis, Annie R. ( CMS/ CMCS) Sent: Tuesday, February 18, 2014 9: 39 AM To: Strom, Mandy L. ( CMS/ CMCHO) Cc: Kress, Marielle J. ( CMS/ CMCS) Subject: RE: UT 14-0007- MM PE Hospital SPA= CMS Informal Comments Thank you for following up? Let me know if/ when you hear. Today is day 46 for UT, just FYI. From: Strom, Mandy L. ( CMS/ CMCHO) Sent: Thursday, February 13, 2014 4:20 PM To: Hollis, Annie R. ( CMS/ CMCS) Cc: Kress, Marielle J. ( CMS/ CMCS) Subject: RE: UT 14- 0007-MM PE Hospital SPA= CMS Informal Comments Hi Annie, I just wanted to follow- up with you. I have left Gayle Six in Utah two voicemails regarding scheduling a call to discuss your comments. I still haven' t heard back from her, but will let you know as soon as I do. When I do get her on the phone, I will make sure to get some times so we can move this call forward. I also have alerted her to the fact that we are trying to get all MAGI SPAS approved by end of March. I know she has a lot on her plate, but hopefully things will start moving soon on this SPA. Mandy Mandy Strom 303) 844- 7068 Mandy.Strom @cros. hhs.gov From: Hollis, Annie R. ( CMS/ CMCS) Sent: Monday, February 10, 2014 7: 45 AM To: Strom, Mandy L. ( CMS/ CMCHO) Cc: Kress, Marielle J. ( CMS/ CMCS) Subject: RE: UT 14- 0007- MM PE Hospital SPA= CMS Informal Comments Hi Mandy, Have you heard back from the state about a call to discuss this SPA? Thanks, Annie From: Strom, Mandy L. ( CMS/ CMCHO) Sent: Thursday, January 30, 2014 5: 14 PM 2

To: Gayle M. Six ( gaylesix@utah. gov) Cc: Jeff Nelson (jeffnelsonPutah. Qov); Craig Devashrayee ( cdevashra Michelle Smith michellesmith( Lutah. gov); Kress, Marielle J. ( CMS/ CMCS); Hollis, Annie R. ( CMS/ CMCS) Subject: UT 14- 0007- MM PE Hospital SPA= CMS Informal Comments Hi Gayle, Attached are CMS' comments to Utah' s MAGI PE Hospital SPA. In addition to the comments attached, I have one more related to the 179 that Craig and I had discussed. The 179 shows$ 0 fiscal impact, but also needs to reference that the fiscal impact is included with 14- 0001-MM SPA. Once you have had a chance to look over the attached comments, CMS would like to schedule a call to discuss. Let me know what your availability is over the next couple of weeks and I will work to try to get something scheduled. Let me know if you have questions. Mandy P. S. I have unlocked the SPA in MMDL. 4hw4 Stwml Division of Medicaid and Children's Health Operations I Denver Regional Office I Centers for Medicare& Medicaid Services 11600 Broadway, Suite 700, Denver, CO 80202 19:( 303) 844- 7068 1 --:( 443) 380- 60911. ms. hhs.go d' 1, Er oi Mir3«>z tltr; czirirusi s r. sr lsr° 1+ 3t prinling i16,; e- mail. 3

Strom, Mandy L. ( CMS/ CMCHO) From: Strom, Mandy L. ( CMS/ CMCHO) Sent: Thursday, January 30, 2014 3: 14 PM To: Gayle M. Six( gaylesix@utah.gov) Cc: Jeff Nelson oeffnelson @utah. gov); 'Craig Devashrayee( cdevashrayee @utah.gov)'; Michelle Smith ( michellesmith @utah.gov); Kress, Marielle J. ( CMS/ CMCS); Hollis, Annie R. ( CMS/ CMCS) Subject: UT 14- 0007- MM PE Hospital SPA= CMS Informal Comments Attachments: Comments- to- UT 1- 30- 14.pdf Hi Gayle, Attached are CMS' comments to Utah' s MAGI PE Hospital SPA. In addition to the comments attached, I have one more related to the 179 that Craig and I had discussed. The 179 shows$ 0 fiscal impact, but also needs to reference that the fiscal impact is included with 14-0001- MM SPA. Once you have had a chance to look over the attached comments, CMS would like to schedule a call to discuss. Let me know what your availability is over the next couple of weeks and I will work to try to get something scheduled. Let me know if you have questions. Mandy P. S. I have unlocked the SPA in MMDL. A1.art4 Stwntl Division of Medicaid and Children's Health Operations I Denver Regional Office I Centers for Medicare& Medicaid Services 11600 Broadway, Suite 700, Denver, CO 80202 19:( 303) 844- 70681 ( 443) 380- 60911 Mandy.Strom@cros.hhs. gov t 5 I' 1= rt, E ccris ilfrr 11w t• nr-iroiimeni bc[ ore priitIing flii;<t- 11wil. 1

Utah State Plan Amendment( SPA) 521— Hospital Presumptive Eligibility CMS Comments for SPA Submission The Centers for Medicare & Medicaid Services ( CMS) is reviewing State plan amendment ( SPA) S21 submitted by the Utah Department of Health. This SPA proposes to enact changes related to hospital presumptive eligibility( HPE). Thank you for the opportunity to review this SPA. In this document, CMS provides comments for this SPA for the State' s consideration and to facilitate future discussion. Please note that we may have further questions, pending the State' s responses. We are available to discuss these at the State' s request. General Questions 1. Please provide a copy of the single streamlined application with the required fields noted that the state will use to determine HPE. 2. Please provide a copy of the application cover sheet that identifies the necessary fields for HPE, as referenced in the training materials. Page 2 of 3 3. The state has indicated that it is establishing standards for qualified hospitals making eligibility determinations. a. The state has written that it will require hospitals to assist applicants in completing a full Medicaid application and the hospital will submit these applications to the Department of Workforce Services for 100% of the individuals completing an application for a presumptive eligibility decision. i. Please note that a full Medicaid application cannot be a requirement of an HPE determination. ii. Please describe how the state arrived at the 100% standard. b. The state has written that it will require that the hospital will maintain an 85% accuracy rate for its presumptive eligibility determinations. Does the state plan to review every HPE determination made for accuracy? c. The state has selected that it will require a standard of 65% of individuals who are determined presumptively eligible are determined eligible for full Medicaid. Please briefly describe how the state selected this 65% standard. d. Please provide a description of how the state will retrain hospitals and institute corrective action for underperforming hospitals. Attachment: HPE Training Manual 4. There are additional immigration statuses that are considered eligible immigration statuses for purposes of Medicaid eligibility. It may help hospitals to provide this list and say that the individual must be a " U. S. Citizen or have eligible immigration status". The list can be found here: https:/,,www.liealtheare. 4ov/ iniuni-, rat ion-status- and- the- marketplace/. 5. On page 9, please either include the five percent disregard for each of the eligibility levels, or direct the hospitals to subtract five percent from each individual' s FPL found from their gross income. Page 1 of 1

Utah State Plan Amendment( SPA) S21— Hospital Presumptive Eligibility CMS Comments for SPA Submission 6. On page 13, it may make sense to include the questions that ascertain which group the individual may be eligible for. For example, the state should include a question on whether the individual was in foster care at age 18, or whether they are a parent or caretaker relative with a dependent child under age 19. 7. On page 15, the training materials state that " DWS will issue the HPE card for the current month and determine eligibility for ongoing Medicaid. DWS will send the approval/ denial notice and card." a. Please note that a full Medicaid application cannot be a requirement of an HPE determination. i. Please describe the state' s process to ensure an opt-out mechanism for individuals who cannot or do not want to file a full Medicaid application. ii. If only the sections necessary for HPE are completed and the information is transmitted to DWS, will this result in a denial for full Medicaid based on a submission of incomplete information? This could have the unintended consequence of ending an HPE period earlier than the period that the individual is entitled to, regardless of whether or not the individual files a full Medicaid application. b. Please add information clarifying the HPE coverage in the event that an individual does not complete a full Medicaid application. If a full Medicaid application is not filed by the last day of the month following the month in which HPE eligibility was determined, then HPE coverage ends on the last day of the month following the month in which HPE eligibility was determined. Attachment: HPE Training Powerpoint 8. On slide 12, please clarify that for pregnant women, only ambulatory prenatal care is covered during an HPE period. Page 2 of 1

Strom, Mandy L. ( CMS/ CMCHO) From: Kress, Marielle J. ( CMS/ CMCS) Sent: Thursday, January 30, 2014 3: 04 PM To: Strom, Mandy L. ( CMS/ CMCHO); Kress, Marielle J. ( CMS/ CMCS) Cc: Hollis, Annie R. ( CMS/ CMCS) Subject: Re: Utah submitted PE Hospital SPA 14- 0007- MM in MMDL Perfect, thank you very much? From: Strom, Mandy L. ( CMS/ CMCHO) Sent: Thursday, January 30, 2014 05: 00 PM To: Kress, Marielle J. ( CMS/ CMCS) Cc: Hollis, Annie R. ( CMS/ CMCS) Subject: RE: Utah submitted PE Hospital SPA 14- 0007- MM in MMDL Hi Marielle, I do not have any additional questions except for the fiscal impact modification to the 179 that I mentioned in my earlier email. I will go ahead and get the questions sent to the State and work to get a call set up. Thanks, Mandy Mandy Strom 303) 844- 7068 Mandy.Strom @cros. hhs.p,ov From: Kress, Marielle J. ( CMS/ CMCS) Sent: Thursday, January 30, 2014 12: 28 PM To: Strom, Mandy L. ( CMS/ CMCHO) Cc: Hollis, Annie R. ( CMS/ CMCS) Subject: RE: Utah submitted PE Hospital SPA 14- 0007- MM in MMDL Hi Mandy, Attached please find our review of Utah' s S21 SPA and questions and comments for the state. Let us know if you have anything to add/ any questions. We would like to discuss with the state, so could you work on getting a call on the calendar? Let us know if you need us to provide specific times or would want to reach out to get the state's availability first. Many thanks, Marielle From: Strom, Mandy L. ( CMS/ CMCHO) Sent: Monday, January 27, 2014 4: 05 PM To: Kress, Marielle J. ( CMS/ CMCS) Subject: RE: Utah submitted PE Hospital SPA 14- 0007- MM in MMDL Hi Marielle, 1

I just wanted to follow-up with you on Utah 14-0007- MM PE SPA. Have you had a chance to review it? I have looked over the template and training materials and it looked pretty good to me, but I am also not a PE expert. The one comment I did have is below: Utah needs to add a note as to why fiscal impact is$ 0 and reference 14-0001- MM. The State could not break out its fiscal impact for all the different MAGI SPAs so they plan to include the full impact in 14-0001- MM and just put$ 0 for the others and reference back to 0001. Thanks, Mandy Mandy Strom 303) 844-7068 Mandy.Strom @cros. hhs. gov From: Corddry, Mary C. ( CMS/ CMCS) Sent: Monday, January 06, 2014 2: 39 PM To: Strom, Mandy L. ( CMS/ CMCHO); Clemens, Ann C. ( CMS/ CMCHO); Kress, Marielle]. ( CMS/ CMCS) Cc: Turner, Trudy]. ( CMS/ WC) Subject: RE: Utah submitted PE Hospital SPA 14- 0007- MM in MMDL Thanks, I' m not reviewing it. Marielle is. Mary From: Strom, Mandy L. ( CMS/ CMCHO) Sent: Monday, January 06, 2014 4: 35 PM To: Corddry, Mary C. ( CMS/ CMCS); Clemens, Ann C. ( CMS/ CMCHO) Cc: Turner, Trudy J. ( CMS/ WC) Subject: Utah submitted PE Hospital SPA 14- 0007- MM in MMDL Hi Ladies, I am not sure if you both will be reviewing the S21 template, but wanted to let you know that Utah submitted it last Friday in MMDL. 3tttruly.Stawml Division of Medicaid and Children' s Health Operations I Denver Regional Office I Centers for Medicare& Medicaid Services 11600 Broadway, Suite 700, Denver, CO 8020219:( 303) 844- 70681 _:( 443) 380- 60911 hhS.-g t a (' fE' c„ r,cfsr iblr t. Ear° si irsrrncxst Iet<, xr lriist.iis this r-ssail. 2

Strom, Mandy L. ( CMS/ CMCHO) From: mmdl.support@truvenhealth.com Sent: Friday, January 03, 2014 8: 58 AM To: Cash, Judith (CMS/ CMCS); Bodon, Maritza ( CMS/ CMCS); Strom, Mandy L. CMS/ CMCHO); Riddle, Cynthia A. ( CMS/ CMCHO); Turner, Trudy J. ( CMS/ WC); formssupport@truvenhealth.com; Washington, Barbara A. ( CMS/ CMCS); maraizu.onyenaka @truvenhealth.com; Billy, Indy A. (CMS/ CMCS); Volesky, Curtis CMS/ CMCHO); Adams, Janice M. ( CMS/ WC); Gaskins, Sheri P. ( CMS/ CMCS); CMS SPA_Waivers_Denver_R08; Jensen, Laurie( CMS/ CMCHO); Kayani, Siani S. ( CMS/ CMCS); marjorie.hatzmann @truvenhealth.com Subject: MAC) Submission { UT.0725.00.00): Submitted MAC) Submission{ UT.0725.00.00): Submitted on{ 01/ 03/ 2014 10: 53: 001. 1

UT.0725. R00.00 - Jan 01, 2014 Page I of 12 Medicai'd StIll"t Plan Eligribill"tv ficaid State Plan ibilits : C,eneral Information State/Territory name: Utah Transmittal Number: UT- 14- 0007 General Information: Submission Title: short( under 100 characters) label used to identify this submission in the web application 14- 0007- MM Description: Presumptive Eligibility by Hospitals- S21 Populations Covered: Mandatory Coverage: Parents and Other Caretaker Relatives Pregnant Women Infants and Children under Age 19 Adult Group Former Foster Care Children Options for Coverage: Individuals above 133% FPL Optional Coverage of Parents and Other Caretaker Relatives Reasonable Classification of Individuals under Age 21 Children with Non IV-E Adoption Assistance Optional Targeted Low Income Children Individuals with Tuberculosis Independent Foster Care Adolescents Individuals Eligible for Family Planning Services Medicaid State Plan Eligibility, 1, He Nianagenlerol ),nlrnary State/Territory name: Utah Transmittal Number: UT- 14- 0007 Type of SPA Form Form Name/ Description Uploaded? Code MAGI-Based Eligibility S14 AFDC Income Standard no Groups MAGI- Based Eligibility S25 Mandatory: Parents and Other Caretakers no Groups MAGI-Based Eligibility S28 Mandatory: Pregnant Women no Groups MAGI- Based Eligibility S30 Mandatory: Infants and Children Under Age 19 no Groups TN: UT- 14- 0007- MM7 Approval Date: 04/ 02/ 2014 Effective Date: 01/ 01/ 2014 Utah http:// 157. 199. 113. 99/ MMDL/ faces/ protected/ mac/ cO]/ print/PrintSelectorjsp 04/ 01/ 2014

UT.0725. R00.00 - Jan 01, 2014 Page 2 of 12 Type of SPA Form Form Name/ Description Uploaded? Code MAGI- Based S32 Mandatory: Individuals Below 133% of the FPL no Eligibility Groups MAGI- Based Mandatory: Former Foster Care Children up to age Eligibility S33 26 no Groups MAGI- Based Eligibility S50 Optional: Individuals Above 133% of the FPL no Groups MAGI- Based Eligibility S51 Optional: Optional Parents and Caretakers no Groups MAGI-Based Eligibility S52 Optional: Reasonable Classifications of Individuals no Groups MAGI- Based Eligibility S53 Optional: Non IV- E Adoption Assistance no Groups MAGI- Based Eligibility S54 Optional: Optional Targeted Low Income Children no Groups MAGI- Based Eligibility S55 Optional: Tuberculosis no Groups MAGI- Based Eligibility S57 Optional: Foster Care Adolescents- Chafee no Groups MAGI- Based Eligibility S59 Optional: Family Planning no Groups Eligibility Single streamlined application or alternative, Process S94 Renewals, Coordination for enrollment and eligibility no agreements with Exchanges) Designates the income options the state is electing in MAGI Income S10 2014( e. g. how pregnant women are counted, no Methodology reasonably predictable changes in income, cash support, how full-time students are counted) Single State Al- 3 Addresses single state agencies delegation of appeals Agency and determinations no Residency S88 State affirms residency regulations and addresses interstate agreements and temporary absence no Citizenship& State affirms citizenship regulations, specifies Immigration S89 reasonable opportunity options, and specifies policy no Status options related to immigrant eligibility Hospital State specifies options for presumptive eligibility Presumptive S21 conducted by hospitals yes Eligibility 1 tli d Sfa,(e Plan l li!'Jbi o Det di m nHirnm:x>. of'o.: rcaa.»uw-ciirrrz;^i„rodv .. e ° ¢ av, 7, . wuee. s>,?.va' aaH»v;+te,',:-! a:iiy i., t;' iFt. TN: UT- 14-0007- MM7 Approval Date: 04/02/ 2014 Effective Date: 01/ 01/ 2014 Utah http:// l 57. 199. 113. 99/ MMDL/faces/ protected/ mac/ c01/ print/PrintSelector.jsp 04/ 01/ 2014

UT.0725. R00.00 - Jan 01, 2014 Page 3 of 12 1,. orm S14,, ,AFOC Income Standards Form Description: Uploaded Form: Support Documents Document 1Ftsa" la"I S25'. ', ligibililly G'a" ourp 9 - A' an"J"'I ory Parents ant.1 Other Caretaker Relalives Form Description: Uploaded Form: Support Documents Document Form, S28: 1', 1i , ibilitv Vlaandaator o ca a! oe, Pre x a< aItt A, It Form Description: Uploaded Form: Support Documents Document F`Orin 30: FIigit,sility' , a°t ups - .- Itlator Cove °agt, v Infants and Mil"a"n law , .. ue 19 v Form Description: Uploaded Form: Support Documents Document TN: UT- 14- 0007- MM7 Approval Date: 04/ 02/ 2014 Effective Date: 01/ 01/ 2014 Utah http:// 157. 199. 113. 99/ MMDL/faces/ protected/ mac/ c01/ print/PrintSelector.jsp 04/ 01/ 2014

UT.0725. R00.00 - Jan 01, 2014 Page 4 of 12 I mrim S32, l, ligI b 11ty QT' oup amdatory o e a- r : Adult G1,011p Form Description: Uploaded Form: Support Documents Document Mandatory asb :, t1 t°,1 ;, ibilit t}i s ndatory . o er t 1ornier Foster, 8' _. i t'> Form Description: Uploaded Form: Support Documents Document Form Sell: 11"' li il:jilit rollp - (40"imns for Coverage; Individuals ,above 1 3'Yo Form Description: Uploaded Form: Support Documents Document ol-1,11 S51: 11-Aiuibilily G,r aups - Options For (" ovel— age: Optional of 1) l°Alts ,j ( 1 t ,,e j` ( retaken Relatives Form Description: Uploaded Form: Support Documents TN: UT- 14-0007- MM7 Approval Date: 04102/ 2014 Effective Date: 01/ 01/ 2014 Utah http:// 157. 199. 113. 99/ MMDL/faces/ protected/ mac/c01/ print/PrintSelector.jsp 04/ 01/ 2014

UT.072l00.0O - Jan Ol, 20| 4 Page 5of |2 EDocument 1, orn) S52: Eligibility Groilps - Option's for Cove't-a'- ez, Reasonable Clas'-dification of Individtials under Form Description: Uploaded Form: Support Documents Document Ftm-m S,,,;3, fli yihifitv Grotips - Options For ('.' overage, ChIldrett with Not), IV- 1' Adoption Assistance Form Description: Uploaded Form: Support Documents Document Income Childrun Form Description: Uploaded Form: Support Documents Document Form S55: Eligibility Grolfps - Opillions for Coverage: Individtialswith Form Description: Tw: UT- 1u- 0oo7- MMr Approval Date: 04/ 02/ 2014 Effective Date: 01m1s04 Utah

lyT]] 725. QUA. 0U - Jan O|, 20| 4 Page 6of\ 2 Uploaded Form: Support Documents Document Fornn, S57- 1" H!gihifity (-'rotjps - Options for Covera-pe., I n( leper),den t 1, ester C i,, e Form Description: Uploaded Form: Support Documents Document 1,' oriri S59: EHL Famoily planning Services Form Description: Uploaded Form: Support Documents Document Form Description: Uploaded Form: Support Documents Document Form Description: Tm: DF1u-0oo7- MMr Approval Date: 0* m2m014 Effective Date: 0101/ 2014 Utah http:H| 57.| g9.\ \ 3. 99/ MK4DL/faoen6protcotcd/ onac/ c0\/ n, int/ prindSc| ccto,' sp 04/ 01/ 2014

UT.0725. R00.00 - Jan 01, 2014 Page 7 of 12 Uploaded Form: Support Documents Document Forin Al 3: Nledicaid A.Amir is ration.: Sin,,Oe State ,Agency Form Description: Uploaded Form: Support Documents Document 1° o o Finanel'al l;li ibility" statc R : idcncv Form Description: Uploaded Form: Support Documents Document orun S89. Non- Financial 1; 1t T11 t1i1: x ( lttzs;'3tshipz and 131 Citizen l figi ) ility Form Description: Uploaded Form: Support Documents Document Form S21:> 1' r° si.iinptiv 1< li_il)iljty t)v lli)spit,,lls Form Description: Presumptive Eligibility by Hospitals TN: UT- 14- 0007- MM7 Approval Date: 04/ 02/ 2014 Effective Date: 01/ 01/ 2014 Utah http:// 157. 199. 1 13. 99/ MMDL/faces/ protected/ mac/cOI/ print/PrintSelector.jsp 04/ 01/ 2014

UT.0725. R00.00 - Jan 01, 2014 Page 8 of 12 Uploaded Form: S21- hospital presumptive.pdf Support Documents Document Please provide a short description of this support document: I Hospital Presumptive Eligibility Application Uploaded Document Name: HPE App with CMS' Feedback.pdf Please provide a short description of this support document: Hospital Presumptive Eligibility Training Powerpoint Uploaded Document Name: HPE Powerpoint updated based on CMS' feedback.pdf Please provide a short description of this support document: Hospital Presumptive Eligibility Training Manual Uploaded Document Name: HPE TRAINING MANUAL updated per CMS feedback.pdf N"Iedicaid State 11311 Eligibility: Tribal hiput State/Territory name: Utah Transmittal Number: UT- 14- 0007 One or more Indian Health Programs or Urban Indian Organizations furnish health care services in this State. This State Plan Amendment is likely to have a direct effect on Indians, Indian health programs or Urban Indian Organizations. The State has solicited advice from Indian Health Programs, Urban Indian Organizations, and/or Tribal governments prior to submission of this State Plan Amendment. Complete thefollowing information regarding any tribal consultation conducted with respect to this submission: Tribal consultation was conducted in the following manner. States are not required to consult with Indian tribal governments, but ifsuch consultation was conducted voluntarily, provide information about such consultation below: Indian Tribes Indian Tribes Name of Indian Tribe: Goshute Indian Tribe Date of consultation: 07/ 16/ 2013 mm/ ddlyyyy) Method/ Location of consultation: Meeting at the Utah Department of Health( Highland Drive Bldg., SLC, UT). Bridge line was available to access meeting by phone. Name of Indian Tribe: Navajo Indian Tribe TN: UT- 14- 0007- MM7 Approval Date: 04/ 02/ 2014 Effective Date: 01/ 01/ 2014 Utah http:// 157. 199. 113. 99/MMDL/faces/ protected/ mac/ c01/ print/ PrintSelectorjsp 04/ 01/ 2014

UT.0725. R00. 00 - Jan 01, 2014 Page 9 of 12 Indian Tribes Date of consultation: 07/ 16/ 2013 mm/ dd/ yYYY) Method/ Location of consultation: Meeting at the Utah Department of Health( Highland Drive Bldg., SLC, UT). Bridge line was available to access meeting by phone. Name of Indian Tribe: Paiute Indian Tribe Date of consultation: 07/ 16/ 2013 mm/ ddlyyyy) Method/ Location of consultation: Meeting at the Utah Department of Health( Highland Drive Bldg., SLC, UT), Bridge line was available to access meeting by phone. Name of Indian Tribe: Shoshone Indian Tribe Date of consultation: 07/ 16/ 2013 mm/ dd/ yyyy) Method/ Location of consultation: Meeting at the Utah Department of Health( Highland Drive Bldg., SLC, UT). Bridge line was available to access meeting by phone. Name of Indian Tribe: Ute Indian Tribe Date of consultation: 07/ 16/ 2013 mm/ ddlyyyy) Method/ Location of consultation: Meeting at the Utah Department of Health( Highland Drive Bldg., SLC, UT). Bridge line was available to access meeting by phone. Indian Health Programs Indian Health Programs Name of Indian Health Programs: Fort Duchesne Health Center Date of consultation: 07/ 16/ 2013 mm/ ddlyyyy) Method/ Location of consultation: Meeting at the Utah Department of Health( Highland Drive Bldg., SLC, UT). Bridge line was available to access meeting by phone. Name of Indian Health Programs: Navajo Area Indian Health Service Date of consultation: 07/ 16/ 2013 mm/ dd/ yYYY) Method/ Location of consultation: Meeting at the Utah Department of Health( Highland Drive Bldg., SLC, UT). Bridge line was available to access meeting by phone. Name of Indian Health Programs: Utah Navajo Indian Health Systems, Inc. TN: UT- 14- 0007- MM7 Approval Date: 04102/2014 Effective Date: 01/ 01/ 2014 Utah http:// 157. 199. 113. 99/ MMDL/faces/ protected/ mac/ c01/ print/PrintSelector.jsp 04/ 01/ 2014

UT.0725. R00.00 - Jan 01, 2014 Page 10 of 12 Indian Health Programs Date of consultation: 07/ 16/ 2013 mm/ dd/ yyyy) Method/ Location of consultation: Meeting at the Utah Department of Health( Highland Drive Bldg., SLC, UT). Bridge line was available to access meeting by phone. Urban Indian Organization Urban Indian Organizations Name of Urban Indian Organization: Urban Indian Center of Salt Lake Date of consultation: 07/ 16/ 2013 mm/ dd/ yyyy) Method/Location of consultation: Meeting at the Utah Department of Health( Highland Drive Bldg., SLC, UT). Bridge line was available to access meeting by phone. The state must upload copies of documents that support the solicitation of advice in accordance with statutory requirements, including any notices sent to Indian Health Programs and/or Urban Indian Organizations, as well as attendee lists if face-to-face meetings were held. Also upload documents with comments received from Indian Health Programs or Urban Indian Organizations and the state' s responses to any issues raised. Alternatively indicate the key issues and summarize any comments received below and describe how the state incorporated them into the design of its program. Document Please provide a short description of this support document: Agenda for ACA Implementation Meeting Uploaded Document Name: Agenda for ACA Implementation Meeting.pdf Indicate the key issues raised in Indian consultative activities: Access Summarize Comments Summarize Response Quality Summarize Comments Summarize Response Cost Summarize Comments Summarize Response TN: UT- 14-0007- MM7 Approval Date: 04/02/ 2014 Effective Date: 01/ 01/ 2014 Utah http://] 57. 199. 113. 99/ MMDL/faces/ protected/ mac/c01/ print/ PrintSelectorjsp 04/ 01/ 2014

UT.0725. R00.00 - Jan 01, 2014 Page 1 I of 12 Payment methodology Summarize Comments Summarize Response Eligibility Summarize Comments Summarize Response Benefits Summarize Comments Summarize Response Service delivery Summarize Comments Summarize Response Other Issue Oleflicair st e JLar), E1i(,2il)i1it : imm.i. r° Pmye ( ; I V79) State/ Territory name: Utah Transmittal Number: Please enter the Transmittal Number( TN) in theformat ST-YY-0000 where ST= the state abbreviation, YY= the last two digits of the submission year, and 0000= afour digit number with leading zeros. The dashes must also be entered. UT- 14- 0007 Proposed Effective Date 01/ 01/ 2014 mm/ dd/ Yyyy) Federal Statute/Regulation Citation Pub. L. No. 1 I 1- 148 Federal Budget Impact Federal Fiscal Year Amount First Year 2014 0. 00 Second Year 2015 0. 00 TN: UT- 14- 0007- MM7 Approval Date: 04/ 02/ 2014 Effective Date: 01/ 01/ 2014 Utah http:// l 57. 199. 113. 99/ MMDL/faces/ protected/ mac/ c01/ print/PrintSelectorjsp 04/ 01/ 2014

UT.0725. R00.00 - Jan 01, 2014 Page 12 of 12 Subject of Amendment Presumptive Eligibility by Hospitals- The fiscal impact for this SPA is included in the fiscal impact entered for the MAGI eligibility group SPA 14- 0001- MM. Governor' s Office Review Governor' s office reported no comment Comments of Governor's_office received Describe: No reply received within 45 days of submittal Other, as specified Describe: Signature of State Agency Official Submitted By: Craig Devashrayee Last Revision Date: Apr 1, 2014 Submit Date: Jan 3, 2014 TN: UT- 14- 0007- MM7 Approval Date: 04/ 02/ 2014 Effective Date: 01/ 01/ 2014 Utah http://] 57. 199. 113. 99/ MMDL/faces/ protected/ mac/ c01/ print/PrintSelector.jsp 04/ 01/ 2014

Table of Contents State/Territory Name: Utah State Plan Amendment (SPA) #: UT- 14- 0035- MMI This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179- like data) 3) Approved SPA Pages TN: UT- 14- 0035- MM 1 Approval Date: 11/ 17/ 2014 Effective Date I 1! 01/ 2014

DEPARTMENT OF HEALTH& HUMAN SERVICES Centers for Medicare& Medicaid Services e00,0 ZRh. M 1600 Broadway, Suite 700 Denver, CO 80202-4967 olow Region VIII November 18, 2014 W. David Patton, Ph.D. Utah Department of Health 288 North 1460 West PO Box 143102 Salt Lake City, UT 84114 RE: Utah # 14- 0035- MM1 Dear Dr. Patton: We have reviewed the proposed MAGI State Plan Amendment (SPA) submitted under transmittal number( TN) 14- 0035- MM1. This SPA removes the presumptive eligibility for children program in Utah. This program was only utilized for a small number of foster care children and is being discontinued due to low/no enrollment. Children can still access presumptive eligibility through the Hospital PE program. Please be informed that this State Plan Amendment was approved November 17, 2014 with an effective date of October 1, 2014. We are enclosing the Summary Form ( similar to the CMS- 179) and the amended plan page( s). If you have any questions concerning this amendment, please contact Ann Clemens at 303) 844- 2125. Sincerely, s/ Mary Marchioni Acting Associate Regional Administrator Division for Medicaid and Children' s Health CC: Michael Hales, Medicaid Director, UT Craig Devashrayee, UT

UT. 1300. R00.00 - Nov 01, 2014 Page 1 of 2 leek"lid State Plan, Flft"" ibilii , Still] mu"li" Pilot' W% 11' State/ Territory name: Utah Transmittal Number: Please enter the Transmittal Number( TN) in theformat ST- YY-0000 where ST= the state abbreviation, YY= the last two digits of the submission year, and 0000= afour digit number with leading zeros. The dashes must also be entered UT- 14- 0035 Proposed Effective Date 11/ 01/ 2014 mm/ ddlyyyy) Federal Statute/ Regulation Citation Pub. L. No. 1 11- 148 Federal Budget Impact Federal Fiscal Year Amount First Year 2015 0. 00 Second Year 2016 0. 00 Subject of Amendment Presumptive Eligibility- This SPA supercedes S30 in TN. No. 14- 0001- MM1. Governor' s Office Review Governor' s office reported no comment Comments of Governor' s office received Describe: No reply received within 45 days of submittal Other, as specified Describe: Signature of State Agency Official Submitted By: Craig Devashrayee Last Revision Date: Nov 4, 2014 Submit Date: Sep 25, 2014 h44r.o•// cvme_mmrll nAcAirlr nom/ N XAFM nrint/PrintCalartnr icn 1 1 / 1 R/ 7( 11 d

601 4CMS Medicaid Eligibility ON113 Control Number 09:38- 1148 ON,lB Expiration date: 10/ 31/ 2014 Eligibility Groups - Mandatory Coverage S30 Infants and Children under Age 19 42 CFR 437. 1 18 1902( a)( I 0)( A)( i)( l 11).( IV),( V1) and( V' 11) 1902( a)( I 0)( 0i i)( l V) and( 1X) 193 1( b) and( d) Infants and Childi-en under• Age 19- Infants and children under age 19 With household income at or below standards established by the state based on age III-OLIP. The LIP ill accordance with the following provisions: state attests that it operates this eligibility group hildren qualifying under this eligibility group must meet the following criteria: Are under age 19 I lave household income at or below the standard established by the state. MAGI- based income methodolo6es are used in calculating household income. please refer as riccessarx to SIO , Vl.AC'jl- Based Income Methodologies, completed by the state. Income standard used for infants under age one Minimum incorne standard The state had an income standard higher than 133% FPL established as of ecember 19, 1989 for determining eligibility for infants under ay one, or as of July 1., 1989, had authorizing legislation to do so. Yes C No The milliMLIM income standard for infants under age one is 13 ,(, FPL Maximum income standard The state certifies that it has subillilted and received approval for its converted income standard( s) for infants 121 under age one to MAGI- equivalent standards and the determination of the maxin'll.1111 income standard to be used for infants under age one. An attachmeni: is submitted. The state' s maximum income standard for this age group is: The state' s highest effective income level for coverage of infants under age one under sections 1931 ( low- income families), 1902( a)( 10)( A)( i)( 111)( qualified children), 1902( a)( 10)( A)( i)( W)( mandatory poverty level- related r infants), 1902( a)( 10)( A)( ii)( IX)( optional poverty level- related infants) and 1902( a)( 10)( A)( ii)( IV) institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI- eqL] iV,IICIlt percent of FPL, UT- 14- 0035- MM1 Approval Date: November 17, 2014 Effective Date: November 1, 2014 Utah S30, Page l

4CMS Medicaid Eligibility The state' s highest effective income level for coverage of infants under age one under sections 193) 1 ( loco- income families), 1902( a)( 10)( A)( i)( 111)( CILialif-tedchil(ii-eii), 1' 902(, i)( 10)( A)( i)( IV)( iiianciatoi-\, poverty level- related infants), 1902( a)( I 0)( A)( ii)( I X)( opt ional poverty levc]- relate(Iiiif',,Iiits) an( I 1902( a)( 10)( A)( ii)( IV) institutionalized children)., in effect under the Medicaid state plan as ot' December 3 1, 2013, converted to a MAGI-equivalent percent of FPL. Fhe state' s effective income level for any population off infants under age one under a Medicaid I I 15 demonstration as of March 23. 2010. converted to a VIAGI- equivalent percent of FPL. C The state' s effective income level for any population of infants under age one under a Medicaid I 115 demonstration as of December 31, 20 13. converted to a MAGI- equivalent percent of FPL 185 FPLe Income standard chosen The state' s income standard used for infants under age one is: C' ' The maximum income standard If not chosen as the maximum income standard, the state' s highest effective income level for coverage of infants under age one under sections 1931 ( low- income families), 1902( a)( I 0)( A)( i)( 111)( qualified children), 1902( a)( 10) W ( A,)(i)( IV)( mandatory poverty level- related infants,), 1902( a)( I 0)( A)( ii)( IX)( optional poverty level- related infants) and 1902( a)( 10)( 0 ii)( IV)( institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI- equivalent percent of FPL. If higher than the highest effective income level IbY this age group under the state plan as of March 23. 2010. and it' not chosen as the maximum income standard, the state' s highest effective inconic level for coverage of infants C under age One under sections 1931 ( low- income fiamili-_s), 1902( a)( I 0)( A)( i)( 111)( qualified children), 1902( x)( 10) A)( i)( IV)( mandatory poverty level- related infants), 1902( a)( I 0)( A)( ii)( 1X)( optional poverty level- related infants) and 1902( a)( I 0)( A)( ii)( IV)( instil lit ional ized children), in effect under the Medicaid state plan as of' December 31, 20 13, converted to a MAGI- equivalent percent of FPL. If higher than the highest effective inconic level for this age group under the state plan as of March 23, 2010, and C, if not chosen as the maximum income standard, the state' s effective income level for any population of infants under age one under a Medicaid 11 15 demonstration as of March 23, 2010, converted to a MAGI- equivalent percent of FPL. If higher than the highest effective income level for this age group Under the state plan as of March 23, 2010,(,in(] C if not chosen as the maximum income standard, the state' s effective income level for any population of iniants under age one under a Medicaid I 115 demonstration as of December 31, 2013, converted to a NIAGI- equivalent percent of FPL Another income standard in- between the minimum and maximum standards allowed, provided it is higher than the effective income standard for this age group in the state plan as of March 23, 2010. The amount of the income standard for infants Under one is: Income standard for children age one through age five. inclusive EN Minimum income standard UT- 14- 0035- MM1 Approval Date: November 17, 2014 Effective Date: November 1, 2014 Utah S30, Page 2 P1,111C, Ilf

Medicaid Eligibility The minimum incorne standard used f6r this age grOUP is 133° a FPI_ Maximum income standard The state certifies that it has subinitted and received approval for its converted 'income standard( s) for children age one through five to MAGI- equivalent standards and the determination of the maximum income standard to be used for children age one through five. F An attachineut is subniitted. The state's maximum incorne standard for children age one through Five is: The state' s highest effective incorne level for coverage of children age one through five under sections 1911 ( lo),v- Ce incorne families), 1902( a)( I 0)( A)( i)( l 11)( qualified children), I 902( a)( I 0)( A)( i)( V 1)( mandator} poverty level- related children age one through five), and 1902( a)( 10)( A)( ii)( IV)( institutionalized children), in effect under the Medicaid state plan as ol" March 23, 2010, converted to a MAGI- equivalent percent of FPL. The state' s highest effective incorne level for coverage of children age one through five under sections 1931 ( low- income families). 1902( a)( 10)( A)( i)( 111)( qualified children), 1902( a)( 10)( A)( i)( VI)( mandatory poverty level- related children age one through five), and 1902( a)( I 0)( A)( ii)( I V)( institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a N,,IAGI- equivalent percent of FPL The state' s effective income level for any population of children age one through five under a Medicaid 1115 C demonstration as of March 23. 2010, converted to a MAGI- equivalent Percent OH-Tt'. The state' s effective income level for any population of children age one through five under a Medicaid 1115 C demonstration as of December 31. 2013, converted to a MAGI- equivalent percent off-TI.. Enter the amount of tile maxiinurn income standard: 139 FPL, Income standard chosen The state' s income standard used for children a,, c one through five is: The rnaxirnUrn income standard if not chosen as the maximum income standard, the state' s highest effective, income level for coverage of,children age one throu- Ii five under sections 1931 ( low- inconie! t"arnilics), I 902( a)( 10)( A)( i)( 111)( qualified children)., I 902( a)( 10)( A)( i)( VI)( mandatory poverty level- related children age one through five), and 1902( a)( 10)( A)( ii) IV)( institutionalized children), in effect under the Medicaid state plan as of March 23. 2010, converted to a MAGI- equivalent percent of'[,' Pl-. If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state' s highest effective income level for coverage of children C age one through five under sections 1931 ( low- income families,), 1902( a)( I 0)( A)( i)( 111)( qualified children). 1902( a)( I 0)( A)( i)( VI)( mandatory poverty level- related children age one through five), and 1902( a)( I 0)( A)( ii) IV)( institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI- equivalent percent of FPI,. UT- 14- 0035-MM1 Approval Date: November 17, 2014 Effective Date: November 1, 2014 Utah S30, Page 3 pnf) e I of 5

Medicaid Eligibility If higher than the highest effective income level for thk age group under the state plan as of' March 23,' 20 10, and if not chosen as the maximum income standard, tile state' s effective income level for any population of children aae one throu- Ii five under a Medicaid I 115 demonstration as orklarch 23, 20 10, converted to a MAGI- equivalent percent of' 111L. If higher than the highest effective income level for this age gyroup under the state plan as ofklarch 23, 20 10, and C, if not chosen as the maxiniuni income standard, tile state' s effective income level for any population ofchildren age one thrOL12h five under a Medicaid I I 1 5 demonstration as of December 3 1. 2013. converted to a MAGI- equivalent percent ofFPL. C Another incorne standard in- between the mininium all([ niaxinium standards allowed, provided it is higher than the effective inCOlTle standard for this age group in the state plan as of March 23, 20 10. Income standard for children age six through age eighteen, inclusive Minimum income standard Tile mininium income standard used for this age proup is 1331") FPL. Maxillufln income standard d( s) for children a- e Fhe state certifies that it has submitted and received approval for its coiiverted income standai ards, in(] the determination oftlic maximurn income standard to be six through eighteen to MAGI- equivalent stand, used for children age six through age eighteen. E_ An attachmenI is sullmitted. The state' s waxiinuin income standard for children age six thrOLILY11 eighteen is: File state' s highest effective income level fior coverage of' children age six through eighteen under sections 193 1 low- income families), 1902( a)( I 0)( A)( i)( 111)( qualified children). 1902( a)( 1 0)( A)( i)( Vil)( mandatory poverty level- related children age six through eighteen) and 1902( a)( I 0)( A)( ii)( IV)( institutionalized children), ill eff ct under the Medicaid state plaii as of March 23. 20 10, converted to a MAGI- equivalent percent off PL. The state' s highest effective income level for coverage of children age six through eighteen under sections 193 1 Zn low- income families). 1902( a)( I 0)( A)( i)( 111)( qualified children). I 9021( a)( 10)( A)( i)( Vil)( mandatory poverty C level- related children a- e six through ei(, Iitecn) and 1902( a)( I 0)( A)( ii)( YV)( institutional i zed children). in effect under the Medicaid state plan as of December 3 1 201. 33. converted to a MAGI- cquivalent percent of FPL C The state' s effective income level for any Population of children age six through eighteen mider a Medicaid 1115 demonstration as of March 23, 20 10. converted to a MAGI- equivalent percent of FPI.. C The state' s effective income level R)r any population of children age six through eighteen Under a Medicaid 1115 demonstration as of December 3 1, 2013, converted to aMAGI- equivalent percent of Fill.. 133,1110 Fptl Income standard chosen The state' s income standard used f6r children age six through eighteen is: UT- 14-0035- MM1 Approval Date: November 17, 2014 EfFec—tiv-6—gat . November 1, 2014 Utah S3o. Page 4

Medicaid Eligib=lity If not chosen as the maximum income standard, the state' s highest effective income level for coverage of children age six through eighteen under sections 1931 ( low- income farni I ies), 1902( a)( 10)( A)( i)( 111) iqua I ificd children), 1902( a)( 10)( A)( i)( VII)( mandatory, poverty level- related children a0e six through ciolliteen) and 190-1( a)( 10)( A) ii)( IV)( institutionalized children), in effect under the Medicaid state plan as of March 23, 20 10, converted to a MAGI-equivalent percent of FTL. I rhi- her than the highest effective income level fbi- this age group under the state plan as of March 2.3. 20 10. and if not chosen as the ma.xinlLull income stanclard. the state' s highest effective income level for coverag-c ofchildren age six through eighteen under sections 193 1 ( low- income families), I 902( a)( 10)( A)( i)( I 11)( qualil'ied children), 1902( a)( I 0)( A)( i)( VII)( niandalory poverty level- related children age six through eighteen) all(] 1902( a)( I 0)( A) ii)( IV)( institutionalized children), in effect under the Nledicaid state plan as ofl)cccrnber', 1, 20 13, converted to I f higher than the highest effective income level for this age i rOUP under tile state plan as ofX1arch 23, 20 10, and if not chosen as the maximum incorne standard, the state' s effective income level fior any populatioll of children age six through eighteen undcr a Medicaid 1115 demonstration as of March 21, 2010, converted to a MAGI- equivalent percent of FPL. If higher than the highest effective income level for this age group under the slate plan as ofMarch 23, 20 10, an(] if not chosen as the iliaximurn income standard, tile state's effective income level for any population oCchildren age six through eighteen under a Medicaid I I 15 demonstration as of' Decernber 3 1, 20 13, converted to a MAGI- equivalent percent of FPL. C Another income standard in- betw-een the ininimuni and maximum standards allowed, provided it is higherthail the effective inconle standard for this age group in the state plan as of March 23, 20 1 O There is no resource test for this cligibility grOL11). NJ Presumptive Eligibility I he state covers children whcn determined presumptively cligible by a qualified entily. PK/\ [} According io tile paperwork Reduction Act of 1995, no persons are required to respond to a collection of information LulleSS it displays a valid OMB control number. The valid OMB control number for this information collection is 0938 | \ 4X. The time required mcomplete this in06nnmioo collection is estimated to average 4U hours per response., including the| imem review instruct ions. search oishxgJuo resources, gather the data needed, and complete and review the intbrmation collection. I fyou have comments concerning the accuracy of the tinle estimate( s) or suggestions for improving this t6rm. please write to: CMS, 7500 Security Boulevard. Attn: PRA Reporls Clearance Officer,& 4ai| Stop[ 420' Oi Baltimore, Maryland 2} 244'| 850. uT' 14-003*' MM1 Approval oum: November 17, uU1* Effective Date: November 1, 2014 Utah Soo, Page pom of

Table of Contents State/Territory Name: Utah State Plan Amendment (SPA) #: UT- 14- 0036 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179- like data) 3) Approved SPA Pages TN: UT- 14- 0036 Approval Date: 11/ 2- 151/20 1 4 Effective Date 12/ 0 I/ M 1- 1

DEPARTMENT OF HEALTH& HUMAN SERVICES Centers for Medicare& Medicaid Services mom AM dwwlft 1600 Broadwav, Suite 700 Denver, CO 80202-4967 twor, Region VIII November 25, 2014 W. David Patton, Ph.D. Utah Department of Health 288 North 1460 West PO Box 143102 Salt Lake City, UT 84114 RE: Utah# 14- 0036 Dear Dr. Patton: We have reviewed the proposed State Plan Amendment ( SPA) submitted under transmittal number( TN) 14- 0036. This SPA amendment allows children who leave the foster care system, and are placed permanently with a relative, to continue to qualify for Medicaid until they turn 18 years old. Please be informed that this State Plan Amendment was approved today with an effective date of December 1, 2014. We are enclosing the CMS- 179 and the amended plan page( s). If you have any questions concerning this amendment, please contact Ann Clemens at 303) 844- 2125. Sincerely, s/ Richard C. Allen Associate Regional Administrator Division for Medicaid and Children' s Health CC: Michael Hales, Medicaid Director, UT Craig Devashrayee, UT

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED HEALTHCARE FINANCING ADMINISTRATION OMB NO. 0938- 0193 r- 1. TRANSMITTAL NUMBER: 2. STATE: TRANSMITTAL AND NOTICE OF APPROVAL OF 14- 036- UT Utah STATE PLAN MATERIAL FOR: HEALTHCARE FINANCING ADMINISTRATION 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT( MEDICAID) TO: REGIONAL ADMINISTRATOR 4. PROPOSED EFFECTIVE DATE HEALTHCARE FINANCING ADMINISTRATION December 1, 2014 DEPARTMENT OF HEALTH AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL( Check One) NEW STATE PLAN AMENDMENT TO BE CONSIDERED AS NEW PLAN AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate Transmittal for each amendment) 6. FEDERAL STATUTE/ REGULATION CITATION: 7. FEDERAL BUDGET IMPACT: a. FFY 2015 $ 0 Section 1902(x) of the Social Security Act b. FFY 2016 $ 0 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT( If Applicable) Page 2 of ATTACHMENT 2. 2- A Page 2 of ATTACHMENT 2.2-A 10. SUBJECT OF AMENDMENT: Coverage for Kinship Guardianship 11. GOVERNOR' S REVIEW ( Check One): GOVERNOR' S OFFICE REPORTED NO COMMENT OTHER, AS SPECIFIED: COMMENTS OF GOVERNOR'S OFFICE ENCLOSED NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL 12. SI 16. RETURN TO: Craig Devashrayee, Manager 13. TYPED NAM David Patton, Ph. D. Technical Writing Unit Utah Department of Heath 14. TITLE: Executive Director, Utah Department of Health PO Box 143102 Salt Lake City, UT 84114-3102 15, DATE SUBMITTED: October 6, 2014 Q ols r_ 4 1i, I, ,": Ii1` F '} ttr!` Ti a re! D 3 11[ ll A1fen i F1. n1, . c1 . R` RrF f OII C JP' ATtA. i I C!

