Model Application Template for the State Childrens Health Insurance Program

Effective Date: 07/01/05

1 Approval Date: _____________/06

OMB #: 0938-0707 Exp. Date:

MODEL APPLICATION TEMPLATE FOR STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT STATE CHILDREN’S HEALTH INSURANCE PROGRAM

Preamble

Section 4901 of the Balanced Budget Act of 1997 (BBA) amended the Social Security Act (the Act) by adding a new title XXI, the State Children’s Health Insurance Program (SCHIP). Title XXI provides funds to states to enable them to initiate and expand the provision of child health assistance to uninsured, low-income children in an effective and efficient manner. To be eligible for funds under this program, states must submit a state plan, which must be approved by the Secretary. A state may choose to amend its approved state plan in whole or in part at any time through the submittal of a plan amendment.

This model application template outlines the information that must be included in the state child health plan, and any subsequent amendments. It has been designed to reflect the requirements as they exist in current regulations, found at 42 CFR part 457. These requirements are necessary for state plans and amendments under Title XXI.

The Department of Health and Human Services will continue to work collaboratively with states and other interested parties to provide specific guidance in key areas like applicant and enrollee protections, collection of baseline data, and methods for preventing substitution of Federal funds for existing state and private funds. As such guidance becomes available, we will work to distribute it in a timely fashion to provide assistance as states submit their state plans and amendments.

Model Application Template for the State Childrens Health Insurance Program

Effective Date: 07/01/05

2 Approval Date: _____________/06 Form CMS-R-211

MODEL APPLICATION TEMPLATE FOR STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT STATE CHILDREN’S HEALTH INSURANCE PROGRAM

(Required under 4901 of the Balanced Budget Act of 1997 (New section 2101(b)))

State/Territory:___________________Virginia____________________________ (Name of State/Territory)

As a condition for receipt of Federal funds under Title XXI of the Social Security Act, (42 CFR, 457.40(b))

________________________________________________________________________ Marilyn B. Tavenner, Secretary of Health and Human Resources

submits the following State Child Health Plan for the State Children’s Health Insurance Program and hereby agrees to administer the program in accordance with the provisions of the approved State Child Health Plan, the requirements of Title XXI and XIX of the Act (as appropriate) and all applicable Federal regulations and other official issuances of the Department.

The following state officials are responsible for program administration and financial oversight (42 CFR 457.40(c)): Name: Marilyn B. Tavenner

Position/Title: Secretary of Health and Human Services Name: Patrick W. Finnerty

Position/Title: Director, Department of Medical Assistance Services Name: Cynthia B. Jones

Position/Title: Chief Deputy Director, Department of Medical Assistance Services Name: Linda L. Nablo

Position/Title: Director, Division of Child Health Insurance According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0707. The time required to complete this information collection is estimated to average 160 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, N2-14-26, Baltimore, Maryland 21244.

Model Application Template for the State Childrens Health Insurance Program

Effective Date: 07/01/05

3 Approval Date: _____________/06 Section 1. General Description and Purpose of the State Child Health Plans and State Child Health Plan Requirements (Section 2101)

1.1 The state will use funds provided under Title XXI primarily for (Check appropriate box) (42 CFR 457.70):

1.1.1 Obtaining coverage that meets the requirements for a separate child health program (Section 2103); OR

1.1.2. Providing expanded benefits under the State’s Medicaid plan (Title XIX); OR

1.1.3. ⌧ A combination of both of the above. (Effective 09/01/02)

1.2 ⌧ Please provide an assurance that expenditures for child health assistance will not be claimed prior to the time that the State has legislative authority to operate the State plan or plan amendment as approved by CMS. (42 CFR 457.40(d))

1.3 ⌧ Please provide an assurance that the state complies with all applicable civil rights requirements, including title VI of the Civil Rights Act of 1964, title II of the Americans with Disabilities Act of 1990, section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, 45 CFR part 80, part 84, and part 91, and 28 CFR part 35. (42CFR 457.130)

1.4

Please provide the effective (date costs begin to be incurred) and implementation (date services begin to be provided) dates for this plan or plan amendment (42 CFR 457.65):

Effective date: Plan: 10/26/98; Amend. 1: 7/01/01; Amend. 2: 12/01/01; Amend. 3: 7/01/01; Amend. 4: 09/01/02; Amend. 5: 08/01/03; Amend. 6: Pending; This Amend.: [(delete ESHI premium assistance program and exempt pregnant children from waiting period 8/01/05; allow for disease management in fee-for-service program 7/01/06)]

Implementation date: 10/26/98; Amend. 1: 8/01/01; Amend. 2: 12/01/01; Amend. 3: 12/01/01; Amend. 4: 09/01/02; Amend. 5: 08/01/03; Amend. 6: Pending; This Amend.: [(delete ESHI premium assistance program and exempt pregnant children from waiting period 8/01/05; allow for disease management in fee-for-service program 7/01/06)]

STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

STATE: Virginia Page 2-4

Effective Date: 07/01/05

4 Approval Date: _____________/06 Section 2. General Background and Description of State Approach to Child Health Coverage and Coordination (Section 2102 (a)(1)-(3)) and (Section 2105)(c)(7)(A)-(B))

2.1. Describe the extent to which, and manner in which, children in the state including targeted low-income children and other classes of children, by income level and other relevant factors, such as race and ethnicity and geographic location, currently have creditable health coverage (as defined in 42 CFR 457.10). To the extent feasible, make a distinction between creditable coverage under public health insurance programs and public-private partnerships (See Section 10 for annual report requirements). (42 CFR 457.80(a))

The Virginia Health Care Foundation conducted two surveys of health access in Virginia. The latest survey was conducted in the Spring of 1997 for the year 1996 of a representative sample of 1,861 households representing 4,694 individuals. The Department of Medical Assistance Services (DMAS) used estimates derived from this survey and census data for its planning purposes rather than from the national Current Population Survey. DMAS' administrative data were used to estimate Medicaid insured children.

