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

July 31, 2026

Steve Ford Medicaid Director Virginia Department of Medical Assistance Services 600 E Broad St Richmond, VA 23219

Dear Director Ford,

The Centers for Medicare & Medicaid Services (CMS) is approving the Commonwealth of Virginia’s request to renew its Medicaid section 1115(a) demonstration entitled, “Building and Transforming Coverage, Services, and Supports for a Healthier Virginia” (BTCSSHV) (Project Number 11-W-00297/3), in accordance with section 1115(a) of the Social Security Act (the Act). This approval is effective August 1, 2026 through December 31, 2031 upon which date, unless renewed or otherwise amended, all authorities granted to operate this demonstration will expire.

CMS has determined that the Building and Transforming Coverage, Services, and Supports for a Healthier Virginia (BTCSSHV) section 1115(a) demonstration is likely to assist in promoting the objectives of the Medicaid statute by increasing access to high-quality, clinically appropriate treatment to beneficiaries with a substance use disorder (SUD) and/or serious mental illness (SMI) while they are short-term residents in residential and inpatient treatment settings that qualify as an Institution for Mental Diseases (IMD). This approval is in alignment with both State Medicaid Director Letter #17-003 RE: Strategies to Address the Opioid Epidemic1 and SMDL #18-011: Opportunities to Design Innovative Service Delivery Systems for Adults with a Serious Mental Illness or Children with a Serious Emotional Disturbance2 and will continue the SUD authority from the 2019 demonstration approval.

CMS’s approval of this section 1115(a) demonstration is subject to the limitations specified in the attached expenditure authorities, special terms and conditions (STCs), and any supplemental attachments defining the nature, character, and extent of federal involvement in this project. The state may deviate from the Medicaid state plan requirements only to the extent those requirements have been specifically listed as waived or not applicable to expenditures under the demonstration.

Program Integrity

1 SMDL #17-003: https://www.medicaid.gov/federal-policy-guidance/downloads/smd17003.pdf 2SMDL #18-011: https://www.medicaid.gov/sites/default/files/federal-policy-guidance/downloads/smd18011.pdf