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Virginia FAMIS MOMS and FAMIS Select Section 1115 Demonstration Demonstration Period: October 25, 2019 through June 30, 2029; Amended November 18, 2021 Page 6 of 61 expenditures, will be available for changes to the demonstration that have not been approved through the amendment process set forth in STC 7, except as provided in STC 3.

7. Amendment Process. Requests to amend the demonstration must be submitted to CMS for approval no later than 120 days prior to the planned date of implementation of the change and may not be implemented until approved. CMS reserves the right to deny or delay approval of a demonstration amendment based on non-compliance with these STCs, including but not limited to failure by the Commonwealth to submit required elements of a viable amendment request as specified in this STC and submission of required deliverables specified in these STCs in accordance with the deadlines specified herein. Amendment requests must include, but are not limited to, the following:

a. Demonstration Amendment Summary and Objectives. The Commonwealth must provide a detailed description of the amendment, including what Virginia intends to demonstrate via this amendment as well as the impact on beneficiaries, with sufficient supporting documentation, the objective of the change and desired outcomes including a conforming title XIX and/or title XXI state plan amendment, if necessary;

b. Allotment Neutrality Worksheet (for changes impacting title XXI funding). The Commonwealth must provide an up-to-date CHIP allotment neutrality worksheet that identifies the impact of the proposed amendment on the Commonwealth’s available title XXI allotment;

c. Budget Neutrality Worksheet (for changes impacting title XIX funding). The Commonwealth must provide an up-to-date data analysis which identifies the specific “with waiver” impact of the proposed amendment on the current budget neutrality agreement. Such analysis must include current total computable “with waiver” and “without waiver” status on both a summary and detailed level through the current approval period using the most recent actual expenditures, as well as summary and detailed projections of the change in the “with waiver” expenditure total as a result of the proposed amendment, which isolates (by Eligibility Group) the impact of the amendment.

d. Waiver and Expenditure Authorities. The Commonwealth must provide a list of waivers and expenditure authorities that are being requested or terminated, along with the programmatic description of why these waivers and expenditure authorities are being requested for the amendment;

e. Evaluation. The Commonwealth must provide updates to existing demonstration reporting and quality and evaluation plans. This includes a description of how the evaluation design and annual progress reports will be modified to incorporate the amendment provisions, as well as the oversight, monitoring, and measurement of the provisions; and,