Revision: HCFA-PM- 91- 4 BPD) ATTACHMENT 2. 2- A August 1991 Page 2 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: UTAH GROUPS COVERED AND AGENCIES RESPONSIBLE FOR ELIGIBILITY DETERMINATION Agency" Citation( s) Groups Covered A. Mandatory Coverage- Categorically Needy and Other Required Special Groups ( Continued) 2. Deemed Recipients of AFDC ( Continued) 408(a)( 1 1)( B), b. An assistance unit deemed to be receiving AFDC for a 1931( c)( 1), and period of four calendar months because the family 1902( a)( 10) becomes ineligible for AFDC as a result of collection A)( i)( 1) of or increased collection of support and meets the the Act requirements of section 408( a)( 1 1)( B) of the Act. 1902( a)( 10)( A)(i)( I) C. Individuals deemed to be receiving AFDC who meet the and 473( b) of the requirements of section 473( b)( 1), ( 2) or( 3) for whom the Act an adoption assistance agreement is in effect or foster care or kinship guardianship maintenance payments are being made under title IV- E of the Act. Agency that determines eligibility for coverage. T. N. # 14- 036 Approval Date 11/ 25114 Supersedes T. N. # 92- 01 Effective Date 12- 1- 14

Table of Contents State/Territory Name'i- Utah, State Plan Amendnient (SPA),## UT- 14- 0001- 1V MI This file contains the following documents in the order listed: 1) Approval Letter, 2) Summary Form 3) Superseding Pages Notice (delete if not applicable) 4) Approved SPA Pages TN: UT-14=0001MMl Approval Date: 05/ 14/2014 Effective Date: 01/ 01/ 2014

DEPARTMENT OF HEALTH& HUMAN SERVICES Centers for Medicare& Medicaid Services We 1600 Broadway, Suite 700 Denver, CO 80202-4967 Region V1II May 20, 2014 W. David Patton, Ph.D. Utah Department ofHealth 288 North 1460 West PO Box 143102 Salt Lake City, UT 84114 RE: Utah# 14- 0001- MM 1 Dear Dr. Patton: Enclosed is an approved copy of Utah' s state plan amendment ( SPA) 14- 0001- MM 1, which was submitted to CMS on August 27,,2013. SPA 14- 0001- MM 1 incorporates the MAGI-based mandatory and optional eligibility groups' requirements into Utah' s Medicaid state plan in accordance with the Affordable' Care Act. The effective date of this SPA is January 1, 2014. We are also sending a copy of the following state plan pages and attachments to be incorporated within a separate section at the end of Utah' s- approved-state plan: S 14, S25, S28, S30, S32, S33; S50, S51, S52, S53,, S54, S5.5, S57, S59 In addition we will send a summary of the state plan pages which are superseded by SPA 14- 0001- MM1, which should also be incorporated into a separate section in the front of the state plan. Superseding pages of state plan material, SPA 14- 0001- MM1 CMS appreciates the significant amount of work your staff dedicated to preparing this state plan amendment. If you have any questions concerning this amendment, please contact Mandy Strom at( 303) 844- 7068. Sincerely, s/ Richard C. Allen Associate Regional,Administrator Division for Medicaid and Children' s Health CC: Michael Hales, Medicaid Director, UT Craig Devashrayee, UT'

UT.0233. R00. 00 - Jan 01, 2014 Page 1 of 15 d State Plam Eti`g*N'Iitv Medicai edicaid State Plan, 11'li4jibilily- 3bhera forina1 o State/Territory name: Utah Transmittal Number: UT-.14- 0001 General Information: Submission Title- short( under 100 characters) label used to identify 66 submission in the web application 14- 0001- MM Description: MAGI- Based Eligibility Groups S14, 525, 528, S30, S32, 533, S50, S5' 1, 552; 553, S54, 555, 557, and S59 Populations Covered: Mandatory Coverage: i Parents and Other Caretaker Relatives Pregnant Women Infants and Children under Age 19 Adult Group ' Former°Foster Care Children Options for Coverage: Individuals above 133% FPL Optional Coverage of Parents and Other Caretaker Relatives Reasonable Classification of Individuals under Age 21 Children with Non1V- E Adoption Assistance Optional Targeted' Low Income Children Individuals' with Tuberculosis IndependentToster Care Adoleseents Individuals.Eligiblefor Family Planning Services Medicaid State Plan E1idib l t-i . File `" l t ement Sulmnairy StatefFerritory name: Utah Transmittal Number: UT- 14- 0001 Type of SPA Cod Form e Form Name/Description Uploaded. MAGI- Based Eligibility S14 AFDC Income Standard yes Groups TN: UT- 14- 0001- MM1 Approval Date: 05/ 14/2014 Effective Date: 01701/ 2014 Utah Summary file:///6:/DMCH%20Share/ UT%2014- 0001- MNA% 2.0Revised% 2OSubmission%x2004. 24.... 05/ 20/ 2014

UT.0233. R00. 00 Jan 01, 2014 Page 2 of 1° 5 Groups MAGI- Based Eligibility S28 Mandatory: Pregnant Women yes Groups MAGI-Based Eligibility S30 Mandatory: Infants and Children Under Age 19 yes Groups MAGI-Based Eligibility S32 Mandatory: Individuals Below 133% of the F,PL yes Groups MAGI- Based Mandatory: Former Foster Care Children up to Eligibility S33 age 26 yes, Groups MAGI- Based Eligibility S50 Optional: Individuals Above 133% of the FPL yes Groups MAGI- Based Eligibility S51 Optional: Optional.Parents and Caretakers yes Groups MAGI- Based Optional: Reasonable Classifications of Eligibility S52 Individuals yes Groups MAGI- Based Eligibility S53 Optional: NowIV-E Adoption. Assistance yes Groups MAGI- Based Eligibility S54 Optional: Optional Targeted Low Income yes Groups Children MAGI-Based Eligibility S55 Optional: Tuberculosis yes Groups MAGI- Based Eligibility S57 ' Optional: Foster Care Adolescents,- Chafee yes Groups MAG[- Based Eligibility S59 Optional: Family Planning yes Groups Eligibility Single streamlined application or alternative, S94 Renewals,,Coordination.for enrollmenVand` no Process eligibility( agreements with Exchanges). Designates the income options the state is electing! MAGI Income m S10 2014( e g. • w ho pregnant women are counted, no Methodology reasonablyp redictable changes in income; cash support; how,full4ime students.are counted) Single Sfate A1- 3 Addresses single state agencies delegation of no Agency appeals and determinations State affirms residency regulations and addresses; Residency S88 no interstate agreements and temporary absence Cifizenship& i . State affirms citizenship regulations, specifies Immigration S89' reasonable opportunity options, and specifies no Status policy options related to immigrant eligibility Hospital State specifies options for presumptive eligibility Presumptive S21 ... ti no TN: UT=14- 0001- MM1 Approval Date: 05/ 14/ 2014 Effective Date: 01/ 01/ 2014 Utah Summary file:///6:/DMCH% 2OShate/ UT%2014- 000.1- MM%20Revised%o20Submission% 2004.24.... 05/ 20/2014

UT.02`33. R00. 00 - Jan 01, 2014 Page 3 of 15 Medicaid edic id STate Ptan fioi ifi( N p Fi l l; l r tll c1 F c c c l xs Form Description: AFDC Income Standards Uploaded Form: Da t, jdoadcd 03/ 10/ 20C' S 14- AFDC income stand- 3. pdf Support Documents Document. Please provide a,short description of this support document: Email approval of converted amounts. Uploaded DocumentName' faie t l oadet : t A011 Z,4,. 1..=,!_ AFDC converted amounts approval.pdf Please provide a short description, of:this support:document: 2014 MAGI Conversion Plan. Uploaded Document.Name: Bate Uploaded:, 03 10/ 2914 Utah' s MAGI Conversion-Plan 20.14. pdf Please provide a short description of this support document: Response to R'A1. Uploaded Document Name: Date Uplipaded. 0,1110/ 2014 SPA 14- 0001 MM.Response to RAI- 3- 6- 14 pdf Please provide.a short description of this support document: Superseding Pages Document Uploaded Document_ Name: Date t'' pl oatcled 04./24%2014 UT 14- 0001 Superseding D._.__- ..___ . .... ....... ......... ocument.pdf Forst S25: FlicTibil t '.ro ps— Mandatory '`over°a,(,,e- Parent's and:Other Cal*0iiker RelAtives Form Description: Parents and Other Caretakers Uploaded Form: S25- Parents rou,. .._ . _._ _, _.._. t mc 1.. I Ioli€ ed. 03/ lt1r201 g p•pdf Support. Documents TN: UT- 14- 0001- MM1 Approval Date: 05/ 14/ 2014 Effective Date: 01/ 01/ 2014 Utah Summary file:/// G:/ DMCH%20Share/ UT%x2014- 0001- MM%20Revised% 2OSubmission% 2004.24.... 05/ 20/ 2014

UT.0233. R00.00 - Jan Ol.; 2014 Page 4 of 15 Document ' F 1 i 2 < l l ill a6da :or f o erAg N` omen Form a Description: Pregnant Women Uploaded Form: W. Date Uploaded: 03/ 10` 2011,' S28- pregnant women.pdf Support Documents Document Please provide a short' description of this support document: Response to RAI_ Uploaded Document:Namet Date U'pl(Imied: 031111/ 2014 SPA 14- 0001- MM-Response to RAI- 3- pdf 6- 1 4 Please,provide a short description of this support document: Baby Your Baby Application. Uploaded Document Name- Date 1. plot de€1: 03/ 10/ 2014 BYB app] English 1- 22- 2014 pdf Please provide a short description ofthis support document' 2014 Baby Your Baby Training,Manual Uploaded Document Name: Dale Uplo*- Ie€1:) 31W2014 BYB Manual3. pdf Form, S30. 1; ilgibility Gro ,1 A. Ma11a1R:1tory C ove a ge: n,fants afid Children' tinder X 0e 19 Form Description: Infants and Children Under' Age 19 Uploaded Form: Mat€ 1 plowl€d: 03'- 10 201 ...,.., S30- children pdf by" w -:.. 5 rc„ rck„ ww,....«'< ` 83 ,"' '. ..« mrc ii.mi,. s,«,.. ', i. «*. '; i....-• . ... Support Documents Document Please provide a short description of this support document: Response to RAI. TN: UT- 14-0001- MM1 Approval Date: 05/ 14/2014 Effective Date: 01/ 01/ 2014 Utah Summary file:///G:/ DMCH%20Share/ UT%2014- 0001- MM%o20Rev ised% 20Subm i's sion% 20,04. 24.... 05/ 20/ 2014

UT.0233. R00.00 - Jan 01, 2014 Page 5 of 15 Uploaded Document Name:. Mac I IW adc€3 03/ 10/ 2`01. 1 SPA 14- 0001- MM Response to RAI- 3- 6-,14. pdf " Please provide a short description of this support document: Presumptive Eligibility Training Uploaded Document Name: Da te t ploaaled:€ 131, 1 11/ 2014 PE Kids Trainmg:pdf Please provide a short-description of this support document: Presumptive Eligibility- Medical Programs Uploaded Document Name: Date 1 pllp adcld 08/ 22/ 21013 S30- Child- Attachment.42: pdf Please provide a short;description of this support document: Application Information. Uploaded Document Name: Date 1; l)1ksaded:, 03 10/ 2tI1. 1 61 HPE appl. pdf Please provide a,short description' of this support document: Presumptive Eligibility Flow Chart Uploaded Document Name: t3aate t. fjo a€ red: Q8/ 221201-3 S30 Child- Attachment# 1 pdf Forni' S` 2: loll$ i1> 11, r e N aticl too ;- ra e.. 1 1 . r°o tea. Form Description: Individuals Below 133% ofthe FPL Uploaded Form: Date Uploaded: 13r' 101"201 532- adult group.pdf Support Documents Document Fo1' in S33 Eligibility Groups - Nlandalory C(A'erage: Former Foster ;;MIC iililt°€ al`s TN: UT- 14- 0001- MM1 Approval Date: 05/ 14/ 2014 Effective Date: 0110112014_ Utah Summary file:///G / DMCH% 20Share/ UT%2014- 0001- MM%20Revised% 2OSubmiSsion%x2004.24.... 05/ 20/ 2014

UT.0233. R00.00 - Jan 01, 2014: Page 6 of 15 Form. Description: Former Foster Care Children up to' Age 26 Uploaded Form: t r, l1 2131 S33- former foster care.pdf eaa .., s ., , ,.,.^ .,... .. {„ „.. ,,, . An", t Support Documents Document Form S50.—Eligibility Groups _ Options. for ; raver,,r e lradivieorrrr'ls above 133%) 1.- 1:x] Form Description: Individuals Above 133% ofthe FPL Uploaded Form: Date r.' ploade(l, 03/ 10/ 2,101 `` S50- over 133. pdf f 3 f+ ,,,,,,,:' ia* ,. uY n ,-- S„` 4' s`. bEVavvr Support Documents Document Form S, 1 b Opfiorrs lira Coveragea OfAhonal C"overa— le of* arenits and Other r' aretak Relatives Form Description: Optional Parents and Caretakers Uploaded Form: Date U'ploade : 03/ 10/ 201- S5.1 optional parents. pdf. Support Documents Document a- o rrr 2: Eligibility (T'roups - Options for Cow rage: asmiabl :' lassifi a iorr of' foldivir rraa1s under .ikoe 21 TN: UT- 14- 0001- MM1 Approval Date: 05/ 14/ 2014 Effective Date: 01/ 01/ 2014 Utah Summary file:/// G:/ DMCH%20Share/ UT%2014- 0001- MM%20Revised% 2OSubmission% 2004.24.... 05/ 20/ 2014

UT.0233 R60.00 - Jan 01, 2014 Page 7 of 15 Form Description: Reasonable Classifications of Individuals Unloaded Form: Date 1.pk) ded: ti / 0/ 201 . S52 Reasonable Classifications.pdf A r.,,,.,.,. r ,, ; „„. gym°* s,. :.: n i. ,,,... w..., a« w., _. T..., a Support Documents Document Please provide ashort description of this support document: Reasonable Classifications of Individuals- SPA Pages Uploaded Document Name: Daft,,Uplonded 081,15/ 2013 S52- Reasonable Classifications- Attachment.pdf 1` rl ° :'. Eligibility ~t l s 1 1 0, € age, ` 1 il. 1, 11 o - E Adoption Assistance Form Description: Non IV- E Adoption Assistance Uploaded. Form: l Me PLipfl ade83: $)'a3/ 111 201. ..,.. S53- non-[ _ _,_... . mr_ W,_ ,_.__ , .•_.. .__ VE adoption.pdf Support Documents Document 1E' ttr°n 54; figibility 1is ° _: as i' ll'Y1f ° g1 1.," y 1.ncome Children Form Description: Optional Targeted Low Income Children Uploaded Form: Mat-, plta3dedl 3/ 10/ 2131. S54- optional targeted child.pdf Support Documents Document Form : E1i i ilil,4` ' 0'roups - Options for (..overage. Individuals with T'llb€rc io is TN: UT- 14- 0001- MM1 Approval Date: 05/ 14/2014 Effective Date: 01/ 01/ 2014 Utah Summary file:// G:/ DMC"%. 20Share/ UT%2014- 0001- MM%.20Revised%o2OSubmission%.2004.24.... 05/ 20/2014

UT.0233. R00.00 - Jan 01, 2014 Page 8 of 15 Form Description: Tuberculosis Uploaded Form 1rt Uploaded,- 03/ 10,201 S55- optional TB. pdf NON Support Documents- Document Form S,57. Eli ibility Gromps - Options for overa ee—hrdetie dent Foster Care Adolescents . nts . Form Description: Foster Care Adolescents,- Chafee Uploaded Form: Date U1.4 aaa ed—, 03111011"X11 e„. l S57- optional Independent FC. pdf y.. Support Documents Document Eligibility ',,mops - ljti.on fp h; li i ee m Form V Description: Family Planning Uploaded Form: la tc 1att.; ta1€;t1 1.1;?% ttt1 111-- _. S59- optional family plannmg.pdf r Support Documents Document' 1k`ors A Gener l : l ih lity eq iret e s. Eligibility Process TN: UT- 14- 0001- MM1 Approval Date: 05/ 14/2014 Effective Date: 01/ 01/ 20141 Utah Summary, file:///G:/ DMCH 6/o20Share/ UT% 2014-0001- MM%20Revised%o2OSubiniss on% 2004.24.... 05/ 20/2014

UT.0233. R00. 00 - Jan 01, 2014 Page 9 of 15 Form Description: Uploaded Form: Date p'l44Wlded Support Documents Document Form S.10: MAC'1- as d uh; e iv lbodol gibes. Form Description: Uploaded Form: Support Documents IDocument- Form A 1- 3: Medicaid' A- t bolls S I iDgle I RAN' :' Form Description: Uploaded Form: nj a,_. _ e Date. l il toka€ ed Support Documents Document Please provide a short description of this support document:. UploadedD_. ocnment Nam_ e: Date U, sloa ed.— 08/ 15/ 2013 W.. W.. _,._ . ._._._ ._._ DMHF Or"g Chart.pdf TN: UT- 14=0001- MM1 Approval Date: 05/ 14/ 2014 Effective Date: 01/ 01/ 2014 Utah Summary file:///G:/ DMCH% 20Share/ UT% 2014- 0001- MM%2ORevised°/ o2OSubmission%2004. 24.... 05/ 20/2014

UT.0233. R0000'- Jan 01, 2014 Page. 10 of 15 Form r3 Description: I Uploaded Form: taatt L. t: lza r1tt€t "..• r Support Documents Document 1. or m 9: on- 1 Citizenship. ., a ld NOII- izeax , Ii gi Form Description: Uploaded Form: Mate, I-. plow'k' IAA Support Documents Document Pcore S21: Presumptive ive 1 licH)'Ifity by Hospitals srcuce^^zrci..:, ; „ a i,' .. 3'.3r„ ": .:.,,..,., sa,„„... Yaar.. r;,:,, n;...:. cn.: r., z; ur.^ ; spa < e Form Description: Uploaded. Form: Date Jolo tcled .. t Support Documents Document Yt ( 1 State State/Territory name: Utah TN: UT- 14- 0001- MM1 Approval Date: 05/ 14/ 2014 Effective Date: 01/ 01/ 2014 Utah Summary file:///G:/ DMCH%20Share/ UT%2014=0001- MM%20 Rev ised% 20Submission% 2004.24.... 05/ 20/ 2014

UT.0233. R00. 00 - Jan 01, 2014 Page l 1 of 15 Transmittal Number: UT- 14- 0001 rr One or more Indian Health Programs or Urban Indian Organizations furnish health care services in this y State. f This State, Plan Amendment is likely to have a direct effect on Indians, Indian health programs or Urban Indian Organizations. The State has solicited advice,from; Indian Health Programs, Urban Indian Organizations, and/or Tribal;governments prior to submission of-.this,State Plan,Ameridmen"t. Complete thefollowing.infdrtnation regarding any tribal consultation conducted with respect,to,this submission: Tribal consultation was conductedin the following manner. States are not required to consult with Indian tribal governments, buf.if such consultation was conducted,voluntarily, provide,information about such con_sultation below: 71 Indian Tribes Indian Tribes El Name of Indian Tribe`. Goshute Indian Tribe Date of consultation: 07/ 16/ 2013 E ( mm/ ddly_y Method/ Location,of consultation: Meeting at,the.Utah Departriment.o"f Health( Highland Drive:B1dg:, SLC, UT). Bridge line was avaiI able.to,access- meeting by phone: Name of Indian Tribe: Navajo Indian Tribe Date of consultation: 07/ 16/ 2013 mm/ ad/ YYYY) Method/ Location of consultation: Meeting at the Utah Departmentof Health,( Highland Drive B1dg., SLC, UT). Bridge line was-available-to access meeting by, phone. Name of Indian.'Tribe: Paiute Indian Tribe N.... Date,of consultation: 07/ 16/ 2013 mm/ ddlyyyy) Method/ Location of consultation: Meeting at the Utah Department of Health( Highland Drive Bldg.,SLC, UT). Bridge line was available to access meeting by phone: Name of Indian Tribe: Shoshone Indian Tribe Date of consultation: 07/.16/ 2013 mmydd/ YYYY) Method/ Location of consultation: Meeting at the Utah Department of Health( Highland Drive BIdg.,$ LC, UT). Bridge line was available to access meeting by phone. Name of Indian Tribe: TN: UT=14- 0001- MM1 Approval Date: 05/ 14/ 2014 Effective Date: 01/ 01/ 2014 Utah Summary file:///G:/ DMCH%o20Share/ UT% 2014- 0001- MM%o20Revised%o20Submission%2004:24:... 05/ 20/ 2014

UT.0233. R00.00 Jan 01, 2014 Page 1, 2 of 1. 5 Ute:Indian;Tribe: wr Date,of consultation: 071 16/ 2013 inm/ dd/ YYYY) Method/ Location of consultation: Meeting at the' Utah Department of Health( Highland Drive Bldg.,SLC, UT). Bridge line w,as,availableto access meeting by,phone. Indian Health Programs Indian Health Programs Name of Indian Health Programs:. Fort Duchesne Health Center Date,of consultation: 07/ 16/ 2013 inm/ dd/ YYYY) Method/ Location ofconsultation: Meeting at the Utah Department of Health( Highland Drive Bldg., SLC, UT). Bridge line was available to access meeting by, phone. Name of Indian Health Programs: Navajo Area Indian. Healt Health Service Date of consldltatio n; 07/ 16/ 2013 mmlddlYYYy) Method/ Location ofconsultation: Meeting at the Utah Department of Health( Highland Drive Bldg.,SLC, UT). Bridge line was; available to access meeting by phone. Name of Indian Health Programs: UtahNavajo.lndian Health Systems, Inc. f consultation: 07/ 16/ 2013 mm/ dd/ YYYY) Method/ Location of consultation: Meeting at the Utah Department of Health( Highland Drive Bldg.,SLC, UT). Bridge line_was availablel to access meeting by phone. i Urban Indian Organization Urban Indian Organizations Name of Urban Indian Organization: Urban Indian Center of Salt Lake Date"of consultation: 07/ 16/ 2013 mm/ dd/ YYYY) Method/Location ofconsultation: Meeting atAhe Utah Department of Health.( Highland Drive Bldg.,SLC, UT). Bridge line was available to access meeting by phone. The state must upload copies of documents that support the solicitation of advice in accordance with statutory requirements, including any notices sent to Indian Health Programs and/or Urban Indian Organizations, as well as atte,ndee•lists if`face- to-face meetings were held. Also upload documents with comments received from Indian Health-Programs or Urban Indian Organizations and the state' s responses to any issues raised. Alternatively indicate the key issues and summarize any comments received below and describe how the state incorporated them into the design of its TN: UT- 14- 0001- MM1 Approval Date: 05/ 14/2014 Effective Date: 01/ 01/ 2014 Utah Summary file:///G;/ DMCH6/o20Share/ UT%2014=0001- MN4% 20Revised% 2OSubmission% 2004.24.... 05/ 20/ 2014

UT.0233. R00.00 - Jan 01, 2014 Page 13 of 15 program. Document Please provide a short description of this support document: Agenda for' ACA Implementation Meeting Uploaded Document,Name:, Jploaded. 08/ 16,1013 Agenda for ACA Implementation MOeting.pdf Indicate the key issues raised in' Indi'aii consultative-attivities: Access Summarize Comments Summarize Response 3 . Quality Summarize"Comments w Summarize Response e Cost Summarize Comments A question was raised assto whether Individual Indian Money accounts are exempt from these SPA Changes. Summarize Response Utah Medicaid confirmed that the money accounts are exempt. Payment methodology Summarize Comments M, Summarize Response Eligibility Summarize Comments Summarize Response Benefits Summarize Comments Summarize Response e._._ ...... Service delivery Summarize Comments TN: UT- 14- 0001- MM1 Approval Date: 05/ 14/ 2014 Effective Date: 01/ 01/ 2014 Utah Summary file:/// G:/ DMCH% 20Share/ UT%02614=0001- MM%20Revised% 2OSubmission% 2004. 24.... 05/ 20/ 2014

UT.0233. R00. 00 - Jan 01., 2014 Page 14 of 15 Summarize Response Other Issue Medicaid SLate Ian. l i i li ty: unini r lage ( 1179 State/Territory name: Utah Transmittal Number: Please enter the Transmittal Number( TN) in.the.format,,ST-YY-000O where ST= the state abbreviation, YY=' the.last two digits of the subttiission year, and 0000= a four digit number with leading zeros. The dashes must also be entered. UT- 14- 0001 Proposed Effective Date 01/ 01/ 2014 i ( mm/ dd/ yyyy) Federal Statute/Regulation Citation Pub. L. No. I 1 1- 148 Federal Budget Impact Federal Fiscal Year Amount First Year ` 2014 1168800. 00 Second Year 2015 - 4675300. 00 Subject of Amendment MAGI-Based Eligibility Groups- The estimated federal fiscal impact accounts for all the other Affordable`Care Act SPAS. Governor' s Office Review Governor' s office reported no.comment Comments of Governor' s office received Describe: No reply':received within-45 days of submittal. Other, as specified Describe: Signature of State Agency Official Submitted By: Craig Devashrayee Last Revision TN: UT- 14- 0001- MM1 Approval Date' 05/,14/ 2014 Effective Date: 01/ 01/2014 Utah Summary file:///6:/DMCH%20Share/ UT%2014- 0001- MM%o20Revised% 20Submission%02004.24.... 05/ 20/2014

UT.0233. R00. 00 - Jan O f,,.20°l;4 Page 15 of 15 Date: Apr 24,,2014. Submit-Date: Aug 27, 1013 TN: UT- 14- 0001- MM1 Approval Date: 05/ 14/ 2014 Effective Date: 01/ 01/ 2014 Utah Summary file ///G:/ DMCH%2OShare/ UT%2014=0001- MM%20Revised%o2OSubmission% 2004.24.... 05/ 20/20'14

SUPERSEDING. PAGES OF STATE, FLAN MATERIAL TRANSMITTAL NUMBER: STATE: 14- C Jl Utah' Pages or sections of pages being supe,rseded by 514, 52:;, S , b, San S5L S5L S53, U5 , and S57, and related pages or sections of a( Tes being deletc._i as obsolete State Plan Section Complete. Pages Removed Partial Pages Removed Page . 1. Page 2, A. 2. Page 3 Page 2, A. 2. c Pale 3- Page 2a, h.? Page . Page 5, A. I' Page 4a Page: gc,' 8. 1 : fo :: Page 12 caretaker e'_ relati es u Attachment 2. 2- A Page 13 regna-nt women Page 23a Page 20, B. 14 age 14 Page 23a, 8. 20 gage 1, Pace 23, C. 4 Prge 21 Page 23 Page 23c Page 2. Supplement 1 to Attachment 2. 2- A Page 1 age 3b Page 1, ... 2. a ( i) and age 13 Page 6 related to AFDC age 19a recipients, pregnant Palo lab wowen, infants, Kati..,_; Attachment 2. 6- A Page 21 children Page 7, naill and ( 2) Page 12, C. I. e ( 2 Page , 18, C. .,. e Page 12b, C. 1. i Y........ Supplement 1 to .Attachment 2. 6- A Pages 1, 4 Supplement 2 to Attachment 2. 6- A Pages 1- 5 i 1 TN: UT- 14- 0001- MM1 Approval Date: 05114/ 2014 Effective Date: 01/ 01/ 2014 Utah Superseding Document

F riee,iy Supplement. 8a to Attachment 2. 6- A Page 2, re -- ed o and related a re Supplement & b to Attachment 2. 6'- A h-4 ldrc-n except Supplement 12a to Attachment 2 ` 6 A P a g 7.., l.a, I. , 1' any: 3 Supplement 14 to Attachment 2. 6- A Page 1 2 TN: UT-14- 0001- MM1 Approval Date: 05/ 14/2014 Effective Date: 01/ 01/ 2014 Utah Superseding Document

Eligibility OMB Control Number 0938,-11:48 OMB Expiration date I 3 / 2'014 AT°°T) C` Tncome°Stanc ar i5 i j s i i W k 14 Enter the AFDC Standards below. , ill stages miust:e'nter MAGI- equivalent AFDC Payment Standard, in Effect As of May 1, 1988 and AFDC`.Payment Standard in Effect As of July 16, 1: 996 Entry of other standards is optional. 4' ATiralert AH T.+ ` a entecY c a1T ar N fT Inc(.erne to diff loll ° r sou Ai tcir t 4 The standard is as follows: Statewide standard f z Standard varies by reoion Standard varies by living ah'angement j Standard varies in some other wad- TN: UT- 14- 001- MM Approved: 05/ 14/ 2014 Effective Date: 01/ 01/ 2014 Utah S14 Pane I of

e . _ Additional incremental amount Household size Standard($) 9; Yes (- j No 1 302 Increment amount RUM 41 8 3 522, 4 61' 3 5 703 6 780 7 829 8 88'0 9 932 IM' 0 X 982, . 11 1,032 r 12 1, 083 1411 13 1. 134 14 1, 1. 84 y 1S i, 236 f 16 1 ' 86 The dollar amounts increase automatically each year 7; Yes ( 0- No AIU G Paylllell illldald IIICffect; f duly 16 1 b Inc€ e standard EIItIy . llcllrmoullt` f11tlt}IIl tI Incres ) ticn A The standard is as follows: C®=Statewide standard. I C= Standard varies by region Utah S14 Nw)e`2 of.6

Medicaid ty C"' Standard varies by' living arrangement Standard varies in some other way i iltt r tf1E ttM'I''at' s I a s., Additional incremental amount I I lousehold size Standard( Sl Yes t No I 246 Increment amount 34? 426. 4 498 567 6 625 7 6:54 8 685 9 717 r e+ y 10 747 1 803 k 13 X840 1. 4 870 LIM 902 j 3 I 16 933 The dollar amounts increase automatically each year rt Yes (- v No N AG. equival >nt u z conri StaIaic try cl1a At€Inc ' ltutcaaaut ° aca "4ptxin In 53: W. arm TN: UT- 14- 001- MM Approved: 05/ 14/ 2014 Effective Date: 01/ 01/ 2014 Utah S14 13a2e 3 of'6

d 1 Thestatii and is as follows: j Statewide standard f-;'Standard varies by region i C,,.Standard varies by living arrangement C Standard varies in some other way The dollar amounts increase automatically each year 7 Yes ( No A1.:.)+ cl tacarcl"finectA1 Jul lk6 s1.196 nccsnte tit <rlarttntr llollarA + unt Autarrctis ncle s Option Sf3;t y.,. The standard is as follovvs Statewide standard 1 71 Standard varies by region Standard varies by living arrangement C, Standard varies in sorne blher way j The dollar amounts increase automatically each year C` Yes C: No tat claircl gwn f €t As fJu Y,. ti, 199E ner ascurvy n for tlia tl e >1 ro to s v k s F v y w Rsr.. a aw>t the Cpnrrmir 1' c 1` t , lrtr url cc st r etr. 0 1' 1 > C1 suclaclate nct at St tr cl trd l try` loll ii Amount 4r trritrc lncw e' ttan13aI The standard is as fr) Statewide standard 7; Standard varies by region Standard varies by living arrangement 7; Standard varies in so ie.other way The dollar amount's increase autonati'cally each year 1 i Yes C`: No TN: UT- 14- 001- MM Approved: 05/ 14/ 2014 Effective Date: 01/ 0192014 Utah S14 Page 4 of 6

j Ml '1eq i alei A e Iµ r ffe t c , a y 16, T Cr, ncr se i Iiy c i' e that tine erccritage t cr at ease IIn ti e Gonsurr er ' rI( lncie $f+ r urban ct x surne r 1 since y CII I ic rrntsi< nr3ard ifntr ia u eas The standard is as follows: Statewide standard Standard varies by region Standard varies by living arrangOnent. Standard varies in some othciVay The dollar amoLints increase automatically each year Yes No g y y y M TIT t t°6iIFAi#AU ? J f, , s \ YCw\ Aft llnec n Stadar n fitry =1) aiirtii nt rutcimatc ncaea t yi The standard is as follows: t° Statewide standard 7. Standard varies by region Standard varies by living arrangement 7, Standard varies in some,other way i i The dollar amounts increase automatically z",ch year Y es Jo NIt e u aiet N atxaerat' tau€i'aad core Stu irc t+ at y\- lloi tr Aruratut€ rrt tt4creus Sy tarr ya a The standard is as follows: Statewide standard I Standard varies by region Standard varies by living Arrangement 7, Standard varies in same-other way ApPFGved: 06/ 14/ 2044_ FffE6tbl2-D21E:..-.QlA-1•/? t1=4.— _.. Utah S14 Pn)e of 6

i The dollar armmnts increase automatically each year Yes No i 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 ONIB control number for this infornation collection is 0938- 1148. The time required to complete tins information collection is estimated to average-40 hours perxesponse, includi'ngthe 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 improying;this form, please write to.: CMS, 7500 Securav Boulevard, Atim PRA Reports Clearance Officer, Mail Stop C4 26. 05, Baltimore, Maryland' 21244=1, 850. TN; UT- 14- 001- MM Approved: 05/ 14/ 2014 Effective Date: 01/ 01/ 2014 Utah S14 Page 6 of 6

OM13 Control Number 008- 114& OMB Expiration date I0i311201.4' al krl%tarts 1VIat€'y : ti irae Parents and Other Caret er Rc es. rt _ ml 42 CFR 43 11. 1902( a)( I0)( A)( i)( 1) 1931'( b) and( d) Parents and Other Caretaker Relatives- Parents and other caretaker relatives of dependent children with household income at or below a standard established by the state. The state attests that it opeirates.tliis cligihi ity grcitip in accordance with the followinalirovisions: lndividuals qualifying under this eligihility P-i•map must meet;the following criteria: Are parents or other caretaker relatives( defined at 4 2" C l"R 435. 4), including pregnant women, of dependent children defined at 42 C; FR 4.f 5, l) underage 1 SpoLises of patients and other caretaker' relatives are also included. The state elects the follovv,ing:options: his eliaibility group includes individuals who are'parents or o'th'er° carctakers of children who are 18 years old, provided the•children are fitly-time,,students iii asecondarys school or the equivalent level of vocational or technical training. Options relating to the definition ofcaretaker relative( sclecrarl that apply): E] Options relating to the definition ofdependent child( scica the one that applies): f Have household income,at orbelow,the standard establishedby the state VI, GI- based income methodologies are used in calculating household income. Please refer as necessary to S10 N,IAGI- lased income' Methodologies, completed,by the state. Incorne standard used for this group Minimum inconi& standard The minimum income standard used for this group is the state's AFDC; payment standard in effect as of May 1, 1988, converted to NiAG1- equivalent amounts by, household size. Therstandard is•described in S 14- AFDC." Income Standards. Fhe state certifies that it has submitted and received approval for„its converted Nlay 1, 1988 AFDC payment standard. r A a t An aft achn cnt v ittedNhu Maximum income standard The, state certifies that it has submitted and received approval for its conve.rted"income standard("s). for parents and other caretakcr,relatiwes to MAGI- equivalent standards and the determination of thC°mahimum income standard to be used for parents and other caretaker relatives under this eligibility group: ip Il 41tt lehirleltt# Sum tteCl eI Ai ` v The state' s maximum income standard foi- this eligibility group is: t t4=0©01= 1Gtfvlfi---- a' .. @ate 05t14Y2S14— Ef#,active date 64fo4/ e4 - Utah S25 Pap i of 4

gibifity I lie state' s effective income level for Section 19,31 families under the Medicaid stage plan as of March 23, 2010; converted to a iVIAGl- equivalent percent of FPL, or amounts by house hold.size. flee state' s effective income level for section 1931 ran-ii Iies under the,Medicai( I state plan as of December 31. C, 2013, converted to a MAGI-equivalent percent of FPL or amounts by household size. The state' s effective;incorne level for any population of parents/caretaker relatives under a_Medicaid 1 115 demonstration as of March 23, 20'10: converted to a. MAGI- cOi"valent percent.of FPL or amounts by household size. The state's effective income level for:any population of parents/ caretaker relatives tinder a' Nledicaid 1 115 demonstration as of:December 31. 2013,: converied to,a MAGI- equ`iValent percent of P PI_,or amounts by household size. Enter the amount:,of the maximum income standard: A percentage of the federal`poverty' l'evel: The state' s AFDC payment standard in effect' as of' July 161, 1996, converted to N/IAGI- equivalent standard. The standard is described in: Sl4 AFDC, Income Standards. The state' s AFDC; payment standard in effect.as of July 16, l f)96, increased by no niore than the percentage. increase in the Consumer Price Index for urban consumers(. CPI- U), since such date, converted to a MAGI- equivalent standard.' ifhe°standard is described in S 14 AFDC Income Standards. The state' s TANF payment standard, converted to a MAGI- equivalent standard. The standard is described in. S14 AFDC' Income. Standards. e' Other dollar amount . increStanarc entryr311< r: nu'nf yutc l«>ttt< lre3tJo The standard is as follows: Statewide standard f Standard varies by region t"' Standard varies by living arrangement t ) Standard varies in some other way i Later the 4taixde stanard % f 33° yy t TN: UT-14-0001- MM1 Approval Date: 05/ 14/2014 Effective Date: 01/ 01/ 2014 Utah S25 Pate 2 of

Additional incremental amount I Tousehold size- Standard ($) o-; Yes - No 438 Increment amount S 62 544 3 6,78 f I 4 797 5 912 6 1, 012 7 1. 072. w I 91, a.96 TO 1, 257 11 1, 320 12 1, 382 T3' 1; 443 114 1, 505 2 15 I - 69 r 16 I The dollaeatnounts increase automatically each year C;; Yes (' m No Income standard choseln: Indicate the state's incorne, stan,dard-Used for this eligibility group: 7 The Irinilnurn income standard o' The maximum income standard The state' s AFDC payment standard in effect as ol'July 16, 1996, increased by no more than the percentage increase in the Consumer Price Index for urban consumers( CPI- l) sincesuch date." I he standard is described in S.14 Af`DC Income Standards. Approval Date" Effective Date: u / 0 014 Utah S25 Pape 3 oF4