HEALTH INSURANCE STATUS OF VIRGINIA CHILDREN 0-18, BY POVERTY LEVEL 1996

Insured Uninsured

Poverty Level Medicaid Private Total Insured Medicaid Eligible Other Uninsured Total Uninsured Total Children Under 100% 206,550 2,430 208,980 34,020 0 34,020 243,000 100% to 125% 33,450 3,570 37,020 10,980 9,000 19,980 57,000 125% to 150% 31,500 4,860 36,360 12,920 12,720 25,640 62,000 150% to 175% 37,500 9,140 46,640 22,080 17,280 39,360 86,000 175% to 200% 6,000 44,000 50,000 2,000 33,000 35,000 85,000 200% to 250% 0 57,000 57,000 0 20,000 20,000 77,000 Above 250% 0 979,000 979,000 0 40,000 40,000 1,019,000 Totals 315,000 1,100,000 1,415,000 82,000 132,000 214,000 1,629,000

STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

STATE: Virginia Page 2-5

Effective Date: 07/01/05

5 Approval Date: _____________/06 DMAS assumes that insured/uninsured individuals are evenly distributed by age below 100% of poverty. Above 100% of poverty more of the uninsured are ages 6-18. Virginia Medicaid covers children 0 through 5 up to 133% and covers children ages 6 through 18 up to 100% of poverty. Effective 9/01/02, Virginia’s Medicaid Program was expanded through Title XXI to cover additional targeted low-income children ages 6 through 18 with family income equal to or less than 133% of FPL.

2.2. Describe the current state efforts to provide or obtain creditable health coverage for uncovered children by addressing: (Section 2102)(a)(2) (42CFR 457.80(b))

2.2.1. The steps the state is currently taking to identify and enroll all uncovered children who are eligible to participate in public health insurance programs (i.e. Medicaid and state-only child health insurance):

In Virginia, determinations of eligibility for Medicaid (Title XIX) are made by the local Departments of Social Services and by Medicaid State agency staff co-located at the Title XXI Central Processing Unit. Applicants have the option of mailing in both their application for assistance and needed verifications, so that no face-to-face interview is required. Virginia also has eligibility workers outstationed in selected hospital sites and local health departments to identify potentially eligible and enroll eligible Medicaid (Title XIX) participants.

Determinations of eligibility for the state child health insurance program, The Family Access to Medical Insurance Security (FAMIS) Plan (Title XXI), are completed at a Central Processing Unit or Local Department of Social Services (LDSS). The Central Processing Unit screens applicants for Medicaid eligibility prior to completing a FAMIS eligibility determination. LDSS determines eligibility for Medicaid first and then determines FAMIS eligibility for children denied Medicaid due to excess income. Families may apply by mail, by phone or by fax; there is no requirement for a face-to- face interview.

In addition, many community groups have trained volunteers to help parents of potential Medicaid (Title XIX) and FAMIS (Title XXI) eligible individuals by answering questions and helping to complete applications and gather verifications needed to process cases.

Virginia’s Title XXI program is known as the Family Access to Medical Insurance Security Plan (FAMIS). The FAMIS program replaced Virginia’s original Title XXI program in August 2001. FAMIS was designed to simplify and speed-up the eligibility determination and enrollment process, and increase access to a broader array of providers through private-sector health insurance programs. These actions were taken to improve public perception and acceptance of the program, thereby increasing enrollment. In

STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

STATE: Virginia Page 2-6

Effective Date: 07/01/05

6 Approval Date: _____________/06 September 2002, the FAMIS program was revised again to provide for better coordination with the Medicaid program and to simplify the application process. FAMIS provides comprehensive health benefits for children from birth through age 18 who are not covered under health insurance and are not members of a family employed by a state agency or local government entity that contributes to the cost of dependent health care coverage. A mail-in application is used which addresses specific questions about other current and prior health insurance coverage A family may call a toll-free number and begin the application process. The FAMIS Central Processing Unit mails a preprinted Child Health Insurance application which can be completed, signed, and returned via mail or fax to the Central Processing Unit for Medicaid screening and FAMIS eligibility determination. If it appears the child is eligible for Medicaid, the application is forwarded to the outstationed Medicaid staff located at the Central Processing site or to the LDSS in the city or county where the family resides for Medicaid eligibility determination. Child Health Insurance applications may also be submitted to any LDSS for determination of eligibility of Medicaid and FAMIS. Expenditures for children who meet Medicaid eligibility criteria is claimed at the Commonwealth’s regular Medicaid FMAP. Effective 9/01/02, the Commonwealth began claiming enhanced funding for optional targeted low-income children who qualify under the Medicaid expansion. Expenditures for the children determined eligible under the Family Access to Medical Insurance Security Plan are claimed at the State’s enhanced FMAP.

No Entitlement: In accordance with § 2102(b)(4) of the Social Security Act (42 U.S.C. § 1397bb(b)(4)) and § 32.1-353 of the Code of Virginia, the Family Access to Medical Insurance Security Plan shall not create any individual entitlement for payment of medical services or any right or entitlement to participation.

2.2.2. The steps the state is currently taking to identify and enroll all uncovered children who are eligible to participate in health insurance programs that involve a public- private partnership:

Virginia currently has no health insurance programs that involve a public-private partnership.

2.3. Describe the procedures the state uses to accomplish coordination of SCHIP with other public and private health insurance programs, sources of health benefits coverage for children, and relevant child health programs, such as title V, that provide health care services for low-income children to increase the number of children with creditable health coverage. (Previously 4.4.5.) (Section 2102)(a)(3) and 2102(c)(2) and 2102(b)(3)(E)) (42CFR 457.80(c))

STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

STATE: Virginia Page 2-7

Effective Date: 07/01/05

7 Approval Date: _____________/06

The FAMIS program coordinates with the Virginia Department of Health, including Children’s Specialty Services and the Maternal and Child Health programs, with State teaching hospitals serving indigent families, and with local government health delivery programs which serve low income children. The Commonwealth’s goal is to provide all targeted low-income children with an accessible and comprehensive system of care that secures a medical home for children. This coordination is directed to ensuring that FAMIS does not supplant or replace existing programs. Rather, the goal of coordination is the close cooperation between these programs to enhance the health care resources available to low income children. DMAS, the single State agency that administers the Medicaid program, also administers FAMIS. Thus, Virginia ensures that the plan is closely coordinated with Medicaid in identifying and facilitating enrollment in the respective programs.

DMAS is responsible for the coordination of outreach and education efforts for all children whether they qualify for Medicaid or for FAMIS. Community-based organizations participating in this effort direct families to the appropriate program and assist them with applying for either FAMIS or Medicaid. Public programs that have established networks serving families who would meet either FAMIS or Medicaid’s income eligibility requirements are used as a resource in reaching eligible children.

