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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 26 of 61 calculating the overall budget neutrality limit for the demonstration, a separate annual budget limit will be calculated for each demonstration year on a total computable basis, by multiplying the predetermined “per member, per month” (PMPM) cost for the (title XIX) “Postpartum Extension” eligibility group by the corresponding actual member months total, and summing the results of that calculation. The federal share of this limit will represent the maximum amount of FFP that the Commonwealth may receive during the demonstration period for the types of demonstration expenditures described below. The federal share will be calculated by multiplying the total computable budget neutrality limit by the Composite Federal Share, which is defined in STC 57 below. The demonstration expenditures subject to the budget neutrality limit are those reported using the assigned waiver name - “Postpartum Extension.”

54. Reporting Member Months. The following describes the reporting of member months for the demonstration:

a. For the purpose of calculating the budget neutrality expenditure limit, the state must provide to CMS, as part of the Annual Monitoring Report required per STC 28, the actual number of eligible member months for all demonstration enrollees. The state must submit a statement accompanying the Annual Monitoring Report certifying the accuracy of this information.

b. The term “eligible member months” refers to the number of months in which persons enrolled in the demonstration are eligible to receive services. For example, a person who is eligible for three month contributes three eligible member months to the total. Two individuals who are each eligible for two months, each contribute two eligible member months, for a total of four eligible member months.

55. Budget Neutrality Annual Expenditure Limits. For each demonstration year (reflected as “DY” in the below table), an annual budget limit will be calculated for the demonstration. For the purposes of this demonstration, the state’s demonstration cycle is based on the state fiscal year which starts July 1 through June 30 of each year. Virginia will report expenditures in accordance with the annual demonstration cycles outlined as follows:

Demonstration Year 17 – July 1, 2021 – June 30, 2022

Demonstration Year 18 – July 1, 2022 – June 30, 2023

Demonstration Year 19 – July 1, 2023 – June 30, 2024

Demonstration Year 20 – July 1, 2024 – June 30, 2025

Demonstration Year 21 – July 1, 2025 – June 30, 2026 Demonstration Year 22 – July 1, 2026 – June 30, 2027 Demonstration Year 23 – July 1, 2027 – June 30, 2028 Demonstration Year 24 – July 1, 2028 – June 30, 2029

PMPM Cost. The following table provides the PMPM (total computable) cost ceiling for each demonstration year represented in this demonstration approval period. The PMPM cost ceilings were constructed based on the state’s historical expenditures from July 1, 2015 through June 30, 2020 and increased by a 5.2 percent rate of