Medicaid Eligibility Another income standard in- between, the minimum and maximum standards allowed There is no resource test for this eligibility group. Presumptive Eligibility The state covers individuals under this group when determined presuntptrvely eligible by a tlualified entity. The state assures it also covers individuals under tile Pregnant Women( 42.C1' R 435: 116) and/ or Infants and Children under Age 19( 42 CI' R' 435. 118) eligibility groups when determined presumptively eligible. 71 Yes ( 7e No PRA Disclosure Statement According to the Paperwork- Reduction Act of1995_,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.D cot lection is 0938- 1148, The time required to complete this information collection is estimated to average-40:hours per response, inclPding;the time,to review instructions., search existing data resources, gather the data needed, and complete and review the- nf'ormation collection. If you have comments concerning the accuracy of the time or suggestions for improving this form, please write to: CMS,.7500 SeeurityBoulevard. Attn: PRA Reports Clearance Officer, Mail Stop C4- 26- 05, Baltimore, Maryland 21244- 1850. TN: UT- 14- 0001- MM1 Approval Date: 05/ 14/2014 Effective Date: 01/ 01/ 2014 Utah S25 Page 4 of4

d fig"Wilty, QMB Control Number 0 938- 11 148 OMB Expiration date 10,%. 31/ 2014, Q,, p ant a>t ><- C r bra s X5 8 K y a Ri v s` L' diti (}lllf'II sA yi . E s.. mss.; 42 C,FR 4:35. 1 16 1, 902( a)( 10)( A)( i)( I11-) and( IV) 1902( u)( 10)( A)( ii)( I),(: IV) and( IX) 1931( b) and( d) 1920 Pregnant Women- Women who are pregnant or post-partum, with household income; at or below a standard established by the state. The state attests that it operates this eligibility group in accordance with the followi'itg„provisions: Individuals qualifying under this,eligibility group must be pregnant or post- partum, as defined in 42 CFR 435. 4. Pregnant women in the IasHrintester ctftheir.preeiiat?ey"witnotat dependent children are' eligible for full benefits under this group in accordance with section 19311 of the Act, if they meet the income standard for state plan Parents and Other Caretaker Relatives at 42 CF'R 435. 11' 0. Yes C, No MAGI-based income methodologies Iare usi d in calculating household incc,nme'. Please refer as necessary to S 10 MAGI- Based' Income Methodologies, competed by the state. Income standard used for this gaup Minimum income standard( Once enterea, alid approved by Ciy'iS, the•minimum income standard cannot be changed.) The state had an income standard higberthan 133°ro FPL established as ofUecember 19, 1989( or determining eligibility for pregnant women, or as,of July 1,' 1989, had authorizing legislation to do so. Yes 1r; ` Jo The minimum income standard fir this eligibility group is 133% FPl- Maximum income standard The state certifies that it has submitted and receive(] approval f'or its converted income standard( s) f,mpreamint 0 women to MAGI- cquivalent.startdards,and the determination orthe inahimurri, income standard to be used for pregnant wumen. under this eligibility gaup. c Xz ” y Aidatt c i nent rt Sub n tt€ The state`s maximum income standard for this eligibility, grout is: The state' s highest effective income level for coverage of pregnant W0111en under sections 1931 ( low- income families). 1902( a)'( 10)( A)( 0( 111)( qualified pregnant womeri), I" 2( a)( 10)(. A)(. i)(IV)( mandatory poverty level- related pregnant women), 1902( a)( 10)( A)( ii)( IX)( optional poverty level- related pregnant women), I902( a)( 10) f , A)( ii)( 1)( pregnant° tivoarten who meet AFDC Tivancial eli,givility criteria) and I902(a)( i0)(A)( ii)(.lV) institutionalized pregnant vvomen) in effect under the Medicaid state plan as of' March 23, 2010, converted to a MAGI-equiy-alert percent of FPL. TN: UT- 14- 0001- MM1 Approval Date: 05/ 14/2014 Effective Date: 01/ 0112014 Utah S28 Pate 16f 4

e 4 GG. r nw+a^-4' zxtt.•.; bY%ca-a.F v The. state' s highest effective income"level for coverage of pregnant women under sections 1931 ( low-income families), 1902( a)( I0)( A)( i:)( 11l}( qualified pregnant women), 1902( a)( 10)( A)( i)( 1V)( mandatary poverty level- related pregnant women), 1 902( a)( 1` 0)( A)( ii)( 1X)( optional poverty level- related pregnant women), 1902( a)( 10) A)( ii)( l)( pregnant women who, meet AFDC financial.eligibility criteria)-and 1902( a)( l0)(; a)( ii)(IV) institutionalized pregnant women) i.n effect under the Medicaid statepl3r, as of Decentbe.r.31, 2013, converted' to a MAGI-equivalent. percent of FPL. I'he state' s effective income level for any populationof`pregnant women under a 4vledicaid I i 15 demonstration as of March 23, 2010, converted to a MAGI- equivalent percent of I; L. I'he state' s effective income led of for any population of pregnant women under a Medicaid 1 115 demonstration as, of December 31, 20`f3, converted to a MAGkequivalent percent of'F'PL. e 18.5% FP L, Income standard chosen Indicate the state' s incorne,stan'dard used for this eligibility group: 7. The minimum incomestandard fr'; The maximum income:standard Ce': ; mother income,standard in- between the minimum and maximum standards allowed. The amount.of'the incomestandai•d for this eligibility group is. 13') ° j FPI., FO There is no resource test for this eligibility group. Benefits for individuals in this eligibility group,consistofthe following: F All pregnant women eligible under this group receive full Medicaid coverage under this state plan. Pregnant women whose income exceeds the income lirnit'specified below for' full coverage of pregnant women receive only pregnancy- related services. Presumptive Eligibility The state covers' ambulatory prenatal care for individuals under this group when deterrnined presum.pdvely eligibl bya qualified entity. fei Yes t ! No The presumptive period begins on the date the determination is made. The end( late of the.presumptive, period is the earlier of: The date the eligibility determination for regular Medicaid is made, if aii application toi- Medicaid is tiled by the last day of the month followinb,the month in which the determination of presuriiptive eligibility is made; or The last day of the month following the month in which the determination of presumptive eligibility is made. if no application for Medicaid. is filed by that date. F "There may be no. inore than one period of presumptive eligibility per pregnancy. A written application: must be signed by the applicant r r representative. TN- I IT- 14- 0001- MEA1 Approval Date- 05/ 1412n14 Effective Date 01/ 01/ 2014 Utah S28 Page 2 of4'

s • o o e o Y e S YI 1vo 7;The state uses a; single application form for Medicaid and presumptiveeligibility. approved by 04S. I' he state uses a separate application fp in for presumptive eligibility, approved by CMS. A copy of the t! application form is included; IrY lh a attach nen s ilbnt Yted may . 0 The presumptive eligibility determination is based on the fOl'lowino: factors: The woman must be pregnant Household income must not exceed the applicable income,standard at 42 CF`R 435. 1 16. f State residency Z Citizenship Status as a national, or satisfactor) l immigration status The state uses giaalified entities, asrdefned in section 1920A of the Act, to determine eligibility presumptively for this eligibility group. L>< st OfQ, will W Vii, es I 1, Sl A qualified`entity is ail entity that is determined by the agency to be capable of making presumptive eligibility deterin i nations base&on ari individual" s houselibldincome and other requirements, and that meets at least one of the followin(f requirements. Select One or more oldie Following types of entities used to determine presiimptrve eligibilifyfor this eligibility group`. Furnishes health care items or,servicescovered under the-staters approved Medicaid state plan and . E is eligible to receive payments under the plan Is authorized to determine c_hild' s eligibility to participate: in a Head Stai1 program under the Head Start Act Is authorized to determine a child' s eligibility to rcc.eive•child care services for which Financial assistance is provided under' thc C hifd Care and Development Block Grant. Act of 1990 Is authorized to determine a child' s eligibility to receive assistance under.tlie Special Supplemental Food Program for Women, Infants and Children tWIC) under section 17` Ofthe Child Nutrition Act of 1966. Is authorized to determine a child' s eligibility' underthe Medicaid state plan or for child health El assistance under the Childrents Health Program ( CHIP) IS an elementaryor secondary sch ol,:as defined in section 141011 ofthe Elementary and Secondary F.dc3Cation Act of 1965 ( 20 US-C. 8,4011) E] Is an elementary or secondary school operated. or sulported by the Bureau of Indian Affairs Is a state or Tribal child support enforcement agency under title IV- D ofthe Act is an organization that°provides emergency food and shelter under a grant under the Stewart B. McKinney Homeless Assistance Act Is a state or Tribal Oftipe or e rtity involved in enrollment in' the program under Medicaid, CHIP, or 0 title IV-A of the Act TN`.UT- 14- 0001- MM1 App_rovalDate: 05/ 14/ 2014 Effective Date: 01/ 01/ 2014 Utah S28 Nwe' 3 of I

r Medic, 4 Eft I Is an oman-ization that determines eligibility for any assistance or benefits provided under any program of public or, issrst, d Housing that receives l iederal funds, includinb the program under section 8 or any other section cif the Unit-O°d Statcs. l lousing Act`of 1937( 42 UJ. S'.C. 1. 437) or under the dative American Housing:Assistance and Self Dete) ntination Act of(' 99()( 25 UES. C. 4101 et seq.) Is a health cility operated z n rate by the Indian Health Service, a Tribe, or Tribal organization, or an Urban Indian Other entity the agency determines. is capable,of mml ing presumptive eligibility determinations: Vane pf entity Description Designated lrmployces in the Division of Disease Control and Prevention, Bureau of I lealth Baby Your Baby 1 k ti_ine Promotionyvho:iakc online applications for presumptive eligibility. The state assures that it tias cionimunicated the requirements' for qualified entities, at 1920A( b)( 3) of the Act, and has provided adequate training to the entities and organizailons involved. A copy of the training materials has been included. MPWA Ari attach7nentis S, u tt" PRA' Di'sclosure' Statement According to the Paperwork Reduction Act of 1` 995', no persons are required to; resporid to,8 collection of information unless it displays a valid ONIB control number. The valid OMB controlnumberforthi's inforinatioii•collection is 093$- 11,48. The tiriie required to complete this information collection is estimated to:average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete brid revievu°the infornvation: collection. I`f you have comments concerning the accuracy of thc' time estimate( s) or sug,gTestions or 111 wbVingthis form :please write to: C; MS, 7500 Security BouIevard, Attn: PRA Reports Clearance Officer, 1ai1 Stop C4- 26- 05, Baltimore, Maryland 21244- 1$ 0. TN: UT- 1470001- MM1 Approval Date: 05/ 14/ 2014 Effective Date: 01/ 01/ 2014 Utah S28 Pape 4 of,4

REW Medicaid I OM13 Control Rirmber' 0938-' 11 18 OMB Expiration date: 10/ 3 014 Tlitb'lt C: rou +5 1VIancatcu°y' Cn cra S Infants a>ud Ck<ilcrentl wcerr ; e WQ r 42 C"FR 43 . 1 18 190,2( a)( 1' 0)( A)( i)( 111),( IV),( VI) and( VII) I902( a)( 10)( A)( ii)( IV) and( 1X) 19'31(' b) and( d) Infants and Children under. age 19- Infants and children under age 19 with household income at or below standards established by the state based on age group. J The state attests that it operates this eligibility group in accordance with the follotiving provisions: Children' qualifying urid`er this eligibility group must, n eetlhe following cHteria: Are under age 19 1 lave household income at or below the standard established_by the "state. MAGI-based income methodologres are used. in calculating household income. Please refer as necessary to S10 MAGI Based Income Methodologies; c, oinpleled by the state. Income standard used for infants under age one Minimum income standard The state had an income standard higher than 13360 FPI, established as,of December 1`9, . 1989 for determining eligibility for infants under age one. oras of July 1, 11 989, had authorizing legislation to do so. 7, Yes (®; No The minimum income standard for infants under age one is 1, 33(,"0 I'PL. E Maximum income standard The state certifies.that it' has subrn teed and received approval for its concerted income standard( s) for infants under age_one to MAGI- equivalent standards and the determination ofthe maximum income standard tote used for infants' under age one. s A- "'t c' It 11tA'JeI nlerlt Iti 6UIDtTlltteCl The state' s maximum income standard for this age group is The state's highest.effective income level for coverage of infants under age one under sections 193 l ( low- incoine farni'hes), 1' 902( a)( 10`)( A)( i)( 111),( q6alitied children); 1902( a)(] 0)( A)(. i)( IV)( mandatory poverty level- related f infants), 0 2( a)( 10.)( A)( ii)( 1X)( optilonal poverty level- related infants)-and 1902( a}( 10)( A)( ii)( tV) institution-dlized children), in- effect trnder the Medicaid state plan as of March 23, 2010, converted to a MAGI- equivalent percent of FPL,. TN: UT- 14- 0001 7MM1 Approval Date: 05/ 14/ 2014 Effective Date: 011.01/ 2014 Utah S30 Pavel of 9

Medkaid ER The state' s highest effective income.Icvel for coverage of infants under age one under sections 1931 ( low- income families), 1902( a)( 10)( A)( i)( 1 I1)( qualified children), I902( a)( 1O)( A)( i)( IV)( mandatory poverty level- related 71 infants), 1902( a)( 10)( A)( ii)'(IX).(optional poverty level- related infants) and 1902( a)( I0)( A)( ii)( I ) institutionalized children), ineffect,under the Medicaid state plan as of Occetnber 31, 2013, converted to a MAGI-equivalent percent of F PL.. The state's effective income level for any°population of infants under age one under a Medicaid 1 1 15 demonstration as of March 23. 201.0, converted to a MAGI- equivalent percent of FPL. The state' s effective income level for,,anv' population of infants underage one under a Medicaid 11 15 f demonstration as of December 11, 20 13 converted to a MAGI-equivalent percent of FPL. 185% FPL 0 Income standard chosen The state' s income standard ukd'for infants underage one is The maximum incoine' stancard If not chosen as the maximum income standard, the. state' s higheste'ffective, ineome level for coverage of infants under age one Under' sect 1- 931 ( low-income families), I,902( a)( h0)( A)( i)( III)( qualified children), 1902( a)( 10) o} ( A)( i)( IV)( mandatory poverty level- related;infants); 1902( a)(',10)( Aj)(ii)( IX)( optional poverty Ievel- related infants) and 190a)('10)(•A) 000V)( institutionalized children), in effect-under the INledicaid state plan as of March 23, 2010, convertecfto a: MAGI-equivalent percent of FPL. If higher than the' highest effective income level for this agetgroup mider the state plan as cf March 23, 2010, and i'f not chosen is the maximum income standard, the state' s highesteffective,:income level for coverage of infants under age one under sections 1931 ( low-income farniltes), 19(72( 4)( I0)( A)( i)( III)( qualified children), 1902( a)( 10) A)( i)( IV)( mandatory-poveal:y level- related infants),, 102( a)( 10)( A)( ii)( 1X)( optional poverty level- related infants) and 1902( a)( 10)( A)( ii)( 1V)'( insti'tutionalizeci children), in effect tui,der the tVtedicaicl state plait as of December 31, 2013_;converted to a NIAGI- equivalent percent of FP1,. If higher than the highest effective income level for this age group under the=state plan as ofAlarch 23, 2010, and if not chosen as the°rnaximunt income standard, the state' s effective inconte level for any population of infants C; C i der age one under a Medicaid 1 I15 demonstration as of March 23; 2010, converted to a[ v1AG1- equivalent percent of FPL. If higher than the highest effective inconte level fibr this age.group' urader the state plan as of March 23, 2010; and if not chosen as the maximum income standard, the states effective income: level for any population of infants under age one under a Medicaid l I I5' denionst ration`as of December 31, 2013, converted to a MAGI- equivalent percent of 1"PL. Another inconte sta)idard i'ii- between the minimum and maximum standards allowed, provided it is higher than C the effective income standard lbr this,ace group in the state plan as of March 23, 2010. The amount of the income standard for infants. under one is I FPL F' Income standard for children age one through age five, inclusive liuirnunt income staridarcl TN UT- 14- 0001- MM1 Approval Date: 05/ 14/ 2014 Effective Date: 01/ 01/ 2014 Utah S30 Paey e 2 of 8

Meffica"O .E.Jigibility, The minimum income_standard used' for this age group is 1= 3% FPI..,. 0 Maximum income standard The state:certifies that it has submitted and received approval for its converted income standard( s) for children age one through five to MAGI- equivalent standards and the determination of the maximum income standard to be used for children age one through five. g w An attkhkTrettt is sub atecl r t The state' s maximum inc6ine standard fear children age one through Five is: The state' s h0ghest effective income level for coverage ofchildren age one through five under sections 1931 ( low- income families), 1902( a)( 1' 0)( 4}( i)( 1[ 1j( qualified children), 1902( a)( 10)( A)( i)( VI)(' mandatory poverty level- related children age one through five). and 002Ga)([ 0)( A)( i00 V)( institutionalized children). in effect under the Medicaid state plan as of March 23,; 2010, converted, to a MAGI- equivalent percent of FPL. The state' s highest effective income level for coverage of children age one through five under sections 1931 ( low- income families). 1902( aj(tO)( A)( i)( Ill)( qualified children), 1902( a)( I0)(A)( i)( Vl)( mandatory poverty level- related children age one,through five), and 1902( a)( 1. 0)( A)( ii)( lti)( institutionalized children), in effect under the Medicaid state plan as of December"3. 1, 20 13, converted to a MAGI-equivalent percent of FPL. The state' s effective income Level for any population of hddren age:one through five under a Medicaid 1 1 15 C. demonstration as of March 23 20111.0. converted to MIAMI-equivalent percent of FPL: The state' s effective income level for any population of children age onetlirough five under a Medicaid -I 1 15 demonstration as of December 31. 2013, converted to a MAGI- egrivalent percent of FPL. Lnter the amount of the maximum inconrc standard: 1: 3r) % FPL Income standard chosen The state's income standard used for°ehildren age one through five is: 9`° The maximum income standard Iftrot chosen as the maximum income standard, the state' s highest effective income level for coverage of children age. onc, throubh five under sections 1931 ( low- income farnili'es), 1902( a)( I0)(A)(_i)( 111)( qualified children); 1902( a)( I0.)(r1}( i)( Vl)( mandatory poverty level- related children age one through five), and 1902( a)( I0)( A)( ii) IV)( institutionalized children), in, effect under the Medicaid' state plan as of March 23, 2010, converted to:a MAGI- equivalent percent of FPL. If higher than the,highesteffective income level for this age, group under the-suite plan as of March 23, 2010, and if not chosen as the maximum income standard, the state' s hiohest effective income level for coverage of children age one through five under sections 1931 ( 1mvi- income families), 1902( a)( I0)( A)( i)( 111)( qualified children); 1902('a)( r0)( A)( i)( V1)( mandatory poverty level- related children age one through five), and 1902( x)( I0)( A)( ii) W)( institutionalized children), in effect under the Medicaid state plan as of December 3 1, 2013, converted to a MAGI- equivalent percent of FPL. TN: UT-14-0001- MM1 Approval Date: 05/ 14/ 2014 Effective Date: 01/ 01/ 2014 Utah S30 Pap e 3 of 8

Medicaid Eligibility If' higher than.the highesref'fective income level for this.age group under the state plan as of March 23, 2010, and if not chosen as,.the maximum income standard the statc s effective income level for any population of children age-one through five under a, Medicaid 1 115 demonstration as of March 23. 2010, converted to a MAGI- equivalent percent if FPL. If higher than the highest effective incorne level for this age' group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state' s effective income level for any population of children age one through five under a Medicaid 1 1 15 demonstration;as of December 37, 20 13, converted to a NlA(:, I- equivalent percent ofFPL. Another income standard in Between the miniittum and maximum standards allowed, provided it is higher than the effective income standard for this age group in the state plan as ofMarch 23, 2010. income standard for children age six through age eighteen, inclusive Minimum income standard The minimum incorne standard used for this age oroup; is 133% FPL, Maximum incorne standard The state.certiFies that it has subn) itted and received approval for its converted incorne standards) for children age 0 six through eighteen,to MAGI-equivalent standards: and the determination of the rnaximttm income standard to be used for children age six through age eighteen. M01111, 491% 3 A atttcirntettt rs sulatnrtteti ~ k ti• e i, The state's maximtun income standard for children age six throur:h eighteen is: The state' s highest effectivediicorne level for eovera,ge,of children age six through eighteen under sections 1931 low- income families), 1902( a)( 10)( A)( i)( IIL)( qualified children), 1902( a)( 10)( A)( i)( ViI)( niandatorypoverty level- related children a. e six through eighteen), and.I902 a l.0 A)( i_i)( iV :(institutionalized-children), in effect under the Medicaid state plan as of March 23, 201 Q, converted to a MAGI- equivalent percent of FPL„ The state' s highest effective income level for coverage,of children age six throughh eighteen tender sections 1931 low income taniilies), 1902( a)( 10)( A)( i)( Ill)( qualified children), 1902( a)( 10)( A)( i)( VIl)( mandatory poverty level- related children age six througIveighteen) and'' l902(a)( 10)( A)( ii)(-IV)( institutional i zed, chi'ldren), to effect under the: Medicaid state plan as of December 31, 2013, converted to a MAGI- equivalent percent of hPL. The state' s effective income level for any population,of children.age six.through eighteen under a Medicaid 1 115 demonstration as of March 23, 2010, converted t&a MAGI=e-quivalet)t percent of FPL. The state's effective income level for any po,prtlation,of children age six throueh,eighteen( ender a Medicaid l l 15 demonstration as of December 31, 2013, converted to a MAGI- equivalent,percentof FPL. 133`, 0 FPL Income standard' chosen The state's incorne standard used for children age six through eighteen is: TN: UT- 14- 0001= MM1 Approval Date: 05114/ 2014 Effective Date: 01%01%2014 Utah S30 Pape 4 of

Ob*' 16, ty The maxiinurn income standard If not,chosen As the maxi,muni.income standard, the state,'s highest effective income level for coverage of children age six through eighteen under sections 1931 ( low- income,familie's) . 1902( a)( 10)( A)( i)( Ill)( qualified children), 1902( a)( 10)( A)( i)( V•Il)( ma ldatory,poverty 1'el el- related children.age six through eighteen) and 1902( a)( 10)( A) ii)( IV)( institutionalized children),, in effect undmthe Mcdicaid' state plan as of March 23, 2010, converted to a MAGI- equivalent percent of F? PL.. It' higherthanthehi 9hest effective incorrle' level for this a e group under the: stage plan as or March 23, 2010, and if riot chosen as the:nlaxirnurn income standard, the state' s hi'ghest' ef°fective income level for coverage of children age six through eighteen brtder sections 1931 ( low- income families)„ 1902( a)( 10)( A)( i)( l11)( qualified children), 1902( a)( 10)( A)( i)( VII)( mandatory poverty level- related children_a; e six through eighteen) and 1902( a)( I0)(A) ii)( IV)( institut onalized,eljildren), in effect.Under t(ie Medicaid state plan as-of December 31, 2013, converted to a IMAGI- equivalentpercenrof FP:L. If higher than t}ie, highest effective income,level for this age group under the state plan as of N'larch 23, 2010, and if not chosen as the maximum income standard, the state's effective income level' for any population of children age six tht•ough, eighteen under a Medicaid 11 15 demonstration as-of March 23, 20`10, converted to a MAGI- equivalent percent.of FPL. If higher than the highest effective ineome.level for this agegroupunder the state plan as of;/ larch 23, 2010, and if not chosen as the:maximunt income standard, the states effective income level for any population of children age six through eighteen under-a Medicaid 11 l5 demonstration as of Decenber 31, 2013, converted to a MAGI- . equivalent percent ofFPL. Another income standard in- between' the- minimum and. maximunt standards allowed, provided it is higher than the effective income standard for this age group in`the state plan as of March 23, 2010. There is no resource test for this eligibility group. Presumptive Eligibility The state covers children when determined presumptively,eligible.by a qualified entity. r Yes ( 7 No E eY1 7 r WI 015 l 3 es11 Ul s w l' 902( aj(47) 1920A 42 CFit 435. 1101 42 CFR 43 5. 1 102 The state providers Medicaid coverage to children when determined presumptively eligible by a qualified entity under the.following,prov;isio'ns: TN; UT,-14- 0001- MM1 Approval Date: 05/ 14/2014 Effective Date: 01/ 01/ 2014 Utah S30 Page 5 of$ I

acaid El.- If the state has elected to cover Optional' Targeted Low-Income Children(42 CFR 35. 229), the income°standard for presumptive eligibility is the' Higher of the standard Used for Optioni l" targeted Low- Income Children or the standard used for Infants and C:`hildren under 19( 42 CFR 43'5, 118). for that child' s age. If the state has not elected to:cover Optional,Targeted LOWIncome:Chil'dren( 42 CFR 435. 229), Cite income standard for presurnptiye. ehgibility is the standard used under the lnfants.and Children Under Age 19 eligibility group( 42 CFR 435. 1 18),, for that chikf' s age. Children under the following age may be:detennined presumptively eligible: Under age 19 0 'I he presrnnptive period begins on the date the determination is ma le, RM The end date of the presumptive period is the earlier of: The daze the eligibility det'ermination for regular kledi.ca.id' is,made. i-f,an application for- Medicaid is Fled by the last day of the month lollowing,the month in which the determination ofpresumptive eligibility is made; or The last day of the month"iol'lowing,the month in which the:determindtion o. f presumptive eligibility is made, if no application for Medicaid' is riled by that date. Periods of pt-esumptiv.c eligibility are limited as foi,lows: C No more than one period. within a calendar year. No more thawone period within two calendar years: No more than=.one period within a twelve- rnonth: period', starting with the effective date of the initial presumptive eligibility' period. o; Other reasonable limitation: W Name:of`limitation, Description Arnit o priimptive decisions A child can only be determined presumptively i n es eligible oncemduringany six month period. The state requires that.a written;application be signed by the applicant, parent-or representative, as appropriate. o The=state uses a single application form for Medicaid and presumptive eligibility, approved by CNIS, The state uses,a separate application form for presumptive eligibility,,approved by CMS. A copy of the application form is included. i F X n at(kljri ent ac ul)tnttted l The l resumptive,eligibility determination is-based on the fpllowing factors: Household income must not exceed the applicable income standard described above, for the child's age. State resideney O' Giti enship, status,as a national, or satisfrctor, imrnigiatiomstatus TN UT- 14- 0001- MM1 Approval Date: 05/ 14/ 2014 Effective Date: 01/ 01/ 2014 Utah S30 Page 6. of'8

Medicaid bAffifty pY btatn• 2 The state uses qualified entities, as defined in section 1920A of the, pct, to determine eligibility presumptively fc?r this eligibility group. In 1 qualified entity is an entity that is determined: by°the agency. to be capable of making presumptive eligibility determinations based oil an. individual' s household income and other requirements. and that meets at least one of the following requirements. Select one•or more ofthe f illowing types of entities used to deternune presuitiptiVe eligibility for this eligibility croup: Furnishes health care items.or services covered under the states approved Medicaid state plan and is eligible to receive payments underahe plan Is Star au tAct determine a chi'ld.'s eligibility to paftici_pate in a, Head Start program under the Head Is authorized to determine a child's eligibility to receive child care services for which financial assistance is provided under the C: l ild Care and Developtient Block Grant Act of' 1990 Is authorized to& termine a,child's eligibility to,receive assistan'b,under the. Special Supplemental Food Program for Women, Infants and Children( WIC) under. sect i6n 17 Of Child Nutrition Act of 1966 Is authorized to determine a child's eligibility under the.Medicaid:state P`lan or for child health assistance under the Children.s4lealth Insurance Program( C. I, IIP) Is an elementary or secondary school, as defined in section 141.01_ofthe Elementary and Secondary Education Act of 1965 ( 20 U. S. C. 880)) Is an, elementary or secondary school operated or supported by the Bureau of Indian Affairs Is a state or Tribal child,support enforcement agency under title IV--D of the. Act Is an orgabization that provides emergency food and shelter under a.grant under the Stewart B. McKinriev'Homeless Assistance. Act. Is.a state or Tribal office or entity involved in enrollment in the pr6iTam. under Medicaid. C1 11P.. or 021 title IV- A of` the Act Is an omanization that,determines eligibility for any assistance or benefits provided under any program, of;public or assisted housing that receives. Federal fundsJncluding the pr<tgratn under section 8 or any other section, of the Unite& States Housing Act of 1937( 421 U S. C. 1437) or under the Native American Housing Assistance,and Self Determination Act of 1996(25 U. S. C. 4;10' 1 et seq.) Is a health facility operated by-the Indian Health Service, a Tribe, or Tribal organization, or an Urban Indian Organization f C) ther•entity.the.agency` deter•rnines is,capahie of making presumptive eligibility determinations: Janie of entity description The Department ofaluman Services. Division of Child and Familti Services and Juvenile Justice Title 1 v- E agency, t Services aF TN: UT-14- 0001- MM1 Approval Date: 05/ 14/ 2014 Effective Date: 01/ 01/ 2014 Utah S30 Nee 7 of 8

Medicaid., i ' k The state assures ghat it has communicated t lie requirements for civalified entities, at 1920A( b)( 3)(? f`the Act, and provided adequateArainingto the entities and organizations involved. A copy ofthe training materials has been included. Z K' 1, ttachynent t subniattecl l 5 t PRA Disc . . According to the Paperwork Reduction. het 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 093$- 1. 1. 48. The time required to complete this information collection is estimated to ayerne 40 hours per response, including the tinie'to re' iew instructionS, search existing data resources, gather the data needed, and complete and review the information collection. If you have CO'lln Tents concerning the accuracy of the tine estimate( s) or suggestions for improving this form, please write to: C IS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer,!' flail Stop C4 26. 05, Baltimore,-klaryland_2) 244- 1850. TN: UT=14- 0001- MM1 Approval Date: 05/ 14/ 2014 Effective Date: 01/ 0172014 Utah S30 Pa)' c 8 of 8

Medici ty ElIgibill OMB Control- Number09 8- 1148 OMB Expiration date 10/ 3 1/ 20 14 , IiNb i . rcris Mancatc>ryCcrueraeM q q ; l I uUI3 na, ,, 1902( a)(. I: 0)( A)( i)( VI11) 42 CFR 435. 119 Fhe state covers the Adult Group as described•.at42 ClIR 435. 119. Yes (--- No PRA Disclosure St A&men( 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- 1 148.. The time required to complete this information collection is estimated to average 40 hours perfresponse, including°the time to review instructions. search existing data. resources, gather the data' needed, and e6mplete and review the information collection. If you°have comments concernin- the accuracy of the time estimate( s) or suggestions for improving this ti rm,, please write to: CMS, 7500,Security Boulevard. Attn: PRA Reports Clearance Officer, klail Stop C4- 26 05, Baltimore, Maryland 21244:-1850. TN: UT- 14- 0001- MM1 Approval Date: 05/ 1`4/ 2014 Effective Date:- 01/ 01/ 2014 Utah S32 Pale 1 of l

Medica*d i x•. 0 OMB Control Number 0938-:11-48 C) M13 Expiration date 10/ 3]/ 014: I+lt; tbtl t C:' ci S Vtancltciry C"ivcira 533 Frcncr t .: w... 42' C-FR X135. 150 1902( a)( 10)'( A)( i)( IX) Former foster Care Children --Indi-viduals under the age, of?6, not otherwisc,mandatorily eligible, who were on Medicaid and in fester care when they turned age 18. or aged out offoster care. The state attests that it operates this eligibility group under-the fbI lowing provisions, F Individuals qualifying under this eligibility group must meet the iollv ving criteria: 0 Arc under. age 26. this group takes pracedertcexwer eligibility under the Adult' Group. under cite state plai7, except that eligibility unclez• 4re:not otherwise eligible for and enrolled for mandator coverag Were in foster care under t} te respcinsibility ofthe suite or Tribe.and were enrolled in Medicaid under the state' s state plan or 1 1 15 demonstration when they turned 18 or at the tine of aging out ofthat state' s or Tribe' s foster care program. The state elects to cover chiid_ren who were in foster care and on Medicaid in anv state at the time they turned 18 oi- aged out ofthe foster care system. 7, Yes No fhe state covers individuals under this group When deterinined presumptively eligible by a qualified entity. ' file state assures it also' covers individuals under=.the Pregnant Women ( 42 CI' R 43-5. 116) and/ or Infants and Children under Age 19( 42 CFR 435. 1 18`) eligibility groups when, determined presumptively eligible. Yes + No PRA QiSC-IOsure_Statetfnent Aecording:t6 the-? iperw& k Reduttion Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB•control number. They valid OMB control' number for this information collection is 0938- 17148. The time required to complete this information coll`ecti' h is, estiinated to average 40 hours per response; inCludiitg the tinie tub review, instructions, search existing data. resources, gather-the. clata needed; and complete and,rev-i'ew the infgrmatior collection. If you have comments concerning the accuracy of the time estintate('s) or suggestions for improving,tl is rorrn, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail StOli. C4 26- 05, Fialtiinore, Mary land°21244 T850. TN: UT- 140001- MM1 Approval Date: 0511412014 Effective Date: 01/ 01/ 2014 Utah S33 Pause I of I

Medicaid ElIgibRity OMB Control Number 0938- 1148 01,413 Expiration date: 10i31120 14 Fl rbN C;ior jzs w, ir Brag ' a I rEcivtcluals above 133'`foF ? F I t 1 r .. 190?( a)( 1' 0)( A)( i i)(\ X) 1' 9Q2( hh) 42 CFR 435. 218 Individuals above 133% FIRL-' I he state elects:to cover individuals under.65, nlot otherwise mandatorily or optionally eligible. with income above 133°4) FPL and at or below a standard' established by the state and in accordance with provisions described at 42 CFR 435. 218. Yes (* No I' R Di scl. sure Statement According to the Paperwork. Reduction Act of'1995, no persons,are required to respond to a collection of information unless it displays a validOMB control rn.nnber. The valid OMB control number for this information collection is 0938- 1148. The time required to complete this information collection is estimated to average 40 Hours per response,' including the time to reN,iew instructions, search existino data resources; gather the data needed, and c niplete',= d review the information collection`: if you: have comments concerning the accuracy of the time estimates) or suggestions for improving°this=form,,please write to: CNIS, 7500 Security:>3'oul'evard, Attn: PRA, Reports Clearance Officer,_Mail Stop C4-26- 05, Baltimore. Marvland 21244- 1`850. 1 6 TN: UT714- 0001- MM1 Approval Date: 05/ 14/ 2014 Effective Date: 01/ 01/ 2014 Utah S50 Pap-e 1 of,I.

Medica"'d Efl OMB Control Nuniber Q938- 1148 01013 Expiratiomdate: 10/ 31'. 2014 F1t; Mb'Nl : rou s PtatilnS%*6r0i c a; H U, t nalCov ta ego#` ' ak- ntand iJ ter aretatkcr Rc t es' a 42 CkR.435. 220 1902( a)( 1, 0)( A)( i i)( 1) t 7 individuals qualifying as parents or other Q' zCiarral. C.crveira ' e of I arents and Other• CareC ker Relatives- The tndiv caretaker relatives who are not mandatorily eligible and who' have income at or' below a standard established by the state and in accordance with provisions described at 42 CFR 435:? 20. Yes re No IRA Disclosure-Statement According to the Paperwork Reduction: pct of 1995, no persons are required to respond to a collection-of information Unless it displays a valid OMB control number. The valid' OMI3 control nurribbir for this inforrnatiorj.collection is 0938-,11-48. The time required to.complete this information collection is estimated to average 40 houfs peir - eslionse, iileludin?-the time to rev ieW instructions, search existing data resources, gather the data needed, and complete and revicAv the information collection. If vOLI haa?c comiilients.concerning the accuracy of the time e.stimate( s) w suggestions for im proving,this form, please write to: CMS, 7,500 Security Boulevard; Attn: PRA Reports Clearance Officer, Mail Stop C4-26- 05, Baltimore, Maryland 21244- 1850. TM; UT- 14-0001'- MM 1 Approval Date: 05/ 14/ 2014 Effective Date: 01/ 01/ 2014 Utah S51 Pa>;e I of' I

Medicaid Efii.glffifli OMB Control Dumber 0938- 1148 ON/113 Expiration date. 10/ 1/' 2014 her Edi d rl t : r u ac Tor i a F escrialaledassificaton crfi incd duls >;ncterge 21 ( 2' 42 CF`R 435. 222 1902( a)( 1 f))( A) t i i)(< 1) 1902( a)( M)( A)( ii)( W) Reasonable Classification of Individuals under Age 21'- The state-elects to cover.one or more reasonable classifications of individuals underage 21 who are not man datorily eligible;and who have income at orbelbw alsmandard established by the state and in accordance with pr« vi,sions described at 42 CF' R 435.222. 7; Yes (- e No PRA_Di sdosure,Statemen( According to the Paperwork Reduction pct of 1995,, no pecsons:are required to respond to a,co'llection of information unless it displays a. valid ONIB control number. The valid() NIB control nurpher for this information' collection lis 0938- 1 143. The lime required to complete this information collection istestimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the in collection. If ybu have.comments concerning the accuracy of the time estimate(s) or suggestions For impr(.wing this form,,please write to C'MS; 7500 Security F3oulevard, Attn: PRA Reports Clearance, Officer, Mail Stop C4- 26- 05, Baltimore. Maryland-21244- 18.50. TN: UT- 14- 0001- MM1 Approval Date: 05114/ 2014 Effective Date: 01/ 01/ 2014 Utah, SU Pae'e 1 of

OMB Control Number 0938- 1148 OMB F,xpiratiotl c[ate: 10/ 31/ 2614 FI rlialttC rcu; t c tftr Ccu f Uft" I 42 C}[ t.435. 227 1902( a)( 10)( A)( ii)( V I II) Ctrildvenwith Non 1V.-1: Adoption Assistance- The state elects to cover children.witli special iiee_& F6'r whom fliers is a non IV- E adoption, assistance,agreernent in effect with a stage;:who were eligible for Medicaid, or w,ho had. income at or below a standard established by the state and in accordance w;rtlh provisions' described at 42 t R 435.227. Yes C, No The°state attests that it operates this eligibility group in accordance,with,the following proiisions: Individuals q ualifying under this eli'pibility group must meet the=following criteria: I,he state adoption agency has determined that they cannot be( laced without Medicaid coverage because of special needs for medical or rehabilitative care; D Are under the following age( seethe.Guidance for restrictions on 4heselection,dNn age): Under age 21 7 Linder age 20 7, Under age 19 Under age 18 MAGi-based income rnethodologimare. used' in calculating*) usehold income. Please refer asnecessary, to S10 MAGI- MAGI-based Based Inc'orne Methodologies, completed' by the state. The°state covered this eligibility group. in the Medicaid state plan as of December 31, 20-13, or under a Medicaid 1 115 Demonstration as of Mar=ch 23, 2010 or.December 31, 2013. t® Yes C No n The state also covered this eligibility group in the Medicaid state l lan as of March 23, 2010. t , Yes- { No Individuals qualify under this eligibility group if they were eligibletunder the state' s approved state plan prior to the execution oftlie adoption agreement. The. state used.an income:standard or.disregarded all income for this,eligibility group: either~in the Medicaid stake plan as of March 23, 2010 or December 31, 2013, or tinder a Medicaid 1 1 15 Demonstration as of March 23, 2010 or December 3l; 2013. Yes (; No E11] IrrCOnte standard used for this eligibility group Minimum income standard The minimum income"standard for this eligibility group must exceed the lowest-income standard chosen for children under.this age underthe Infants and Children under Age 19 eligibility group. Maximum income standard TN: UT- 14-0001- MM1 Approval Date: 05/ 14/ 2014 Effective Date: 01/ 01/ 2014 Utah S53 Pape I of`2

No income testwas=used( all income was disregarded) fur this.'eligibilitygroup either in the Medicaid state. plan as of March 23, 2010 or' December 3 1, 2013, or under a, Medicaid i l 15 Demonstration as of IVl arch 2"), 2010 or December 31, 2013. 7io, Yes ("°, No No income test was used( all income was disregarded) for this eligibility group under check all that apply):. The Nled ' id state plan as of March 23-20=10. f The,.Medicaid state plan as of December 31; 21713. A Medicaid. H 15 Demonstration as of March 23, 2010. A Medicaid' I l Fbemonstrat.ion as ofDecember 31, 20,0. The state' s maximurn, standard for this eligibility group is no ineome' test( all income is disregarded). Income standard chosen ndividuals-dualify under this eligibility group under the following' incotne.standard, which must be higher than the minimum for this child's, age his eligibility;group,does not use an income test:(al'l income is disregarded:). Another income,sCaridard h:igher than both the minimum income standard and the effective income level far this eligibility group in the state plan as of March,23; 2010,,co_nverted to a MAGI- equivalent J There is no resource test foi tl is eligibility Group. R:(?t Disclosure Stateinetat According to the Paperwork Reduction Act-of I W, 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- 110. The time required to complete this informatii5n collection is estimated to a erage 40 hoursper response,' including.the time to review instructions. search existing data resources, gather the data needed, and coniplete.and review the' information collection. if you have comments concerning the accuracy of the time estimate( s) or suggestions foe imp' ov.inb this form. blease% rite.tot CMS. 7 00' Secut°ity Boulevard. Attn: PRA Reports Clearance Officer, Mail Stop C4- 26- 05, Baltimore, MaryIand 2124 - 1850. TN: UT-14=0001- MM1 Approval Date: 05/ 14/ 2014 Effective Date: 01/ 01/ 2014 Utah S53 Page 2 of 2

l OMB Control' NUmber0938- 1148 OMB Expiration date: 10/ 3 1/ 211 14 r l ll lill ( iltllD t10N15" fL11'(} UC"Ta$ E' 6 rtl nal Taetec .c>rxcca ldre a d 902( a)( 10)( A)( i i)(; MV) 42 CFR 435: 229 and 435. 4 1905( u)( 2')( B) 0pti'onaI Targeted Low Incoine Chi Fdren ' Elie state elects : to cover uninsured children; who nteeOhe definition of optional targeted love income children at 42 CFR 435.4, vv-ho have household income it or belo,,v a standard establi'shcd by the state and in accordance with provisions described at 42 CFR 435. 229. t Yes (° No PRA Disclosure Statement According to the Paperwork Reduction ,pct of 1995', no.persons are±reyuired to respond to<a collection of information unless it displays a valid OMB control number. The valid ON11.3 ynt_rcii uUmber for this information collection is 0938- 1148. The time required to complete this information collection is estimated to: averagea40' 4ours per response, including the time to review insteuctiorrs, search existing data resources, gather the data needed, and complete and revievv theJnformation colleetion. lfvotr have comments concerning the accuracy of the time estimate( s) or suggestions for improving this form.;•please:write to: C' MS,,7500 Security Boulevard, Attn: PRA Reports Clearance O't'Rer; Mail Stop C' 4- 26- 0, Baltimore, Maryland 21244- 1850. TN: UT- 14- 0001- MM1 Approval DateS 05/ 14/ 2014 Effective Date: 01/ 01/ 2014 Utah S54 Pale 1 of 1

OMB Control Number 0938- 11, 48, Q'413 Expiration date: 10/ 31/ 201'.4 Tliyst% rit5 ( 3 > tt i frr' c tr i I'c>€ viclU vwith auk ecrcztlr s>< s 4 z S 1902'(a)( 10)( A)(' ii)( XIi') 19:02( z) I Individuals widi Tuberculosis- The state, elecis to cover individuals infeciedwith tuberculosis who have income at or below a standard established by the state, limited to tuberculosis_-related' services. C, Yes ( 7;. N 0 The state altests that it operates this eligibility group in accordance with the llolloWing provisions: Individuals qualifying under this eligibility group must.meet the I61lowi-ng criteria:. Are infected with tuberculosis. F_ Are not otherwise eligible for;mandatory-coverage under the Medicai'd, state plan.. Have household income under a, standard established by the state. MAGI- based income methodologies are used in calculating household inebme. Please refer as necessary to 510 MAGI- Based income Methodologies completes! by the state. Income standard used for this group Fm Maximum income standard First: indicate the rnaxirnum, incorne. standard that could be used fiar this group and then indicate the income standard the state uses for the group.. The state elects to convert the effective income level. f zr coverage of this 6'gibility group in effect in the Nledicaid state plan as of March 23,. 2010 and D& erriber 31, 2013 to. NL1G1'-equivalent startdards. C' Yes Ca' N o I he state' s maximum income standard for this eligibilitygroup is: t`® The break- even point lctr earned income under' the-SSi program. I he effective income level for this eligibility group under the Medicaid state iplan in effect as of March 23, 2010, not converted to a MAGI- egit ivalent: standard. The effective mcoine level for this eligibility Troup tinder the Medicaid stage plan in effect as of December 3],, 20 13, riot. converted to. a MAGI- eituivalent standard. Income standard chosen The state's inco ne standard used fbr this eligibility croup is: Cw, The maximum iri m e, standard. If trot chosen as( lie_maxlnum income standard, the break-even point fir earned income under the SSI prograrn. Another income standard less. than the maximum standard allowed. Individuals rae i following services,. provided the service is related to the dagn si treatment or nagentett if the r> dvidual s tuberculoss F.,Prescribed drugs. described in 42 C: 1=R 440. 120 1 A- nm 1 Date 05/ L41? n14 EI1 dive-Date 01/ 01/ 2014 Utah S55 Parse I of 2