DMAS has developed an interagency committee specifically to address the health care needs of children, pregnant women, and special needs populations. The group meets periodically to discuss issues of mutual concern, solicit support, and cooperation, and share creative approaches to serving these unique populations. Information regarding FAMIS as well as Medicaid is routinely shared and discussed with these individuals. A part of this group effort is the identification and coordination of Title V children. In addition, through its many other committees comprised of non-agency membership (e.g., Board of Directors, Managed Care Advisory Committee, Provider Advisory Council), DMAS solicits input and advice from public and private entities on its programs.

STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

STATE: Virginia Page 4-8

Effective Date: 07/01/05

8 Approval Date: _____________/06 Section 3. Methods of Delivery and Utilization Controls (Section 2102)(a)(4))

Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan, and continue on to Section 4.

3.1. Describe the methods of delivery of the child health assistance using Title XXI funds to targeted low-income children. Include a description of the choice of financing and the methods for assuring delivery of the insurance products and delivery of health care services covered by such products to the enrollees, including any variations. (Section 2102)(a)(4) (42CFR 457.490(a))

The Commonwealth of Virginia’s Title XXI State Plan utilizes two Secretary-approved benefit packages within FAMIS. One Secretary-approved coverage is a modified Medicaid look-alike component offered through a fee-for-service program and a Primary Care Case Management (PCCM) Program previously approved and continually provided under the State’s original Title XXI program, Virginia Children’s Medical Security Insurance Plan (VCMSIP). The group of children receiving services through a PCCM program are comprised of children who transitioned into FAMIS from either VCMSIP or Medicaid with a prior primary care case management (PCCM) history. Such children are initially assigned to the PCP with whom they had a previous relationship. The other Secretary-approved coverage is modeled after the state employee plan in effect in June 2000, provided under the current Title XXI State Plan, approved by the Centers for Medicare and Medicaid Services (CMS) December 22, 2000 and delivered by contracted (Managed Care Organizations) MCOs.

The Commonwealth is providing two benefit packages since no responding MCO was awarded specific geographic areas during the procurement process. The Commonwealth offers Secretary- approved coverage through the fee-for-service component or the PCCM program in areas that do not have contracted MCOs to offer Secretary-approved coverage modeled after the state employee plan in effect in June 2000. In areas without contracted MCOs, those recipients who transitioned from the VCMSIP or Medicaid programs to FAMIS and who were assigned to a primary care provider continue to receive services through the Primary Care Case Management program. All other newly eligible and enrolled FAMIS recipients in these areas are assigned to the fee-for- service program. Financing

Coverage under the fee-for-service/PCCM components (modified Medicaid look-alike component) will be reimbursed on a fee-for-service basis by the Department.

The managed care organizations (MCOs) are at risk for all services provided. The plans have the discretion in reimbursing and contracting with providers and must ensure services are provided and a sufficient network exists. FAMIS rates are actuarially sound rates, and are established in a

STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

STATE: Virginia Page 4-9

Effective Date: 07/01/05

9 Approval Date: _____________/06 manner consistent with CMS regulations promulgated pursuant to the Balanced Budget Act of 1997. A managed care savings factor shall be applied to determine the final rates. The savings factor shall be determined annually.

PRIMARY CARE CASE MANAGEMENT

Secretary-approved coverage through the PCCM Program is provided through a Primary Care Case Management (PCCM) delivery system. The PCCM delivery system manages and delivers health care for enrollees and is reimbursed on a fee-for-service basis. This program is administered in conjunction with the State’s MEDALLION Primary Care Case Management program.

A. For areas that do not have contracted MCOs, children transitioning to FAMIS from VCMSIP and Medicaid PCCM programs are enrolled in the PCCM Program. The PCCM Program enrolls members with a primary care provider who acts as a health care manager, provides primary and preventive care, and authorizes most specialty services. . Members can access any program provider for specialty services if they obtain the necessary authorization from the PCP. Referrals are not required for the following services: mental health, family planning, dental, emergency services, obstetrical, vision, psychiatric and psychological services, substance abuse treatment for pregnant women, pharmacy services, transportation services, EPSDT services, school-based services, targeted case management, treatment of sexually transmitted diseases, and immunizations provided by local health departments.

B. Currently, there are approximately 3,031 active PCPs in the program’s network that includes practitioners, health departments, and community health clinics. The PCPs are reimbursed on a fee-for-service basis plus a $3.00 per member per month case manager's fee. Existing PCCM program capacities meet or exceed projected enrollment for Secretary-approved coverage in all service areas. The PCP capacity is monitored quarterly and enrollment is tracked monthly.

FEE-FOR-SERVICE

Coverage under the modified Medicaid look-alike component is based on the fee-for-service program and providers are reimbursed by the Department.

COVERAGE PROVIDED UNDER MCOs

The second benefit package is Secretary-approved coverage modeled after the state employee plan in effect in June 2000, provided under the current Title XXI State Plan through contracted MCOs.

Secretary-approved coverage modeled after the state employee health plan provides a comprehensive array of health care benefits for eligible enrollees. DMAS has contracted with various managed care health insurers that meet certain requirements and standards in order to

STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

STATE: Virginia Page 4-10

Effective Date: 07/01/05

10 Approval Date: _____________/06 provide a comprehensive health benefits plan to FAMIS enrollees on a regional basis. . The plans have the discretion in reimbursing and contracting with providers and must ensure services are provided and a sufficient network exists.

3.2. Describe the utilization controls under the child health assistance provided under the plan for targeted low-income children. Describe the systems designed to ensure that enrollees receiving health care services under the state plan receive only appropriate and medically necessary health care consistent with the benefit package described in the approved state plan. (Section 2102)(a)(4) (42CFR 457.490(b))

A. FFS/PCCM Utilization Controls.

Utilization controls for providers offering Secretary-approved coverage through the fee-for- service and the PCCM Program component are administrative mechanisms that are designed to ensure that children use only health care that is appropriate, medically necessary, and approved by DMAS. DMAS relies on the utilization controls already established and operational in the Title XIX program for eligibles under Title XXI. Administrative mechanisms to be employed include the following: prepayment reviews, prior authorizations and internal reviews, post payment and SURS reviews.

Managed Care Organization Utilization Controls

Managed care organizations providing the Secretary-approved coverage modeled after the State employee plan in effect in June 2000 are required by contract to manage service utilization and have in place a process of evaluating the necessity, appropriateness and efficiency of health care services against established guidelines and criteria. The utilization program may include drug formulary decisions and criteria. The UM program must demonstrate that enrollees have equitable access to care across the network and that UM decisions are made in a fair, impartial, and consistent manner that serves the best interest of the enrollees. The MCO’s UM program reflects standards for utilization management from the most current nationally accepted standards. The program must have mechanisms to detect over-utilization and/or under-utilization of care, including, but not limited to, provider profiling and disease management programs. MCOs must ensure that the preauthorization requirements do not apply to emergency care, family planning services, preventative services, and basic prenatal care.

