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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 1 of 61 CENTERS FOR MEDICARE & MEDICAID SERVICES SPECIAL TERMS AND CONDITIONS (STCs)

DEMONSTRATION NUMBERS: 21-W-00058/3 and 11-W-00381/3

TITLE: FAMIS MOMS and FAMIS Select

AWARDEE: Virginia Department of Medical Assistance Services

I. PREFACE

The following are Special Terms and Conditions (STCs) for the Virginia FAMIS MOMS and FAMIS Select section 1115 demonstration program. The parties to this agreement are the Virginia Department of Medical Services (Commonwealth) and the Centers for Medicare & Medicaid Services (CMS). These STCs set forth in detail the nature, character, and extent of federal involvement in the demonstration and the Commonwealth’s obligations to CMS during the approved demonstration period specified in these STCs. All previously approved STCs, waivers, and expenditure authorities are superseded by the STCs set forth below. These STCs are effective November 18, 2021, the date of the CMS approval letter that accompanied these STCs, through June 30, 2029.

The STCs have been arranged into the following subject areas:

II. Program Description and Historical Context III. General Program Requirements IV. Eligibility and Enrollment V. Benefits VI. Cost Sharing VII. Delivery System VIII. General Reporting Requirements IX. Monitoring X. Evaluation of the Demonstration XI. General Financial Requirements XII. Monitoring Allotment Neutrality XIII. Monitoring Budget Neutrality

Attachment A: Developing the Evaluation Design Attachment B: Preparing the Interim and Summative Evaluation Reports Attachment C: CMS Approved Demonstration Evaluation Plan Attachment D: Proxy Methodology for the Title XIX New Adult Group (reserved for CMS approval)