3 Physician services, described' in 42 CFR 44.0. 50 Outpatient hospital and rural health clinic described in 42 CF-R.440.20' and federally-qualified health center services Laboratory and x- ray-sery ices flncluding services to cofffirm the presence of the infection). described in 42 CFR 440.30 Fp Clinic services, described m 42 CFR 446.90 F Case management services defined in,42 CFR 440, 169 Services other than roorn and board designed toencouraoc. compl'etion of regimens of prescribed drugs by out-patients, including services' to observe directly the intake of prescription drugs. Limitations related to tuberculosis- related services may be found inthe Acxiefatssection. PRA..Disclosure_Statement According to the Paperwork Reduction Act of 1995, no persons are required' to respond to a.cotlection of information unless it displays valid OIL B control number. ' I`he valid OMB control nuirab'er for this iniorniation collection is 0938- 1148. The time required to complete this information collection is estimated to average 40 hours per response„ including-the' tinte to review: instructions. search existing data resources, gather the data needed, and complewand review'the information collection. Ifyou have comments concerning the accuracy of the time estimate(s) or suggestioriS for improving this form, please write.to: CMS; 7500' Security, Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26- 05, Baltimore, Maryland"2124;4- 18'50. TN: UT- 14=0001- MM1 Approval Date: 05/ 14/2014 Effective Date: 01/ 01/ 2014 Utah S55 Pave 2 of

1 OMB Control Number0938- i 148 c) MB Expiration date: 10/ 31./ 2014 T 1 1l ) l lt', ( rI ou1)s 1( D S, ft) C f1r( i'2t 4 s I1CCIl C1€ClI FLS i1" r iE' 1' CC* G7lti s 42 CFR 43.5. 226 1902( a)( 10)( A)( ii)( XV I I) independenUF'oster' Care Adolescents- 1h state elects to cover°individuals under an age specified by the state, less than a`=e 41, who were in state- sponsored foster care, on their 18th birthday and who meet the incotne standard established by the state and in. accordance with the provisions described-at,42 CI' R 435226. C® Yes ( = No The state attests that it operatesahis:eligibility group in accordance with the following proxvisions: 0 Individuals qualifying under this eligibility group must meet the Billowing criteria: Are under the fdliow,ing_age t® (_! nder' age 21 Under age 20 t . Under age• 19 Were in foster care under the responsibiiity.of a state on their 18th birthday. Are not eligible and enrolled for mandatory coverage under the Medicaid state plan. Have household income at or.below a standard established by the state. MAGI based income methodologies are used in calculating household income. Please refer as necessary to S10 MAGI Based Income\ klethodologies', completed by the state. Tile state covered this eligibility group under its Medicaid state plan as of.Decernber 3;'1, 2013, or under a Medicaid 1115 demonstration as of March 23,, 2010 or December 31, 201-3. Yes No The state also-covered this eligibiIity!group in the 1Vledicaid state plan as oFMarch 23,. 2010. Yes ( No The state coversichildren under this cligihility group, as follows( selection may not be more restrictive than the coverage in the Medicaid state plan as ofiMarch 23, 2010 until October I, 2019,.nur more liberal than the most A liberal coverage in. the-Medicaid state plan as of December 31, 2013, or under a Medicaid I 1 15 demonstration as Of March 23, 20:16 or December 31,' 2013): All children under the age selected A' ceasonable•classifiOtion of children under the age selected: J Income standard used For this eligibility group Minimum income standard The minimum incomestandardforthis classification' ofchildren is the AFDC payment standard in effect as of July 146, 1996, not converted to MAG[- equivalent. This standard is described in S14 AFDC Income Standards. TN: UT- 14- 0001- MM1 Approval Date: 05/ 14/ 2014 Effective Date: 01/ 01/ 2014 Utah S57 Page I of:2

Medic r Maximum income standard No income test was used.( all income wasxdisregarded) for this eligibility gro,ul either in the Medicaid state plan as of March 213,, 201;0 or December 31, 2013. or under a Medicaid I I I5 Demonstration as of March 23, 2010 or December 31; 2013, te` Yes ( 7,' No No income.test was used( all income was disregarded) for".this eligibilitygroup under check all that apply): The Medicai& state plan as of March 23, 201 ot. The Medicaid state plan,as of December; i1, 20,13. A Medicaid 1115 demonstration gas of M'arch.23: 20 W., A Medicaid 1 l 15 demonstration as of'Deceniber 31, 20l 3. The state' s maximum standard for this eligibility grcurp is no income' test( all income is disregarded). Income standard chosen Individuals quality under this eligibility group under the following income standard: This eligibility group does not use an income test( alb income is disregarded). There.is no resource test for`this eligibility group. PRA DiSCIoSUre Statement According to the.Paperwork Reduction Act of 105,:no persons are required to respond to a. collection of information unless it displays a valid OMB.control number. The valid ONTO control number for this information collection-is 09,38- 1 148, " T"he time required to complete this information collection is estimated tq average 0 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 ter: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4- 26- 05, Baltimore, Maryland 21244- 1850. TN' UT- 14- 00.01- MM:1 Approval Date: 05/ 14/ 2014 Effective, Date: 01/ 01/ 2014 Utah S57 Pae 22 of 2'

OMB Control Nurnber 0938- 1148 011013 Expiration elate 10.`3, 1/ 20,14 Tli Arsl >< itat ns°fr z<° Cr, era M Inclt< clualsEliil l foFar Pnninc > iccs I. 1902( a)( 10)( A)( i i)( XXI) 42 CFR 435. 214 Individuals Eligible for Family Planning Services- The state elects to corer indi:vi duals. yho are: not pregnant. and have household income at or below a standard established by the state. whose coverage is limited' to family planning and related services and in accordance with provisions described at 42 C: FR.435: 214. C i Yes C : No 3 PRA Discl'osure Statement According to the Paperwork Reduction Act of 1995, no persons are requi'red-to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this int,on atiori cgllectiu,n is 0038 77 148. ' The time required to complete this information collection is estimaied' to:average,4.0: llouis per response-. including tile' time to review instructions, search existing data resources, gather the data needed, and- complete and. review' the information collection: ' ifyQrt hive conurrents.concerning the accuracy of' the time estimates) or suggestions for improving this farm, please write to: CMS, 7500 Security Boulevard, lm: PRA Reports Clearance Officer, Mail Stop C4- 26- 05, Baltimore, Maryland 21244- 1850. i TN: UT-14-00017MM1 Approval Date: 05/ 14/ 2014 Effective Date: 01/ 01/ 2014 Utah S59 aye 1 of 1

Table of Contents State/Territory Name: Utah State Plan Amendment (SPA)#: UT-15-0018-MM This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages TN: UT-15-0018-MM Approval Date: 05/14/:20 l 5 Effective Date 0 l /01/2015

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 1961 Stout Street, Room 08-148 Denver, CO 80294 Region VIII May 15,2015 W. David Patton, Ph.D. Utah Department of Health 288 North 1460 West PO Box 143102 Salt Lake City, UT 84114 RE: Utah #15-0018-MM Dear Dr. Patton: s We have reviewed the proposed State Plan Amendment (SPA) submitted under transmittal number (TN) 15-0018-MM. This State Plan Amendment updates Utah Medicaid's eligibility marriage policy. Please be informed that this State Plan Amendment was approved today with an effective date of January 1, 2015. We are enclosing the CMS-179 and the amended plan page(s). If you have any questions concerning this amendment, please contact Mandy Strom at (303) 844-7068. CC: Michael Hales, Medicaid Director, UT Craig Devashrayee, UT Sincerely, /s/ Richard C. Allen Associate Regional Administrator Division for Medicaid and Children's Health

UT.I657.ROO.OO- Jan OI, 20I5 Page I of2 Statefferritory name: Utah 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 jour digit number with leading zeros. The dashes must also be entered. UT-15-0018 Proposed Effective Date 01/01/2015 (mm/dd/yyyy) Federal Statute/Regulation Citation Pub.L.No.lll-148 Federal Budget Impact Federal Fiscal Year First Year 2015 Second Year 2016 Subject of Amendment Medicaid Eligibility Marriage Policy Governor's Office Review $0.00 $0.00 Governor's office reported no comment Comments of Governor's office received Describe: No reply received within 45 days of submittal Other, as specified Describe: Signature of State Agency Official Submitted By: Last Revision Date: Submit Date: Craig Devashrayee Mar 23,2015 Mar 23,2015 Amount https:/ /wms-mmdl.cdsvdc .com/M MD Llfaces/protected/mac/ cO I I print/PrintSe lector .j sp 03/23/20I5

UT.1657.ROO.OO- Jan OJ, 2015 Page 2 of2 https:/ /wms-mmdl.cdsvdc.com/MMD Llfaces/protected/mac/ cO I /print/PrintSel ector .j sp 03/23/2015

Medicaid Eligibility State Transmittal Number: UT - 15-0018 OTvtB Control Number: 0938 1148 I '"' Medic~Jd EJ~glbiU~ .MirrhtfieJ'olicy./ I 1902( e)( 14 )(G) 1902(a)( 17) ~ With respect to individuals for whom the state must complete a determination of income either based on MAGI or for MAGI- excepted groups utilizing AFDC-related or SSI-related methodologies. the state: r. Recognizes same-sex couples as spouses, if they are legally married under the laws of the state, territory, or foreign jurisdiction in which the marriage was celebrated. Does not recognize same-sex couples as spouses. even if they were legally married in a state. territory, or foreign jurisdiction that recognizes same-sex marriages. With respect to individuals whose eligibility for Medicaid is based on eligibility for another benefit program, and f()r whom the ~ state does not complete a determination of income for Medicaid eligibility. the state will not make any determination concerning marital status. Medicaid eligibility will continue to be based on the determination of eligibility f()r the applicable benefits. ~ The option elected above, with respect to income determinations, also governs the state's definition f{)r post-eligibility issues. including spousal impoverishment, asset transfers and estate recovery rules, to the degree permitted by state law. PRA Disclosure Statemcn1 S12 According to the Paperwork Reduction Act of I 995. no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number f()r this infom1ation collection is 09381148. The time required to complete this information collection is estimated to average I hour per response. including the time to review instructions. search existing data resources, gather the data needed. and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN NO: UT-15-0018-MM Utah Approval Date: 5/15/2015 V.2tll41n21 Effective Date: 1/1/2015 Page I of I

Table of Contents State/Territory Name: Utah State Plan Amendment (SPA) #: UT -16 -0002 -MM This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179 -like data) 3) Approved SPA Pages TN: UT -16 -0002 -MM Approval Date: 03/ 18/ 2016 Effective Date 01/ 01/ 2016

DEPARTMENTOFHEALTH & HUMANSERVICES CentersforMedicare & MedicaidServices 1961StoutStreet, Room08-148 Denver, CO 80294 RegionVIII March18, 2016 JosephK. Miner, M.D., MSPH, ExecutiveDirector UtahDepartmentofHealth P.O. Box141000 SaltLakeCity, UT 84114-1000 RE: Utah #16-0002 DearDr. Miner: WehavereviewedtheproposedStatePlanAmendment (SPA) submittedundertransmittal number (TN) 16-0002. ThepurposeofthisamendmentistoaddFormerFosterCareYouth: Addseligibilityforindividualswhowereinfostercarefromotherstates. PleasebeinformedthatthisStatePlanAmendmentwasapprovedMarch18, 2016withan effectivedateofJanuary1, 2016. WeareenclosingtheCMS-179andtheamendedplanpage(s). Ifyouhaveanyquestionsconcerningthisamendment, pleasecontactMandyStromat 303) 844-7068. Sincerely, s/ RichardC. Allen AssociateRegionalAdministrator DivisionforMedicaid & Children’sHealthOperations cc: NathanChecketts, ActingMedicaidDirector, UT CraigDevashrayee, UT

UT.2364. R00. 00 - Jan 01, 2016 Page 1 of 13 Medicaid State Plan Eligibility Medicaid State Plan Eligibility: General Information State/Territory name: Transmittal Number: Utah UT -16- 0002 General Information: Submission Title: short (under 100 characters) label used to identify this submission in the web application 16 -0002 -MM PDFs superseded by this SPA Include Transmittal Number): S33 - 14 -000l -MMI Description: Former Foster Care Youth from Other States Medicaid State Plan Eligibility: File Management Summary State/Territory name: Transmittal Number: Utah UT -16- 0002 Type of SPA Code Form Name/ Description Uploaded? MAGI -Based Eligibility Groups S14 AFDC Income Standard no MAGI -Based Eligibility Groups S14T Income Standards - Territories no MAGI -Based Eligibility Groups S25 Mandatory: Parents and Other Caretakers no MAGI -Based Eligibility Groups S28 Mandatory: Pregnant Women no MAGI -Based Eligibility Groups S28T Mandatory: Pregnant Women - Territories no MAGI -Based Eligibility Groups S30 Mandatory: Infants and Children Under Age 19 no MAGI -Based Eligibility Groups S3OT Mandatory: Infants and Children Under Age 19 - Territories no MAGI -Based Eligibility Groups S32 Mandatory: Individuals Below 133% of the FPL no MAGI -Based Eligibility Groups S33 Mandatory: Former Foster Care Children up to age 26 yes S50 Optional: Individuals Above 133% of the FPL no UT -16-0002 Approved Date: 3/ 18/2016 Effective Date: 1/ 1/ 2016 https:// wms- mmdl.cdsvdc. com/MMDL/ faces/ protected/mac/ co 1/ print/PrintSelector.jsp 12/ 23/ 2015

UT.2364.R00.00 - Jan 01, 2016 Type of SPA Form Code Form Name/Description Uploaded? MAGI -Based Eligibility Groups MAGI -Based Eligibility Groups S51 Optional: Optional Parents and Caretakers no MAGI -Based Eligibility Groups S52 Optional: Reasonable Classifications of Individuals no MAGI -Based Eligibility Groups S53 Optional: Non IV -E Adoption Assistance no MAGI -Based Eligibility Groups S54 Optional: Optional Targeted Low Income Children no MAGI -Based Eligibility Groups S55 Optional: Tuberculosis no MAGI -Based Eligibility Groups S57 Optional: Foster Care Adolescents - Chafee no MAGI -Based Eligibility Groups S59 Optional: Family Planning no Eligibility Process S94 Single streamlined application or alternative, Renewals, Coordination for enrollment and eligibility agreements with Exchanges) no MAGI Income Methodology S10 Designates the income options the state is electing in 2014 (e. g. how pregnant women are counted, reasonably predictable changes in income, cash support, how full-time students are counted) no Single State Agency Al -3 Addresses single state agencies delegation of appeals and determinations no Residency S88 State affirms residency regulations and addresses interstate agreements and temporary absence no Citizenship & Immigration Status S89 State affirms citizenship regulations, specifies reasonable opportunity options, and specifies policy options related to immigrant eligibility no Hospital Presumptive Eligibility S21 State specifies options for presumptive eligibility conducted by hospitals no Marriage Policy S12 Medicaid Eligibility Marriage Policy no Medicaid State Plan Eligibility: File Management Detail Page 2 of 13 Form S14: AFDC Income Standards Form Description: A UT -16- 0002 Approved Date: 3/ 18/2016 Effective Date: 1/ 1/ 2016 https:// wms-mmdl.cdsvdc.com/MMDL/faces/protected/mac/ c01/ print/PrintSelectorjsp 12/ 23/ 2015

UT.2364. R00. 00 - Jan 01, 2016 Page 3 of 13 Uploaded Form: Date U oaded: Support Documents Document F0111 Sl4T: Income Standards - Territories Form Description: Uploaded Form: Support Documents Date Uploaded: Document Form S25: Eligibility Groups - Mandatory Coverage: Parents and Other Caretaker Relatives Form Description: Uploaded Form: Support Documents Date Uploaded: 1 I IDocument Form S28: Eligibility Groups - Mandatory Coverage: Pregnant ' o Form Description: liploaded Form: Support Documents Date Uploaded: Document Form S28T: Mandatory: Pregnant Women - Territories UT -16- 0002 Approved Date: 3/ 18/ 2016 Effective Date: 1/ 1/ 2016 https:// wms- mmdl.cdsvdc. com/ MMDL/faces/ protected/ mac/ c01/ print/PrintSelector.jsp 12/ 23/ 2015

UT.2364.R00. 00 - Jan 01, 2016 Page 4 of 13 UT - 16- 0002 Approved Date: 3/ 18/ 2016 Effective Date: 1/ 1/ 2016 https:// wms- mmdl. cdsvdc. com/ MMDL/ faces/ protected/ mac/ c01 / print/ PrintSelector. j sp 12/ 23/ 2015 Form Description: Uploaded Form: Date Uploaded: Support Documents IDocument Form S30: Age 19 Eligibility Groups - Mandatory Coverage: Infants and Children under Form Description: Uploaded Form: Date Uploaded: Support Documents IDocument Form S3OT: Mandatory: Infants and Children Under Age 19 - Territories Form Description: Uploaded Form: Date Uploaded: Support Documents Document Form S32: Eligibility Groups - Mandatory Coverage: Adult Group Form Description: Uploaded Form: Date Uploaded: Support Documents Document UT - 16- 0002 Approved Date: 3/ 18/ 2016 Effective Date: 1/ 1/ 2016 https:// wms- mmdl. cdsvdc. com/ MMDL/ faces/ protected/ mac/ c01 / print/ PrintSelector. j sp 12/ 23/ 2015

UT.2364.R00.00 - Jan 01, 2016 Page 5 of 13 Form S33: Eligibility Groups - Mandatory Coverage: Former Foster Care Children Form Description: Uploaded Form: Support Documents Former Foster Care Children Date Uploaded: 12/ 15/ 2015 S33. pdf Document Form S50: Eligibility Groups - Options for Coverage: Individuals above 133% FPL Form Description: Uploaded Form: Support Documents Date Uploaded: Document Form S51: Eligibility Groups - Options for Coverage: Optional Coverage of Parents and Other Caretaker Relatives Form Description: Uploaded Form: Support Documents Date Uploaded: IDocument Form S52: Eligibility Groups - Options for Coverage: Reasonable Classification of Individuals under Age 21 Form Description: Uploaded Form: Date Uploaded: UT -16- 0002 Approved Date: 3/ 18/ 2016 Effective Date: 1/ 1/ 2016 https:// wms-mmdl.cdsvdc.com/MMDL/faces/ protected/mac/ c01/ print/PrintSelector.jsp 12/ 23/ 2015

UT.2364. R00.00 - Jan 01, 2016 Page 6 of 13 UT - 16- 0002 Approved Date: 3/ 18/ 2016 Effective Date: 1/ 1/ 2016 https:// wms- mmdl. cdsvdc. com/ MMDL/ faces/ protected/ mac/ c01/ print/ PrintSelector . j sp 12/ 23/ 2015 Support Documents Document Form S53: Eligibility Groups - Options for Coverage: Children with Non IV -E Adoption Assistance Form Description: Uploaded Form: Support Documents Date Uploaded: Document Form S54: Eligibility Groups - Options for Coverage: Optional Targeted Low Income Children Form Description: Uploaded Form: Support Documents Date Uploaded: Document Form S55: Eligibility Groups - Options for Coverage: Individuals with Tuberculosis Form Description: Uploaded Form: Support Documents Date Uploaded: Document UT - 16- 0002 Approved Date: 3/ 18/ 2016 Effective Date: 1/ 1/ 2016 https:// wms- mmdl. cdsvdc. com/ MMDL/ faces/ protected/ mac/ c01/ print/ PrintSelector .j sp 12/ 23/ 2015

UT.2364.R00.00 - Jan 01, 2016 Page 7 of 13 Form S57: Eligibility Groups - Options for Coverage: Independent Foster Care Adolescents Form Description: r Uploaded Form: Date Uploaded: Support Documents IDocument I Form S59: Eligibility Groups - Options for Coverage: Individuals Eligible for Family Planning Services Form Description: Uploaded Form: Support Documents Date Uploaded: Document Form S94: General Eligibility Requirements: Eligibility Process Form Description: l! ploaded Form: Support Documents Date Uploaded: IDocument Form SIO: MAGI -Based Income Methodologies Form Description: Uploaded Form: Date 1: p aded: UT -16-0002 Approved Date: 3/ 18/2016 Effective Date: 1/ 1/ 2016 hups:// wrns- mmdl.cdsvdc.com/ MMDL/faces/ protected/ mac/ c01/ print/ PrintSelectorjsp 12/ 23/ 2015

UT.2364.R00.00 - Jan 01, 2016 Page 8 of 13 Support Documents Document Form A1- 3: Medicaid Administration: Single State Agency Form Description: Uploaded Form: Support Documents Date Uploaded: Document Form S88: Non -Financial Eligibility: State Residency Form Description: Uploaded Form: Support Documents eN Date Uploaded: Document Form S89: Non -Financial Eligibility: Citizenship and Non -Citizen Eligibility Form Description: Uploaded Form: Support Documents Date Uploaded: Document Form S21: Presumptive Eligibility by Hospitals Form Description: Uploaded Form: Date Uploaded: UT -16- 0002 Approved Date: 3/ 18/2016 Effective Date: 1/ 1/ 2016 https:// wms-mmdl.cdsvdc.com/ MMDL/faces/protected/mac/ c01 /print/PrintSelector.jsp 12/ 23/ 2015

UT.2364.R00. 00 - Jan 01, 2016 Page 9 of 13 Support Documents Document Form S12: Medicaid Eligibility Marriage Policy Form Description: Uploaded Form: Support Documents Dale Uploaded: Document Medicaid State Plan Eligibility: Tribal Input State/Territory name: Transmittal Number: Utah UT -16- 0002 I One or more Indian Health Programs or Urban Indian Organizations furnish health care services in this State. This State Plan Amendment is likely to have a direct effect on Indians, Indian health programs or Urban Indian Organizations. The State has solicited advice from Indian Health Programs, Urban Indian Organizations, and/or Tribal governments prior to submission of this State Plan Amendment. Complete the following information regarding any tribal consultation conducted with respect to this submission: Tribal consultation was conducted in the following manner. States are not required to consult with Indian tribal governments, but ifsuch consultation was conducted voluntarily, provide information about such consultation below: Indian Tribes Indian Tribes Name of Indian Tribe: Confederated Tribes of the Goshute Reservation Date of consultation: 12/ 11/ 2015 ( mm/ dd/ yyyy) Method/Location of consultation: Meeting at the Utah Department of Health (Highland Drive Bldg., SLC, UT) Bridge line was available to access meeting by phone. Name of Indian Tribe: Northwestern Band of the Shoshone Nation Date of consultation: 12/ 11/ 2015 ( mm/ dd/ yyyy) UT -16- 0002 Approved Date: 3/ 18/ 2016 Effective Date: 1/ 1/ 2016 https:// wms- mmdl.cdsvdc.com/MMDL/faces/ protected/mac/ c0 1 / print/PrintSelector. j sp 12/ 23/ 2015

UT.2364. R00.00 - Jan 01, 2016 Page 10 of 13 Indian Tribes Method/ Location of consultation: Meeting at the Utah Department of Health (Highland Drive Bldg., SLC, UT) Bridge line was available to access meeting by phone. Name of Indian Tribe: Paiute Indian Tribe of Utah Date of consultation: 12/ 11/ 2015 ( mm/ dd/ yyyy) Method/Location of consultation: Meeting at the Utah Department of Health (Highland Drive Bldg., SLC, UT) Bridge line was available to access meeting by phone. j. Indian Health Programs Indian Health Programs Name of Indian Health Programs: Phoenix Area Indian Health Services Date of consultation: 12/ 11/ 2015 ( mm/ dd/ YYYY) Method/Location of consultation: Meeting at the Utah Department of Health (Highland Drive Bldg., SLC, UT) Bridge line was available to access meeting by phone. Name of Indian Health Programs: Utah Division of Indian Affairs Date of consultation: 12/ 11/ 2015 ( mm/ dd/ yyyy ) Method/ Location of consultation: Meeting at the Utah Department of Health (Highland Drive Bldg., SLC, UT) Bridge line was available to access meeting by phone. Name of Indian Health Programs: Utah Navajo Health System, Inc. Date of consultation: 12/ 11/ 2015 ( mm/ dd/ YYYY) Method/Location of consultation: Meeting at the Utah Department of Health (Highland Drive Bldg., SLC, UT) Bridge line was available to access meeting by phone. Name of Indian Health Programs: Ute Mountain Ute Health Center Date of consultation: 12/ 11/ 2015 ( mm/ dd /yyyy ) Method/Location of consultation: Meeting at the Utah Department of Health (Highland Drive Bldg., SLC, UT) Bridge line was available to access meeting by phone. Urban Indian Organization Urban Indian Organizations Name of Urban Indian Organization: Urban Indian Center of Salt Lake UT -16-0002 Approved Date: 3/ 18/2016 Effective Date: 1/ 1/ 2016 https:// wms-mmdl.cdsvdc. com/MMDL/faces/protected/mac/ c01 /print/PrintSelector.jsp 12/ 23/ 2015

UT.2364.R00.00 - Jan 01, 2016 Page 11 of 13 Urban Indian Organizations Date of consultation: 2015 mm/ dd/ yyyy) Method/ Location of consultation: Meeting at the Utah Department of Health ( Highland Drive Bldg., SLC, UT) Bridge line was available to access meeting by phone. The state must upload copies of documents that support the solicitation of advice in accordance with statutory requirements, including any notices sent to Indian Health Programs and/or Urban Indian Organizations, as well as attendee lists if face- to- face meetings were held. Also upload documents with comments received from Indian Health Programs or Urban Indian Organizations and the state' s responses to any issues raised. Alternatively indicate the key issues and summarize any comments received below and describe how the state incorporated them into the design of its program. Document Please provide a short description of this support document: UIHAB Meeting Agenda 12- 11- 15 Uploaded Document Name: Date t ploaded: 2015 UIHAB Agenda Dec.pdf Indicate the key issues raised in Indian consultative activities: Access Summarize Comments Summarize Response Quality Summarize Comments Summarize Response Cost Summarize Comments Summarize Response Payment methodology Summarize Comments Summarize Response j Eligibility Summarize Comments UT -16-0002 Approved Date: 3/ 18/2016 Effective Date: 1/ 1/ 2016 https:// wms- mmdl.cdsvdc. com/MMDL/faces/ protected/ mac/ c01 /print/PrintSelector.jsp 12/ 23/ 2015

UT.2364. R00. 00 - Jan 01, 2016 Page 12 of 13 Phoenix Area Indian Health Services asked whether this amendment also applies to children who were previously under tribal foster care. Summarize Response The agency confirmed that children who were previously under tribal foster care are also covered under this amendment. Benefits Summarize Comments Summarize Response Service delivery Summarize Comments Summarize Response Other Issue Medicaid State Plan Eligibility: Summary Page ( CMS 179) State/Territory name: Utah 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 -16- 0002 Proposed Effective Date 01/ 01/ 2016 mm/ dd/ yyyy) Federal Statute/ Regulation Citation Pub. L. No. 1 1 1- 148 Federal Budget Impact Federal Fiscal Year First Year Second Year 2016 2017 Subject of Amendment Former Foster Care Youth from Other States Amount 87400.00 87400.00 Governor' s Office Review Governor's office reported no comment Comments of Governor' s office received Describe: UT -16-0002 Approved Date: 3/ 18/ 2016 Effective Date: 1/ 1/ 2016 https:// wms-mmdl. cdsvdc. com/MMDL/faces/protected/mac/ c01 /print/PrintSelector.jsp 12/ 23/ 2015

UT.2364. R00. 00 - Jan 01, 2016 Page 13 of 13 No reply received within 45 days of submittal Other, as specified Describe: Signature of State Agency Official Submitted By: Craig Devashrayee Last Revision Date: Dec 23, 2015 Submit Date: Dec 23, 2015 UT -16- 0002 Approved Date: 3/ 18/ 2016 Effective Date: 1/ 1/ 2016 https:// wms- mmdl.cdsvdc.com/MMDL/ faces/ protected/ mac/ c01/ print/PrintSelector.jsp 12/ 23/ 2015

State Name: Medicaid Eligibility Utah Transmittal Number: UT - 16 - 0002 OMB Control Number: 0938- 1148 Expiration date: 10/ 31/ 2014 42 CFR 435. 150 1902( a)( 10)( A)( i)( IX) Former Foster Care Children - Individuals under the age of 26, not otherwise mandatorily eligible, who were on Medicaid and in foster care when they turned age 18 or aged out of foster care. The state attests that it operates this eligibility group under the following provisions: Q Individuals qualifying under this eligibility group must meet the following criteria: Are under age 26. ro Are not otherwise eligible for and enrolled for mandatory coverage under the state plan, except that eligibility under this group takes precedence over eligibility under the Adult Group. Were in foster care under the responsibility of the state or Tribe and were enrolled in Medicaid under the state' s state Q plan or 1 1 15 demonstration when they turned 18 or at the time of aging out of that state' s or Tribe' s foster care program. The state elects to cover children who were in foster care and on Medicaid in any state at the time they turned 18 or aged out of the foster care system. Yes C No The state covers individuals under this group when determined presumptively eligible by a qualified entity. The state assures it also covers individuals under the Pregnant Women ( 42 CFR 435. 1 16) and/or Infants and Children under Age 19 ( 42 CFR 435. 118) eligibility groups when determined presumptively eligible. C Yes ( No PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938- 1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. if you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4- 26- 05, Baltimore, Maryland 21244- 1850. UT -16-0002 Approval Date: 3/ 18/ 16 V 20140415 Effective Date: 1/ 1/ 16 Page 1 of 1

Table of Contents State/Territory Name: Utah State Plan Amendment (SPA) #: UT- 17- 0001 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179- like data) 3) Approved SPA Pages TN: UT- 17- 0001 Approval Date: 08/ 18/ 2017 Effective Date 07/ 01/ 2017

DEPARTMENT OF HEALTH& HUMAN SERVICES Centers for Medicare & Medicaid Services Denver Regional Office 1961 Stout Street, Room 08- 148CMSDenver, CO 80294 CENTERS FOR MEDICARE& MEDICAID SERVICES REGION VIII- DENVER August 18, 2017 Nathan Checketts, Medicaid Director Utah Department of Health P. O. Box 141000 Salt Lake City, UT 84114- 1000 RE: Utah 417- 0001 Dear Mr. Checketts: We have reviewed the proposed State Plan Amendment ( SPA) submitted under transmittal number (TN) 17- 0001. This State Plan Amendment updates the Medicaid cost-sharing policy in accordance with the Affordable Care Act, effective July 1, 2017. Please be informed that this State Plan Amendment was approved today with an effective date of July 1, 2017. We are enclosing the CMS- 179 and the amended plan page( s). If you have any questions concerning this amendment, please contact Mandy Strom at 303) 844- 7068. Sincerely, Richard C. Allen Associate Regional Administrator Division for Medicaid & Children' s Health Operations cc: John Curless, UT Craig Devashrayee, UT

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED HEALTHCARE FINANCING ADMINISTRATION OMB NO. 0938µ0193 1. TRANSMITTAL NUMBER: 2. NATE: TRANSMITTAL AND NOTICEAPPROVAL OF 17- 0001- UT Utah TATE PLAN MATERIAL FOR: HEALTH CARE FINANCING AD'MINISTRATIO'N 3• PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCi, SECURITY ACT (MEDICAID) TO: REGIONAL ADMINISTRATOR 4. PROPOSED EFFECTIVE DATE HEALTHCARE FINANCING ADMINISTRATION July 1, 2017 DEPARTMENT OF HEALTH AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL ( Check One) NEW STATE PLAN AMENDMENT TO BE CONSIDERED AS NEW PLAN Z AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT ( Separate Transmittal foreach amendment) 6. FEDERAL STATU'TETREGULATION CITATION: 7. FEDERAL BUDGET IMPACT: a. FFY 2017 $[ 75,000] 42 CFR 447.50 through 447. 57 h. IFFY 2018 $[ 280,000 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT'. 0. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT( if Applicable) Pages 1 through 4 of ATTACHMENTS 4. 15- A and 4. 18- C; Pages 54, 5 , 55a, 56, 56a, 56c, 56d, 56e, and 56f of Section 4 are Pages 1 through 3 of ATTACHMENTS 4. 18-A and 4. 18- C; deleted. Pages 54, 55, 55a, 56, 56a, 56c, 56d, 56e, and 56f of Section 4 are deleted. I 10. SUBJECT OF AMENDMENT: Medicaid Cost Sharing 11. GOVERNOR' S REVIEW ( Check One).- GOVERNOR' S ne). GOVERNOR' S OFFICE REPORTED NO COMMENT OTHER, AS SPECIFIED:. COMMENTS OF GOVERNOR' S OFFICE ENCLOSED NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL 12. SIGNATURE OF STATE AGENCY OFFICIAL: 16. RETURN TO: Craig Devashrayee, Manager 13. TYPED ME: Joseph K. Miner, MID Technical Writing Unit Utah Department of Heath 14. TITLE: Deputy Director, Utah Department of Health PO 'Box 143102 Salt Lake City, UT 84114-3102 15. DATE SUBMITTED: May 22, 2017 16. i 17. DATE RECEIVED: 18. DATE APPROVED: MU 22, 2017 August 18, 2017 FOR REGIONAL USE ONLY 19. EFFECTIVE DATE OF APPROVED MATERIAL: 20.. SIGNATURE OF REGIONAL OFFICIAL: July 1, 2017 21. TYPED NAME: 22. TITLE: Richard C. Allen ARA, DMCHO PLAN APPROVED ONE COPY ATTACHED 3. REMARKS FORM HCFA-179( 07-92)

Revision: HCFA-PM- 85- 14 BERC) ATTACHMENT 4. 18-A Page 1 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: UTAH A. Effective October 1, 2017 unless otherwise noted, the following charges are imposed for services: Medicaid Service Cost Sharing Amount and Basis for Determination Non- Emergency Services 8 for each non- emergency use of the Received in Emergency emergency department. Departments. Inpatient Hospital Stay Effective July 1, 2017, $75 for each inpatient hospital stay( episode of care). Physician or Podiatrist Services $ 4 for each outpatient services visit physician visit, podiatry visit, physical therapy, etc.). Outpatient Hospital Services 4 for each outpatient hospital service visit, ( maximum of one per person, per hospital, per date of service). Pharmacy Services 4 for each prescription. Chiropractic Services 1 for each chiropractic visit ( maximum of one per date of service). Vision Services 3 for each pair of eyeglasses. Note: Additional ER copay information is found in Attachment 4. 18-H, Page 1. T. N. # 17- 0001 Approval Date 8/ 18/ 2017 Supersedes T. N. #. 08-001 Effective Date 7- 1- 17

Revision: HCFA-PM- 85- 14 BERC) ATTACHMENT 4. 18-A Page 2 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: UTAH B. The method used to collect cost sharing charges for categorically needy individuals: X Providers are responsible for collecting the cost sharing charges from individuals. The agency reimburses providers the full Medicaid rate for services and collects the cost sharing charges from individuals. C. Individuals whose countable household income, before deductions, is less than the TANF standard payment for a family of the applicable size are exempt from all cost sharing noted in Subsection A. D. Cost sharing eligible members who present at an emergency department for a non- emergency service will be charged a copayment. T. N. # 17-0001 Approval Date 8/ 18/2017 Supersedes T. N. # 02- 001 Effective Date 7- 1- 17

Revision: HCFA- PM- 85- 14 ( BERC) ATTACHMENT 4. 18-A Page 3 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: UTAH E. Members outside the exempt status will receive a Medicaid Benefit Letter with co-pay information listed during their eligibility period. F. The state includes an indicator in the Medicaid Management Information System ( MMIS) G. The state includes an indicator in the Eligibility and Enrollment System H. The state includes an indicator in the Eligibility Verification System I. Providers may verify a members copay requirements at: https:Hmedicaid. utah.gov/eligibility. J. The State applies incurred- cost sharing to the aggregate limit when claims are submitted for dates of service within the current monthly cap period. Once the aggregate limit is reached, cost-sharing liability stops. For households that may have paid copays in excess of the aggregate limits: The member contacts a Utah Medicaid health program representative noting the out- of-pocket amounts paid. Medicaid staff verifies the amounts based on paid claims. Medicaid staff enters the household as exempt from cost sharing for the duration of the limit period. Medicaid staff will initiate, as appropriate, a reprocessing of the claim(s) that made the household exceed the aggregate limits. Medicaid staff will work with impacted providers to ensure the household is reimbursed for copay differences that were paid by the household. K. Medicaid members described in 42 CFR 447. 56(a)( 1) are exempt from copayment requirements. T. N. # 17- 0001 Approval Date 8/ 18/2017 Supersedes T. N. # 10- 010 Effective Date 7- 1- 17

Revision: HCFA- PM- 85- 14 ( BERC) ATTACHMENT 4. 18-A Page 4 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: UTAH L. The following conditions apply to the AI/ AN copayment exemption: Those individuals who have a verified or pending AI/AN status on their eligibility record and have an established relationship with one of the following types of facilities ( I/ T/Us) will be exempted from cost sharing: Indian Health Service facility Tribal clinic Urban Indian Organization facility The State will perform a regular review of Medicaid claims to identify users of I/ T/ U facilities and will flag those users as exempt from cost sharing. In addition, individuals who present a letter or other document verifying current or previous use of services provided at an I/ T/ U facility, or services referred through contract health services in any State, will be flagged as exempt from cost sharing. The following services do not require copayments: 1. Family planning services, including contraceptives and pharmaceuticals; 2. Preventive services, including vaccinations and health education; 3. Pregnancy-related services, including tobacco cessation; 4. Emergency services (emergency use of an emergency room); and 5. Provider-preventable condition ( PPC) services. M. Cumulative maximums on charges: State policy does not provide for cumulative maximums. X Cumulative maximums have been established as described below: 75 for each inpatient hospital stay( episode of care). A cumulative copayment amount that does not exceed $ 100 per year is allowed for physician services, podiatrist services, outpatient hospital services, and chiropractic services. 20 cumulative monthly maximum copayment amount aggregated for pharmacy services. T. N. # 17-0001 Approval Date 8/ 18/ 2017 Supersedes T. N. # New Effective Date 7- 1- 17

Revision: HCFA-PM- 85- 14 BERC) ATTACHMENT 4. 18- C Page 1 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: UTAH A. Effective October 1, 2017 unless otherwise noted, the following charges are imposed for services: Medicaid Service Cost Sharing Amount and Basis for Determination Non- Emergency Services 8 for each non- emergency use of the Received in Emergency emergency department. Departments. Inpatient Hospital Stay Effective July 1, 2017, $75 for each inpatient hospital stay( episode of care). Physician or Podiatrist Services $ 4 for each outpatient services visit physician visit, podiatry visit, physical therapy, etc.). Outpatient Hospital Services 4 for each outpatient hospital service visit, ( maximum of one per person, per hospital, per date of service). Pharmacy Services 4 for each prescription. Chiropractic Services 1 for each chiropractic visit ( maximum of one per date of service). Vision Services 3 for each pair of eyeglasses. Note: Additional ER copay information is found in Attachment 4. 18-H, Page 1. T. N. # 17- 0001 Approval Date 8/ 18/2017 Supersedes T. N. #. 08-001 Effective Date 7- 1- 17

Revision: HCFA-PM- 85- 14 BERC) ATTACHMENT 4. 18- C Page 2 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: UTAH B. The method used to collect cost sharing charges for categorically needy individuals: X Providers are responsible for collecting the cost sharing charges from individuals. The agency reimburses providers the full Medicaid rate for services and collects the cost sharing charges from individuals. C. Individuals whose countable household income, before deductions, is less than the TANF standard payment for a family of the applicable size are exempt from all cost sharing noted in Subsection A. D. Cost sharing eligible members who present at an emergency department for a non- emergency service will be charged a copayment. T. N. # 17-0001 Approval Date 8/ 18/2017 Supersedes T. N. # 02- 001 Effective Date 7- 1- 17

Revision: HCFA- PM- 85- 14 ( BERC) ATTACHMENT 4. 18-C Page 3 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: UTAH E. Members outside the exempt status will receive a Medicaid Benefit Letter with co-pay information listed during their eligibility period. F. The state includes an indicator in the Medicaid Management Information System ( MMIS) G. The state includes an indicator in the Eligibility and Enrollment System H. The state includes an indicator in the Eligibility Verification System I. Providers may verify a members copay requirements at: https:Hmedicaid. utah.gov/eligibility. J. The State applies incurred- cost sharing to the aggregate limit when claims are submitted for dates of service within the current monthly cap period. Once the aggregate limit is reached, cost-sharing liability stops. For households that may have paid copays in excess of the aggregate limits: The member contacts a Utah Medicaid health program representative noting the out- of-pocket amounts paid. Medicaid staff verifies the amounts based on paid claims. Medicaid staff enters the household as exempt from cost sharing for the duration of the limit period. Medicaid staff will initiate, as appropriate, a reprocessing of the claim(s) that made the household exceed the aggregate limits. Medicaid staff will work with impacted providers to ensure the household is reimbursed for copay differences that were paid by the household. K. Medicaid members described in 42 CFR 447. 56(a)( 1) are exempt from copayment requirements. T. N. # 17- 0001 Approval Date 8/ 18/ 2017 Supersedes T. N. # 10- 010 Effective Date 7- 1- 17

Revision: HCFA- PM- 85- 14 ( BERC) ATTACHMENT 4. 18-C Page 4 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: UTAH L. The following conditions apply to the AI/ AN copayment exemption: Those individuals who have a verified or pending AI/AN status on their eligibility record and have an established relationship with one of the following types of facilities ( I/ T/Us) will be exempted from cost sharing: Indian Health Service facility Tribal clinic Urban Indian Organization facility The State will perform a regular review of Medicaid claims to identify users of I/ T/ U facilities and will flag those users as exempt from cost sharing. In addition, individuals who present a letter or other document verifying current or previous use of services provided at an I/ T/ U facility, or services referred through contract health services in any State, will be flagged as exempt from cost sharing. The following services do not require copayments: 1. Family planning services, including contraceptives and pharmaceuticals; 2. Preventive services, including vaccinations and health education; 3. Pregnancy-related services, including tobacco cessation; 4. Emergency services (emergency use of an emergency room); and 5. Provider-preventable condition ( PPC) services. M. Cumulative maximums on charges: State policy does not provide for cumulative maximums. X Cumulative maximums have been established as described below: 75 for each inpatient hospital stay( episode of care). A cumulative copayment amount that does not exceed $ 100 per year is allowed for physician services, podiatrist services, outpatient hospital services, and chiropractic services. 20 cumulative monthly maximum copayment amount aggregated for pharmacy services. T. N. # 17-0001 Approval Date 8/ 18/2017 Supersedes T. N. # New Effective Date 7- 1- 17

Revision: HCFA- PM- 91- 4 ( BPD) Page 54 August 1991 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM State: UTAH SECTION 4 - GENERAL PROGRAM ADMINISTRATION ( Continued) 4. 18 Recipient Cost Sharing and Similar Charges Deleted 7- 1- 17 T. N. # 17- 0001 Approval Date 8/ 18/2017 Supersedes T. N. # 91- 20 Effective Date 7- 1- 17

Revision: HCFA- PM- 91- 4 ( BPD) Page 55 August 1991 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM State: UTAH SECTION 4 - GENERAL PROGRAM ADMINISTRATION ( Continued) 4. 18 Recipient Cost Sharing and Similar Charges (Continued) Deleted 7- 1- 17 T. N. # 17- 0001 Approval Date 8/ 18/2017 Supersedes T. N. # 03-016 Effective Date 7- 1- 17

Revision: HCFA- PM- 91- 4 ( BPD) Page 55a August 1991 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM State: UTAH SECTION 4 - GENERAL PROGRAM ADMINISTRATION ( Continued) 4. 18 Recipient Cost Sharing and Similar Charges (Continued) Deleted 7- 1- 17 T. N. # 17- 0001 Approval Date 8/ 18/2017 Supersedes T. N. # 03-016 Effective Date 7- 1- 17

Revision: HCFA- PM- 91- 4 ( BPD) Page 56 August 1991 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM State: UTAH SECTION 4 - GENERAL PROGRAM ADMINISTRATION ( Continued) 4. 18 Recipient Cost Sharing and Similar Charges (Continued) Deleted 7- 1- 17 T. N. # 17-0001 Approval Date 8/ 18/ 2017 Supersedes T. N. # 94- 01 Effective Date 7- 1- 17

Revision: HCFA- PM- 91- 4 ( BPD) Page 56a August 1991 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM State: UTAH SECTION 4 - GENERAL PROGRAM ADMINISTRATION ( Continued) 4. 18 Recipient Cost Sharing and Similar Charges (Continued) Deleted 7- 1- 17 T. N. # 17- 0001 Approval Date 8/ 18/2017 Supersedes T. N. # 94-01 Effective Date 7- 1- 17