For more information on utilization controls, please refer to the current Title XXI State Plan § 7 - Quality and Appropriateness of Care.

STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

STATE: Virginia Page 4-11

Effective Date: 07/01/05

11 Approval Date: _____________/06 Section 4. Eligibility Standards and Methodology. (Section 2102(b))

Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan, and continue on to Section 5.

4.1. The following standards may be used to determine eligibility of targeted low-income children for child health assistance under the plan. Please note whether any of the following standards are used and check all that apply. If applicable, describe the criteria that will be used to apply the standard. (Section 2102)(b)(1)(A)) (42CFR 457.305(a) and 457.320(a))

4.1.1. ⌧ Geographic area served by the Plan:

State wide.

4.1.2. ⌧ Age:

From birth through age 18.

4.1.3. ⌧ Income:

Effective September 1, 2002, the Commonwealth’s Medicaid program was expanded under Title XXI to provide coverage for children from age 6 through age 18 who live in families with income in excess of 100% of FPL, but less than or equal to 133% FPL. The income limit prior to this date was less than or equal to 100% FPL for children age 6 through 18. All Medicaid income disregards, deductions and methodologies used for the Poverty Level group of Medicaid eligible children in the State’s Title XIX plan apply to this expanded group. The Commonwealth claims enhanced funding for optional targeted low-income children who qualify under the Medicaid expansion. Regular FMAP is claimed for those children who do not meet the definition of optional targeted low- income child. The Family Access to Medical Insurance Security Plan, Virginia’s separate Title XXI plan, was also revised to cover children from birth through age 18 in families with gross incomes at or below 200% of the FPL, but in excess of 133% of the federal poverty level. Formerly, FAMIS covered children from birth through age 5 in families with gross income in excess of 133% of the FPL but at or below 200% of the FPL and children from age 6 through 18 in families with gross incomes in excess of 100% of the FPL but at or below 200% of the FPL.

STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

STATE: Virginia Page 4-12

Effective Date: 07/01/05

12 Approval Date: _____________/06 The former Title XXI program, CMSIP, covered children up to 185% of the FPL and used the same income methodologies applied under the Virginia State Plan for Medical Assistance that are applied to children in the poverty income related groups.

Children who were enrolled in CMSIP on the date of FAMIS implementation, August 2001, were automatically enrolled in FAMIS. The income methodology for these children is protected. In the event that their gross family income exceeds the FAMIS limits, their eligibility will be determined using the income requirements of the CMSIP program for as long as they remain continuously eligible.

4.1.4. Resources (including any standards relating to spend downs and disposition of resources):

4.1.5. ⌧ Residency (so long as residency requirement is not based on length of time in state):

Eligible children must be Virginia residents.

4.1.6. Disability Status (so long as any standard relating to disability status does not restrict eligibility):

4.1.7. ⌧ Access to or coverage under other health coverage:

Any child covered under a group health plan or under health insurance coverage, as defined in § 2791 of the Public Health Service Act (42 U.S.C. § 300gg-91(a) and (b)(1)) shall not be eligible for the program.

4.1.8. ⌧ Duration of eligibility:

Children enrolled in FAMIS are eligible for coverage as of the first day of the month in which a signed application is received at either the local department of social services in the locality where the child resides or at the FAMIS Central Processing Unit. Effective 08-01-06, if a child enrolled in FAMIS is born within the three months prior to the month in which a signed application is received, coverage is effective retroactive to their date of birth if they would have met all eligibility criteria during that time.

STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

STATE: Virginia Page 4-13

Effective Date: 07/01/05

13 Approval Date: _____________/06

Effective 08-01-03, enrollment is for 12 continuous months, unless one of the following events occurs before the annual renewal: 1) an increase in gross monthly income to above 200% FPL; 2) a child moves out of state; 3) a child turns age 19; 4) the family requests cancellation; or 5) the family applies for Medicaid and the child is determined eligible for Medicaid. Families must report the following changes before the annual renewal: 1) an increase in gross monthly income or change in family size resulting in a family income above 200% FPL; or 2) an enrolled child moving out of the Commonwealth of Virginia. If none of the above changes is reported, eligibility will be renewed annually.

4.1.9. ⌧ Other standards (identify and describe):

Children are not eligible for the Family Access to Medical Insurance Security Plan: (1) if they are a member of a family eligible for employer-sponsored dependent health insurance coverage under any Virginia State Employee Health Insurance Plan, (2) if they are inmates of public institutions, (3) if they are inpatients in an institution for mental disease, or (4) if their parent or other authorized representative does not meet the requirements on assignment of rights to benefits or cooperation with the agency in identifying and providing information to assist the Commonwealth in pursuing any liable third party.

4.2. The state assures that it has made the following findings with respect to the eligibility standards in its plan: (Section 2102)(b)(1)(B)) (42CFR 457.320(b))

4.2.1. ⌧ These standards do not discriminate on the basis of diagnosis. 4.2.2. ⌧ Within a defined group of covered targeted low-income children, these standards do not cover children of higher income families without covering children with a lower family income. 4.2.3. ⌧ These standards do not deny eligibility based on a child having a pre- existing medical condition.

4.3. Describe the methods of establishing eligibility and continuing enrollment. (Section 2102)(b)(2)) (42CFR 457.350)

Effective September 1, 2002, the State intensified efforts to enroll children in health care coverage through both its FAMIS and Medicaid programs. The Medicaid income limits for poverty level children were increased to 133% of the federal poverty level for children ages 6-19, thereby creating a single income limit for all poverty level children. A Title XIX State Plan

STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

STATE: Virginia Page 4-14

Effective Date: 07/01/05

14 Approval Date: _____________/06 Amendment effective September 1, 2002 was submitted to expand this income limit. Note: Children with income in excess of 100% FPL but equal to or less than 133% FPL who are currently enrolled in FAMIS became Medicaid eligible effective on this date. Families of these children were notified of this change, the different benefit package available to Medicaid recipients, and the fact that their children’s cases would be transferred to and maintained by the local department of social services in the locality where they reside.

