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Virginia FAMIS MOMS and FAMIS Select Section 1115 Demonstration Page 1 of 3 CMS Approved October 25, 2019 – June 30, 2029; amended November 18, 2021

CENTERS FOR MEDICARE & MEDICAID SERVICES EXPENDITURE AUTHORITY

NUMBER: 21-W-00058/3 and 11-W-00381/3

TITLE:

Virginia FAMIS MOMS and FAMIS Select Section 1115 Demonstration

AWARDEE: Virginia Department of Medical Assistance Services Expenditure Authority

All requirements of Medicaid and the Children’s Health Insurance Program (CHIP) shall apply to the demonstration populations and expenditures listed below, except those identified below as “not applicable.” All Medicaid and CHIP rules not expressly waived or identified as not applicable in this document shall apply to the demonstration. These expenditure and “non- applicable” authorities, as well as the associated Special Terms and Conditions (STCs), are in effect as of November 18, 2021, the date on the accompanying CMS approval letter, through June 30, 2029, except where otherwise noted in these expenditure authorities.

Under the authority of section 1115(a)(2) of the Social Security Act (the Act), expenditures made by the Commonwealth of Virginia for the items identified below (which are not otherwise included as expenditures under section 1903 or section 2107(e)(2)(A)) shall, for the period of this demonstration in accordance with the STCs, be regarded as matchable expenditures under Virginia’s title XXI and title XIX state plan:

Title XXI Expenditure Authority:

1. Expenditures for extending health insurance coverage through CHIP to uninsured pregnant individuals with income up to and including 200 percent of the federal poverty level (FPL), who are not otherwise Medicaid eligible. This includes those pregnant individuals who are lawfully residing in the United States and those with access to state employees’ health benefit coverage. These expenditures are authorized for the “FAMIS MOMS” component of the demonstration.

Should the Commonwealth freeze enrollment or otherwise discontinue coverage of the CHIP pregnant woman population, the title XXI expenditure authority will terminate and will not be subject to extension.

2. Expenditures for extending health insurance coverage to children in families with income up to and including 200 percent of the FPL, who are eligible for Virginia’s separate title XXI CHIP coverage but choose to elect a monthly premium assistance subsidy for private or employer-sponsored insurance coverage. These expenditures are authorized for the “FAMIS Select” component of the demonstration.