Revision: HCFA- PM- 91- 4 ( BPD) Page 56c August 1991 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM State: UTAH SECTION 4 - GENERAL PROGRAM ADMINISTRATION ( Continued) 4. 18 Recipient Cost Sharing and Similar Charges ( Continued) Deleted 7- 1- 17 T. N. # 17- 0001 Approval Date 8/ 18/2017 Supersedes T. N. # 91- 20 Effective Date 7- 1- 17

Revision: HCFA- PM- 91- 4 ( BPD) Page 56d August 1991 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM State: UTAH SECTION 4 - GENERAL PROGRAM ADMINISTRATION ( Continued) 4. 18 Recipient Cost Sharing and Similar Charges ( Continued) Deleted 7- 1- 17 T. N. # 17- 0001 Approval Date 8/ 18/2017 Supersedes T. N. # 91- 20 Effective Date 7- 1- 17

Revision: HCFA- PM- 91- 4 BPD) Page 56e August 1991 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM State: UTAH SECTION 4 - GENERAL PROGRAM ADMINISTRATION ( Continued) 4. 18 Recipient Cost Sharing and Similar Charges ( Continued) Deleted 7- 1- 17 T. N. # 17- 0001 Approval Date 8/ 18/2017 Supersedes T. N. # 94-01 Effective Date 7- 1- 17

Revision: HCFA- PM- 91- 4 ( BPD) Page 56f August 1991 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM State: UTAH SECTION 4 - GENERAL PROGRAM ADMINISTRATION ( Continued) 4. 18 Recipient Cost Sharing and Similar Charges ( Continued) Deleted 7- 1- 17 T. N. # 17- 0001 Approval Date 8/ 18/2017 Supersedes T. N. # 94-01 Effective Date 7- 1- 17

Table of Contents State/Territory Name: Utah State Plan Amendment (SPA) #: UT- 17- 0017 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179- like data) 3) Approved SPA Pages TN: UT- 17- 0017 Approval Date: 07/ 08/ 2017 Effective Date 07/ 01/ 2017

DEPARTMENT OF HEALTH& HUMAN SERVICES Centers for Medicare& Medicaid Services 1961 Stout Street, Room 08448 Denver, CO 80294 MS CENTERS FOR MEDICARE& MEDICAID SERVICES Region VIII July 10, 2017 Nathan Checketts, Medicaid Director Utah Department of Health P. O. Box 141000 Salt Lake City, UT 84114- 1000 RE: Utah# 17- 0017 Dear Mr. Checketts: We have reviewed the proposed State Plan Amendment( SPA) submitted under transmittal number( TN) 17- 0017. This State Plan Amendment implements a disregard from resources and income in regard to the Utah Educational Savings Plan and eligibility determinations for certain Medicaid programs. Please be informed that this State Plan Amendment was approved July 8, 2017, with an effective date of July 1, 2017. We are enclosing the CMS- 179 and the amended plan page( s). Ifyou have any questions concerning this amendment, please contact Mandy Strom at 303) 844- 7068. Sincerely, Richard C. Allen Associate Regional Administrator Division for Medicaid & Children' s Health Operations cc: Jeff Nelson, UT Craig Devashrayee, UT

V DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED HEALTHCARE FINANCING ADMINISTRATION OMB NO. 0938-0193 1. TRANSMITTAL NUMBER: 2. STATE: TRANSMITTAL AND NOTICE OF APPROVAL OF 17- 0017- UT Utah STATE PLAN MATERIAL FOR: HEALTH CARE FINANCING ADMINISTRATION 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT( MEDICAID) TO: REGIONAL ADMINISTRATOR 4. PROPOSED EFFECTIVE DATE HEALTHCARE FINANCING ADMINISTRATION July 1, 2017 DEPARTMENT OF HEALTH AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL ( Check One) NEW STATE PLAN AMENDMENT TO BE CONSIDERED AS NEW PLAN AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT ( Separate Transmittal for each amendment) 6. FEDERAL STATUTE/ REGULATION CITATION: 7. FEDERAL BUDGET IMPACT: a. FFY 2017 +$ 400 Section 1902( r)( 2) of the Social Security Act b. FFY 2018 +$ 1, 700 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT( If Applicable) Page 3 of SUPPLEMENT 8a TO ATTACHMENT 2. 6- A; Page 2 of SUPPLEMENT 8b TO ATTACHMENT 2.6-A I Page 2 of SUPPLEMENT 8b TO ATTACHMENT 2.6- A. 10, SUBJECT OF AMENDMENT: Utah Educational Savings Plan 11. GOVERNOR' S REVIEW (Check One): GOVERNOR' S OFFICE REPORTED NO COMMENT OTHER, AS SPECIFIED: COMMENTS OF GOVERNOR' S OFFICE ENCLOSED NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL 12. SIGNATURE OF STATE AGENCY OFFICIAL: 16. RETURN TO: Craig Devashrayee, Manager 13, TYPED- AM Joseph K. Miner, MD Technical Writing Unit Utah Department of Heath 14. TITLE: Executive Director, Utah Department of Health PO Box 143102 Salt Lake City, UT 84114- 3102 15. DATE SUBMITTED: May 18, 2017 6 L DATE I"' ' r Irl' 1l3 1- VA -r A F-FEr`t!fI- 1. i. . I, AZ July 8, 2017 i.7 ..C+_l[ 7/;„ iAl + = 0r 1i July 1, 2011 n' -$ Richard G Allen ARA, IT)MCHO

SUPPLEMENT 8a TO ATTACHMENT 2. 6- A Page 3 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: UTAH MORE LIBERAL METHODS OF TREATING INCOME UNDER SECTION 1902( r)( 2) OF THE ACT For the following eligibility groups, the State disregards as income, any interest earned on funds held in an excluded Utah Educational Savings Plan ( 529 account). X Medically Needy Children under 1902( a)( 10)( C)( ii)( 1); X Medically Needy Children under 1905( a)( i), who are 18 years old, in school, and expected to graduate before turning 19 years of age; X Medically Needy Pregnant Women under 1902( 1)( 10)( c)( ii)( 1); X Medically Needy Parents and Caretaker Relatives under 1905(a)( ii). T. N. # 17-0017 Approval Date July 8, 2017 Supersedes T.N. # New Effective Date 7- 1- 17

SUPPLEMENT 8b TO ATTACHMENT 2. 6-A Page 2 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: UTAH MORE LIBERAL METHODS OF TREATING RESOURCES UNDER SECTION 1902( r)( 2) OF THE ACT Section 1902(f) State X Non-Section 1902(f) State For the following eligibility groups, the State disregards from resources, funds held in a Utah Educational Savings Plan ( 529 account). X Medically Needy Children under 1902( a)( 10)( C)( ii)( 1); X Medically Needy Children under 1905( a)( i), who are 18 years old, in school, and expected to graduate before turning 19 years of age; X Medically Needy Pregnant Women under 1902( a)( 10)( C)( ii)( 11); X Medically Needy Parents and Caretaker Relatives under 1905( a)( ii). T. N. # 17-0017 Approval Date July 8, 2017 Supersedes T. N. # 11- 003 Effective Date 7- 1- 17

Table of Contents State/Territory Name: Utah State Plan Amendment (SPA) #: 19- 0002 This file contains the following documents in the order listed: 1) Approval Letter 2) 179 3) Approved SPA Pages TN: UT- 19- 0002 Approval Date: 08/27/ 2019 Effective Date: 04/ 01/ 2019

CMS- 10434 OMB 0938- 1188 Package Information Package ID UT2018MS00030 Submission Type Official Program Name N/ A State UT SPA ID UT- 19- 0002 Region Denver, CO Version Number 7 Package Status Approved Submitted By Craig Devashrayee Submission Date 3/ 7/ 2019 Package Disposition Approval Date 8/ 27/ 2019 4:44 PM EDT Priority Code P2

DEPARTMENT OF HEALTH& HUMAN SERVICES MIMM Centers for Medicare& Medicaid Services Denver Regional Office 1961 Stout Street, Room 08- 148 Denver, CO 80294 R MIMI:*SRI IN MAID Division of Medicaid and Children' s Health Operations August 27, 2019 Nathan Checketts Medicaid Director Utah Department of Health P. O. Box 141000 Salt Lake City, UT 84114-1000 Re: Approval of State Plan Amendment UT- 19- 0002 Dear Nathan Checketts: On March 07, 2019, the Centers for Medicare and Medicaid Services( CMS) received Utah State Plan Amendment( SPA) UT- 19- 0002 to include the adult group in the groups for which hospitals may do hospital presumptive eligibility( HPE) determinations.. We approve Utah State Plan Amendment( SPA) UT- 19- 0002 on August 27, 2019 with an effective date( s) of April 01, 2019. We understand Utah currently uses a paper application for presumptive eligibility( PE) determinations, but that it intends to allow qualified entities the option to make PE determinations using an online portal. CMS has reviewed both the paper HPE application, and screenshots of the online portal HPE application that were submitted with this SPA. Please note that accompanying the approval of SPA 19- 0002 is the enclosed companion letter regarding the need for Utah to make modifications to its HPE Application online portal). Utah will provide dates for completion of outstanding changes within 60 days of approval of this SPA, and will implement revised HPE online application addressing CMS concerns by the dates listed in the companion letter. Name Date Created No items available If you have any questions regarding this amendment, please contact Mandy Strom at 3038447068 or mandy.strom@cros. hhs.gov. Sincerely, Richard C. Allen Director, Western Regional Operations Group Denver Regional Office Division of Medicaid and Children' s Health Operations RAI CMS is issuing this Request for Additional Information( RAI) pursuant to Section 1915(f) of the Social Security Act( added by P. L. 97- 35). This request has the effect of stopping the 90-day time period for CMS to act on the material. A new 90 day time frame will not begin until we receive your response to this request. In accordance with our guidelines to all State Medicaid directors dated January 2, 2001, and subsequently reiterated in the August 16, 2018 Center for Medicaid and CHIP Services Informational Bulletin, if a response to a formal request for additional information from CMS is not received from the state within 90 days of issuance, CMS will initiate disapproval of the SPA or waiver action. In addition, because this amendment was submitted after January 2, 2001 and is effective after January 1, 2001, please be advised that we will defer federal financial participation( FFP) for state payments made in accordance with this amendment until it is approved. Upon approval, FFP will be available for the period beginning with the effective date through the date of approval. Submission Package UT2018MS00030 Agency Name Utah Department of Health Authority Eligibility Submission Date Mar 7, 2019 State UT Priority Code P2 All Questions t CMS question to the State Question ID Reference Policy/ Regulation State Response

CMS question to the State Question ID Reference Policy/ Regulation State Response 1 Applicants may only be asked The HPE onlineportal 42 CFR 435.907(e)( 1) The State is working through to provide information application does not provide the necessary changes to only necessary to make an clear' instructions at section B require PE questions of PE eligibility determination. explaining which questions applicants. Within system' are mandatory for applicant limitations, the State will only household members, and display appropriate questions which are not required of to PE applicants.' Non- non-applicant household applicants will only be asked members.' Specifically, the questions relevant to the PE following questions'should determination. not appear in the online environment for non- If the applicants' choose, they applicant household may complete the entire members:' sex,' citizenship, medical application for full state residency, marital Medicaid benefits. status. If the system is unable to accommodate this programming change, the State will reach out and work through an alternative with CMS. The State is looking to implement these changes by September' 2019. The definition of eligible non- citizen is not accurate as it states these are individuals lawfully admitted for permanent residence." This could cause confusion and it permanent residence" appears that only lawful reference was removed from permanent residents, or LPRs are eligible for HPE. The the training manual in March The agency must provide 2019 and is reflected in the definition of eligible non- hospitals with information current training manual sent to CMS. The training needed to make eligibility citizens includes certain 42 CFR 435. 1102( x)( 1); g manual 2 determinations consistent qualified noncitizens and 435. 1102(b)( 3) also has the URL to the lawfully present children with the statute and under age 19. Since the eligible non- citizen statuses. regulations. application does not provide a dropdown list of eligible The training manual has contacts at the DOH to reach non- citizen statuses, this definition should be revised out to for assistance. to provide a correct definition of eligible non- citizen statuses in Utah, and/ or link to the state manual with the definition. The mandatory questions at Section D numbers 2,3A and Applicants may only be asked 5 in the online portal to provide information application should only be 3 asked of household members 42 CFR 435. 907(e)( 1) Refer to Question ID( 1). necessary to make an eligibility determination. who are also applying for coverage, and should not be required of non-applicant household members. 4 The agency may establish The state indicated it has 42 CFR 435. 1110( d) This has been completed and standards for qualified elected to establish a the State has selected" yes" in hospitals related to performance standard that Section C concerning performance. hospitals will make PE standards for hospitals. The determinations with 85% State has addressed the accuracy based on applicants' standard in Section H of the attested information. This RU. information must be included in the Reviewable Unit( RU) in MACPRo. The state understands this may be explained in section H, and that CMS is determining if the RU can be changed to allow

CMS question to the State Question ID Reference Policy/ Regulation State Response the state to include a performance standard other than the two prepopulated options that appear in section C. The state has explained it will revise the language' on the HPE approval notice explaining that a photo ID is needed at all medical The State has made the appointments. The state changes and a copy of the The agency may not impose explained that since providers notice will be uploaded into other conditions for can accept self-attestation to MACPro. 5 42 CFR 435. 1102( d)( 2) presumptive eligibility not verify an individual' s identity, specified in regulation. this information will be The State expects to included in the HPE approval implement this in August notice. Utah will share a draft 2019. of the revised instructions with CMS and provide a timeline for implementing this change. The 5/ 2019 HPE Training Manual- Section 5- p. 6- says The agency must provide the state will deny incomplete Medicaid during a PE period applications. Please change This has been completed. 6 to individuals who are these instructions since 42 CFR 435. 1110( a) The corrected training determined eligible by a providers make the PE manual will be uploaded into qualified hospital. determination and the state MACPro. agency does not have the authority to deny or approve PE. 1- 6of6 Submission Package was updated by the State in accordance with the response above Yes No Submission - Summary MEDICAID I Medicaid State Plan I Eligibility I UT2018MS00030 UT- 19- 0002 Package Header Package ID UT2018MS0003O SPA ID UT- 19- 0002 Submission Type Official Initial Submission Date 3/ 7/ 2019 Approval Date 8/ 27/ 2019 Effective Date N/ A Superseded SPA ID N/ A State Information State/ Territory Name: Utah Medicaid Agency Name: Utah Department of Health Submission Component 10 State Plan Amendment Medicaid CHIP

Submission - Summary MEDICAID I Medicaid State Plan I Eligibility I UT2018MS00030 I UT- 19-0002 Package Header Package ID UT2018MS0003O SPA ID UT- 19- 0002 Submission Type Official Initial Submission Date 3/ 7/ 2019 Approval Date 8/ 27/ 2019 Effective Date N/ A Superseded SPA ID N/ A SPA ID and Effective Date SPA ID UT- 19- 0002 Reviewable Unit Proposed Effective Date Superseded SPA ID Presumptive Eligibility 4/ 1/ 2019 New Presumptive Eligibility by Hospitals 4/ 1/ 2019 UT- 16- 0005

Submission - Summary MEDICAID I Medicaid State Plan I Eligibility I UT2018MS00030 I UT- 19-0002 Package Header Package ID UT2018MS0003O SPA ID UT- 19- 0002 Submission Type Official Initial Submission Date 3/ 7/ 2019 Approval Date 8/ 27/ 2019 Effective Date N/ A Superseded SPA ID N/ A Executive Summary Summary Description Including Adding ability to complete presumptive determinations for our new adult group. The adult group is part of our 1115 Goals and Objectives Demonstration Waiver. Federal Budget Impact and Statute/ Regulation Citation Federal Budget Impact Federal Fiscal Year Amount First 2019 600000 Second 2020 1200000 Federal Statute/ Regulation Citation 42 CFR 435. 1110 Supporting documentation of budget impact is uploaded( optional). Name Date Created No items available

Submission - Summary MEDICAID I Medicaid State Plan I Eligibility I UT2018MS00030 UT- 19- 0002 Package Header Package ID UT2018MS00030 SPA ID UT- 19- 0002 Submission Type Official Initial Submission Date 3/ 7/ 2019 Approval Date 8/ 27/ 2019 Effective Date N/ A Superseded SPA ID N/ A Governor' s Office Review No comment Comments received No response within 45 days Other

Submission - Public Comment MEDICAID I Medicaid State Plan I Eligibility I UT2018MS00030 I UT- 19-0002 Package Header Package ID UT2018MS0003O SPA ID UT- 19- 0002 Submission Type Official Initial Submission Date 3/ 7/ 2019 Approval Date 8/ 27/ 2019 Effective Date N/ A Superseded SPA ID N/ A Indicate whether public comment was solicited with respect to this submission. Public notice was not federally required and comment was not solicited Public notice was not federally required, but comment was solicited Public notice was federally required and comment was solicited

Submission - Tribal Input MEDICAID I Medicaid State Plan I Eligibility I UT2018MS00030 I UT- 19-0002 Package Header Package ID UT2018MS0003O SPA ID UT- 19- 0002 Submission Type Official Initial Submission Date 3/ 7/ 2019 Approval Date 8/ 27/ 2019 Effective Date N/ A Superseded SPA ID N/ A One or more Indian health programs or Urban Indian Organizations furnish This state plan amendment is likely to have a direct effect on Indians, health care services in this state Indian health programs or Urban Indian Organizations Yes Yes No No The state has solicited advice from Indian Health Programs and/ or Urban Indian Organizations, as required by section 1902( a)( 73) of the Social Security Act, prior to submission of this SPA Complete the following information regarding any solicitation of advice and/ or tribal consultation conducted with respect to this submission: Solicitation of advice and/ or Tribal consultation was conducted in the following manner: All Indian Health Programs Date of solicitation/ consultation: Method of solicitation/ consultation: 1/ 11/ 2019 Monthly advisory meeting. q All Urban Indian Organizations Date of solicitation/ consultation: Method of solicitation/ consultation: 1/ 11/ 2019 Monthly advisory meeting. States are not required to consult with Indian tribal governments, but if such consultation was conducted voluntarily, provide information about such consultation below: All Indian Tribes Date of consultation: Method of consultation: 1/ 11/ 2019 Monthly advisory meeting. The state must upload copies of documents that support the solicitation of advice in accordance with statutory requirements, including any notices sent to Indian Health Programs and/ or Urban Indian Organizations, as well as attendee lists if face-to-face meetings were held. Also upload documents with comments received from Indian Health Programs or Urban Indian Organizations and the state' s responses to any issues raised. Alternatively indicate the key issues and summarize any comments received below and describe how the state incorporated them into the design of its program. Name Date Created UIHAB Agenda 1- 11- 19( 1) 374/ 2019 5: 59 PM EST Indicate the key issues raised( optional) Access Quality Cost Payment methodology Eligibility

Summarize comments: No comments received. Summarize response: No response because there were no comments. Benefits Service delivery Other issue

Medicaid State Plan Eligibility Eligibility and Enrollment Processes Presumptive Eligibility MEDICAID I Medicaid State Plan I Eligibility I UT2018MS00030 I UT- 19-0002 Package Header Package ID UT2018MS0003O SPA ID UT- 19- 0002 Submission Type Official Initial Submission Date 3/ 7/ 2019 Approval Date 8/ 27/ 2019 Effective Date 4/ 1/ 2019 Superseded SPA ID New User- Entered The state provides Medicaid services to individuals during a presumptive eligibility period following a determination by a qualified entity. Presumptive eligibility covered in the state plan includes: Eligibility Groups Eligibility Group Name Covered In State Plan Include RU In Package 0 Included in Another Source Type A Submission Package Presumptive Eligibility for Children under Age 19 NEW Parents and Other Caretaker Relatives- Presumptive NEW Eligibility Presumptive Eligibility for CONVERTED Pregnant Women Adult Group- Presumptive NEW Eligibility Individuals above 133% FPL under Age 65 Presumptive r NEW Eligibility' Individuals Eligible for Family Planning Services- NEW Presumptive Eligibility Former Foster Care Children- Presumptive Eligibility NEW Individuals Needing Treatment for Breast or N EW Cervical Cancer- Presumptive Eligibility Hospitals Eligibility Group Name Covered In State Plan Include RU In Package 0 Included in Another Source Type 0 Submission Package Presumptive Eligibility by Hospitals 0 APPROVED

Presumptive Eligibility MEDICAID I Medicaid State Plan I Eligibility I UT2018MS00030 I UT- 19-0002 Package Header Package ID UT2018MS0003O SPA ID UT- 19- 0002 Submission Type Official Initial Submission Date 3/ 7/ 2019 Approval Date 8/ 27/ 2019 Effective Date 4/ 1/ 2019 Superseded SPA ID New User- Entered Eligibility Groups Deselected from Coverage The following eligibility groups were previously covered in the source approved version of the state plan and deselected from coverage as part of this submission package: N/ A

Medicaid State Plan Eligibility Presumptive Eligibility Presumptive Eligibility by Hospitals MEDICAID I Medicaid State Plan I Eligibility I UT2018MS00030 I UT- 19-0002 Package Header Package ID UT2018MS0003O SPA ID UT- 19- 0002 Submission Type Official Initial Submission Date 3/ 7/ 2019 Approval Date 8/ 27/ 2019 Effective Date 4/ 1/ 2019 Superseded SPA ID UT- 16- 0005 System- Derived The state provides an assurance that it has policies and procedures in place to enable qualified hospitals to determine presumptive eligibility under 42 CFR 435. 1110, and the state is providing Medicaid coverage for individuals determined presumptively eligible under this provision. The state attests that presumptive eligibility by hospitals is administered in accordance with the following provisions: A. Qualifications of Hospitals A qualified hospital is a hospital that: 1. Participates as a provider under the state plan or a Medicaid 1115 Demonstration, notifies the Medicaid agency of its election to make presumptive eligibility determinations and agrees to make presumptive eligibility determinations consistent with state policies and procedures. 2. Has not been disqualified by the Medicaid agency for failure to make presumptive eligibility determinations in accordance with applicable state policies and procedures or for failure to meet any standards that may have been established by the Medicaid agency. 3. Assists individuals in completing and submitting the full application and understanding any documentation requirements. Yes No

Presumptive Eligibility by Hospitals MEDICAID I Medicaid State Plan I Eligibility I UT2018MS00030 I UT- 19-0002 Package Header Package ID UT2018MS0003O SPA ID UT- 19- 0002 Submission Type Official Initial Submission Date 3/ 7/ 2019 Approval Date 8/ 27/ 2019 Effective Date 4/ 1/ 2019 Superseded SPA ID UT- 16- 0005 System- Derived B. Eligibility Groups or Populations Included The eligibility groups or populations for which hospitals determine eligibility presumptively are: 1. Pregnant Women 2. Infants and Children under Age 19 3. Parents and Other Caretaker Relatives 4. Adult Group, if covered by the state 5. Individuals above 133% FPL under Age 65, if covered by the state 6. Individuals Eligible for Family Planning Services, if covered by the state 7. Former Foster Care Children 8. Certain Individuals Needing Treatment for Breast or Cervical Cancer, if covered by the state The state limits qualified hospitals for this group to providers who conduct screenings for breast and cervical cancer under the state's Centers for Disease Control and Prevention's National Breast and Cervical Cancer Early Detection Program. Yes No 9. Other Medicaid state plan eligibility groups: 10. Demonstration populations covered under section 1115 Description: Adult group at or under 95% FPL.

Presumptive Eligibility by Hospitals MEDICAID I Medicaid State Plan I Eligibility I UT2018MS00030 I UT- 19-0002 Package Header Package ID UT2018MS0003O SPA ID UT- 19- 0002 Submission Type Official Initial Submission Date 3/ 7/ 2019 Approval Date 8/ 27/ 2019 Effective Date 4/ 1/ 2019 Superseded SPA ID UT- 16- 0005 System- Derived C. Standards for Participating Hospitals The state establishes reasonable standards for qualified hospitals making presumptive eligibility determinations. Yes No The state has a standard requiring that a percentage of individuals who are determined presumptively eligible submit a regular application, as described at 42 CFR 435.907, before the end of the presumptive eligibility period. The state has a standard requiring that a percentage of individuals who are determined presumptively eligible be determined eligible for Medicaid based on the submission of an application before the end of the presumptive eligibility period. D. Presumptive Eligibility Period 1. The presumptive period begins on the date the determination is made. 2. The end date of the presumptive period is the earlier of: The date the eligibility determination for regular Medicaid is made, if an application for Medicaid is filed by the last day of the month following the month in which the determination of presumptive eligibility is made; or The last day of the month following the month in which the determination of presumptive eligibility is made, if no application for Medicaid is filed by that date. 3. Periods of presumptive eligibility are limited as follows: a. No more than one period within a calendar year. b. No more than one period within two calendar years. c. No more than one period within a six-month period, starting with the effective date of the initial presumptive eligibility period. d. No more than one period within a twelve-month period, starting with the effective date of the initial presumptive eligibility period. e. Other reasonable limitation:

Presumptive Eligibility by Hospitals MEDICAID I Medicaid State Plan I Eligibility I UT2018MS00030 I UT- 19-0002 Package Header Package ID UT2018MS0003O SPA ID UT- 19- 0002 Submission Type Official Initial Submission Date 3/ 7/ 2019 Approval Date 8/ 27/ 2019 Effective Date 4/ 1/ 2019 Superseded SPA ID UT- 16- 0005 System- Derived E. Application for Presumptive Eligibility 1. The state uses a standardized screening process for determining presumptive eligibility. 2. The state uses a single application form for Medicaid and presumptive Name Date Created eligibility, approved by CMS. A copy of the single streamlined application with questions necessary for a PE determination highlighted or denoted is included. 04- 01- 2019 ENGLISH 61 MED 4/ 29/ 2019 3: 27 PM EDT 3. The state uses a separate paper application form for presumptive eligibility, approved by CMS. A copy of the application form is included. 4. The state uses an online portal or electronic screening tool for presumptive Name Date Created eligibility approved by CMS. Screenshots of the tool included. PEP Screenshots- Application 4/ 2/ 2019 12: 14 PM EDT PEP Screenshots- Provider Queue 4/ 2/ 2019 12: 14 PM EDT PEP Screenshots- Eligible non'- 4/ 29/ 2019 31: 34 PIM EDT citizen drop down eREP Approval Notice 8/ 8/ 2019 4:20 PM EDT eREP Denial Notice. docx 8/ 8/ 2019 4:20 PM EDT PE Determination Receipt- 8/ 8/ 2019 4:20 PM EDT Paper.docx PE Determination Receipt- 8/ 8/ 2019 4:20 PM EDT PortaJ. docx 1- 7of7 F. Presumptive Eligibility Determination The presumptive eligibility determination is based on the following factors: 1. The individual' s categorical or non-financial eligibility for the group for which the individual' s presumptive eligibility is being determined( e. g., based on age, pregnancy status, status as a parent/caretaker relative, disability, or other requirements specified in the Medicaid state plan or a Medicaid 1115 demonstration for that group) 2. Household income must not exceed the applicable income standard for the group for which the individual' s presumptive eligibility is being determined, if an income standard is applicable for this group. a. A reasonable estimate of MAGI- based income is used to determine household income. b. Gross income is used to determine household size. c. Other income methodology 3. State residency 4. Citizenship, status as a national, or satisfactory immigration status

Presumptive Eligibility by Hospitals MEDICAID I Medicaid State Plan I Eligibility I UT2018MS00030 I UT- 19-0002 Package Header Package ID UT2018MS00030 SPA ID UT- 19- 0002 Submission Type Official Initial Submission Date 3/ 7/ 2019 Approval Date 8/ 27/ 2019 Effective Date 4/ 1/ 2019 Superseded SPA ID UT- 16- 0005 System- Derived G. Qualified Entity Requirements 4 1. The state assures that it has communicated the requirements for qualified hospitals, and has provided adequate training to the hospitals. 2. A copy of the training materials has been uploaded for review during the submission process. Name Date Created Form 140 4/ 2/ 2019 121:37 PIM EDT xx HPE Training May 2019 5/ 22/ 2019 11: 08 AM EDT HPE TRAINING MANUAL May 2019 7/ 31/ 2019 61: 21 PM EDT H. Additional Information (optional) Screen shot of eligible non- citizen' is the drop down field if the client checks they are this status. It is self attestation, no further drop down field. The' notice of PE determination' is the electronic one that will be generated through our portal. The state has an 85% accuracy rate standard for HPE providers concerning their HPE determinations. This is based on client self-attestation and evaluated with monthly audits by the state.

PRA Disclosure Statement: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938- 1188. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate( s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26- 05, Baltimore, Maryland 21244- 1850. This view was generated on 8/ 29/ 2019 11: 53 AM EDT

Table of Contents State/Territory Name: Utah State Plan Amendment (SPA) #: 19- 0011 This file contains the following documents in the order listed: 1) Approval Letter 2) 179 3) Approved SPA Pages TN: UT- 19- 0011 Approval Date: 10/ 18/ 2019 Effective Date: 10/ 01/ 2019

Records Submission Packages UT - Submission Package - UT2019MS0001 Q - ( UT- 19-0011) - Eligibility Summary Reviewable Units versions Correspondence Log Analyst Notes Review Assessment Report Approval Letter Transaction Logs News e Package Information Package ID UT2019MS0001 O Submission Type Official Program Name NIA State DT SPA ID UT- 19- 0011 Region Denver, CO Version Number 2 Package Status Approved Submitted By Craig Devashrayee Submission Date 9/ 15/ 2019 Package Disposition Approval Date 10/ 18/ 2019 1: 39 AM EDT 0 Priority Code P2

DEPARTMENT OF HEALTH& HUMAN SERVICES Centers for Medicare& Medicaid Services Denver Regional Office 1961 Stout Street, Room 08- 148 Denver, CO 80294 i1% ii W% F 4 su Ni i ml eu i t. w l s. uu F u u 1, Division Medicaid it r n' s Health Operations October 18, 2019 Nathan Checketts Medicaid Director Utah Department of Health P. O. Box 141000 Salt Lake City, UT 84114-1000 Re: Approval of State Plan Amendment UT- 19- 0011 Dear Nathan Checketts: On September 15, 2019, the Centers for Medicare and Medicaid Services( CMS) received Utah State Plan Amendment( SPA) UT- 19- 0011 to allow the state to provide Medicaid coverage for former foster care individuals enrolled in Medicaid under Utah' s Medicaid state plan at anytime during the foster care period in which they turned 18.. We approve Utah State Plan Amendment( SPA) UT- 19- 0011 on October 18, 2019 with an effective date(s) of October 01, 2019. Name Date Created No items available If you have any questions regarding this amendment, please contact Mandy Strom at mandy.strom@cros. hhs.gov. Sincerely, Richard C. Allen Director, Western Regional Operations Group Division of Medicaid and Children' s Health Operations SubmissionSummary Package Pleader Package ID UT2019MS000I O SPA ID UT- 19- 0011 Submission Type Official Initial Submission Date 9115/ 2019 Approval Date 10/ 18/ 2019 Effective Date N/ A Superseded SPA ID N/ A State Information State/ Territory Name: Utah Medicaid Agency Name: Utah Department of Health Submission Comp nent State Plan Amendment Medicaid CHIP

Submission m Summary Package Meader Package ID UT2019M50001 O SPAID UT- 19- 0011 Submission Type Official Initial Submission Date 911512019 Approval Date 10/ 18/ 2019 Effective Date N/ A Superseded SPA ID N/ A SPA 1 D and Effective Date SPA ID UT- 19- 0011 Reviewable Unit Proposed Effective Date Superseded SPA ID Mandatory Eligibility Groups 1011/ 2019 UT-19- 0001 Former Faster Care Children 1011/ 2019 UT- 18- 0002

Submission - Summary Package Meader Package ID UT2019M50001 O SPAID UT- 19- 0011 Submission Type Official Initial Submission Date 911512019 Approval Date 10/ 18/ 2019 Effective Date N/ A Superseded SPA ID N/ A Executive Summary Summary Description Including Allowing FC individuals who age out and have received Medicaid anytime during the foster care period they turn 18 to Goals and Objectives receive FFC coverage. Federal Budget Impact and Statute/ Regulation Citation Federal Budget Impact Federal Fiscal Year Amount First 2019 39322 Second 2020 39322 Federal Statute/ Regulation Citation 42 CFR 435- 150 Supporting documentation of budget impact is uploaded( optional). Name Date Created No iterr7s available

Submission - Summary NIR)€ pry. . , _ df , c Package Meader Package ID UT2019M50001 O SPAID UT- 19- 0011 Submission Type Official Initial Submission Date 911512019 Approval Date 10/ 18/ 2019 Effective Date N/ A Superseded SPA ID N/ A Governor' s Office Review No comment Comments received No response within 45 days Other

SubmissionPublic t Package Pleader Package ID UT2019MS000I O SPA ID UT- 19- 0011 Submission Type Official Initial Submission Date 411512019 Approval Date 10/ 18/ 2019 Effective Date N/ A Superseded SPA ID NIA Indicate whether public comment was solicited with respect to this submission. Public notice was riot federally required and comment was not solicited Public notice was not federally required, but comment was solicited Public notice was federally required and comment was solicited

Submission - Tribal Input Package Pleader Package ID UT2019MS000I O SPA ID UT- 19- 0011 Submission Type Official Initial Submission Date 9/ 15/ 2019 Approval Date 10/ 18/ 2019 Effective Date N/ A Superseded SPA ID N/ A One or more Indian Health Programs or Urban Indian Organizations This state plan amendment is likely to have a direct effect on Indians, furnish health care services in this state Indian Health Programs or Urban Indian Organizations, as described in Yes the state consultation plan. No Yes No The state has solicited advice from Indian Health Prograrns and/ or Urban Indian Organizations, as required by section 1902( a)( 73) ot- the Social Security Act, and in accordance with the state consultation plan, prior to submission of this SPA. Complete the following information regarding any solicitation of advice and/ or tribal consultation conducted with respect to this submission: Solicitation of advice and/ or Tribal consultation was conducted in the following manner: All Indian Health Programs Date of solicitation/ consultation: Method of solicitation/ consultation: 9/ 13/ 2019 Utah Indian Health Advisory Board All Urban Indian Organizations Date of solicitation/ consultation: Method of solicitation/ consultation: 9/ 13/ 2Q19 Monthly UIHAB meeting with tribes. States are not required to consult with Indian tribal governments, but if such consultation was conducted voluntarily, provide information about such consultation below: All Indian Tribes Date of consultation: Method of consultation: 9/ 13/ 2019 Monthly UIHAB meeting with tubes. The state must upload copies of documents that support the solicitation of advice in accordance with statutory requirements, including any notices sent to Indian Health Programs and/ or Urban Indian Organizations, as well as attendee lists if face-to-face meetings were held. Also upload documents with comments received from Indian Health Programs or Urban Indian Organizations and the state's responses to any issues raised. Alternatively indicate the key issues and summarize any comments received below and describe how the state incorporated them into the design of its program. Name Date Created t!I HAB Agenda 9- 13- 19 9/ 13/ 2019 2: 43 PM EDT Indicate the key issues raised( optional) Access Quality Cost Payment methodology Eligibility

Benefits Service delivery Other issue

Medicaid State Plan Eligibility Mandatory Eligibility Groups Package Pleader Package ID UT2019MS0001 O SPA ID UT- 19- 0011 Submission Type Official Initial Submission Date 9115/ 2019 Approval Date 10/ 18/ 2019 Effective Date 10/ 1/ 2019 Superseded SPA ID UT- 19- 0001 Mandatory Coverage A. The state provides Medicaid to mandatory groups of individuals. The mandatory groups covered are: Families and Adults Eligibility Group Name Covered In State Plan Include RU In Included in Another Source Type Package 0 Submission Package Infants and Children CONVERTED underage 19 Parents and Other APPROVED Caretaker Relatives Pregnant Women CONVERTED Deemed Newborns NEW Children with Title IV- E Adoption Assistance, NEW Foster Care or Guardianship Care Former Foster Care t APPROVED Children t Transitional Medical NEW Assistance Extended Medicaid due to Spousal NEW Support Collections m Aged, Blind and disabled Eligibility Group Name Covered In State Plan Include RU In Included in Another Source Type Package 0 Submission Package SSI Beneficiaries NEW Closed Eligibility T, NEW Groups t Individuals Deemed To NEW Be Receiving SSI r- 1t Working Individuals NEW under 1619( b) Qualified Medicare Beneficiaries NEW Qualified Disabled and NEW Individuals NEW Specified Loam Income NEW Medicare Beneficiaries

Eligibility Group Name Covered In State Plan Include RU In Included in Another Source Type 0 Package 0 Submission Package Qualifying Individuals je` NEW

Mandatory Eligibility Groups Package Meader Package ID UT2019M500010 SPAID UT- 19- 0011 Submission Type Official Initial Submission Date 911512019 Approval Date 10/ 18/ 2019 Effective Date 10/ 1/ 2019 Superseded SPA ID UT- 19- 0001 B. The state elects the Adult Group, described at 42 CPR 435. 119. Yes No C. Additional Information( optional) Eligibility Groups Deselected from Coverage The following eligibility groups were previously covered in the source approved version of the state plan and deselected from coverage as part of this submission package: N/ T,

Medicaid State Plea Eligibility Eligibility Groups m Mandatory Cover Former Foster Care Children a ) Pder e age G >>, rc r , < r.z, x 1« i, . t, t ie., c . c>s .. ra.. Ono mster, a .., r "} >. a Package Pleader Package ID UT2019MS0001 O SPAID UT- 19- 0011 Submission Type Official Initial Submission Date 911512019 Approval Date 10/ 18/ 2019 Effective Date 101112019 Superseded SPA ID UT_18. 0002 The state covers the mandatory former foster care children group in accordance with the following provisions: A. Characteristics Individuals qualifying under this eligibility group must meet the following criteria: 1. Are under age 26 2. Are not otherwise eligible for and enrolled for mandatory coverage under the state plan, except that eligibility under this group takes precedence over eligibility under the Adult Group B. Individuals v r d 1. The state covers individuals who were in foster care under the responsibility of the state or a Tribe within the state( including children who were cared for through a grant to the state under the unaccompanied refugee minor program) and were enrolled in Medicaid under the state' s Medicaid state plan or 1115 demonstration when they turned 18 or a higher age at which that state' s or Tribe' s foster care assistance ends under title DrE of the Act. 2. Additionally, the state covers individuals who were in foster care under the responsibility of the state or a Tribe within the state( including children who were cared for through a grant to the state under the unaccompanied refugee minor program) when they turned 18 or a higher age at which the state' s or Tribe' s foster care assistance ends under title IV-E of the Act, and meet the following criteria: a. Theywere enrolled in Medicaid under the state' s Medicaid state plan or 1115 demonstration at anytime during the foster care period in which they turned 18 or a higher age at which the state' s or Tribe' s foster care assistance ends. b. They were placed by the state or Tribe in another state and were enrolled in Medicaid under the other state's Medicaid state plan or 1115 demonstration project when they turned 18 or a higher age at which the state' s or Tribe' s foster care assistance ends. c. They were placed by the state or Tribe in another state and were enrolled in Medicaid under the other state' s Medicaid state plan or 1115 demonstration project at any time during the foster care period in which they turned 18 or a higher age at which the state' s or Tribe' s foster care assistance ends.

Former Foster Care Children Package Meader Package ID UT2019M500010 SPAID UT- 19- 0011 Submission Type Official Initial Submission Date 911512019 Approval Date 10/ 18/ 2019 Effective Date 10/ 1/ 2019 Superseded SPA ID UT- 18- 0002 C. Additional Information (optional)

r4 a ipe5. 1, ater il M- P r r" ar f ie ejrN rage Not Lj( fl ri! 11 r( I e, M 0 e Y,( tiq dat e pa,f r r i. - r- C, iit d C, 1 Jre r 1 p,' r 9 !( 1, M, p ej FTAn!, p,) U—ion( cCim— j cf;f ii' i. 3. 1t: .) rr1 xri This view wasgenerated on 7017812019 10:41 AM EDT

Table of Contents State/Territory Name: Utah

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

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Center for Medicaid & CHIP Services 233 North Michigan Ave., Suite 600 Chicago, Illinois 60601 Financial Management Group Nathan Checketts Medicaid Director Utah Department of Health P.O. Box 141000 Salt Lake City, UT 84114-1000 Dear Mr. Checketts: RE: Utah Transmittal Notice (TN) 20-0001 We have reviewed the proposed Utah State Plan Amendment (SPA) to Attachment 4.19-B, Utah TN#20-0001, which was submitted to the Centers for Medicare & Medicaid Services (CMS) on April 15, 2020. This State Plan Amendment updates the effective date on the introduction page. Based upon the information provided by the State, we have approved the amendment with an effective date of July 1, 2020. We are enclosing the approved CMS-179 and a copy of the new state plan page. If you have any additional questions or need further assistance, please contact Tamara Sampson at 214-767-6431 or Tamara.Sampson@cms.hhs.gov. Sincerely, Todd McMillion Director Division of Reimbursement Review Enclosures May 13, 2020

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED HEALTHCARE FINANCING ADMINISTRATION OMB NO. 0938-0193 1. TRANSMITTAL NUMBER: 2. STATE: TRANSMITTAL AND NOTICE OF APPROVAL OF 20-0001-UT Utah STATE PLAN MATERIAL

FOR: HEALTH CARE FINANCING ADMINISTRATION

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

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

4. PROPOSED EFFECTIVE DATE July 1, 2020

5. TYPE OF PLAN MATERIAL (Check One)

O NEW STATE PLAN

(0 AMENDMENT TO BE CONSIDERED AS NEW PLAN

Bd AMENDMENT

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

6. FEDERAL STATUTE/REGULATION CITATION:

Section 1902(a)(30)(A) of the Social Security Act

7. FEDERAL BUDGET IMPACT: a. FFY 2020 $+543,700 b. FFY 2021 $+2,153,300

8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:

Introduction Page of ATTACHMENT 4.19-B

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

Introduction Page of ATTACHMENT 4.19-B

10. SUBJECT OF AMENDMENT: Annual Rebasing Update

11. GOVERNOR'S REVIEW (Check One): EK GOVERNOR'S OFFICE REPORTED NO COMMENT [LJ COMMENTS OF GOVERNOR'S OFFICE ENCLOSED

(1 OTHER, AS SPECIFIED:

L] NOREPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL

12, SIGNATURE OF STATE AGENCY OFFICIAL:

13. TYPED NAME: Joseph K. Miner, M.D.

14. TITLE: Executive Director, Utah Department of Health

15. DATE SUBMITTED: April 15, 2020

16. RETURN TO:

Craig Devashrayee, Manager Technical Writing Unit

Utah Department of Heath

PO Box 143102

Salt Lake City, UT 84114-3102

16.