Instead of having a separate application form for each program, Medicaid and FAMIS, a single child health insurance application form was implemented. The single application form is accepted at the FAMIS Central Processing Unit and at any local department of social services in the Commonwealth. In addition to the single application form, children in families who apply at local departments of social services for Medicaid using a multi-program application form and who are determined to be ineligible for Medicaid will also have their eligibility for FAMIS determined by the local department. A supplement has been developed for use with the multi-program application form to collect information not applicable to Medicaid but necessary to determine FAMIS eligibility.

The Commonwealth continues to contract with a private entity to operate a Central Processing Unit for receipt and review of applications, for conducting a screen for Medicaid eligibility and for making FAMIS eligibility determinations for those children who do not appear to be eligible for Medicaid. The Central site receives applications from numerous sources. Families are able to apply by mail, by phone or by fax. Contract staff at the Central Processing Unit review documentation and input data from the single application form into an automated system that screens the data for potential Medicaid eligibility. If a child appears potentially eligible for Medicaid, the contract staff transfers the application to Medicaid State staff co-located at the Central Processing Unit. State Medicaid staff reviews the case for Medicaid and determines if the child or his family has an active case with a local department of social services (Medicaid, Food Stamps or TANF). If the child or family has an active case, the State Medicaid staff transfers the application to the local department of social services in the city or county where the child resides for a complete eligibility determination and enrollment in the Medicaid program. If the child or family does not have an active case with a local department of social services, State Medicaid staff complete the Medicaid eligibility determination and enroll eligible children in the Medicaid program. Approved cases are then transferred to the local department of social services in the city or county where the child resides for on-going case maintenance.

Local departments of social services accept applications by mail, by fax or in person. Eligibility staff at the local agencies process child health applications received for Medicaid eligibility and, if eligible, enroll the child or children in the Medicaid program. If the child is found ineligible for Medicaid because of excess income, local departments of social services then complete a FAMIS eligibility determination. Children eligible for FAMIS are enrolled in the FAMIS program and their cases are transferred to the FAMIS Central Processing Unit for ongoing case maintenance. The family is not required to file a new application.

STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

STATE: Virginia Page 4-15

Effective Date: 07/01/05

15 Approval Date: _____________/06

FAMIS eligibility staff and eligibility workers at the local departments of social services evaluate applications for children determined not to be Medicaid eligible and having family income at or below 200% of the FPL and notify applicants of their eligibility. Children determined to be FAMIS-eligible have their cases maintained at the central site. Children determined to be Medicaid-eligible have their cases maintained at the local department of social services in their locality of residence. FAMIS cases are reviewed annually to determine continued eligibility. Effective 08-01-03, enrollment is for 12 continuous months, unless one of the following events occurs before the annual renewal: 1) an increase in gross monthly income to above 200% FPL; 2) a child moves out of state; 3) a child turns age 19; 4) the family requests cancellation; or 5) the family applies for Medicaid and the child is determined eligible for Medicaid. Families must report the following changes before annual renewal: 1) an increase in gross monthly income or change in family size that results in family income above 200% FPL; or 2) an enrolled child moves out of the Commonwealth of Virginia. Medicaid cases are reviewed in accordance with established Medicaid policy. At the time of redetermination and/or renewal, a child found ineligible for either Medicaid or FAMIS will have his eligibility automatically determined in the other program.

No Entitlement: In accordance with § 2102(b)(4) of the Social Security Act and § 32.1-353 of the Code of Virginia, the Family Access to Medical Insurance Security Plan shall not create any individual entitlement for payment of medical services or any right or entitlement to participation.

4.3.1 Describe the state’s policies governing enrollment caps and waiting lists (if any). (Section 2106(b)(7)) (42CFR 457.305(b))

⌧ Check here if this section does not apply to your state.

4.4. Describe the procedures that assure that:

4.4.1. Through the screening procedures used at intake and follow-up eligibility determination, including any periodic redetermination, that only targeted low- income children who are ineligible for Medicaid or not covered under a group health plan or health insurance coverage (including access to a state health benefits plan) are furnished child health assistance under the state child health plan. (Sections 2102(b)(3)(A) and 2110(b)(2)(B)) (42 CFR 457.310(b) (42CFR 457.350(a)(1)) 457.80(c)(3))

The child health insurance application asks for employer information and whether children currently have health insurance. Children with health coverage or those who have access to the State Employee Insurance Plan are ineligible for FAMIS.

As described in § 4.3 above, all applications for child health insurance coverage are

STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

STATE: Virginia Page 4-16

Effective Date: 07/01/05

16 Approval Date: _____________/06 screened for completeness of information, the presence of other health insurance, verification of income, health coverage or access to the State Employee Health Insurance Plan, and Medicaid eligibility. If it appears that the child is Medicaid eligible, the case is referred for a Medicaid eligibility determination.

Applications received by the Central Processing site are screened for potential Medicaid eligibility first. If it appears that the child is Medicaid eligible, the case is referred for Medicaid eligibility determination. The State utilizes a screening process that consists of applying the Medicaid disregards to the gross family income and comparing the remainder to the Medicaid income limit for the family size. The single child health application collects all income and child care expense information needed to determine potential Medicaid eligibility. Individuals who are identified as potentially Medicaid eligible will not be enrolled in Title XXI without a full Medicaid determination and finding of ineligibility. Applications received at local departments of social services have full Medicaid eligibility determinations completed. If a child is determined ineligible for Medicaid, a FAMIS eligibility determination is then conducted.

At the time of a renewal of eligibility, the child’s insurance status and Medicaid eligibility is reviewed to ensure continued eligibility for enrollment in FAMIS.

4.4.2. The Medicaid application and enrollment process is initiated and facilitated for children found through the screening to be potentially eligible for medical assistance under the state Medicaid plan under Title XIX. (Section 2102)(b)(3)(B)) (42CFR 457.350(a)(2))

Child health applications received at the FAMIS Central Processing Unit are screened for Medicaid eligibility and, if found to be potentially eligible for Medicaid, are transferred directly by the FAMIS staff to Medicaid eligibility workers co-located at the FAMIS Central Processing Unit. In accordance with procedures described in §4.3 above, Medicaid workers, either at the Central Processing Unit, or at local departments of social services complete a Medicaid eligibility determination on all applications, those screened as potentially eligible for Medicaid by the FAMIS staff, as well as those received at local departments of social services directly from applicants.

The Commonwealth tracks applications that are referred by the Central Processing Unit for a Medicaid eligibility determination to monitor the accuracy of the Medicaid screening and the number of children enrolled in Medicaid through an application filed at the FAMIS Central Processing Unit.

4.4.3. The State is taking steps to assist in the enrollment in SCHIP of children determined ineligible for Medicaid. (Sections 2102(a)(1) and (2) and 2102(c)(2)) (42CFR

STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

STATE: Virginia Page 4-17

Effective Date: 07/01/05

17 Approval Date: _____________/06 431.636(b)(4))

Applications filed on behalf of children determined to be ineligible for Medicaid by Medicaid eligibility staff co-located at the Central Processing Unit or by Medicaid staff at local departments of social services undergo a FAMIS eligibility determination. A single child health insurance application form and process facilitates this eligibility determination and enrollment of children in the appropriate program, either Medicaid or FAMIS.

4.4.4 The insurance provided under the state child health plan does not substitute for coverage under group health plans. Check the appropriate box. (Section 2102)(b)(3)(C)) (42CFR 457.805) (42 CFR 457.810(a)-(c))

4.4.4.1. ⌧ Coverage provided to children in families at or below 200% FPL: describe the methods of monitoring substitution.

Only uninsured children shall be eligible for FAMIS. The single child health application form requests information on health insurance coverage the child may have or had within the past four months. Each application and redetermination of eligibility documents inquiry about health insurance within the past 4 months. If the child has been covered under a health insurance plan within 4 months of application for or receipt of FAMIS services, the child will be ineligible, unless they are pregnant at the time of application or unless good cause for discontinuing the coverage is demonstrated.

Good Cause: A child shall not be ineligible for FAMIS if health insurance was discontinued within the four month period prior to the month of application if one of the following good cause exceptions is met:

1. The family member who carried insurance changed jobs or stopped employment, and no other family member’s employer contributes to the cost of family health insurance coverage. 2. The employer stopped contributing to the cost of family coverage and no other family member’s employer contributes to the cost of family health insurance coverage. 3. The child’s coverage was discontinued by an insurance company for reasons of uninsurability, e.g., the child has used up lifetime benefits or the child’s coverage

STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

STATE: Virginia Page 4-18

Effective Date: 07/01/05

18 Approval Date: _____________/06 was discontinued for reasons unrelated to payment of premiums. 4. Insurance was discontinued by a family member who was paying the full cost of the insurance premium under the COBRA policy and no other family member contributes to the cost of family health insurance coverage. 5. Insurance on the child was discontinued by someone other than the child (if 18 years of age), or, if under age 18, the child’s parent, or step-parent, e.g., the insurance was discontinued by the child’s grandparent, aunt, uncle, godmother, etc. 6. Insurance on the child was discontinued because the cost of the premium exceeds 10% of the family’s gross monthly income or exceeded 10% of the family’s gross monthly income at the time the insurance was discontinued. 7. Other good cause reasons as may be established by the DMAS Director.

Staff at the central site reports information to DMAS, which will monitor the trends in health insurance coverage for children enrolling in FAMIS to determine the degree substitution is occurring. Assignment of rights to medical support is a condition of eligibility.

4.4.4.2. Coverage provided to children in families over 200% and up to 250% FPL: describe how substitution is monitored and identify specific strategies to limit substitution if levels become unacceptable.

4.4.4.3. Coverage provided to children in families above 250% FPL: describe how substitution is monitored and identify specific strategies in place to prevent substitution.

4.4.4.4 If the state provides coverage under a premium assistance program, describe:

The minimum period without coverage under a group health plan, including any allowable exceptions to the waiting period.

The minimum employer contribution.

STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

STATE: Virginia Page 4-19

Effective Date: 07/01/05

19 Approval Date: _____________/06 The cost-effectiveness determination.

4.4.5 Child health assistance is provided to targeted low-income children in the state who are American Indian and Alaska Native. (Section 2102)(b)(3)(D)) (42 CFR 457.125(a))

American Indian and Alaska Native children are eligible for the Family Access to Medical Insurance Security Plan on the same basis as any other children in the Commonwealth. Virginia has no federally recognized Indian tribes; however, ongoing communication will occur with Indian tribes in Virginia to ensure that Indian families understand the program and can access the provider network to secure covered services.

No cost sharing is imposed on American Indian and Alaska Native children.

STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

STATE: Virginia Page 5-20

Effective Date: 07/01/05

20 Approval Date: _____________/06 Section 5. Outreach (Section 2102(c))

Describe the procedures used by the state to accomplish:

Outreach to families of children likely to be eligible for child health assistance or other public or private health coverage to inform them of the availability of the programs, and to assist them in enrolling their children in such a program: (Section 2102(c)(1)) (42CFR 457.90)

Pursuant to § 32.1-351.2 of the Code of Virginia, DMAS has established an Outreach Oversight Committee composed of representatives from community-based organizations engaged in outreach activities, advocates, social services eligibility workers, the provider community, health plans, other state agencies, and consumers. The Committee meets quarterly to discuss strategies to improve outreach activities. The Committee makes recommendations regarding state-level outreach activities, coordination of regional and local outreach activities, and procedures for streamlining and simplifying the application process, brochures, other printed materials, forms, and applicant correspondence.

The Commonwealth is broadening its outreach focus to child health insurance, which includes FAMIS and Medicaid. With assistance and advice from the Outreach Oversight Committee, DMAS will create a comprehensive outreach plan that includes specific strategies for: (i) improving outreach and enrollment in those localities where enrollment is less than the statewide average, and (ii) enrolling eligible children in either the FAMIS or Medicaid programs.

Virginia works with community based organizations that have expertise in providing translation services to reach eligible families with limited English speaking abilities. All outreach material is available in both English and Spanish. DMAS will continue to provide these community-based organizations with the support and tools needed to reach these families.

DMAS coordinates a comprehensive marketing and outreach effort. The marketing and outreach efforts promote FAMIS and Medicaid and may include the following:

Public Relations Firm -- The agency contracts with a firm to assist with development of a statewide marketing plan. The plan is directed toward informing the target market, stimulating interest and promoting enrollment in the State’s FAMIS and Medicaid programs. The contractor also assists with the design, production, and distribution of multimedia materials for the marketing plan. The contractor and the agency engage in an ongoing evaluation of the marketing plan utilizing data from public responses, enrollment statistics, and other sources.