17, DATE RECEIVED:

18. DATE APPROVED:

5/13/2020

FOR REGIONAL USE ONLY

19. EFFECTIVE DATE OF APPROVED MATERIAL:

7/1/2020

20. SIGNATURE OF REGIONAL OFFICIAL:

21. TYPED NAME:

Todd McMillion

22. TITLE:

Director, Division of Reimbursement Review

PLAN APPROVED — ONE COPY ATTACHED

23. REMARKS

FORM HCFA-179 (07-92)

ATTACHMENT 4.19-B Introduction STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: UTAH Payment rates for the services listed below are effective for services provided on or after the corresponding date: Service Attachment Effective Date Physician and Anesthesia Services Attachment 4.19-B, Pages 4 and 5 July 1, 2020 Optometry Services Attachment 4.19-B, Page 7 July 1, 2020 Eyeglasses Services Attachment 4.19-B, Page 8 July 1, 2020 Home Health Services Attachment 4.19-B, Page 10 July 1, 2020 Clinic Services Attachment 4.19-B, Pages 12b and 34 July 1, 2020 Dental Services and Dentures Attachment 4.19-B, Page 13 July 1, 2020 Physical Therapy and Occupational Therapy Attachment 4.19-B, Page 14 July 1, 2020 Speech Pathology Services Attachment 4.19-B, Page 16 July 1, 2020 Audiology Services Attachment 4.19-B, Page 17 July 1, 2020 Transportation Services (Special Services) Attachment 4.19-B, Page 18 July 1, 2020 Transportation Services (Ambulance) Attachment 4.19-B, Page 18 July 1, 2020 Targeted Case Management for Individuals with Serious Mental Illness Attachment 4.19-B, Page 22a July 1, 2020 Rehabilitative Mental Health Services Attachment 4.19-B, Page 25 July 1, 2020 Chiropractic Services Attachment 4.19-B, Page 30 July 1, 2020 T.N. # 20-0001 Approval Date__________ Supersedes T.N. # 19-0015 Effective Date 7-1-20 5-13-20

Table of Contents State/Territory Name: Utah

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

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Center for Medicaid & CHIP Services 233 North Michigan Ave., Suite 600 Chicago, Illinois 60601 Financial Management Group Nathan Checketts Medicaid Director Utah Department of Health P.O. Box 141000 Salt Lake City, UT 84114-1000 Dear Mr. Checketts: RE: Utah Transmittal Notice (TN) 20-0004 We have reviewed the proposed Utah State Plan Amendment (SPA) to Attachment 4.19-B, Utah TN#20-0004, which was submitted to the Centers for Medicare & Medicaid Services (CMS) on April 15, 2020. This State Plan Amendment updates the utilization trend for the outpatient hospital Upper Payment Limit (UPL) in State Fiscal Year (SFY) 2021. Based upon the information provided by the State, we have approved the amendment with an effective date of July 1, 2020. We are enclosing the approved CMS-179 and a copy of the new state plan page. If you have any additional questions or need further assistance, please contact Tamara Sampson at 214-767-6431 or Tamara.Sampson@cms.hhs.gov. Sincerely, Todd McMillion Director Division of Reimbursement Review Enclosures May 26, 2020

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED HEALTHCARE FINANCING ADMINISTRATION OMB NO. 0938-0193 1. TRANSMITTAL NUMBER: 2. STATE: TRANSMITTAL AND NOTICE OF APPROVAL OF 20-0004-UT Utah STATE PLAN MATERIAL

FOR: HEALTH CARE FINANCING ADMINISTRATION

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

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

4. PROPOSED EFFECTIVE DATE July 1, 2020

h

5. TYPE OF PLAN MATERIAL (Check One)

O NEW STATE PLAN

(0 AMENDMENT TO BE CONSIDERED AS NEW PLAN

Bd AMENDMENT

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

6. FEDERAL STATUTE/REGULATION CITATION:

42 CFR 440.90

7. FEDERAL BUDGET IMPACT: a. FFY 2020 $+2,695,332 b. FFY 2021 $+10,781,328

8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:

Page 2f of ATTACHMENT 4.19-B

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

Page 2f of ATTACHMENT 4.19-B

10, SUBJECT OF AMENDMENT: Outpatient Hospital Supplemental Payments

11. GOVERNOR'S REVIEW (Check One):

[J GOVERNOR'S OFFICE REPORTED NO COMMENT L] COMMENTS OF GOVERNOR'S OFFICE ENCLOSED

(0 ‘OTHER, AS SPECIFIED:

[1 NOREPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL

OFFICIAL:

13. TYPED NAME: Joseph K. Miner, M.D.

14. TITLE: Executive Director, Utah Department of Health

15. DATE SUBMITTED: April 15, 2020

16. RETURN TO:

Craig Devashrayee, Manager Technical Writing Unit

Utah Department of Heath

PO Box 143102

Salt Lake City, UT 84114-3102

16.

17. DATE RECEIVED:

18. DATE APPROVED:

05/26/2020

FOR REGIONAL USE ONLY

19. EFFECTIVE DATE OF APPROVED MATERIAL:

7/1/2020

21. TYPED NAME: Todd McMillion

Pe Vlin bess

Director, Division of Reimbursement Review

PLAN APPROVED — ONE COPY ATTACHED

23. REMARKS

FORM HCFA-179 (07-92)

42 CFR Attachment 4.19-B 440.90 Page 2f 14. UPL Calculation Overview For purposes of calculating the Medicaid outpatient hospital upper payment limits for hospitals, the state shall utilize hospital specific Medicare outpatient cost to charge ratios applied to Medicaid charges. The Medicaid upper payment limit for state hospitals and non-state government owned hospitals are independently calculated. Each Medicaid upper payment limit shall be offset by hospital Medicaid and other third party outpatient payments to determine the available spending room (i.e., the gap) applicable to each Medicaid upper payment limit. The base year utilized to determine each Medicaid upper payment limit shall be trended to the applicable spending year as follows: • Inflation trend shall be an annual average calculated using the consumer price index available the December prior to the start of each state fiscal year for "Outpatient Hospital Services" as published by the U.S. Department of Labor, U.S. Bureau of Labor Statistics as compared to the previous December. • Utilization trend shall be calculated using historical Utah Medicaid outpatient hospital services data. The utilization trend for State Fiscal Year 2021 shall be -2.8 percent. Following is the data used to calculate the UPL for each state fiscal year: Medicare Cost to Charge ratio: • 2552-96: Costs are from Worksheet D, Part V, Columns 9, 9.01, 9.02, 9.03 line 104 • 2552-10: Costs are from Worksheet D, Part V, Columns 5, 6, and 7 line 202 • 2552-96: Charges are from Worksheet D, Part V, Columns 5, 5.01, 5.02, 5.03 line 104 • 2552-10: Charges are from Worksheet D, Part V, Columns 2, 3, 4 line 202 Note: As Medicare may amend the cost report structure from that noted above, corresponding Medicare Cost Report data will be used in place of the elements noted above. The hospitals in the analysis have fiscal year ends during the state fiscal year Medicaid Charges and payments - Paid hospital outpatient claims from services in a recent period and as available at the time the calculation is made. Costs for critical access hospitals shall be calculated at 101 percent of cost with any appropriate inflation and utilization added as noted above. __________________________________________________________________________________________________ T.N. # 20-0004 Approval Date________ Supersedes T.N. # 19-0008 Effective Date 7-1-20 05/26/20

7DEOH RI &RQWHQWV 6WDWH7HUULWRU\ 1DPH 8WDK State Plan Amendment (SPA) #: 20-000Ŝ This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-26-12 Baltimore, Maryland 21244-1850 May 18, 2020 Nathan Checketts, Medicaid Director Utah Department of Health P.O. Box 141000 Salt Lake City, UT 84114- 1000 Re: Utah State Plan Amendment (SPA) 20-0006 Dear Mr. Checketts: We have reviewed the proposed amendment to add section 7.4 Medicaid Disaster Relief for the COVID-19 National Emergency to your Medicaid state plan, as submitted under transmittal number (TN) 20-0006. This amendment proposes to implement temporary policies, which are different from those policies and procedures otherwise applied under your Medicaid state plan, during the period of the Presidential and Secretarial emergency declarations related to the COVID-19 outbreak (or any renewals thereof). On March 13, 2020, the President of the United States issued a proclamation that the COVID-19 outbreak in the United States constitutes a national emergency by the authorities vested in him by the Constitution and the laws of the United States, including sections 201 and 301 of the National Emergencies Act (50 U.S.C. 1601 et seq.), and consistent with section 1135 of the Social Security Act (Act). On March 13, 2020, pursuant to section 1135(b) of the Act, the Secretary of the United States Department of Health and Human Services invoked his authority to waive or modify certain requirements of titles XVIII, XIX, and XXI of the Act as a result of the consequences of the COVID-19 pandemic, to the extent necessary, as determined bythe Centers for Medicare & Medicaid Services(CMS),to ensurethatsufficienthealth careitemsand servicesare available to meet theneeds of individuals enrolledin therespective programsand to ensurethat health care providersthatfurnish such items and services in good faith, but are unable to comply with one or more of such requirements as a result of the COVID-19 pandemic, may be reimbursed for such items and services and exempted fromsanctionsforsuchnoncompliance,absentanydeterminationoffraud orabuse.Thisauthoritytook effect as of 6PM Eastern Standard Time on March 15, 2020, with a retroactive effective date of March 1, 2020. The emergency period will terminate, and this state plan provision will no longer be in effect, upon termination of the public health emergency, including any extensions. 3XUVXDQW WR VHFWLRQ  E

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& RI WKH $FW &06 LV DSSURYLQJ WKH VWDWH V UHTXHVW WR ZDLYH WKHVH QRWLFH UHTXLUHPHQWV RWKHUZLVH DSSOLFDEOH WR 63$ VXEPLVVLRQV The State of Utah also requested a waiver to modify the tribal consultation timeline applicable to this SPA submission process. 3XUVXDQW WR VHFWLRQ  E

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 WKH 63$ GRHV QRW UHVWULFW RU OLPLW SD\PHQW RU VHUYLFHV RU RWKHUZLVH EXUGHQ EHQHILFLDULHV DQG SURYLGHUV DQG  WKH 63$ LV WHPSRUDU\ ZLWK D VSHFLILHG VXQVHW GDWH WKDW LV QRW ODWHU WKDQ WKH ODVW GD\ RI WKH GHFODUHG &29,' SXEOLF KHDOWK HPHUJHQF\ RU DQ\ H[WHQVLRQ WKHUHRI  :H QRQHWKHOHVV HQFRXUDJH VWDWHV WR PDNH DOO UHOHYDQW LQIRUPDWLRQ DERXW WKH 63$ DYDLODEOH WR WKH SXEOLF VR WKH\ DUH DZDUH RI WKH FKDQJHV We conducted our review of your submittal according to the statutory requirements at section 1902(a) of the Act and implementing regulations. This letter is to inform you that Utah’s Medicaid SPA Transmittal Number 20-0006 is approved effective March 18, 2020. Enclosed is a copy of the CMS-179 summary form and the approved state plan pages. Please contact Mandy Strom at 303-844-7068 or by email at Mandy.Strom@cms.hhs.gov if you have any questions about this approval. We appreciate the efforts of you and your staff in responding to the needs of the residents of the State of Utah and the health care community. Sincerely, Anne Marie Costello Deputy Director Center for Medicaid & CHIP Services Enclosures Copy to: Craig Devashrayee, Utah Department of Health Anne M. Costello -S Digitally signed by Anne M. Costello -S Date: 2020.05.18 09:50:31 -04'00'

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED

HEALTHCARE FINANCING ADMINISTRATION OMB NO. 0938-0193 1. TRANSMITTAL NUMBER: 2. STATE:

TRANSMITTAL AND NOTICE OF APPROVAL OF 20-0006-UT Utah

STATE PLAN MATERIAL

FOR: HEALTH CARE FINANCING ADMINISTRATION 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) TO: REGIONAL ADMINISTRATOR 4. PROPOSED EFFECTIVE DATE

HEALTHCARE FINANCING ADMINISTRATION DEPARTMENT OF HEALTH AND HUMAN SERVICES

March 18, 2020

5. TYPE OF PLAN MATERIAL (Check One)

[_NEW STATE PLAN

[_ AMENDMENT TO BE CONSIDERED AS NEW PLAN

J AMENDMENT

COMPLETE BLOCKS 6 THRU 10 IF THIS IS Al

N AMENDMENT (Separate Transmittal for each amendment)

6. FEDERAL STATUTE/REGULATION CITATION:

7. FEDERAL BUDGET IMPACT: a. FFY 2020 $+5,740,000

Section 1135b of the Social Security Act b. FFY 2021 $+5,720,000 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (if Applicable)

Section 7.5

10. SUBJECT OF AMENDMENT: COVID-19 Emergency Disaster

Relief

11. GOVERNOR'S REVIEW (Check One): [] GOVERNOR'S OFFICE REPORTED NO COMMENT (J COMMENTS OF GOVERNOR'S OFFICE ENCLOSED

(1 +OTHER, AS SPECIFIED:

( NOREPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL

12. SIGNATURE OF STATE AGENCY OFFICIAL:

16. RETURN TO:

Craig Devashrayee, Manager

13. TYPED NAME: Joseph K. Miner, M.D.

Technical Writing Unit Utah Department of Heath

14. TITLE: Executive Director, Utah Department of Health

PO Box 143102 Salt Lake City, UT 84114-3102

15. DATE SUBMITTED: April 30, 2020

16.

17. DATE RECEIVED:

18. DATE APPROVED:

April 30, 2020 May 18, 2020 . FOR REGIONAL USE ONLY 18. EFFECTIVE DATE OF APPROVED MATERIAL: 20. SIGNATURE OF REGIONAL OFFICIAL: Digitally signed by Anne M. Costello

March 18, 2020

Anne M. Costello -S-s

Date: 2020.05.18 09:50:57 -0400"

21. TYPED NAME:

Anne Marie Costello

22. TITLE:

Deputy Director, CMCS

PLAN APPROVED — ONE COPY ATTACHED

23. REMARKS

FORM HCFA-179 (07-92)

^ƚĂƚĞͬdĞƌƌŝƚŽƌLJ͗ hd, 71   $SSURYDO 'DWH 6XSHUVHGHV 71  1HZ (IIHFWLYH 'DWH  ^ĞĐƚŝŽŶ ϳ ʹ 'ĞŶĞƌĂů WƌŽǀŝƐŝŽŶƐ ϳ͘ϱ͘ DĞĚŝĐĂŝĚ ŝƐĂƐƚĞƌ ZĞůŝĞĨ ĨŽƌ ƚŚĞ Ks/Ͳϭϵ EĂƚŝŽŶĂů ŵĞƌŐĞŶĐLJ KŶ DĂƌĐŚ ϭϯ͕ ϮϬϮϬ͕ ƚŚĞ WƌĞƐŝĚĞŶƚ ŽĨ ƚŚĞ hŶŝƚĞĚ ^ƚĂƚĞƐ ŝƐƐƵĞĚ Ă ƉƌŽĐůĂŵĂƚŝŽŶ ƚŚĂƚ ƚŚĞ Ks/Ͳϭϵ ŽƵƚďƌĞĂŬ ŝŶ ƚŚĞ hŶŝƚĞĚ ^ƚĂƚĞƐ ĐŽŶƐƚŝƚƵƚĞƐ Ă ŶĂƚŝŽŶĂů ĞŵĞƌŐĞŶĐLJ ďLJ ƚŚĞ ĂƵƚŚŽƌŝƚŝĞƐ ǀĞƐƚĞĚ ŝŶ Śŝŵ ďLJ ƚŚĞ ŽŶƐƚŝƚƵƚŝŽŶ ĂŶĚ ƚŚĞ ůĂǁƐ ŽĨ ƚŚĞ hŶŝƚĞĚ ^ƚĂƚĞƐ͕ ŝŶĐůƵĚŝŶŐ ƐĞĐƚŝŽŶƐ ϮϬϭ ĂŶĚ ϯϬϭ ŽĨ ƚŚĞ EĂƚŝŽŶĂů ŵĞƌŐĞŶĐŝĞƐ Đƚ ;ϱϬ h͘^͘͘ ϭϲϬϭ Ğƚ ƐĞƋ͘Ϳ͕ ĂŶĚ ĐŽŶƐŝƐƚĞŶƚ ǁŝƚŚ ƐĞĐƚŝŽŶ ϭϭϯϱ ŽĨ ƚŚĞ ^ŽĐŝĂů ^ĞĐƵƌŝƚLJ Đƚ ;ĐƚͿ͘ KŶ DĂƌĐŚ ϭϯ͕ ϮϬϮϬ͕ ƉƵƌƐƵĂŶƚ ƚŽ ƐĞĐƚŝŽŶ ϭϭϯϱ;ďͿ ŽĨ ƚŚĞ Đƚ͕ ƚŚĞ ^ĞĐƌĞƚĂƌLJ ŽĨ ƚŚĞ hŶŝƚĞĚ ^ƚĂƚĞƐ ĞƉĂƌƚŵĞŶƚ ŽĨ ,ĞĂůƚŚ ĂŶĚ ,ƵŵĂŶ ^ĞƌǀŝĐĞƐ ŝŶǀŽŬĞĚ ŚŝƐ ĂƵƚŚŽƌŝƚLJ ƚŽ ǁĂŝǀĞ Žƌ ŵŽĚŝĨLJ ĐĞƌƚĂŝŶ ƌĞƋƵŝƌĞŵĞŶƚƐ ŽĨ ƚŝƚůĞƐ ys///͕ y/y͕ ĂŶĚ yy/ ŽĨ ƚŚĞ Đƚ ĂƐ Ă ƌĞƐƵůƚ ŽĨ ƚŚĞ ĐŽŶƐĞƋƵĞŶĐĞƐ Ks/Ͳϭϵ ƉĂŶĚĞŵŝĐ͕ ƚŽ ƚŚĞ ĞdžƚĞŶƚ ŶĞĐĞƐƐĂƌLJ͕ ĂƐ ĚĞƚĞƌŵŝŶĞĚ ďLJ ƚŚĞ ĞŶƚĞƌƐ ĨŽƌ DĞĚŝĐĂƌĞ Θ DĞĚŝĐĂŝĚ ^ĞƌǀŝĐĞƐ ;D^Ϳ͕ ƚŽ ĞŶƐƵƌĞ ƚŚĂƚ ƐƵĨĨŝĐŝĞŶƚ ŚĞĂůƚŚ ĐĂƌĞ ŝƚĞŵƐ ĂŶĚ ƐĞƌǀŝĐĞƐ ĂƌĞ ĂǀĂŝůĂďůĞ ƚŽ ŵĞĞƚ ƚŚĞ ŶĞĞĚƐ ŽĨ ŝŶĚŝǀŝĚƵĂůƐ ĞŶƌŽůůĞĚ ŝŶ ƚŚĞ ƌĞƐƉĞĐƚŝǀĞ ƉƌŽŐƌĂŵƐ ĂŶĚ ƚŽ ĞŶƐƵƌĞ ƚŚĂƚ ŚĞĂůƚŚ ĐĂƌĞ ƉƌŽǀŝĚĞƌƐ ƚŚĂƚ ĨƵƌŶŝƐŚ ƐƵĐŚ ŝƚĞŵƐ ĂŶĚ ƐĞƌǀŝĐĞƐ ŝŶ ŐŽŽĚ ĨĂŝƚŚ͕ ďƵƚ ĂƌĞ ƵŶĂďůĞ ƚŽ ĐŽŵƉůLJ ǁŝƚŚ ŽŶĞ Žƌ ŵŽƌĞ ŽĨ ƐƵĐŚ ƌĞƋƵŝƌĞŵĞŶƚƐ ĂƐ Ă ƌĞƐƵůƚ ŽĨ ƚŚĞ Ks/Ͳϭϵ ƉĂŶĚĞŵŝĐ͕ ŵĂLJ ďĞ ƌĞŝŵďƵƌƐĞĚ ĨŽƌ ƐƵĐŚ ŝƚĞŵƐ ĂŶĚ ƐĞƌǀŝĐĞƐ ĂŶĚ ĞdžĞŵƉƚĞĚ ĨƌŽŵ ƐĂŶĐƚŝŽŶƐ ĨŽƌ ƐƵĐŚ ŶŽŶĐŽŵƉůŝĂŶĐĞ͕ ĂďƐĞŶƚ ĂŶLJ ĚĞƚĞƌŵŝŶĂƚŝŽŶ ŽĨ ĨƌĂƵĚ Žƌ ĂďƵƐĞ͘ dŚŝƐ ĂƵƚŚŽƌŝƚLJ ƚŽŽŬ ĞĨĨĞĐƚ ĂƐ ŽĨ ϲWD ĂƐƚĞƌŶ ^ƚĂŶĚĂƌĚ dŝŵĞ ŽŶ DĂƌĐŚ ϭϱ͕ ϮϬϮϬ͕ ǁŝƚŚ Ă ƌĞƚƌŽĂĐƚŝǀĞ ĞĨĨĞĐƚŝǀĞ ĚĂƚĞ ŽĨ DĂƌĐŚ ϭ͕ ϮϬϮϬ͘ dŚĞ ĞŵĞƌŐĞŶĐLJ ƉĞƌŝŽĚ ǁŝůů ƚĞƌŵŝŶĂƚĞ͕ ĂŶĚ ǁĂŝǀĞƌƐ ǁŝůů ŶŽ ůŽŶŐĞƌ ďĞ ĂǀĂŝůĂďůĞ͕ ƵƉŽŶ ƚĞƌŵŝŶĂƚŝŽŶ ŽĨ ƚŚĞ ƉƵďůŝĐ ŚĞĂůƚŚ ĞŵĞƌŐĞŶĐLJ͕ ŝŶĐůƵĚŝŶŐ ĂŶLJ ĞdžƚĞŶƐŝŽŶƐ͘ dŚĞ ^ƚĂƚĞ DĞĚŝĐĂŝĚ ĂŐĞŶĐLJ ;ĂŐĞŶĐLJͿ ƐĞĞŬƐ ƚŽ ŝŵƉůĞŵĞŶƚ ƚŚĞ ƉŽůŝĐŝĞƐ ĂŶĚ ƉƌŽĐĞĚƵƌĞƐ ĚĞƐĐƌŝďĞĚ ďĞůŽǁ͕ ǁŚŝĐŚ ĂƌĞ ĚŝĨĨĞƌĞŶƚ ƚŚĂŶ ƚŚĞ ƉŽůŝĐŝĞƐ ĂŶĚ ƉƌŽĐĞĚƵƌĞƐ ŽƚŚĞƌǁŝƐĞ ĂƉƉůŝĞĚ ƵŶĚĞƌ ƚŚĞ DĞĚŝĐĂŝĚ ƐƚĂƚĞ ƉůĂŶ͕ ĚƵƌŝŶŐ ƚŚĞ ƉĞƌŝŽĚ ŽĨ ƚŚĞ WƌĞƐŝĚĞŶƚŝĂů ĂŶĚ ^ĞĐƌĞƚĂƌŝĂů ĞŵĞƌŐĞŶĐLJ ĚĞĐůĂƌĂƚŝŽŶƐ ƌĞůĂƚĞĚ ƚŽ ƚŚĞ Ks/Ͳϭϵ ŽƵƚďƌĞĂŬ ;Žƌ ĂŶLJ ƌĞŶĞǁĂůƐ ƚŚĞƌĞŽĨͿ͕ Žƌ ĨŽƌ ĂŶLJ ƐŚŽƌƚĞƌ ƉĞƌŝŽĚ ĚĞƐĐƌŝďĞĚ ďĞůŽǁ͗ Eͬ EKd ͗ ^ƚĂƚĞƐ ŵĂLJ ŶŽƚ ĞůĞĐƚ Ă ƉĞƌŝŽĚ ůŽŶŐĞƌ ƚŚĂŶ ƚŚĞ WƌĞƐŝĚĞŶƚŝĂů Žƌ ^ĞĐƌĞƚĂƌŝĂů ĞŵĞƌŐĞŶĐLJ ĚĞĐůĂƌĂƚŝŽŶ ;Žƌ ĂŶLJ ƌĞŶĞǁĂů ƚŚĞƌĞŽĨͿ͘ ^ƚĂƚĞƐ ŵĂLJ ŶŽƚ ƉƌŽƉŽƐĞ ĐŚĂŶŐĞƐ ŽŶ ƚŚŝƐ ƚĞŵƉůĂƚĞ ƚŚĂƚ ƌĞƐƚƌŝĐƚ Žƌ ůŝŵŝƚ ƉĂLJŵĞŶƚ͕ ƐĞƌǀŝĐĞƐ͕ Žƌ ĞůŝŐŝďŝůŝƚLJ͕ Žƌ ŽƚŚĞƌǁŝƐĞ ďƵƌĚĞŶ ďĞŶĞĨŝĐŝĂƌŝĞƐ ĂŶĚ ƉƌŽǀŝĚĞƌƐ͘ ZĞƋƵĞƐƚ ĨŽƌ tĂŝǀĞƌƐ ƵŶĚĞƌ ^ĞĐƚŝŽŶ ϭϭϯϱ ϭ͘ ܈dŚĞ ĂŐĞŶĐLJ ƐĞĞŬƐ ƚŚĞ ĨŽůůŽǁŝŶŐ ƵŶĚĞƌ ƐĞĐƚŝŽŶ ϭϭϯϱ;ďͿ;ϭͿ;Ϳ ĂŶĚͬŽƌ ƐĞĐƚŝŽŶ ϭϭϯϱ;ďͿ;ϱͿ ŽĨ ƚŚĞ Đƚ͗ Ă͘ ܈^W ƐƵďŵŝƐƐŝŽŶ ƌĞƋƵŝƌĞŵĞŶƚƐ ʹ ƚŚĞ ĂŐĞŶĐLJ ƌĞƋƵĞƐƚƐ ŵŽĚŝĨŝĐĂƚŝŽŶ ŽĨ ƚŚĞ ƌĞƋƵŝƌĞŵĞŶƚ ƚŽ ƐƵďŵŝƚ ƚŚŝƐ ^W ĂŶĚ ĂŶLJ ŽƚŚĞƌ Ks/Ͳϭϵ ƌĞůĂƚĞĚ ^WƐ ďLJ DĂƌĐŚ ϯϭ͕ ϮϬϮϬ͕ ƚŽ ŽďƚĂŝŶ Ă ^W ĞĨĨĞĐƚŝǀĞ ĚĂƚĞ ĚƵƌŝŶŐ ƚŚĞ ĨŝƌƐƚ ĐĂůĞŶĚĂƌ ƋƵĂƌƚĞƌ ŽĨ ϮϬϮϬ͕ ƉƵƌƐƵĂŶƚ ƚŽ ϰϮ &Z ϰϯϬ͘ϮϬ͘ ď͘ ܈WƵďůŝĐ ŶŽƚŝĐĞ ƌĞƋƵŝƌĞŵĞŶƚƐ ʹ ƚŚĞ ĂŐĞŶĐLJ ƌĞƋƵĞƐƚƐ ǁĂŝǀĞƌ ŽĨ ƉƵďůŝĐ ŶŽƚŝĐĞ ƌĞƋƵŝƌĞŵĞŶƚƐ ƚŚĂƚ ǁŽƵůĚ ŽƚŚĞƌǁŝƐĞ ďĞ ĂƉƉůŝĐĂďůĞ ƚŽ ƚŚŝƐ ^W ĂŶĚ ĂŶLJ ŽƚŚĞƌ Ks/Ͳϭϵ ƌĞůĂƚĞĚ ^WƐ ƐƵďŵŝƐƐŝŽŶ͘ dŚĞƐĞ ƌĞƋƵŝƌĞŵĞŶƚƐ ŵĂLJ ŝŶĐůƵĚĞ ƚŚŽƐĞ ƐƉĞĐŝĨŝĞĚ ŝŶ ϰϮ &Z ϰϰϬ͘ϯϴϲ ;ůƚĞƌŶĂƚŝǀĞ ĞŶĞĨŝƚ WůĂŶƐͿ͕ ϰϮ &Z ϰϰϳ͘ϱϳ;ĐͿ ;ƉƌĞŵŝƵŵƐ ĂŶĚ ĐŽƐƚ ƐŚĂƌŝŶŐͿ͕ ĂŶĚ ϰϮ &Z ϰϰϳ͘ϮϬϱ ;ƉƵďůŝĐ ŶŽƚŝĐĞ ŽĨ ĐŚĂŶŐĞƐ ŝŶ ƐƚĂƚĞǁŝĚĞ ŵĞƚŚŽĚƐ ĂŶĚ ƐƚĂŶĚĂƌĚƐ ĨŽƌ ƐĞƚƚŝŶŐ ƉĂLJŵĞŶƚ ƌĂƚĞƐͿ͘ Đ͘ ܈dƌŝďĂů ĐŽŶƐƵůƚĂƚŝŽŶ ƌĞƋƵŝƌĞŵĞŶƚƐ ʹ ƚŚĞ ĂŐĞŶĐLJ ƌĞƋƵĞƐƚƐ ŵŽĚŝĨŝĐĂƚŝŽŶ ŽĨ ƚƌŝďĂů ĐŽŶƐƵůƚĂƚŝŽŶ ƚŝŵĞůŝŶĞƐ ƐƉĞĐŝĨŝĞĚ ŝŶ hƚĂŚ DĞĚŝĐĂŝĚ ƐƚĂƚĞ ƉůĂŶ͕ ĂƐ ĚĞƐĐƌŝďĞĚ ďĞůŽǁ͗ 

^ƚĂƚĞͬdĞƌƌŝƚŽƌLJ͗ hd, 71   $SSURYDO 'DWH 6XSHUVHGHV 71  1HZ (IIHFWLYH 'DWH  dŚĞ ĞƉĂƌƚŵĞŶƚ ƉƌĞƐĞŶƚĞĚ ƚŚŝƐ ^W ƚŽ ƚŚĞ hƚĂŚ /ŶĚŝĂŶ ,ĞĂůƚŚ ĚǀŝƐŽƌLJ ŽĂƌĚ ŽŶ DĂLJ ϴ͕ ϮϬϮϬ͘ ^ĞĐƚŝŽŶ  ʹ ůŝŐŝďŝůŝƚLJ ϭ͘ ܈dŚĞ ĂŐĞŶĐLJ ĨƵƌŶŝƐŚĞƐ ŵĞĚŝĐĂů ĂƐƐŝƐƚĂŶĐĞ ƚŽ ƚŚĞ ĨŽůůŽǁŝŶŐ ŽƉƚŝŽŶĂů ŐƌŽƵƉƐ ŽĨ ŝŶĚŝǀŝĚƵĂůƐ ĚĞƐĐƌŝďĞĚ ŝŶ ƐĞĐƚŝŽŶ ϭϵϬϮ;ĂͿ;ϭϬͿ;Ϳ;ŝŝͿ Žƌ ϭϵϬϮ;ĂͿ;ϭϬͿ;ĐͿ ŽĨ ƚŚĞ Đƚ͘ dŚŝƐ ŵĂLJ ŝŶĐůƵĚĞ ƚŚĞ ŶĞǁ ŽƉƚŝŽŶĂů ŐƌŽƵƉ ĚĞƐĐƌŝďĞĚ Ăƚ ƐĞĐƚŝŽŶ ϭϵϬϮ;ĂͿ;ϭϬͿ;Ϳ;ŝŝͿ;yy///Ϳ ĂŶĚ ϭϵϬϮ;ƐƐͿ ŽĨ ƚŚĞ Đƚ ƉƌŽǀŝĚŝŶŐ ĐŽǀĞƌĂŐĞ ĨŽƌ ƵŶŝŶƐƵƌĞĚ ŝŶĚŝǀŝĚƵĂůƐ͘ /ŶĐůƵĚĞ ŶĂŵĞ ŽĨ ƚŚĞ ŽƉƚŝŽŶĂů ĞůŝŐŝďŝůŝƚLJ ŐƌŽƵƉ ĂŶĚ ĂƉƉůŝĐĂďůĞ ŝŶĐŽŵĞ ĂŶĚ ƌĞƐŽƵƌĐĞ ƐƚĂŶĚĂƌĚ͘ dŚĞ ƐƚĂƚĞ ĞůĞĐƚƐ ƚŽ ĐŽǀĞƌ Ăůů ƵŶŝŶƐƵƌĞĚ ŝŶĚŝǀŝĚƵĂůƐ ĂƐ ĚĞĨŝŶĞĚ ƵŶĚĞƌ ϭϵϬϮ;ƐƐͿ ŽĨ ƚŚĞ Đƚ ƉƵƌƐƵĂŶƚ ƚŽ ^ĞĐƚŝŽŶ ϭϵϬϮ;ĂͿ;ϭϬͿ;Ϳ;ŝŝͿ;yy///Ϳ ŽĨ ƚŚĞ Đƚ͘ Ϯ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ĨƵƌŶŝƐŚĞƐ ŵĞĚŝĐĂů ĂƐƐŝƐƚĂŶĐĞ ƚŽ ƚŚĞ ĨŽůůŽǁŝŶŐ ƉŽƉƵůĂƚŝŽŶƐ ŽĨ ŝŶĚŝǀŝĚƵĂůƐ ĚĞƐĐƌŝďĞĚ ŝŶ ƐĞĐƚŝŽŶ ϭϵϬϮ;ĂͿ;ϭϬͿ;Ϳ;ŝŝͿ;yyͿ ŽĨ ƚŚĞ Đƚ ĂŶĚ ϰϮ &Z ϰϯϱ͘Ϯϭϴ͗ Ă͘ ͺͺͺͺͺ ůů ŝŶĚŝǀŝĚƵĂůƐ ǁŚŽ ĂƌĞ ĚĞƐĐƌŝďĞĚ ŝŶ ƐĞĐƚŝŽŶ ϭϵϬϱ;ĂͿ;ϭϬͿ;Ϳ;ŝŝͿ;yyͿ /ŶĐŽŵĞ ƐƚĂŶĚĂƌĚ͗ ͺͺͺͺͺͺͺͺͺͺͺͺͺ ͲŽƌͲ ď͘ ͺͺͺͺͺ /ŶĚŝǀŝĚƵĂůƐ ĚĞƐĐƌŝďĞĚ ŝŶ ƚŚĞ ĨŽůůŽǁŝŶŐ ĐĂƚĞŐŽƌŝĐĂů ƉŽƉƵůĂƚŝŽŶƐ ŝŶ ƐĞĐƚŝŽŶ ϭϵϬϱ;ĂͿ ŽĨ ƚŚĞ Đƚ͗ /ŶĐŽŵĞ ƐƚĂŶĚĂƌĚ͗ ͺͺͺͺͺͺͺͺͺͺͺͺͺ ϯ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ĂƉƉůŝĞƐ ůĞƐƐ ƌĞƐƚƌŝĐƚŝǀĞ ĨŝŶĂŶĐŝĂů ŵĞƚŚŽĚŽůŽŐŝĞƐ ƚŽ ŝŶĚŝǀŝĚƵĂůƐ ĞdžĐĞƉƚĞĚ ĨƌŽŵ ĨŝŶĂŶĐŝĂů ŵĞƚŚŽĚŽůŽŐŝĞƐ ďĂƐĞĚ ŽŶ ŵŽĚŝĨŝĞĚ ĂĚũƵƐƚĞĚ ŐƌŽƐƐ ŝŶĐŽŵĞ ;D'/Ϳ ĂƐ ĨŽůůŽǁƐ͘ >ĞƐƐ ƌĞƐƚƌŝĐƚŝǀĞ ŝŶĐŽŵĞ ŵĞƚŚŽĚŽůŽŐŝĞƐ͗ >ĞƐƐ ƌĞƐƚƌŝĐƚŝǀĞ ƌĞƐŽƵƌĐĞ ŵĞƚŚŽĚŽůŽŐŝĞƐ͗ 

^ƚĂƚĞͬdĞƌƌŝƚŽƌLJ͗ hd, 71   $SSURYDO 'DWH 6XSHUVHGHV 71  1HZ (IIHFWLYH 'DWH  ϰ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ĐŽŶƐŝĚĞƌƐ ŝŶĚŝǀŝĚƵĂůƐ ǁŚŽ ĂƌĞ ĞǀĂĐƵĂƚĞĚ ĨƌŽŵ ƚŚĞ ƐƚĂƚĞ͕ ǁŚŽ ůĞĂǀĞ ƚŚĞ ƐƚĂƚĞ ĨŽƌ ŵĞĚŝĐĂů ƌĞĂƐŽŶƐ ƌĞůĂƚĞĚ ƚŽ ƚŚĞ ĚŝƐĂƐƚĞƌ Žƌ ƉƵďůŝĐ ŚĞĂůƚŚ ĞŵĞƌŐĞŶĐLJ͕ Žƌ ǁŚŽ ĂƌĞ ŽƚŚĞƌǁŝƐĞ ĂďƐĞŶƚ ĨƌŽŵ ƚŚĞ ƐƚĂƚĞ ĚƵĞ ƚŽ ƚŚĞ ĚŝƐĂƐƚĞƌ Žƌ ƉƵďůŝĐ ŚĞĂůƚŚ ĞŵĞƌŐĞŶĐLJ ĂŶĚ ǁŚŽ ŝŶƚĞŶĚ ƚŽ ƌĞƚƵƌŶ ƚŽ ƚŚĞ ƐƚĂƚĞ͕ ƚŽ ĐŽŶƚŝŶƵĞ ƚŽ ďĞ ƌĞƐŝĚĞŶƚƐ ŽĨ ƚŚĞ ƐƚĂƚĞ ƵŶĚĞƌ ϰϮ &Z ϰϯϱ͘ϰϬϯ;ũͿ;ϯͿ͘ ϱ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ƉƌŽǀŝĚĞƐ DĞĚŝĐĂŝĚ ĐŽǀĞƌĂŐĞ ƚŽ ƚŚĞ ĨŽůůŽǁŝŶŐ ŝŶĚŝǀŝĚƵĂůƐ ůŝǀŝŶŐ ŝŶ ƚŚĞ ƐƚĂƚĞ͕ ǁŚŽ ĂƌĞ ŶŽŶͲƌĞƐŝĚĞŶƚƐ͗ ϲ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ƉƌŽǀŝĚĞƐ ĨŽƌ ĂŶ ĞdžƚĞŶƐŝŽŶ ŽĨ ƚŚĞ ƌĞĂƐŽŶĂďůĞ ŽƉƉŽƌƚƵŶŝƚLJ ƉĞƌŝŽĚ ĨŽƌ ŶŽŶͲĐŝƚŝnjĞŶƐ ĚĞĐůĂƌŝŶŐ ƚŽ ďĞ ŝŶ Ă ƐĂƚŝƐĨĂĐƚŽƌLJ ŝŵŵŝŐƌĂƚŝŽŶ ƐƚĂƚƵƐ͕ ŝĨ ƚŚĞ ŶŽŶͲĐŝƚŝnjĞŶ ŝƐ ŵĂŬŝŶŐ Ă ŐŽŽĚ ĨĂŝƚŚ ĞĨĨŽƌƚ ƚŽ ƌĞƐŽůǀĞ ĂŶLJ ŝŶĐŽŶƐŝƐƚĞŶĐŝĞƐ Žƌ ŽďƚĂŝŶ ĂŶLJ ŶĞĐĞƐƐĂƌLJ ĚŽĐƵŵĞŶƚĂƚŝŽŶ͕ Žƌ ƚŚĞ ĂŐĞŶĐLJ ŝƐ ƵŶĂďůĞ ƚŽ ĐŽŵƉůĞƚĞ ƚŚĞ ǀĞƌŝĨŝĐĂƚŝŽŶ ƉƌŽĐĞƐƐ ǁŝƚŚŝŶ ƚŚĞ ϵϬͲĚĂLJ ƌĞĂƐŽŶĂďůĞ ŽƉƉŽƌƚƵŶŝƚLJ ƉĞƌŝŽĚ ĚƵĞ ƚŽ ƚŚĞ ĚŝƐĂƐƚĞƌ Žƌ ƉƵďůŝĐ ŚĞĂůƚŚ ĞŵĞƌŐĞŶĐLJ͘ ^ĞĐƚŝŽŶ  ʹ ŶƌŽůůŵĞŶƚ ϭ͘ ܈dŚĞ ĂŐĞŶĐLJ ĞůĞĐƚƐ ƚŽ ĂůůŽǁ ŚŽƐƉŝƚĂůƐ ƚŽ ŵĂŬĞ ƉƌĞƐƵŵƉƚŝǀĞ ĞůŝŐŝďŝůŝƚLJ ĚĞƚĞƌŵŝŶĂƚŝŽŶƐ ĨŽƌ ƚŚĞ ĨŽůůŽǁŝŶŐ ĂĚĚŝƚŝŽŶĂů ƐƚĂƚĞ ƉůĂŶ ƉŽƉƵůĂƚŝŽŶƐ͕ Žƌ ĨŽƌ ƉŽƉƵůĂƚŝŽŶƐ ŝŶ ĂŶ ĂƉƉƌŽǀĞĚ ƐĞĐƚŝŽŶ ϭϭϭϱ ĚĞŵŽŶƐƚƌĂƚŝŽŶ͕ ŝŶ ĂĐĐŽƌĚĂŶĐĞ ǁŝƚŚ ƐĞĐƚŝŽŶ ϭϵϬϮ;ĂͿ;ϰϳͿ;Ϳ ŽĨ ƚŚĞ Đƚ ĂŶĚ ϰϮ &Z ϰϯϱ͘ϭϭϭϬ͕ ƉƌŽǀŝĚĞĚ ƚŚĂƚ ƚŚĞ ĂŐĞŶĐLJ ŚĂƐ ĚĞƚĞƌŵŝŶĞĚ ƚŚĂƚ ƚŚĞ ŚŽƐƉŝƚĂů ŝƐ ĐĂƉĂďůĞ ŽĨ ŵĂŬŝŶŐ ƐƵĐŚ ĚĞƚĞƌŵŝŶĂƚŝŽŶƐ͘ WůĞĂƐĞ ĚĞƐĐƌŝďĞ ƚŚĞ ĂƉƉůŝĐĂďůĞ ĞůŝŐŝďŝůŝƚLJ ŐƌŽƵƉƐͬƉŽƉƵůĂƚŝŽŶƐ ĂŶĚ ĂŶLJ ĐŚĂŶŐĞƐ ƚŽ ƌĞĂƐŽŶĂďůĞ ůŝŵŝƚĂƚŝŽŶƐ͕ ƉĞƌĨŽƌŵĂŶĐĞ ƐƚĂŶĚĂƌĚƐ Žƌ ŽƚŚĞƌ ĨĂĐƚŽƌƐ͘ ĚĚŝŶŐ ƵŶŝŶƐƵƌĞĚ ŝŶĚŝǀŝĚƵĂůƐ ĨŽƌ Ks/Ͳϭϵ ƚĞƐƚŝŶŐ ĂŶĚ ƌĞůĂƚĞĚ ƐĞƌǀŝĐĞƐ ĂƐ Ă ,ŽƐƉŝƚĂů WƌĞƐƵŵƉƚŝǀĞ

ůŝŐŝďŝůŝƚLJ ;,W Ϳ ŐƌŽƵƉ͘ dŚĞ ^ƚĂƚĞ ŝƐ ƐĞůĞĐƚŝŶŐ ƵŶůŝŵŝƚĞĚ W ƉĞƌŝŽĚƐ ĨŽƌ ƚŚĞ Ks/ ƚĞƐƚŝŶŐ ŐƌŽƵƉ ŽŶůLJ͘ dŚĞ ^ƚĂƚĞ ǁŝůů ĐŽŶƚŝŶƵĞ ƚŚĞ ƌĞĂƐŽŶĂďůĞ ůŝŵŝƚƐ ƚŚĞ ^ƚĂƚĞ ĞůĞĐƚĞĚ ŝŶ ŝƚƐ ĂƉƉƌŽǀĞĚ ,W ^W ĨŽƌ Ăůů ŽƚŚĞƌ ŐƌŽƵƉƐ͘ dŚĞ ^ƚĂƚĞ ŝƐ ŶŽƚ ĐŚĂŶŐŝŶŐ ƚŚĞ ĞdžŝƐƚŝŶŐ ƉĞƌĨŽƌŵĂŶĐĞ ƐƚĂŶĚĂƌĚƐ ĨŽƌ ,W ƉƌŽǀŝĚĞƌƐ͘ Ϯ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ĚĞƐŝŐŶĂƚĞƐ ŝƚƐĞůĨ ĂƐ Ă ƋƵĂůŝĨŝĞĚ ĞŶƚŝƚLJ ĨŽƌ ƉƵƌƉŽƐĞƐ ŽĨ ŵĂŬŝŶŐ ƉƌĞƐƵŵƉƚŝǀĞ ĞůŝŐŝďŝůŝƚLJ ĚĞƚĞƌŵŝŶĂƚŝŽŶƐ ĚĞƐĐƌŝďĞĚ ďĞůŽǁ ŝŶ ĂĐĐŽƌĚĂŶĐĞ ǁŝƚŚ ƐĞĐƚŝŽŶƐ ϭϵϮϬ͕ ϭϵϮϬ͕ ϭϵϮϬ͕ ĂŶĚ ϭϵϮϬ ŽĨ ƚŚĞ Đƚ ĂŶĚ ϰϮ &Z WĂƌƚ ϰϯϱ ^ƵďƉĂƌƚ >͘ WůĞĂƐĞ ĚĞƐĐƌŝďĞ ĂŶLJ ůŝŵŝƚĂƚŝŽŶƐ ƌĞůĂƚĞĚ ƚŽ ƚŚĞ ƉŽƉƵůĂƚŝŽŶƐ ŝŶĐůƵĚĞĚ Žƌ ƚŚĞ ŶƵŵďĞƌ ŽĨ ĂůůŽǁĂďůĞ W