Coordination with Other State Agencies -- Assistance is sought from other agencies, including Virginia’s Department of Education, Department of Health, Department of Social Services, and State Employment Commission with referrals for potential new enrollees. These agencies are

STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

STATE: Virginia Page 5-21

Effective Date: 07/01/05

21 Approval Date: _____________/06 supplied with enrollment information and outreach materials. Utilizing the same criteria as the School Lunch Program, school systems are a primary vehicle for sending information home to parents about the FAMIS program. In addition, State agencies are routinely educated and trained about the program and are provided with informational fact sheets and brochures.

Coordination with other Community Based Organizations -- The Commonwealth actively encourages participation of a wide range of organizations, including, but not limited to, those organizations that target high concentrations of uninsured children. DMAS has partnered with a network of Community Based Organizations (CBO) to promote and facilitate enrollment of children in the FAMIS and Medicaid programs. DMAS will continue to build coalitions and infrastructure at the state and local level that will provide awareness and application assistance in both FAMIS and Medicaid. DMAS continues to work closely with its contractor, the Virginia Health Care Foundation, in coordinating local outreach efforts through Project Connect and Robert Wood Johnson Grantees, and other Community-Based Organizations. Virginia works with community based organizations that have expertise in providing translation services to reach eligible families with limited English speaking abilities. All outreach materials are available in both English and Spanish. DMAS continues to provide these community-based organizations with the support and tools needed to reach these families

Coordination with the Business Community -- The Commonwealth is developing a statewide business outreach strategy. DMAS will contact Virginia businesses and business associations to request their cooperation in enrolling employees’ children, sponsorship opportunities, advertising partnerships, gifts and in-kind contributions in support of the State’s child health insurance programs. These groups will be provided with materials outlining the importance and benefits of the program so that they can make informed decisions on their ability and level of participation.

Coordination with the Health Care Associations and Providers -- The Commonwealth partners with health care associations and requests their cooperation in performing outreach for Virginia’s child health insurance programs. Outreach information is provided to health care associations and health care providers so that they can distribute FAMIS and Medicaid information to their members. The Outreach Oversight Committee helps identify and target providers.

Central Processing Unit – The Commonwealth, through a contractor, provides a call center with a toll-free helpline number to be located at the Central Processing Unit. The call center serves as a distribution point for applications, assists callers with completing applications, serves as a source for answering questions, and provides eligibility status. DMAS continues to coordinate outreach efforts in conjunction with the call center and works to develop better outreach evaluation methods. It is required that the contractor responsible for operating the call center provides translation services for non-English speaking callers. This requirement may be met through an arrangement with a contracted service such as AT&T Language Line Services, which provides interpretation services in 148 of the most commonly spoken languages around the world. Translation services are available during the call center hours of operation and must be accessible via a toll-free number. Callers requiring translation services are not required to hang up and call

STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

STATE: Virginia Page 5-22

Effective Date: 07/01/05

22 Approval Date: _____________/06 another number. A translator is conferenced in the call providing a three-way conversation between the call center representative, the translator, and the caller if a bilingual operator is not available.

Robert Wood Johnson Foundation -- “It’s a New Day for Child Health Insurance in Virginia” is the theme of the Virginia Health Care Foundation grant proposal. The Commonwealth supported the Virginia Health Care Foundation as the Lead Agency for the Robert Wood Johnson Foundation, Covering Kids and Families Grant for FYs 2002-2005. The grant was awarded to the Virginia Health Care Foundation in July, 2002, and provides funding for three pilot programs to conduct innovative SCHIP outreach for four consecutive years. The three pilots represent a grassroots approach for statewide outreach. The goal of the three pilots is to enroll children into the CHIP program by identifying and overcoming enrollment barriers and developing effective community tailored outreach mechanisms. The three pilots are: United Way-Thomas Jefferson (Charlottesville, Albermarle, Fluvanna, Greene, and Louisa counties); CINCH (Norfolk, Portsmouth, Newport News, Hampton, Chesapeake, Suffolk, and Virginia Beach); and Radford University School of Social Work in conjunction with Partnership for Access to Health (Radford, Galax and counties of Carroll, Giles, Montgomery, Pulaski, and Wythe). Each pilot employs a multifaceted approach, collaborating with local hospitals, schools, churches, physicians’ offices, referrals from DSS offices, health districts, free clinics, school nurses/counselors, and local workforce development centers to identify uninsured children. In addition, the three pilots collaborate with state and local agencies, and other community-based organizations to reach eligible families in their respective areas. The Commonwealth does not receive in-kind contributions from the pilots. Any Title XXI funds provided to the pilots consist of the proportionate share of state and federal funds. No private entity funds are used to draw-down the Title XXI federal match through this program.

The Commonwealth has not received any gifts or in-kind contributions from the business community to support the Commonwealth’s Child Health Insurance Program. Any gifts, donations, or in-kind contributions that have been provided have been given directly to the outreach efforts (as described above) or have been provided directly to the grantees providing/supporting the outreach efforts. As stated above, none of these funds are used to draw- down the Title XXI federal match.

Virginia currently has no health insurance programs that involve a public-private partnership.

STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

STATE: Virginia Page 6-23

Effective Date: 07/01/05

23 Approval Date: _____________/06 Section 6. Coverage Requirements for Children’s Health Insurance (Section 2103)

Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the states Medicaid plan, and continue on to Section 7.

6.1. The state elects to provide the following forms of coverage to children: (Check all that apply.) (42CFR 457.410(a))

6.1.1. Benchmark coverage; (Section 2103(a)(1) and 42 CFR 457.420) 6.1.1.1. FEHBP-equivalent coverage; (Section 2103(b)(1)) (If checked, attach copy of the plan.) 6.1.1.2. State employee coverage; (Section 2103(b)(2)) (If checked, identify the plan and attach a copy of the benefits description.) 6.1.1.3. HMO with largest insured commercial enrollment (Section 2103(b)(3)) (If checked, identify the plan and attach a copy of the benefits description.)

6.1.2. Benchmark-equivalent coverage; (Section 2103(a)(2) and 42 CFR 457.430) Specify the coverage, including the amount, scope and duration of each service, as well as any exclusions or limitations. Please attach a signed actuarial report that meets the requirements specified in 42 CFR 457.431. See instructions.

6.1.3. Existing Comprehensive State-Based Coverage; (Section 2103(a)(3) and 42 CFR 457.440) [Only applicable to New York; Florida; Pennsylvania] Please attach a description of the benefits package, administration, date of enactment. If existing comprehensive state-based coverage is modified, please provide an actuarial opinion documenting that the actuarial value of the modification is greater than the value as of 8/5/97 or one of the benchmark plans. Describe the fiscal year 1996 state expenditures for existing comprehensive state-based coverage.