ƉĞƌŝŽĚƐ͘ ϯ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ĚĞƐŝŐŶĂƚĞƐ ƚŚĞ ĨŽůůŽǁŝŶŐ ĞŶƚŝƚŝĞƐ ĂƐ ƋƵĂůŝĨŝĞĚ ĞŶƚŝƚŝĞƐ ĨŽƌ ƉƵƌƉŽƐĞƐ ŽĨ ŵĂŬŝŶŐ ƉƌĞƐƵŵƉƚŝǀĞ ĞůŝŐŝďŝůŝƚLJ ĚĞƚĞƌŵŝŶĂƚŝŽŶƐ Žƌ ĂĚĚƐ ĂĚĚŝƚŝŽŶĂů ƉŽƉƵůĂƚŝŽŶƐ ĂƐ ĚĞƐĐƌŝďĞĚ ďĞůŽǁ ŝŶ ĂĐĐŽƌĚĂŶĐĞ ǁŝƚŚ ƐĞĐƚŝŽŶƐ ϭϵϮϬ͕ ϭϵϮϬ͕ ϭϵϮϬ͕ ĂŶĚ ϭϵϮϬ ŽĨ ƚŚĞ Đƚ ĂŶĚ ϰϮ &Z WĂƌƚ ϰϯϱ ^ƵďƉĂƌƚ >͘ 

^ƚĂƚĞͬdĞƌƌŝƚŽƌLJ͗ hd, 71   $SSURYDO 'DWH 6XSHUVHGHV 71  1HZ (IIHFWLYH 'DWH  /ŶĚŝĐĂƚĞ ŝĨ ĂŶLJ ĚĞƐŝŐŶĂƚĞĚ ĞŶƚŝƚŝĞƐ ĂƌĞ ƉĞƌŵŝƚƚĞĚ ƚŽ ŵĂŬĞ ƉƌĞƐƵŵƉƚŝǀĞ ĞůŝŐŝďŝůŝƚLJ ĚĞƚĞƌŵŝŶĂƚŝŽŶƐ ŽŶůLJ ĨŽƌ ƐƉĞĐŝĨŝĞĚ ƉŽƉƵůĂƚŝŽŶƐ͘ WůĞĂƐĞ ĚĞƐĐƌŝďĞ ƚŚĞ ĚĞƐŝŐŶĂƚĞĚ ĞŶƚŝƚŝĞƐ Žƌ ĂĚĚŝƚŝŽŶĂů ƉŽƉƵůĂƚŝŽŶƐ ĂŶĚ ĂŶLJ ůŝŵŝƚĂƚŝŽŶƐ ƌĞůĂƚĞĚ ƚŽ ƚŚĞ ƐƉĞĐŝĨŝĞĚ ƉŽƉƵůĂƚŝŽŶƐ Žƌ ŶƵŵďĞƌ ŽĨ ĂůůŽǁĂďůĞ W ƉĞƌŝŽĚƐ͘ ϰ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ĂĚŽƉƚƐ Ă ƚŽƚĂů ŽĨ ͺͺͺͺͺ ŵŽŶƚŚƐ ;ŶŽƚ ƚŽ ĞdžĐĞĞĚ ϭϮ ŵŽŶƚŚƐͿ ĐŽŶƚŝŶƵŽƵƐ ĞůŝŐŝďŝůŝƚLJ ĨŽƌ ĐŚŝůĚƌĞŶ ƵŶĚĞƌ ĂŐĞ ĞŶƚĞƌ ĂŐĞ ͺͺͺͺͺ ;ŶŽƚ ƚŽ ĞdžĐĞĞĚ ĂŐĞ ϭϵͿ ƌĞŐĂƌĚůĞƐƐ ŽĨ ĐŚĂŶŐĞƐ ŝŶ ĐŝƌĐƵŵƐƚĂŶĐĞƐ ŝŶ ĂĐĐŽƌĚĂŶĐĞ ǁŝƚŚ ƐĞĐƚŝŽŶ ϭϵϬϮ;ĞͿ;ϭϮͿ ŽĨ ƚŚĞ Đƚ ĂŶĚ ϰϮ &Z ϰϯϱ͘ϵϮϲ͘ ϱ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ĐŽŶĚƵĐƚƐ ƌĞĚĞƚĞƌŵŝŶĂƚŝŽŶƐ ŽĨ ĞůŝŐŝďŝůŝƚLJ ĨŽƌ ŝŶĚŝǀŝĚƵĂůƐ ĞdžĐĞƉƚĞĚ ĨƌŽŵ D'/ͲďĂƐĞĚ ĨŝŶĂŶĐŝĂů ŵĞƚŚŽĚŽůŽŐŝĞƐ ƵŶĚĞƌ ϰϮ &Z ϰϯϱ͘ϲϬϯ;ũͿ ŽŶĐĞ ĞǀĞƌLJ ͺͺͺͺͺ ŵŽŶƚŚƐ ;ŶŽƚ ƚŽ ĞdžĐĞĞĚ ϭϮ ŵŽŶƚŚƐͿ ŝŶ ĂĐĐŽƌĚĂŶĐĞ ǁŝƚŚ ϰϮ &Z ϰϯϱ͘ϵϭϲ;ďͿ͘ ϲ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ƵƐĞƐ ƚŚĞ ĨŽůůŽǁŝŶŐ ƐŝŵƉůŝĨŝĞĚ ĂƉƉůŝĐĂƚŝŽŶ;ƐͿ ƚŽ ƐƵƉƉŽƌƚ ĞŶƌŽůůŵĞŶƚ ŝŶ ĂĨĨĞĐƚĞĚ ĂƌĞĂƐ Žƌ ĨŽƌ ĂĨĨĞĐƚĞĚ ŝŶĚŝǀŝĚƵĂůƐ ;Ă ĐŽƉLJ ŽĨ ƚŚĞ ƐŝŵƉůŝĨŝĞĚ ĂƉƉůŝĐĂƚŝŽŶ;ƐͿ ŚĂƐ ďĞĞŶ ƐƵďŵŝƚƚĞĚ ƚŽ D^Ϳ͘ Ă͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ƵƐĞƐ Ă ƐŝŵƉůŝĨŝĞĚ ƉĂƉĞƌ ĂƉƉůŝĐĂƚŝŽŶ͘ ď͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ƵƐĞƐ Ă ƐŝŵƉůŝĨŝĞĚ ŽŶůŝŶĞ ĂƉƉůŝĐĂƚŝŽŶ͘ Đ͘ ͺͺͺͺͺ dŚĞ ƐŝŵƉůŝĨŝĞĚ ƉĂƉĞƌ Žƌ ŽŶůŝŶĞ ĂƉƉůŝĐĂƚŝŽŶ ŝƐ ŵĂĚĞ ĂǀĂŝůĂďůĞ ĨŽƌ ƵƐĞ ŝŶ ĐĂůůͲĐĞŶƚĞƌƐ Žƌ ŽƚŚĞƌ ƚĞůĞƉŚŽŶĞ ĂƉƉůŝĐĂƚŝŽŶƐ ŝŶ ĂĨĨĞĐƚĞĚ ĂƌĞĂƐ͘ ^ĞĐƚŝŽŶ  ʹ WƌĞŵŝƵŵƐ ĂŶĚ ŽƐƚ ^ŚĂƌŝŶŐ ϭ͘ ܈dŚĞ ĂŐĞŶĐLJ ƐƵƐƉĞŶĚƐ ĚĞĚƵĐƚŝďůĞƐ͕ ĐŽƉĂLJŵĞŶƚƐ͕ ĐŽŝŶƐƵƌĂŶĐĞ͕ ĂŶĚ ŽƚŚĞƌ ĐŽƐƚ ƐŚĂƌŝŶŐ ĐŚĂƌŐĞƐ ĂƐ ĨŽůůŽǁƐ͗ WůĞĂƐĞ ĚĞƐĐƌŝďĞ ǁŚĞƚŚĞƌ ƚŚĞ ƐƚĂƚĞ ƐƵƐƉĞŶĚƐ Ăůů ĐŽƐƚ ƐŚĂƌŝŶŐ Žƌ ƐƵƐƉĞŶĚƐ ŽŶůLJ ƐƉĞĐŝĨŝĞĚ ĚĞĚƵĐƚŝďůĞƐ͕ ĐŽƉĂLJŵĞŶƚƐ͕ ĐŽŝŶƐƵƌĂŶĐĞ͕ Žƌ ŽƚŚĞƌ ĐŽƐƚ ƐŚĂƌŝŶŐ ĐŚĂƌŐĞƐ ĨŽƌ ƐƉĞĐŝĨŝĞĚ ŝƚĞŵƐ ĂŶĚ ƐĞƌǀŝĐĞƐ Žƌ ĨŽƌ ƐƉĞĐŝĨŝĞĚ ĞůŝŐŝďŝůŝƚLJ ŐƌŽƵƉƐ ĐŽŶƐŝƐƚĞŶƚ ǁŝƚŚ ϰϮ &Z ϰϰϳ͘ϱϮ;ĚͿ Žƌ ĨŽƌ ƐƉĞĐŝĨŝĞĚ ŝŶĐŽŵĞ ůĞǀĞůƐ ĐŽŶƐŝƐƚĞŶƚ ǁŝƚŚ ϰϮ &Z ϰϰϳ͘ϱϮ;ŐͿ͘ dŚĞ ^ƚĂƚĞ ǁĂŝǀĞƐ ĐŽƐƚ ƐŚĂƌŝŶŐ ĨŽƌ ƚĞƐƚŝŶŐ ƐĞƌǀŝĐĞƐ ;ŝŶĐůƵĚŝŶŐ ŝŶͲǀŝƚƌŽ ĚŝĂŐŶŽƐƚŝĐ ƉƌŽĚƵĐƚƐͿ͕ ƚĞƐƚŝŶŐͲ ƌĞůĂƚĞĚ ƐĞƌǀŝĐĞƐ͕ ĂŶĚ ƚƌĞĂƚŵĞŶƚƐ ĨŽƌ Ks/Ͳϭϵ͕ ŝŶĐůƵĚŝŶŐ ǀĂĐĐŝŶĞƐ͕ ƐƉĞĐŝĂůŝnjĞĚ ĞƋƵŝƉŵĞŶƚ ĂŶĚ ƚŚĞƌĂƉŝĞƐ ;ŝŶĐůƵĚŝŶŐ ĚƌƵŐƐͿ͕ ĨŽƌ ĂŶLJ ƋƵĂƌƚĞƌ ŝŶ ǁŚŝĐŚ ƚŚĞ ƚĞŵƉŽƌĂƌLJ ŝŶĐƌĞĂƐĞĚ &DW ŝƐ ĐůĂŝŵĞĚ͘ Ϯ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ƐƵƐƉĞŶĚƐ ĞŶƌŽůůŵĞŶƚ ĨĞĞƐ͕ ƉƌĞŵŝƵŵƐ ĂŶĚ ƐŝŵŝůĂƌ ĐŚĂƌŐĞƐ ĨŽƌ͗ Ă͘ ͺͺͺͺͺ ůů ďĞŶĞĨŝĐŝĂƌŝĞƐ ď͘ ͺͺͺͺͺ dŚĞ ĨŽůůŽǁŝŶŐ ĞůŝŐŝďŝůŝƚLJ ŐƌŽƵƉƐ Žƌ ĐĂƚĞŐŽƌŝĐĂů ƉŽƉƵůĂƚŝŽŶƐ͗ WůĞĂƐĞ ůŝƐƚ ƚŚĞ ĂƉƉůŝĐĂďůĞ ĞůŝŐŝďŝůŝƚLJ ŐƌŽƵƉƐ Žƌ ƉŽƉƵůĂƚŝŽŶƐ͘ 

^ƚĂƚĞͬdĞƌƌŝƚŽƌLJ͗ hd, 71   $SSURYDO 'DWH 6XSHUVHGHV 71  1HZ (IIHFWLYH 'DWH  ϯ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ĂůůŽǁƐ ǁĂŝǀĞƌ ŽĨ ƉĂLJŵĞŶƚ ŽĨ ƚŚĞ ĞŶƌŽůůŵĞŶƚ ĨĞĞ͕ ƉƌĞŵŝƵŵƐ ĂŶĚ ƐŝŵŝůĂƌ ĐŚĂƌŐĞƐ ĨŽƌ ƵŶĚƵĞ ŚĂƌĚƐŚŝƉ͘ WůĞĂƐĞ ƐƉĞĐŝĨLJ ƚŚĞ ƐƚĂŶĚĂƌĚ;ƐͿ ĂŶĚͬŽƌ ĐƌŝƚĞƌŝĂ ƚŚĂƚ ƚŚĞ ƐƚĂƚĞ ǁŝůů ƵƐĞ ƚŽ ĚĞƚĞƌŵŝŶĞ ƵŶĚƵĞ ŚĂƌĚƐŚŝƉ͘ ^ĞĐƚŝŽŶ  ʹ ĞŶĞĨŝƚƐ ĞŶĞĨŝƚƐ͗ ϭ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ĂĚĚƐ ƚŚĞ ĨŽůůŽǁŝŶŐ ŽƉƚŝŽŶĂů ďĞŶĞĨŝƚƐ ŝŶ ŝƚƐ ƐƚĂƚĞ ƉůĂŶ ;ŝŶĐůƵĚĞ ƐĞƌǀŝĐĞ ĚĞƐĐƌŝƉƚŝŽŶƐ͕ ƉƌŽǀŝĚĞƌ ƋƵĂůŝĨŝĐĂƚŝŽŶƐ͕ ĂŶĚ ůŝŵŝƚĂƚŝŽŶƐ ŽŶ ĂŵŽƵŶƚ͕ ĚƵƌĂƚŝŽŶ Žƌ ƐĐŽƉĞ ŽĨ ƚŚĞ ďĞŶĞĨŝƚͿ͗ Ϯ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ŵĂŬĞƐ ƚŚĞ ĨŽůůŽǁŝŶŐ ĂĚũƵƐƚŵĞŶƚƐ ƚŽ ďĞŶĞĨŝƚƐ ĐƵƌƌĞŶƚůLJ ĐŽǀĞƌĞĚ ŝŶ ƚŚĞ ƐƚĂƚĞ ƉůĂŶ͗ ϯ͘ ͺͺͺͺͺdŚĞ ĂŐĞŶĐLJ ĂƐƐƵƌĞƐ ƚŚĂƚ ŶĞǁůLJ ĂĚĚĞĚ ďĞŶĞĨŝƚƐ Žƌ ĂĚũƵƐƚŵĞŶƚƐ ƚŽ ďĞŶĞĨŝƚƐ ĐŽŵƉůLJ ǁŝƚŚ Ăůů ĂƉƉůŝĐĂďůĞ ƐƚĂƚƵƚŽƌLJ ƌĞƋƵŝƌĞŵĞŶƚƐ͕ ŝŶĐůƵĚŝŶŐ ƚŚĞ ƐƚĂƚĞǁŝĚĞ ƌĞƋƵŝƌĞŵĞŶƚƐ ĨŽƵŶĚ Ăƚ ϭϵϬϮ;ĂͿ;ϭͿ͕ ĐŽŵƉĂƌĂďŝůŝƚLJ ƌĞƋƵŝƌĞŵĞŶƚƐ ĨŽƵŶĚ Ăƚ ϭϵϬϮ;ĂͿ;ϭϬͿ;Ϳ͕ ĂŶĚ ĨƌĞĞ ĐŚŽŝĐĞ ŽĨ ƉƌŽǀŝĚĞƌ ƌĞƋƵŝƌĞŵĞŶƚƐ ĨŽƵŶĚ Ăƚ ϭϵϬϮ;ĂͿ;ϮϯͿ͘ ϰ͘ ͺͺͺͺͺ ƉƉůŝĐĂƚŝŽŶ ƚŽ ůƚĞƌŶĂƚŝǀĞ ĞŶĞĨŝƚ WůĂŶƐ ;WͿ͘ dŚĞ ƐƚĂƚĞ ĂĚŚĞƌĞƐ ƚŽ Ăůů W ƉƌŽǀŝƐŝŽŶƐ ŝŶ ϰϮ &Z WĂƌƚ ϰϰϬ͕ ^ƵďƉĂƌƚ ͘ dŚŝƐ ƐĞĐƚŝŽŶ ŽŶůLJ ĂƉƉůŝĞƐ ƚŽ ƐƚĂƚĞƐ ƚŚĂƚ ŚĂǀĞ ĂŶ ĂƉƉƌŽǀĞĚ W;ƐͿ͘ Ă͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ĂƐƐƵƌĞƐ ƚŚĂƚ ƚŚĞƐĞ ŶĞǁůLJ ĂĚĚĞĚ ĂŶĚͬŽƌ ĂĚũƵƐƚĞĚ ďĞŶĞĨŝƚƐ ǁŝůů ďĞ ŵĂĚĞ ĂǀĂŝůĂďůĞ ƚŽ ŝŶĚŝǀŝĚƵĂůƐ ƌĞĐĞŝǀŝŶŐ ƐĞƌǀŝĐĞƐ ƵŶĚĞƌ WƐ͘ ď͘ ͺͺͺͺͺ /ŶĚŝǀŝĚƵĂůƐ ƌĞĐĞŝǀŝŶŐ ƐĞƌǀŝĐĞƐ ƵŶĚĞƌ WƐ ǁŝůů ŶŽƚ ƌĞĐĞŝǀĞ ƚŚĞƐĞ ŶĞǁůLJ ĂĚĚĞĚ ĂŶĚͬŽƌ ĂĚũƵƐƚĞĚ ďĞŶĞĨŝƚƐ͕ Žƌ ǁŝůů ŽŶůLJ ƌĞĐĞŝǀĞ ƚŚĞ ĨŽůůŽǁŝŶŐ ƐƵďƐĞƚ͗ dĞůĞŚĞĂůƚŚ͗ ϱ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ƵƚŝůŝnjĞƐ ƚĞůĞŚĞĂůƚŚ ŝŶ ƚŚĞ ĨŽůůŽǁŝŶŐ ŵĂŶŶĞƌ͕ ǁŚŝĐŚ ŵĂLJ ďĞ ĚŝĨĨĞƌĞŶƚ ƚŚĂŶ ŽƵƚůŝŶĞĚ ŝŶ ƚŚĞ ƐƚĂƚĞ͛Ɛ ĂƉƉƌŽǀĞĚ ƐƚĂƚĞ ƉůĂŶ͗ WůĞĂƐĞ ĚĞƐĐƌŝďĞ͘ 

^ƚĂƚĞͬdĞƌƌŝƚŽƌLJ͗ hd, 71   $SSURYDO 'DWH 6XSHUVHGHV 71  1HZ (IIHFWLYH 'DWH  ƌƵŐ ĞŶĞĨŝƚ͗ ϲ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ŵĂŬĞƐ ƚŚĞ ĨŽůůŽǁŝŶŐ ĂĚũƵƐƚŵĞŶƚƐ ƚŽ ƚŚĞ ĚĂLJ ƐƵƉƉůLJ Žƌ ƋƵĂŶƚŝƚLJ ůŝŵŝƚ ĨŽƌ ĐŽǀĞƌĞĚ ŽƵƚƉĂƚŝĞŶƚ ĚƌƵŐƐ͘ dŚĞ ĂŐĞŶĐLJ ƐŚŽƵůĚ ŽŶůLJ ŵĂŬĞ ƚŚŝƐ ŵŽĚŝĨŝĐĂƚŝŽŶ ŝĨ ŝƚƐ ĐƵƌƌĞŶƚ ƐƚĂƚĞ ƉůĂŶ ƉĂŐĞƐ ŚĂǀĞ ůŝŵŝƚƐ ŽŶ ƚŚĞ ĂŵŽƵŶƚ ŽĨ ŵĞĚŝĐĂƚŝŽŶ ĚŝƐƉĞŶƐĞĚ͘ WůĞĂƐĞ ĚĞƐĐƌŝďĞ ƚŚĞ ĐŚĂŶŐĞ ŝŶ ĚĂLJƐ Žƌ ƋƵĂŶƚŝƚŝĞƐ ƚŚĂƚ ĂƌĞ ĂůůŽǁĞĚ ĨŽƌ ƚŚĞ ĞŵĞƌŐĞŶĐLJ ƉĞƌŝŽĚ ĂŶĚ ĨŽƌ ǁŚŝĐŚ ĚƌƵŐƐ͘ ϳ͘ ͺͺͺͺͺ WƌŝŽƌ ĂƵƚŚŽƌŝnjĂƚŝŽŶ ĨŽƌ ŵĞĚŝĐĂƚŝŽŶƐ ŝƐ ĞdžƉĂŶĚĞĚ ďLJ ĂƵƚŽŵĂƚŝĐ ƌĞŶĞǁĂů ǁŝƚŚŽƵƚ ĐůŝŶŝĐĂů ƌĞǀŝĞǁ͕ Žƌ ƚŝŵĞͬƋƵĂŶƚŝƚLJ ĞdžƚĞŶƐŝŽŶƐ͘ ϴ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ŵĂŬĞƐ ƚŚĞ ĨŽůůŽǁŝŶŐ ƉĂLJŵĞŶƚ ĂĚũƵƐƚŵĞŶƚ ƚŽ ƚŚĞ ƉƌŽĨĞƐƐŝŽŶĂů ĚŝƐƉĞŶƐŝŶŐ ĨĞĞ ǁŚĞŶ ĂĚĚŝƚŝŽŶĂů ĐŽƐƚƐ ĂƌĞ ŝŶĐƵƌƌĞĚ ďLJ ƚŚĞ ƉƌŽǀŝĚĞƌƐ ĨŽƌ ĚĞůŝǀĞƌLJ͘ ^ƚĂƚĞƐ ǁŝůů ŶĞĞĚ ƚŽ ƐƵƉƉůLJ ĚŽĐƵŵĞŶƚĂƚŝŽŶ ƚŽ ũƵƐƚŝĨLJ ƚŚĞ ĂĚĚŝƚŝŽŶĂů ĨĞĞƐ͘ WůĞĂƐĞ ĚĞƐĐƌŝďĞ ƚŚĞ ŵĂŶŶĞƌ ŝŶ ǁŚŝĐŚ ƉƌŽĨĞƐƐŝŽŶĂů ĚŝƐƉĞŶƐŝŶŐ ĨĞĞƐ ĂƌĞ ĂĚũƵƐƚĞĚ͘ ϵ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ŵĂŬĞƐ ĞdžĐĞƉƚŝŽŶƐ ƚŽ ƚŚĞŝƌ ƉƵďůŝƐŚĞĚ WƌĞĨĞƌƌĞĚ ƌƵŐ >ŝƐƚ ŝĨ ĚƌƵŐ ƐŚŽƌƚĂŐĞƐ ŽĐĐƵƌ͘ dŚŝƐ ǁŽƵůĚ ŝŶĐůƵĚĞ ŽƉƚŝŽŶƐ ĨŽƌ ĐŽǀĞƌŝŶŐ Ă ďƌĂŶĚ ŶĂŵĞ ĚƌƵŐ ƉƌŽĚƵĐƚ ƚŚĂƚ ŝƐ Ă ŵƵůƚŝͲƐŽƵƌĐĞ ĚƌƵŐ ŝĨ Ă ŐĞŶĞƌŝĐ ĚƌƵŐ ŽƉƚŝŽŶ ŝƐ ŶŽƚ ĂǀĂŝůĂďůĞ͘ ^ĞĐƚŝŽŶ ʹ WĂLJŵĞŶƚƐ KƉƚŝŽŶĂů ďĞŶĞĨŝƚƐ ĚĞƐĐƌŝďĞĚ ŝŶ ^ĞĐƚŝŽŶ ͗ ϭ͘ ͺͺͺͺͺ EĞǁůLJ ĂĚĚĞĚ ďĞŶĞĨŝƚƐ ĚĞƐĐƌŝďĞĚ ŝŶ ^ĞĐƚŝŽŶ  ĂƌĞ ƉĂŝĚ ƵƐŝŶŐ ƚŚĞ ĨŽůůŽǁŝŶŐ ŵĞƚŚŽĚŽůŽŐLJ͗ Ă͘ ͺͺͺͺͺ WƵďůŝƐŚĞĚ ĨĞĞ ƐĐŚĞĚƵůĞƐ ʹ

ĨĨĞĐƚŝǀĞ ĚĂƚĞ ;ĞŶƚĞƌ ĚĂƚĞ ŽĨ ĐŚĂŶŐĞͿ͗ ͺͺͺͺͺͺͺͺͺͺͺͺͺ >ŽĐĂƚŝŽŶ ;ůŝƐƚ ƉƵďůŝƐŚĞĚ ůŽĐĂƚŝŽŶͿ͗ ͺͺͺͺͺͺͺͺͺͺͺͺͺ ď͘ ͺͺͺͺͺ KƚŚĞƌ͗ ĞƐĐƌŝďĞ ŵĞƚŚŽĚŽůŽŐLJ ŚĞƌĞ͘ 

^ƚĂƚĞͬdĞƌƌŝƚŽƌLJ͗ hd, 71   $SSURYDO 'DWH 6XSHUVHGHV 71  1HZ (IIHFWLYH 'DWH  /ŶĐƌĞĂƐĞƐ ƚŽ ƐƚĂƚĞ ƉůĂŶ ƉĂLJŵĞŶƚ ŵĞƚŚŽĚŽůŽŐŝĞƐ͗ Ϯ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ŝŶĐƌĞĂƐĞƐ ƉĂLJŵĞŶƚ ƌĂƚĞƐ ĨŽƌ ƚŚĞ ĨŽůůŽǁŝŶŐ ƐĞƌǀŝĐĞƐ͗ WůĞĂƐĞ ůŝƐƚ Ăůů ƚŚĂƚ ĂƉƉůLJ͘ Ă͘ ͺͺͺͺͺ WĂLJŵĞŶƚ ŝŶĐƌĞĂƐĞƐ ĂƌĞ ƚĂƌŐĞƚĞĚ ďĂƐĞĚ ŽŶ ƚŚĞ ĨŽůůŽǁŝŶŐ ĐƌŝƚĞƌŝĂ͗ WůĞĂƐĞ ĚĞƐĐƌŝďĞ ĐƌŝƚĞƌŝĂ͘ ď͘ WĂLJŵĞŶƚƐ ĂƌĞ ŝŶĐƌĞĂƐĞĚ ƚŚƌŽƵŐŚ͗ ŝ͘ ͺͺͺͺͺ  ƐƵƉƉůĞŵĞŶƚĂů ƉĂLJŵĞŶƚ Žƌ ĂĚĚͲŽŶ ǁŝƚŚŝŶ ĂƉƉůŝĐĂďůĞ ƵƉƉĞƌ ƉĂLJŵĞŶƚ ůŝŵŝƚƐ͗ WůĞĂƐĞ ĚĞƐĐƌŝďĞ͘ ŝŝ͘ ͺͺͺͺͺ Ŷ ŝŶĐƌĞĂƐĞ ƚŽ ƌĂƚĞƐ ĂƐ ĚĞƐĐƌŝďĞĚ ďĞůŽǁ͘ ZĂƚĞƐ ĂƌĞ ŝŶĐƌĞĂƐĞĚ͗ ͺͺͺͺͺ hŶŝĨŽƌŵůLJ ďLJ ƚŚĞ ĨŽůůŽǁŝŶŐ ƉĞƌĐĞŶƚĂŐĞ͗ ͺͺͺͺͺͺͺͺͺͺͺͺͺ ͺͺͺͺͺ dŚƌŽƵŐŚ Ă ŵŽĚŝĨŝĐĂƚŝŽŶ ƚŽ ƉƵďůŝƐŚĞĚ ĨĞĞ ƐĐŚĞĚƵůĞƐ ʹ

ĨĨĞĐƚŝǀĞ ĚĂƚĞ ;ĞŶƚĞƌ ĚĂƚĞ ŽĨ ĐŚĂŶŐĞͿ͗ ͺͺͺͺͺͺͺͺͺͺͺͺͺ >ŽĐĂƚŝŽŶ ;ůŝƐƚ ƉƵďůŝƐŚĞĚ ůŽĐĂƚŝŽŶͿ͗ ͺͺͺͺͺͺͺͺͺͺͺͺͺ ͺͺͺͺͺ hƉ ƚŽ ƚŚĞ DĞĚŝĐĂƌĞ ƉĂLJŵĞŶƚƐ ĨŽƌ ĞƋƵŝǀĂůĞŶƚ ƐĞƌǀŝĐĞƐ͘ ͺͺͺͺͺ LJ ƚŚĞ ĨŽůůŽǁŝŶŐ ĨĂĐƚŽƌƐ͗ WůĞĂƐĞ ĚĞƐĐƌŝďĞ͘ ^ĞĐƚŝŽŶ & ʹ WŽƐƚͲ ůŝŐŝďŝůŝƚLJ dƌĞĂƚŵĞŶƚ ŽĨ /ŶĐŽŵĞ ϭ͘ ͺͺͺͺͺ dŚĞ ƐƚĂƚĞ ĞůĞĐƚƐ ƚŽ ŵŽĚŝĨLJ ƚŚĞ ďĂƐŝĐ ƉĞƌƐŽŶĂů ŶĞĞĚƐ ĂůůŽǁĂŶĐĞ ĨŽƌ ŝŶƐƚŝƚƵƚŝŽŶĂůŝnjĞĚ ŝŶĚŝǀŝĚƵĂůƐ͘ dŚĞ ďĂƐŝĐ ƉĞƌƐŽŶĂů ŶĞĞĚƐ ĂůůŽǁĂŶĐĞ ŝƐ ĞƋƵĂů ƚŽ ŽŶĞ ŽĨ ƚŚĞ ĨŽůůŽǁŝŶŐ ĂŵŽƵŶƚƐ͗ 

^ƚĂƚĞͬdĞƌƌŝƚŽƌLJ͗ hd, 71   $SSURYDO 'DWH 6XSHUVHGHV 71  1HZ (IIHFWLYH 'DWH  Ă͘ ͺͺͺͺͺ dŚĞ ŝŶĚŝǀŝĚƵĂů͛Ɛ ƚŽƚĂů ŝŶĐŽŵĞ ď͘ ͺͺͺͺͺ ϯϬϬ ƉĞƌĐĞŶƚ ŽĨ ƚŚĞ ^^/ ĨĞĚĞƌĂů ďĞŶĞĨŝƚ ƌĂƚĞ Đ͘ ͺͺͺͺͺ KƚŚĞƌ ƌĞĂƐŽŶĂďůĞ ĂŵŽƵŶƚ͗ ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ Ϯ͘ ͺͺͺͺͺ dŚĞ ƐƚĂƚĞ ĞůĞĐƚƐ Ă ŶĞǁ ǀĂƌŝĂŶĐĞ ƚŽ ƚŚĞ ďĂƐŝĐ ƉĞƌƐŽŶĂů ŶĞĞĚƐ ĂůůŽǁĂŶĐĞ͘ ;EŽƚĞ͗ ůĞĐƚŝŽŶ ŽĨ ƚŚŝƐ ŽƉƚŝŽŶ ŝƐ ŶŽƚ ĚĞƉĞŶĚĞŶƚ ŽŶ Ă ƐƚĂƚĞ ĞůĞĐƚŝŶŐ ƚŚĞ ŽƉƚŝŽŶ ĚĞƐĐƌŝďĞĚ ƚŚĞ ŽƉƚŝŽŶ ŝŶ &͘ϭ͘ ĂďŽǀĞ͘Ϳ dŚĞ ƐƚĂƚĞ ƉƌŽƚĞĐƚƐ ĂŵŽƵŶƚƐ ĞdžĐĞĞĚŝŶŐ ƚŚĞ ďĂƐŝĐ ƉĞƌƐŽŶĂů ŶĞĞĚƐ ĂůůŽǁĂŶĐĞ ĨŽƌ ŝŶĚŝǀŝĚƵĂůƐ ǁŚŽ ŚĂǀĞ ƚŚĞ ĨŽůůŽǁŝŶŐ ŐƌĞĂƚĞƌ ƉĞƌƐŽŶĂů ŶĞĞĚƐ͗ WůĞĂƐĞ ĚĞƐĐƌŝďĞ ƚŚĞ ŐƌŽƵƉ Žƌ ŐƌŽƵƉƐ ŽĨ ŝŶĚŝǀŝĚƵĂůƐ ǁŝƚŚ ŐƌĞĂƚĞƌ ŶĞĞĚƐ ĂŶĚ ƚŚĞ ĂŵŽƵŶƚ;ƐͿ ƉƌŽƚĞĐƚĞĚ ĨŽƌ ĞĂĐŚ ŐƌŽƵƉ Žƌ ŐƌŽƵƉƐ͘ ^ĞĐƚŝŽŶ ' ʹ KƚŚĞƌ WŽůŝĐŝĞƐ ĂŶĚ WƌŽĐĞĚƵƌĞƐ ŝĨĨĞƌŝŶŐ ĨƌŽŵ ƉƉƌŽǀĞĚ DĞĚŝĐĂŝĚ ^ƚĂƚĞ WůĂŶ ͬĚĚŝƚŝŽŶĂů /ŶĨŽƌŵĂƚŝŽŶ 

Table of Contents State/Territory Name: Utah State Plan Amendment (SPA) #: 20-0009 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-26-12 Baltimore, Maryland 21244-1850 June 5, 2020 Nathan Checketts State Medicaid Director Division of Health Care Financing Utah Department of Health P O Box 144102 Salt Lake City UT 84114-4102 Re: Utah State Plan Amendment (SPA) UT-20-0009 Dear Mr. Checketts: We have reviewed the proposed amendment to add section 7.5 Medicaid Disaster Relief for the COVID-19 National Emergency to your Medicaid state plan, as submitted under transmittal number (TN) UT-20-0009. This amendment proposes to implement temporary policies, which are different from those policies and procedures otherwise applied under your Medicaid state plan, during the period of the Presidential and Secretarial emergency declarations related to the COVID-19 outbreak (or any renewals thereof). On March 13, 2020, the President of the United States issued a proclamation that the COVID-19 outbreak in the United States constitutes a national emergency by the authorities vested in him by the Constitution and the laws of the United States, including sections 201 and 301 of the National Emergencies Act (50 U.S.C. 1601 et seq.), and consistent with section 1135 of the Social Security Act (Act). On March 13, 2020, pursuant to section 1135(b) of the Act, the Secretary of the United States Department of Health and Human Services invoked his authority to waive or modify certain requirements of titles XVIII, XIX, and XXI of the Act as a result of the consequences of the COVID-19 pandemic, to the extent necessary, as determined by the Centers for Medicare & Medicaid Services (CMS), to ensure that sufficient health care items and services are available to meet the needs of individuals enrolled in the respective programs and to ensure that health care providers that furnish such items and services in good faith, but are unable to comply with one or more of such requirements as a result of the COVID-19 pandemic, may be reimbursed for such items and services and exempted from sanctions for such noncompliance, absent any determination of fraud or abuse.

This authority took effect as of 6PM Eastern Standard Time on March 15, 2020, with a retroactive effective date of March 1, 2020. The emergency period will terminate, and this state plan provision will no longer be in effect, upon termination of the public health emergency, including any extensions. 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. 430.20 that the state submit SPAs related to the COVID- 19 public health emergency by the final day of the quarter, to obtain a SPA effective date during the quarter, enabling SPAs submitted after the last day of the quarter to have an effective date in a previous quarter, but no earlier than the effective date of the public health emergency. The State of Utah also requested a waiver of public notice requirements applicable to the SPA submission process. Pursuant to section 1135(b)(1)(C) of the Act, CMS is waiving public notice requirements applicable to the SPA submission process. Public notice for SPAs is required under 42 C.F.R. §447.205 for changes in statewide methods and standards for setting Medicaid payment rates, 42 C.F.R. §447.57 for changes to premiums and cost sharing, and 42 C.F.R. §440.386 for changes to Alternative Benefit Plans (ABPs). Pursuant to section 1135(b)(1)(C) of the Act, CMS is approving the state’s request to waive these notice requirements otherwise applicable to SPA submissions. The State of Utah also requested a waiver to modify the tribal consultation timeline applicable to this SPA submission process. 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 1902(a)(73) of the Act, including shortening the number of days before submission or conducting consultation after submission of the SPA. These waivers or modifications of the requirements related to SPA submission timelines, public notice, and tribal consultation apply only with respect to SPAs that meet the following criteria: (1) the SPA provides or increases beneficiary access to items and services related to COVID-19 (such as by waiving or eliminating cost sharing, increasing payment rates or amending ABPs to add services or providers); (2) the SPA does not restrict or limit payment or services or otherwise burden beneficiaries and providers; and (3) the SPA is temporary, with a specified sunset date that is not later than the last day of the declared COVID-19 public health emergency (or any extension thereof). We nonetheless encourage states to make all relevant information about the SPA available to the public so they are aware of the changes. We conducted our review of your submittal according to the statutory requirements at section 1902(a) of the Act and implementing regulations. This letter is to inform you that Utah’s Medicaid SPA Transmittal Number UT-20-0009 is approved effective March 1, 2020. This SPA is in addition to Disaster Relief SPA 20-0006 approved on May 18, 2020, and supersedes the request for waivers under Section 1135: 1.a. SPA submission requirements and 1.b. Public notice requirements on page 1. Enclosed is a copy of the CMS-179 summary form and the approved state plan pages.

Please contact Mandy Strom at (303) 844-7068 or by email at Mandy.Strom@cms.hhs.gov if you have any questions about this approval. We appreciate the efforts of you and your staff in responding to the needs of the residents of the State of Utah and the health care community. Sincerely, Anne Marie Costello Deputy Director Center for Medicaid & CHIP Services Enclosures

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED

HEALTHCARE FINANCING ADMINISTRATION OMB NO. 0938-0193 1. TRANSMITTAL NUMBER: 2. STATE: TRANSMITTAL AND NOTICE OF APPROVAL OF 20-0009-UT Utah STATE PLAN MATERIAL

FOR: HEALTH CARE FINANCING ADMINISTRATION 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL

SECURITY ACT (MEDICAID) TO: REGIONAL ADMINISTRATOR 4. PROPOSED EFFECTIVE DATE HEALTHCARE FINANCING ADMINISTRATION March 1, 2020 DEPARTMENT OF HEALTH AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL (Check One) (1_NEW STATE PLAN (1 AMENDMENT TO BE CONSIDERED AS NEW PLAN [) AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate Transmittal for each amendment) 6. FEDERAL STATUTE/REGULATION CITATION: 7. FEDERAL BUDGET IMPACT: a. FFY 2020 $+10,600,000 Section 1135b of the Social Security Act b. FFY 2021 $0 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION

OR ATTACHMENT (If Applicable) Section 7.5

10. SUBJECT OF AMENDMENT: Disaster Relief Testing Locations

11. GOVERNOR'S REVIEW (Check One): [J GOVERNOR'S OFFICE REPORTED NO COMMENT (+OTHER, AS SPECIFIED: (J COMMENTS OF GOVERNOR'S OFFICE ENCLOSED LJ NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL

12. SIGNATURE OF STATE AGENCY OFFICIAL: 16. RETURN TO: | Craig Devashrayee, Manager 13. TYPED NAME: Joseph K. Miner, M.D. Technical Writing Unit Utah Department of Heath 14. TITLE: Executive Director, Utah Department of Health PO Box 143102

Salt Lake City, UT 84114-3102 15. DATE SUBMITTED: May 15, 2020

16 17. DATE RECEIVED: 18. DATE APPROVED:

May 15, 2020 Sn 5, 2020 FOR REGIONAL USE ONLY

19. EFFECTIVE DATE OF APPROVED MATERIAL: 20. SIGNATURE OF REGIONAL OFFICIAL:

March 1, 2020 21. TYPED NAME: 22. TITLE:

Anne Marie Costello Deputy Director, CMCS PLAN APPROVED - ONE COPY ATTACHED

pen & ink change on page | only to reflect superseded SPA 20-0006

23. REMARKS

FORM HCFA-179 (07-92)

State/Territory: UTAH 0009 Approval Date T.N. # 20- Supersedes T.N. #  Effective Date 3-1-20 Section 7 – General Provisions 7.5. Medicaid Disaster Relief for the COVID-19 National Emergency On March 13, 2020, the President of the United States issued a proclamation that the COVID-19 outbreak in the United States constitutes a national emergency by the authorities vested in him by the Constitution and the laws of the United States, including sections 201 and 301 of the National Emergencies Act (50 U.S.C. 1601 et seq.), and consistent with section 1135 of the Social Security Act (Act). On March 13, 2020, pursuant to section 1135(b) of the Act, the Secretary of the United States Department of Health and Human Services invoked his authority to waive or modify certain requirements of titles XVIII, XIX, and XXI of the Act as a result of the consequences COVID-19 pandemic, to the extent necessary, as determined by the Centers for Medicare & Medicaid Services (CMS), to ensure that sufficient health care items and services are available to meet the needs of individuals enrolled in the respective programs and to ensure that health care providers that furnish such items and services in good faith, but are unable to comply with one or more of such requirements as a result of the COVID-19 pandemic, may be reimbursed for such items and services and exempted from sanctions for such noncompliance, absent any determination of fraud or abuse. This authority took effect as of 6PM Eastern Standard Time on March 15, 2020, with a retroactive effective date of March 1, 2020. The emergency period will terminate, and waivers will no longer be available, upon termination of the public health emergency, including any extensions. The State Medicaid agency (agency) seeks to implement the policies and procedures described below, which are different than the policies and procedures otherwise applied under the Medicaid state plan, during the period of the Presidential and Secretarial emergency declarations related to the COVID-19 outbreak (or any renewals thereof), or for any shorter period described below: N/A NOTE: States may not elect a period longer than the Presidential or Secretarial emergency declaration (or any renewal thereof). States may not propose changes on this template that restrict or limit payment, services, or eligibility, or otherwise burden beneficiaries and providers. Request for Waivers under Section 1135 1. ܈ The agency seeks the following under section 1135(b)(1)(C) and/or section 1135(b)(5) of the Act: a. ܈ SPA submission requirements – the agency requests modification of the requirement to submit this SPA by March 31, 2020, to obtain a SPA effective date during the first calendar quarter of 2020, pursuant to 42 CFR 430.20. b. ܈ Public notice requirements – the agency requests waiver of public notice requirements that would otherwise be applicable to this SPA submission. These requirements may include those specified in 42 CFR 440.386 (Alternative Benefit Plans), 42 CFR 447.57(c) (premiums and cost sharing), and 42 CFR 447.205 (public notice of changes in statewide methods and standards for setting payment rates). c. ܈ Tribal consultation requirements – the agency requests modification of tribal consultation timelines specified in Utah Medicaid state plan, as described below: 6-5-20

State/Territory: UTAH

| The Department presented this SPA to the Utah Indian Health Advisory Board on May 8, 2020.

Section A — Eligibility

1. The agency furnishes medical assistance to the following optional groups of individuals described in section 1902(a)(10)(A)(ii) or 1902(a)(10)(c) of the Act. This may include the new optional group described at section 1902(a)(10)(A)(ii)(XXIII) and 1902(ss) of the Act providing coverage for uninsured individuals.

Include name of the optional eligibility group and applicable income and resource standard.

2. The agency furnishes medical assistance to the following populations of individuals described in section 1902(a)(10)(A)(ii)(XX) of the Act and 42 CFR 435.218:

a. All individuals who are described in section 1905(a)(10)(A)(ii)(XX) Income standard: -or-

b. Individuals described in the following categorical populations in section 1905(a) of the Act:

Income standard:

3. The agency applies less restrictive financial methodologies to individuals excepted from financial methodologies based on modified adjusted gross income (MAGI) as follows.

Less restrictive income methodologies:

Less restrictive resource methodologies:

4. The agency considers individuals who are evacuated from the state, who leave the state for medical reasons related to the disaster or public health emergency, or who are otherwise absent from

T.N. # 20-0009 Approval Date__6-5-20 Supersedes T.N. # New Effective Date. 3-1-20

This SPA page is in addition to Disaster Relief SPA 20-0006 approved on May 18, 2020.

State/Territory: UTAH

the state due to the disaster or public health emergency and who intend to return to the state, to continue to be residents of the state under 42 CFR 435.403(j)(3).

The agency provides Medicaid coverage to the following individuals living in the state, who are non-residents:

The agency provides for an extension of the reasonable opportunity period for non-citizens declaring to be in a satisfactory immigration status, if the non-citizen is making a good faith effort to resolve any inconsistencies or obtain any necessary documentation, or the agency is unable to complete the verification process within the 90-day reasonable opportunity period due to the disaster or public health emergency.

Section B — Enrollment

1. The agency elects to allow hospitals to make presumptive eligibility determinations for the following additional state plan populations, or for populations in an approved section 1115 demonstration, in accordance with section 1902(a)(47)(B) of the Act and 42 CFR 435.1110, provided that the agency has determined that the hospital is capable of making such determinations.

Please describe the applicable eligibility groups/populations and any changes to reasonable limitations, performance standards or other factors.

2. The agency designates itself as a qualified entity for purposes of making presumptive eligibility determinations described below in accordance with sections 1920, 1920A, 1920B, and 1920C of the Act and 42 CFR Part 435 Subpart L.

Please describe any limitations related to the populations included or the number of allowable PE periods.

3. The agency designates the following entities as qualified entities for purposes of making presumptive eligibility determinations or adds additional populations as described below in accordance with sections 1920, 1920A, 1920B, and 1920C of the Act and 42 CFR Part 435 Subpart L. Indicate if any designated entities are permitted to make presumptive eligibility determinations only for specified populations.

Please describe the designated entities or additional populations and any limitations related to the specified populations or number of allowable PE periods.

4. The agency adopts a total of months (not to exceed 12 months) continuous eligibility for children under age enter age (not to exceed age 19) regardless of changes in circumstances in accordance with section 1902(e)(12) of the Act and 42 CFR 435.926.

T.N. # 20-0009 Approval Date__6-5-20_ Supersedes T.N. # New Effective Date. 3-1-20

This SPA page is in addition to Disaster Relief SPA 20-0006 approved on May 18, 2020.

State/Territory: UTAH 0009 Approval Date Effective Date 3-1-20 5. _____ The agency conducts redeterminations of eligibility for individuals excepted from MAGI-based financial methodologies under 42 CFR 435.603(j) once every _____ months (not to exceed 12 months) in accordance with 42 CFR 435.916(b). 6. _____ The agency uses the following simplified application(s) to support enrollment in affected areas or for affected individuals (a copy of the simplified application(s) has been submitted to CMS). a. _____ The agency uses a simplified paper application. b. _____ The agency uses a simplified online application. c. _____ The simplified paper or online application is made available for use in call-centers or other telephone applications in affected areas. Section C – Premiums and Cost Sharing 1. _____ The agency suspends deductibles, copayments, coinsurance, and other cost sharing charges as follows: Please describe whether the state suspends all cost sharing or suspends only specified deductibles, copayments, coinsurance, or other cost sharing charges for specified items and services or for specified eligibility groups consistent with 42 CFR 447.52(d) or for specified income levels consistent with 42 CFR 447.52(g). 2. _____ The agency suspends enrollment fees, premiums and similar charges for: a. _____ All beneficiaries b. _____ The following eligibility groups or categorical populations: Please list the applicable eligibility groups or populations. 3. _____ The agency allows waiver of payment of the enrollment fee, premiums and similar charges for undue hardship. Please specify the standard(s) and/or criteria that the state will use to determine undue hardship. Section D – Benefits Benefits: 1. _____ The agency adds the following optional benefits in its state plan (include service descriptions, provider qualifications, and limitations on amount, duration or scope of the benefit): 6-5-20 T.N. # 20- Supersedes T.N. # New This SPA page is in addition to Disaster Relief SPA 20-0006 approved on May 18, 2020.

State/Territory: UTAH

2.

& The agency makes the following adjustments to benefits currently covered in the state plan:

Effective retroactive to March 1, 2020, for the purposes of testing to diagnose or detect SARS-CoV-2, antibodies to SARS-CoV-2, or COVID-19, tests conducted in non-office settings such as parking lots are covered, exempting requirements in 42 CFR 440.30(b).

Coverage also includes laboratory processing of self-collected test systems that the FDA has authorized for home use, if available to diagnose or detect SARS-CoV-2, antibodies to SARS-CoV-2, or COVID-19, even if those self-collected tests would not otherwise meet the requirements in § 440.30(a) or (b), as long as the self-collection of the test is intended to avoid transmission of COVID-19.

The State will increase bed hold/therapeutic absence days for nursing facilities and ICF/IIDs to 60 days per calendar quarter. This allowance would be through the public health emergency period.

& The agency assures that newly added benefits or adjustments to benefits comply with all applicable statutory requirements, including the statewide requirements found at 1902(a)(1), comparability requirements found at 1902(a)(10)(B), and free choice of provider requirements found at 1902(a)(23).

Application to Alternative Benefit Plans (ABP). The state adheres to all ABP provisions in 42 CFR Part 440, Subpart C. This section only applies to states that have an approved ABP(s).

a. The agency assures that these newly added and/or adjusted benefits will be made available to individuals receiving services under ABPs.

b. Individuals receiving services under ABPs will not receive these newly added and/or adjusted benefits, or will only receive the following subset:

Telehealth:

5.

The agency utilizes telehealth in the following manner, which may be different than outlined in the state’s approved state plan:

Please describe.

Drug Benefit:

6.

The agency makes the following adjustments to the day supply or quantity limit for covered outpatient drugs. The agency should only make this modification if its current state plan pages have limits on the amount of medication dispensed.

Please describe the change in days or quantities that are allowed for the emergency period and for which drugs.

Prior authorization for medications is expanded by automatic renewal without clinical review, or time/quantity extensions.

T.N. #.

20-0009 Approval Date_6-5-20

Supersedes T.N. # New Effective Date. 3-1-20

This SPA page is in addition to Disaster Relief SPA 20-0006 approved on May 18, 2020.

State/Territory: UTAH

8. The agency makes the following payment adjustment to the professional dispensing fee when additional costs are incurred by the providers for delivery. States will need to supply documentation to justify the additional fees.

| Please describe the manner in which professional dispensing fees are adjusted.

9. The agency makes exceptions to their published Preferred Drug List if drug shortages occur. This would include options for covering a brand name drug product that is a multi-source drug if a generic drug option is not available.

Section E— Payments

Optional benefits described in Section D:

1. Newly added benefits described in Section D are paid using the following methodology:

a. Published fee schedules — Effective date (enter date of change):

Location (list published location):

b. Other:

Describe methodology here.

Increases to state plan payment methodologies:

2. The agency increases payment rates for the following services:

[ Please list all that apply. |

a. Payment increases are targeted based on the following criteria:

| Please describe criteria. |

b. Payments are increased through:

i. A supplemental payment or add-on within applicable upper payment limits:

Please describe.

ii. An increase to rates as described below.

Rates are increased:

T.N. # 20-0009 Approval Date__6-5-20 Supersedes T.N. # New Effective Date. 3-1-20

This SPA page is in addition to Disaster Relief SPA 20-0006 approved on May 18, 2020.

State/Territory: UTAH

____ Uniformly by the following percentage:

____ Through a modification to published fee schedules — Effective date (enter date of change): Location (list published location):

____ Up to the Medicare payments for equivalent services.

By the following factors:

Please describe.

Section F — Post-Eligibility Treatment of Income

1. The state elects to modify the basic personal needs allowance for institutionalized individuals. The basic personal needs allowance is equal to one of the following amounts:

a. ______The individual’s total income b. _ 300 percent of the SSI federal benefit rate c. __ Other reasonable amount: 2. ______ The state elects a new variance to the basic personal needs allowance. (Note: Election of this

option is not dependent on a state electing the option described the option in F.1. above.)

The state protects amounts exceeding the basic personal needs allowance for individuals who have the following greater personal needs:

Please describe the group or groups of individuals with greater needs and the amount(s) protected for each group or groups.

Section G — Other Policies and Procedures Differing from Approved Medicaid State Plan /Additional Information

T.N. # 20-0009 Approval Date__6-5-20

Supersedes T.N. # New Effective Date. 3-1-20

This SPA page is in addition to Disaster Relief SPA 20-0006 approved on May 18, 2020.

TABLE OF CONTENTS STATE/TERRIORITY NAME: 8WDK STATE PLAN AMENDMENT (SPA)#: 21-00 This file contains the following documents in the order listed:  Approval Letter  CMS 179 Form  Approved SPA Page

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 601 E. 12th St., Room 355 € RAS

Kansas City, Missouri 64106 CENTERS FOR MEDICARE & MEDICAID SERVICES (CENTER FOR MEDICAID & CHIP SERVICES

Medicaid and CHIP Operations Group

January 14, 2021

Tonya Hales

Interim State Medicaid Director Division of Health Care Financing Utah Department of Health

PO Box 144102

Salt Lake City UT 84114-4102

RE: TN 21-0016 Dear Ms. Hales:

The Centers for Medicare & Medicaid Services (CMS) has completed its review of Utah’s State Plan Amendment (SPA) Transmittal #21-0016, submitted on December 20, 2021. The SPA provides assurances that the State is in compliance with federal regulations regarding third party liability.

CMS approved SPA #21-0016 on January 14, 2022, with an effective date of October 1, 2021. Enclosed is a copy of the CMS-179 summary form, as well as the approved pages for incorporation into the Utah State Plan.

If you have any questions regarding this amendment, please contact Mandy Strom at mandy.strom@cms.hhs.gov or (303)844-7068.

Sincerely,

James G. Scott, Director Division of Program Operations

Enclosures

ce: John Curless, Utah Medicaid Craig Devashrayee, Utah Medicaid

DEPARTMENT OF HEALTH ANDHUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES

FORM APPROVED OMB No. 0938-0193

TRANSMITTAL AND NOTICE OF APPROVAL OF

STATE PLAN MATERIAL

FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES

1. TRANSMITTAL NUMBER 2. STATE 2.1 —0 0 1 6 UTAH

3. PROGRAM IDENTIFICATION: TITLE OF THE SOCIAL SECURITY ACT @) xx © xi

TO: CENTER DIRECTOR CENTERS FOR MEDICAID & CHIP SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES

4. PROPOSED EFFECTIVE DATE October 1, 2021

5. FEDERAL STATUTE/REGULATION CITATION 42 CFR 433.139

6. FEDERAL BUDGET IMPACT (Amounts in WHOLE dollars) a FFY__2022 $_0 b. FFY__2023 $_0

7. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT Page 1 of ATTACHMENT 4.22-B

8. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (/f Applicable) Page 1 of ATTACHMENT 4.22-B

9. SUBJECT OF AMENDMENT

Third Party Liability

10. GOVERNOR'S REVIEW (Check One)

© GOVERNOR'S OFFICE REPORTED NO COMMENT COMMENTS OF GOVERNOR'S OFFICE ENCLOSED O NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL

© oTHER, AS SPECIFIED:

11. SIGNATURE OF STATE AGENCY OFFICIAL

15. RETURN TO

Craig Devashrayee, Manager

12. TYPED NAME Technical Writing Unit Nate Checketts Utah Department of Health 43. TITLE cedevashrayee@utah.gov

Executive Director 14. DATE SUBMITTED December 20, 2021 FOR CMS USE ONLY

16. DATE RECEIVED December 20, 2021

17. DATE APPROVED January 14, 2022

PLAN APPROVED - ONE COPY ATTACHED

18. EFFECTIVE DATE OF APPROVED MATERIAL October 1, 2021

19. SIGNATIIRE AF APPROVING OFFICIAL

20. TYPED NAME OF APPROVING OFFICIAL James G. Scott

21. TITLE OF APPROVING OFFICIAL

Director, Division of Program Operations

22. REMARKS

FORM CMS-179 (09/24)

Instructions on Back

Revision: HCFA-PM-87-9 (BERC) ATTACHMENT 4.22-B November 1993 Page 1 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: UTAH 1. For coordination of benefits, providers are required to bill the liable third parties prior to filing with Utah Medicaid. This includes, but is not limited to, prenatal services, including labor, delivery, and postpartum care services. Understanding the flexibility afforded in the provisions of 1902(a)(25)(E) and (F) of the Social Security Act which would allow the state to cost avoid for up to 90 days for preventive pediatric services, including EPSDT and up to 100 days for claims related to State IV-D, Utah Medicaid is not implementing such options. Rather, to improve access to care, Utah Medicaid will not cost avoid claims for preventive pediatric services, including EPSDT services for members under the age of 21 including individuals on whose behalf child support enforcement is being carried out by the State IV-D agency. 2. Thresholds for Health Insurance Claims $100.00 for single claims (health insurance only) $300.00 for accumulative claims 3. Thresholds for Tort Accident Claims $500.00 for single claims $500.00 for accumulative claims T.N. # 21-0016 Approval Date Supersedes T.N. # 93-38 Effective Date 10-1-21 

Table of Contents State/Territory Name: Utah State Plan Amendment (SPA) #: 23-0007 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS Form 179 3) Approved SPA Pages

Records / Submission Packages - View All UT - Submission Package - UT2023MS0001O - (UT-23-0007) - Eligibility Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter Transaction Logs News Related Actions DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Medicaid and CHIP Operations Group 601 E. 12th St., Room 355 Kansas City, MO 64106 Center for Medicaid & CHIP Services May 19, 2023 Jennifer Strohecker Division of Integrated Healthcare Director Utah Department of Health & Human Services P.O. Box 144102 Salt Lake City, UT 84114 Re: Approval of State Plan Amendment UT-23-0007 Dear Jennifer Strohecker, On February 21, 2023, the Centers for Medicare & Medicaid Services (CMS) received Utah State Plan Amendment (SPA) UT-23-0007, in which the state proposed to adopt the changes to the eligibility rules for the Former Foster Care Children eligibility group, as enacted by the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities (SUPPORT) Act, Pub. L. No. 115-217, section 1002. We approve Utah State Plan Amendment (SPA) UT-23-0007 with an effective date(s) of January 01, 2023. If you have any questions regarding this amendment, please contact Mandy Strom at mandy.strom@cms.hhs.gov Sincerely, James G. Scott Division of Program Operations Director Center for Medicaid & CHIP Services CMS Cf US JOR MEDICARE &MEDICAJO SIIMCES

Records / Submission Packages - View All UT - Submission Package - UT2023MS0001O - (UT-23-0007) - Eligibility Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter Transaction Logs News Related Actions Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | UT2023MS0001O | UT-23-0007 CMS-10434 OMB 0938-1188 Package Header Package ID UT2023MS0001O Submission Type Official Approval Date 5/19/2023 Superseded SPA ID N/A SPA ID UT-23-0007 Initial Submission Date 2/21/2023 Effective Date N/A State Information State/Territory Name: Utah Medicaid Agency Name: Utah Department of Health and Human Services Submission Component State Plan Amendment Medicaid CHIP 0 0 0

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | UT2023MS0001O | UT-23-0007 Package Header Package ID UT2023MS0001O Submission Type Official Approval Date 5/19/2023 Superseded SPA ID N/A SPA ID UT-23-0007 Initial Submission Date 2/21/2023 Effective Date N/A SPA ID and Effective Date SPA ID UT-23-0007 Reviewable Unit Proposed Effective Date Superseded SPA ID Mandatory Eligibility Groups 1/1/2023 UT-19-0011 Former Foster Care Children 1/1/2023 UT-19-0011

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | UT2023MS0001O | UT-23-0007 Package Header Package ID UT2023MS0001O Submission Type Official Approval Date 5/19/2023 Superseded SPA ID N/A SPA ID UT-23-0007 Initial Submission Date 2/21/2023 Effective Date N/A Executive Summary Summary Description Including Goals and Objectives CMS is requiring this SPA Submission. The modifications are in alignment with changes enacted in the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities (SUPPORT) Act that expand eligibility for the Former Foster Care Children eligibility group. Federal Budget Impact and Statute/Regulation Citation Federal Budget Impact Federal Fiscal Year Amount First 2023 $0 Second 2024 $0 Federal Statute / Regulation Citation Section 1902(a)(10)(A)(i)(IX) of the Social Security Act 42 CFR 435.150. Supporting documentation of budget impact is uploaded (optional). Name Date Created No items available

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | UT2023MS0001O | UT-23-0007 Package Header Package ID UT2023MS0001O Submission Type Official Approval Date 5/19/2023 Superseded SPA ID N/A SPA ID UT-23-0007 Initial Submission Date 2/21/2023 Effective Date N/A Governor's Office Review PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state’s program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. This view was generated on 5/22/2023 9:31 AM EDT No comment Comments received No response within 45 days Other 0 0 0 0

Records / Submission Packages - View All UT - Submission Package - UT2023MS0001O - (UT-23-0007) - Eligibility Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter Transaction Logs News Related Actions Medicaid State Plan Eligibility Mandatory Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | UT2023MS0001O | UT-23-0007 CMS-10434 OMB 0938-1188 Package Header Package ID UT2023MS0001O Submission Type Official Approval Date 5/19/2023 Superseded SPA ID UT-19-0011 User-Entered SPA ID UT-23-0007 Initial Submission Date 2/21/2023 Effective Date 1/1/2023 Mandatory Coverage A. The state provides Medicaid to mandatory groups of individuals. The mandatory groups covered are: Families and Adults Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Infants and Children under Age 19 CONVERTED Parents and Other Caretaker Relatives APPROVED Pregnant Women CONVERTED Deemed Newborns NEW Children with Title IV-E Adoption Assistance, Foster Care or Guardianship Care NEW Former Foster Care Children APPROVED Transitional Medical Assistance NEW Extended Medicaid due to Spousal Support Collections NEW Aged, Blind and Disabled Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  SSI Beneficiaries NEW Closed Eligibility Groups NEW Individuals Deemed To Be Receiving SSI NEW

[!] [!] [!] [!] [!] [!] [!] [!] S1I &i!I Iii &i!I ■ &i!I &i!I &i!I □ □ □ □ □ ■ □ □ □ □ □ 0 0 • 0 0 0 0 0 0 0 0 -

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

■ 621 ii ii ii ■ □ □ □ □ 0 0 0 0 0

Mandatory Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | UT2023MS0001O | UT-23-0007 Package Header Package ID UT2023MS0001O Submission Type Official Approval Date 5/19/2023 Superseded SPA ID UT-19-0011 User-Entered SPA ID UT-23-0007 Initial Submission Date 2/21/2023 Effective Date 1/1/2023 B. The state elects the Adult Group, described at 42 CFR 435.119. C. Additional Information (optional) Eligibility Groups Deselected from Coverage The following eligibility groups were previously covered in the source approved version of the state plan and deselected from coverage as part of this submission package: N/A PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state’s program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. This view was generated on 5/22/2023 9:33 AM EDT Yes No 0 0

Records / Submission Packages - View All UT - Submission Package - UT2023MS0001O - (UT-23-0007) - Eligibility Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter Transaction Logs News Related Actions Medicaid State Plan Eligibility Eligibility Groups - Mandatory Coverage Former Foster Care Children MEDICAID | Medicaid State Plan | Eligibility | UT2023MS0001O | UT-23-0007 Individuals under the age of 26, who were in foster care and on Medicaid when they turned age 18 or aged out of foster care. CMS-10434 OMB 0938-1188 Package Header Package ID UT2023MS0001O Submission Type Official Approval Date 5/19/2023 Superseded SPA ID UT-19-0011 User-Entered SPA ID UT-23-0007 Initial Submission Date 2/21/2023 Effective Date 1/1/2023 The state covers the mandatory former foster care children group in accordance with the following provisions: A. Characteristics Individuals qualifying under this eligibility group must meet the following criteria: 1. Are under age 26 2. Were in foster care upon attaining age 18 or a higher age at which the state's or Tribe's foster care assistance ends under title IV-E of the Act (up to age 21). 3. Are described under either Section B. or C. B. Individuals Covered For individuals who turn 18 before January 1, 2023: 1. The state covers individuals who: a. Upon attaining age 18 or a higher age at which the state's or Tribe's foster care assistance ends under title IV-E of the Act (up to age 21) were: i. In foster care under the responsibility of the state or a Tribe within the state (including children who were cared for through a grant to the state under the unaccompanied refugee minor program); and ii. Enrolled in Medicaid under the state's Medicaid state plan or 1115 demonstration; and b. Are not otherwise eligible for and enrolled for mandatory coverage under the state plan, except that eligibility under this group takes precedence over eligibility under the Adult Group. 2. In addition to B.1., the state elects to cover individuals who were in foster care under the responsibility of the state or a Tribe within the state (including children who were cared for through a grant to the state under the unaccompanied refugee minor program) when they turned 18 or a higher age at which the state's or Tribe's foster care assistance ends under title IV-E of the Act, and meet the following criteria: C. Individuals Covered For individuals who turn 18 on or after January 1, 2023: 1. The state covers individuals who: a. Upon attaining age 18 or a higher age at which the state's or Tribe's foster care assistance ends under title IV-E of the Act (up to age 21) were: i. In foster care under the responsibility of any state or a Tribe within any state (including children who were cared for through a grant to the state under the unaccompanied refugee minor program); and ii. Enrolled in Medicaid under a state's Medicaid state plan or 1115 demonstration; and b. Are not enrolled in mandatory coverage under the state plan, except that eligibility under this group takes precedence over eligibility under the Adult Group. a. They were enrolled in Medicaid under the state's Medicaid state plan or 1115 demonstration at any time during the foster care period in which they turned 18 or a higher age at which the state's or Tribe's foster care assistance ends. b. They were placed by the state or Tribe in another state and were enrolled in Medicaid under the other state’s Medicaid state plan or 1115 demonstration project when they turned 18 or a higher age at which the state's or Tribe's foster care assistance ends. c. They were placed by the state or Tribe in another state and were enrolled in Medicaid under the other state’s Medicaid state plan or 1115 demonstration project at any time during the foster care period in which they turned 18 or a higher age at which the state's or Tribe's foster care assistance ends. Iii □ ~

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

Former Foster Care Children MEDICAID | Medicaid State Plan | Eligibility | UT2023MS0001O | UT-23-0007 Package Header Package ID UT2023MS0001O Submission Type Official Approval Date 5/19/2023 Superseded SPA ID UT-19-0011 User-Entered SPA ID UT-23-0007 Initial Submission Date 2/21/2023 Effective Date 1/1/2023 D. Additional Information (optional) PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state’s program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. This view was generated on 5/22/2023 9:35 AM EDT

 



  



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DEPARTMENT OF HEAL TH & HUMAN SERVICES Centers for Medicare & Medicaid Services 601 E. 12th St., Room 355 Kansas City, Missouri 64106 Medicaid and CHJP Operations Group October 31, 2023 Jennifer Strohecker Director Division of Integrated Healthcare Utah Department of Health and Human Services PO Box 143101 Salt Lake City, UT 94114-3101 Re: Utah State Plan Amendment (SPA) 23-0012 Dear Director Strohecker: CLNllRS fOll MWICJ\Rl & MCUKAID SUMCIS CENTER fOR MEDICAJD & CKrP SERVICB The Centers for Medicare & Medicaid Services (CMS) reviewed your Medicaid State Plan Amendment (SPA) submitted under transmittal number (TN) 23-0012. This amendment proposes the tracking of cost sharing using the state's Provider Reimbursement Information System (PRISM). We conducted our review of your submittal according to statutory requirements in Title XIX of the Social Security Act and implementing regulations Sections 1916 and 1916A of the Social Security Act and 42 CFR §§447.50 through 447.57. This letter is to inform you that Utah Medicaid SPA 23-0012 was approved on October 31, 2023, with an effective date of July 1, 2023. If you have any questions, please contact Tyler Deines at 202-571-8533 or via email at Tyler.Deines@cms.hhs.gov . Enclosures cc: Craig Devashrayee, Utah Medicaid James G. Scott, Director Division of Program Operations

Medicaid Premiums and Cost Sharing: Summary Page (CMS 179) State/Territory name: Utah Transmittal Number: Enter the Transmittal Number (TN), including dashes, in the format SS-YY-NNNN or SS-YY-NNNN-xxxx (with x=x being optional to specific SPA types), where SS = 2-character state abbreviation, YY = last 2 digits of submission year, NNNN = 4-digit number with leading zeros, and x=x = OPTIONAL, 1- to 4-character alpha/numeric suffix. UT-23-0012 Proposed Effective Date 07/01/2023 (mm/dd/yyyy) Federal Statute/Regulation Citation Sections 1916 and 1916Aofthe Social Security Act and 42 CFR 447.50 through 447.57 Federal Budget Impact First Year 2023 Second Year 2024 Subject of Amendment Medicaid Cost Sharing Governor's Office Review Federal Fiscal Year Governor's office reported no comment Comments of Governor's office received Describe: No reply received within 45 days of submittal Other, as specified Describe: $ 0.00 $ 0.00 Signature of State Agency Official Submitted By: Last Revision Date: Craig Devashrayee Oct 26, 2023 Submit Date: Aug 4, 2023 Amount





    


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Table of Contents State/Territory Name: Utah State Plan Amendment (SPA) #: 23-0017 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS Form 179 3) Approved SPA Pages

Records / Submission Packages - View All UT - Submission Package - UT2023MS0003O - (UT-23-0017) - Eligibility Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter Transaction Logs News Related Actions DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Medicaid and CHIP Operations Group 601 E. 12th St., Room 355 Kansas City, MO 64106 Center for Medicaid & CHIP Services March 08, 2024 Jennifer Strohecker Division of Integrated Healthcare Director Utah Department of Health and Human Services P.O. Box 144102 Salt Lake City, UT 84114 Re: Approval of State Plan Amendment UT-23-0017 Dear Director Strohecker, On December 15, 2023, the Centers for Medicare and Medicaid Services (CMS) received Utah State Plan Amendment (SPA) UT-23-0017, in which the state proposed to elect the option described in section 1902(e)(16) of the Social Security Act to provide 12 months of postpartum coverage to Medicaid-eligible pregnant individuals. We approve Utah State Plan Amendment (SPA) UT-23-0017 with an effective date(s) of January 01, 2024. If you have any questions regarding this amendment, please contact Tyler Deines at tyler.deines@cms.hhs.gov Sincerely, James G. Scott Division of Program Operations Director Center for Medicaid & CHIP Services - MS amus fOR MEDIC....RE & MEDICAID SIJIVICIS

Records / Submission Packages - View All UT - Submission Package - UT2023MS0003O - (UT-23-0017) - Eligibility Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter Transaction Logs News Related Actions Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | UT2023MS0003O | UT-23-0017 CMS-10434 OMB 0938-1188 Package Header Package ID UT2023MS0003O Submission Type Official Approval Date 03/08/2024 Superseded SPA ID N/A SPA ID UT-23-0017 Initial Submission Date 12/15/2023 Effective Date N/A State Information State/Territory Name: Utah Medicaid Agency Name: Utah Department of Health and Human Services Submission Component State Plan Amendment Medicaid CHIP 0 0 0 -

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | UT2023MS0003O | UT-23-0017 Package Header Package ID UT2023MS0003O Submission Type Official Approval Date 03/08/2024 Superseded SPA ID N/A SPA ID UT-23-0017 Initial Submission Date 12/15/2023 Effective Date N/A SPA ID and Effective Date SPA ID UT-23-0017 Reviewable Unit Proposed Effective Date Superseded SPA ID Continuous Eligibility for Pregnant Women and Extended Postpartum Coverage 1/1/2024 New Continuous Eligibility for Children 1/1/2024 New Page Number of the Superseded Plan Section or Attachment (If Applicable):

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | UT2023MS0003O | UT-23-0017 Package Header Package ID UT2023MS0003O Submission Type Official Approval Date 03/08/2024 Superseded SPA ID N/A SPA ID UT-23-0017 Initial Submission Date 12/15/2023 Effective Date N/A Executive Summary Summary Description Including Goals and Objectives The purpose of this amendment is to provide extended postpartum coverage to pregnant women and continuous eligibility for children under the age of 19. Federal Budget Impact and Statute/Regulation Citation Federal Budget Impact Federal Fiscal Year Amount First 2024 $5212500 Second 2025 $6950000 Federal Statute / Regulation Citation Section 1902(a)(10) of the Social Security Act Supporting documentation of budget impact is uploaded (optional). Name Date Created No items available

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | UT2023MS0003O | UT-23-0017 Package Header Package ID UT2023MS0003O Submission Type Official Approval Date 03/08/2024 Superseded SPA ID N/A SPA ID UT-23-0017 Initial Submission Date 12/15/2023 Effective Date N/A Governor's Office Review PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state’s program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. This view was generated on 3/8/2024 9:40 AM EST No comment Comments received No response within 45 days Other 0 • • •

Records / Submission Packages - View All UT - Submission Package - UT2023MS0003O - (UT-23-0017) - Eligibility Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter Transaction Logs News Related Actions Medicaid State Plan Eligibility Eligibility and Enrollment Processes Continuous Eligibility for Pregnant Women and Extended Postpartum Coverage MEDICAID | Medicaid State Plan | Eligibility | UT2023MS0003O | UT-23-0017 CMS-10434 OMB 0938-1188 Package Header Package ID UT2023MS0003O Submission Type Official Approval Date 03/08/2024 Superseded SPA ID New User-Entered SPA ID UT-23-0017 Initial Submission Date 12/15/2023 Effective Date 1/1/2024 The state provides continuous eligibility for pregnant individuals and extended postpartum coverage in accordance with the following provisions: A. Mandatory Continuous Eligibility for Pregnant Women The state provides continuous eligibility to pregnant individuals who were eligible and enrolled under the state plan, without regard to any changes in income that otherwise would result in ineligibility, through the last day of the month in which a 60-day postpartum period (beginning on the last day of the pregnancy) ends. This extension does not apply to pregnant individuals eligible only during a period of presumptive eligibility. B. Optional 12-Month Postpartum Continuous Eligibility for Pregnant Women The state provides continuous eligibility to pregnant individuals who were eligible and enrolled under the state plan while pregnant (including during a period of retroactive eligibility) through the last day of the month in which a 12-month postpartum period (beginning on the last day of the pregnancy) ends. The 12-month postpartum continuous eligibility option applies for the period beginning on the effective date of this reviewable unit and is available through March 31, 2027 (or other date as specified by law). 1. This extension does not apply to pregnant individuals eligible only during a period of presumptive eligibility. 2. Full benefits are provided for a pregnant or postpartum individual under this option. This includes all items and services covered under the state plan (or waiver) that are not less in amount, duration, or scope than, or are determined by the Secretary to be substantially equivalent to, the medical assistance available for an individual described in subsection 1902 (a)(10)(A)(i) of the Act. 3. Continuous eligibility is provided to pregnant individuals eligible and enrolled under the state plan through the end of the 12-month postpartum period who would otherwise lose eligibility because of a change in circumstances, unless: a. The individual requests voluntary termination of eligibility; b. The individual ceases to be a resident of the state; c. The Medicaid agency determines that eligibility was determined incorrectly at the most recent determination or redetermination of eligibility because of agency error or fraud, abuse or perjury attributed to the individual; or d. The individual dies. C. Additional Information (optional) Section 5113 of the Consolidated Appropriations Act, 2023 eliminated, without replacement, the March 31, 2027, sunset date of the 12-month postpartum continuous eligibility option. Therefore, the durational limit of the option that is described in Section B. does not apply. PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state’s program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. This view was generated on 3/8/2024 9:41 AM EST Yes No 0 0 -

Records / Submission Packages - View All UT - Submission Package - UT2023MS0003O - (UT-23-0017) - Eligibility Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter Transaction Logs News Related Actions Medicaid State Plan Eligibility Eligibility and Enrollment Processes Continuous Eligibility for Children MEDICAID | Medicaid State Plan | Eligibility | UT2023MS0003O | UT-23-0017 CMS-10434 OMB 0938-1188 Package Header Package ID UT2023MS0003O Submission Type Official Approval Date 03/08/2024 Superseded SPA ID New User-Entered SPA ID UT-23-0017 Initial Submission Date 12/15/2023 Effective Date 1/1/2024 The state provides continuous eligibility for children in accordance with the following provisions: A. Mandatory Continuous Eligibility for Hospitalized Children The state provides Medicaid to a child eligible for and enrolled under the Infants and Children under Age 19 (42 CFR 435.118) eligibility group until the end of an inpatient stay for which inpatient services are covered, if the child: 1. Was receiving inpatient services covered by Medicaid on the date the child becomes ineligible under the eligibility group based on the child's age; and 2. Would remain eligible but for attaining such age. B. Options for Continuous Eligibility for Children The state provides continuous eligibility to children. 1. Continuous eligibility is provided to all children of the following age: 2. The continuous eligibility period begins on the effective date of the child's most recent determination or redetermination of eligibility, and ends the last day of the earlier of the following periods: a. The month that the child's age exceeds the age limit to which this provision applies b. The end of the continuous eligibility period, which is: 3. Continuous eligibility is provided to children eligible under all mandatory and optional eligibility groups (excluding Medically Needy) who would otherwise lose eligibility because of any change in circumstances, unless: a. The child dies; b. The child or the child's representative voluntarily requests a termination of the child's eligibility; c. The child ceases to be a resident of the state; d. The Medicaid agency determines that eligibility was determined incorrectly at the most recent determination or redetermination of eligibility because of agency error or fraud, abuse, or perjury attributed to the child or the child's representative; or e. The child attains the maximum age specified in B. C. Additional Information (optional) PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application Yes No a. Under age 19 b. Under other age i. 12 months ii. Another period of continuous eligibility, not to exceed 12 months 0 0 0 0 0 0 -

and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state’s program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. This view was generated on 3/8/2024 9:42 AM EST

Table of Contents State/Territory Name: Utah State Plan Amendment (SPA) #: 24-0007 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS Form 179 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Se1vices 601 E. 12th St., Room 355 Kansas City, Missomi 64106 Medicaid and CHIP Operations Group May 31, 2024 Jennifer Strohecker Director Division of Integrated Healthcare Utah Department of Health and Human Services PO Box 143101 Salt Lake City, UT 94114-3101 Re: Utah State Plan Amendment (SPA) 24-0007 Dear Director Strohecker: CENTERS FOR MEDICARE & MEOICAIO SERVICES CENTER FOR MEDIC41D & CHIP SERVICES The Centers for Medicare & Medicaid Services (CMS) reviewed your Medicaid State Plan Amendment (SP A) submitted under transmittal number (TN) 24-0007. This amendment proposes a tempora1y suspension of cost sharing for prescription drugs. We conducted our review of yom submittal according to statuto1y requirements in Title XIX of the Social Security Act and implementing regulations 42 CFR §447.52 through 54. This letter info1ms you that Utah Medicaid SP A TN 24-0007 was approved on May 31, 2024, with an effective date of Februaiy 21, 2024. Enclosed ai·e copies of Fo1m CMS-179 and approved SPA pages to be inc01porated into the Utah State Plan. If you have any questions, please contact Tyler Deines at 202-571-8533 or via email at Tyler.Deines@cms.hhs.gov. Enclosures cc: Craig Devashrayee, Utah Medicaid James G. Scott, Director Division of Program Operations

Medicaid Premiums and Cost Sharing: Summary Page (CMS 179) St.ate/Ienitory name: Utah Transmittal Numbe1·: Enter the Transmittal Number (TN), including dasltes, in the format SS-YY-NNNN or SS-YY-NNNN-xxxx (with xxxx being optional to specific SPA types), where SS = 2-character state abbreviation, YY= last 2 digUs of submission year, NNNN = 4-digit number with leading zeros, and xxxx = OPTIONAL, 1- to 4-character alp/ta/numeric suffix. I UT-24-0007 I Proposed Effective Date 102121/2024 I (mm/dd/yyyy) Federal Statute/Regulation Citation 11916 and 1916AofSSAand 42 CFR447.50 through 447.57 Federal Budget Impact Federal Fiscal Year First Year [2024 Second Year [2025 Subject of Amendment !Suspension of Medicaid Pharmacy Copayments Governor's Office Review Gove1·11or's office reported no comment Comments of Governor's office received Describe: No reply received within 45 days of submittal Other, as specified Describe: $J395.00 $JO.DO Signature of State Agency Official Submitted By: Last Revision Date: Craig Devashrayee Apr 9, 2024 Submit Date: Mar 20, 2024 Amount

Page 1 of 2 Medicaid Premiums and Cost Sharing State Name: Utah OMB Control Number: 09381148 Transmittal Number: UT - 24 - 0007 Cost Sharing Amounts - Categorically Needy Individuals G2a 1916 1916A 42 CFR 447.52 through 54 The state charges cost sharing to all categorically needy (Mandatory Coverage and Options for Coverage) individuals. Yes Services or Items with the Same Cost Sharing Amount for All Incomes Add Service or Item Amount Dollars or Percentage Unit Explanation Remove Add Non-Emergency Services Received in Emergency Departments. 8.00 $ Encounter $8 for each non-emergency use of the emergency department. Remove Add Inpatient Hospital Stay 75.00 $ Entire Stay Effective July 1, 2017, $75 for each inpatient hospital stay (episode of care). Remove Add Physician or Podiatrist Services 4.00 $ Encounter $4 for each outpatient services visit (physician visit, podiatry visit, physical therapy, etc.). Remove Add Outpatient Hospital Services 4.00 $ Encounter $4 for each outpatient hospital service visit, (maximum of one per person, per hospital, per date of service). Remove Add Pharmacy Services 4.00 $ Prescription $4 for each prescription. For prescriptions dispensed during the 2024 Change Healthcare Network Interruption, member pharmacy cost sharing requirements are suspended through full system restoration. The effective date for this SPA is February 21, 2024, and the sunset date is June 30, 2024. Remove Add Chiropractic Services 1.00 $ Encounter $1 for each chiropractic visit (maximum of one per date of service). Remove Add Vision Services 3.00 $ Encounter $3 for each pair of eyeglasses. Remove Services or Items with Cost Sharing Amounts that Vary by Income Service or Item: Remove Service or Item Indicate the income ranges by which the cost sharing amount for this service or item varies. Add Incomes Greater than Incomes Less than or Equal to Amount Dollars or Percentage Unit Explanation Remove Add Remove Add Service or Item Transmittal Number: UT-24-0007 Supersedes Transmittal Number: UT-23-0012 Approval Date: May 31, 2024 Effective Date: February 21, 2024 - D □ [] D I I D I I □ CJ DI I I II I I I I I I I I 11 1l1 11 I I I I

Page 2 of 2 Medicaid Premiums and Cost Sharing Cost Sharing for Non-preferred Drugs Charged to Otherwise Exempt Individuals If the state charges cost sharing for non-preferred drugs (entered above), answer the following question: The state charges cost sharing for non-preferred drugs to otherwise exempt individuals. No Cost Sharing for Non-emergency Services Provided in the Hospital Emergency Department Charged to Otherwise Exempt Individuals If the state charges cost sharing for non-emergency services provided in the hospital emergency department (entered above), answer the following question: The state charges cost sharing for non-emergency services provided in the hospital emergency department to otherwise exempt individuals. Yes The cost sharing charges for non-emergency services provided in the hospital emergency department imposed on otherwise exempt individuals are the same as the charges imposed on non-exempt individuals. Yes 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 09381148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C42605, Baltimore, Maryland 212441850. V.20181119 Transmittal Number: UT-24-0007 Supersedes Transmittal Number: UT-23-0012 Approval Date: May 31, 2024 Effective Date: February 21, 2024 □ □ □

Table of Contents State/Territory Name: Utah State Plan Amendment (SPA) #: 24-0018 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS Form 179 3) Approved SPA Page

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 601 E. 12th St., Room 355 Kansas City, Missouri 64106 Medicaid and CHIP Operations Group September 27, 2024 Jellillfer Strohecker Director Division of Integrated Healthcare Utah Department of Health and Human Services PO Box 143101 Salt Lake City, UT 84114-3101 Re: Utah State Plan Amendment (SPA) 24-0018 Deai· Director Strohecker: CENTERS FOR MEDICARE & MEDICAID SERVICES CENlER FOR MEDICA.ID & CHIP SERVICE§ The Centers for Medicai·e & Medicaid Services (CMS) reviewed your Medicaid State Plan Amendment (SPA) submitted under transmittal number (TN) 24-0018. This amendment confums third-pai1y payer responsibilities in accordance with the Consolidated Appropriations Act of 2022. We conducted our review of your submittal according to statutory requirements in Title XIX of the Social Security Act and implementing regulations 42 CFR §433.139. This letter info1ms you that Utah Medicaid SPA TN 24-0018 was approved on September 26, 2024 with an effective date of September 1, 2024. Enclosed are copies of Form CMS-179 and approved SP A pages to be inc01porated into the Utah State Plan. If you have any questions, please contact Tyler Deines at 202-571-8533 or via email at Tyler.Deines@cms.hhs.gov. Enclosures James G. Scott Director Division of Program Operations

DEPARTMENT OF HEALTH ANDHUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES TO: CENTER DIRECTOR CENTERS FOR MEDICAID & CHIP SERVICES DEPARTMENT OF HEAL TH AND HUMAN SERVICES 1. TRANSMITTAL NUMBER 2.STATE 2 4 - 0 0 1 8 UTAH -- ---- -- 3. PROGRAM IDENTIFICATION: TITLE OF THE SOCIAL SECURITY ACT @ XIX () XXI 4. PROPOSED EFFECTIVE DATE September 1 , 2024 FORM APPROVED 0MB No. 0938-0193 5. FEDERAL STATUTE/REGULATION CITATION 6. FEDERAL BUDGET IMPACT (Amounts in WHOLE dollars) a FFY 2024 $ (1.176.864) 42 CFR 433.139 42 USC 1396a(25)(I) b. FFY 2025 $ (14,122,370) 7. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT 8. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable) Page 70 of Section 4 Page 70 of Section 4(TN: 91-025) 9. SUBJECT OF AMENDMENT Third-Party Liability: Confirms third-party payer responsibilities in accordance with the Consolidated Appropriations Act of 2022. 10. GOVERNOR'S REVIEW (Check One) <!) GOVERNOR'S OFFICE REPORTED NO COMMENT 0 COMMENTS OF GOVERNOR'S OFFICE ENCLOSED 0 OTHER, AS SPECIFIED: 0 NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL TE AGENCY OFFICIAL 15. RETURN TO ----------------1Craig Devashrayee 12. TYPED NAME Technical Writing Unit _T_ra_c_y_s_._G_r_u_be_r ________________ ..... utah Department of Heath & Human Services 13. TITLE cdevashrayee@utah.gov Executive Director, Utah Dept of Health & Human Services 14. DATE SUBMITTED August 23, 2024 16. DATE RECEIVED Au ust 23. 2024 FOR CMS USE ONLY 17. DATE APPROVED PLAN APPROVED· ONE COPY ATTACHED 18. EFFECTIVE DATE OF APPROVED MATERIAL Se tember 1. 2024 Se tember 26. 2024 20. TYPED NAME OF APPROVING OFFICIAL James G. Scott 21. TITLE OF APPROVING OFFICIAL 22. REMARKS Boxes 5 ,8, and 9: State approved pen and ink changes on 09/20/2024. FORM CMS-179 (09/24) Instructions on Back

Revision: HCFA-PM-91-8 (MB) Page 70 October 1991 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM State: UTAH SECTION 4 - GENERAL PROGRAM ADMINISTRATION (Continued) Citation

4.22 Third-Party Liability (Continued) 42 CFR 433.151(a) 50 FR 46652 (f) The Medicaid agency has written cooperative agreements for the enforcement of rights to and collection of third- party benefits assigned to the State as a condition of eligibility for medical assistance with at least one of the following: (Check as appropriate.) State title IV-D agency. The requirements of 42 CFR 433.152(b) are met. X Other appropriate State agency(s)-- Office of Recovery Services, Department of Human Services Other appropriate agency(s) of another State– _ Courts and law enforcement officials. 42 CFR 433.151(b) (g) The Medicaid agency meets the Secretary’s method as provided in the State Medicaid Manual, Section 3910 for making incentive and for distributing third-party collections. 50 FR 46652 433.153 and 433.154 1906 of the Act

(h) The Medicaid agency specifies group health plan used in determining the cost effectiveness of an employer determining the cost effectiveness of an employer-based group health plan by selecting one of the following: X The State provides methods for determining cost effectiveness on Att. 4-22-C. 1902(a)(25)(I) of the Act (i) The state of Utah has created state statute that (1) bars liable third-party payers from refusing payment for a Medicaid item or service solely on the basis that such item or service did not receive prior authorization under the third-party payer’s rules and (2) specifies that a third party must respond within 60 days of receiving the inquiry regarding a Medicaid health care claim. 71  87 6XSHUVHGHV 71 

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