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STATE: Virginia Page 6-24

Effective Date: 07/01/05

24 Approval Date: _____________/06

6.1.4. ⌧ Secretary-Approved Coverage. (Section 2103(a)(4)) (42 CFR 457.450) 6.1.4.1. Coverage the same as Medicaid State plan 6.1.4.2. Comprehensive coverage for children under a Medicaid Section 1115 demonstration project

6.1.4.3. Coverage that either includes the full EPSDT benefit or that the state has extended to the entire Medicaid population 6.1.4.4. ⌧ Coverage that includes benchmark coverage plus additional coverage 6.1.4.5. Coverage that is the same as defined by existing comprehensive state-based coverage 6.1.4.6. Coverage under a group health plan that is substantially equivalent to or greater than benchmark coverage through a benefit by benefit comparison (Please provide a sample of how the comparison will be done) 6.1.4.7. ⌧ Other (Describe)

A child will receive Secretary-approved coverage modeled after the state employee plan if the child lives in an area in which there is a contracted MCO to offer Secretary-approved coverage modeled after the state employee plan.

Secretary-approved coverage through a modified Title XIX look-alike (a fee-for- service component or the PCCM Program) is the delivery system provided in geographic areas not served by a contracted MCO until such time as a system to offer the Secretary-approved coverage modeled after the state employee plan is implemented.

Secretary-approved coverage modeled after the state employee plan provides coverage using the Key Advantage Plan. This plan is the PPO option for state employees that was offered statewide in June 2000. Several enhanced benefits are added to the plan. The services under the Key Advantage Member Handbook are briefly outlined in the checklist in § 6.2. The enhanced benefits that are provided in addition to the Key Advantage Plan are listed at the end of this checklist.

For children in families receiving the Secretary-Approved coverage through the

STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

STATE: Virginia Page 6-25

Effective Date: 07/01/05

25 Approval Date: _____________/06 fee-for-service program or PCCM program, Virginia provides a Title XIX look- alike program with benefits that are essentially the same as the state’s Title XIX Plan.

6.2. The state elects to provide the following forms of coverage to children: (Check all that apply. If an item is checked, describe the coverage with respect to the amount, duration and scope of services covered, as well as any exclusions or limitations) (Section 2110(a)) (42CFR 457.490)

Secretary-approved coverage modeled after the state employee, Virginia’s Key Advantage State Employee Benefit Plan in effect in June 2000, is summarized in the checklist below (6.2.1 -- 6.2.28). The additional coverage provided is listed separately at the bottom of the checklist. NOTE: The FAMIS program has two separate health care services delivery systems, described immediately below and at 6.2.1.A – 6.2.28.A, below.

6.2.1. ⌧ Inpatient services (Section 2110(a)(1))

365 days per confinement; includes ancillary services.

6.2.2. ⌧ Outpatient services (Section 2110(a)(2))

Outpatient services include emergency services, surgical services, and professional provider services in a physician’s office or outpatient hospital department. Facility charge for outpatient department of a hospital or hospital emergency room, separate from physician or diagnostic services.

6.2.3. ⌧ Physician services (Section 2110(a)(3))

Physician services include services while admitted in the hospital, or in a physician’s office, or outpatient hospital department.

6.2.4. ⌧ Surgical services (Section 2110(a)(4))

Surgical services include services provided in §§ 6.2.1, 6.2.2, and 6.2.3.

6.2.5. ⌧ Clinic services (including health center services) and other ambulatory health care services. (Section 2110(a)(5))

Clinic services include services provided in §§ 6.2.2 and 6.2.3. 6.2.6. ⌧ Prescription drugs (Section 2110(a)(6))

Covered for outpatient prescription drugs. Mandatory generic program.

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STATE: Virginia Page 6-26

Effective Date: 07/01/05

26 Approval Date: _____________/06 6.2.7. Over-the-counter medications (Section 2110(a)(7))

Optional - May be covered at the discretion of the health plan.

6.2.8. ⌧ Laboratory and radiological services (Section 2110(a)(8))

Outpatient diagnostic tests, X-rays, and laboratory services covered in a physician's office, hospital, independent and clinical reference lab.

6.2.9. ⌧ Prenatal care and prepregnancy family services and supplies (Section 2110(a)(9))

Maternity service including routine prenatal care is covered. Prepregnancy family services include coverage for prescription drugs and devices approved by the U.S. Food and Drug Administration for use as contraceptives. Contraceptive drugs and devices eligible for reimbursement are oral contraceptives, depo provera, cervical caps, diaphragms, intrauterine devices and Norplant.

6.2.10. ⌧ Inpatient mental health services, other than services described in 6.2.18., but including services furnished in a state-operated mental hospital and including residential or other 24-hour therapeutically planned structural services. (Section 2110(a)(10))

Inpatient acute mental health services other than those (a) services furnished in a state-operated mental hospital, (b) services furnished by IMDs, or (c) residential services or other 24-hour therapeutically planned structural services.

Includes 30 days total for inpatient hospital care and partial day services per benefit period.

6.2.11. ⌧ Outpatient mental health services, other than services described in 6.2.19, but including services furnished in a state-operated mental hospital and including community-based services (Section 2110(a)(11)

A. Outpatient mental health services, other than services furnished in a state- operated mental hospital.

B. Effective 08-01-2003, the following community mental health services are covered under this state plan and reimbursed directly by DMAS to providers:

1. Intensive in-home services to children and adolescents under age 19 shall be time-limited interventions provided typically but not solely in the

STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

STATE: Virginia Page 6-27

Effective Date: 07/01/05

27 Approval Date: _____________/06 residence of a child who is at risk of being moved into an out-of-home placement or who is being transitioned to home from out-of-home placement due to a documented medical need of the child. These services provide crisis treatment; individual and family counseling; and communication skills (e.g., counseling to assist the child and his parents to understand and practice appropriate problem-solving, anger management, and interpersonal interaction, etc.); case management activities and coordination with other required services; and 24-hour emergency response. These services shall be limited annually to 26 weeks. Services must be directed toward the treatment of the eligible child and delivered primarily in the family's residence with the child present.

2 Therapeutic day treatment provides evaluation; medication; education and management; opportunities to learn and use daily living skills and to enhance social and interpersonal skills (e.g., problem-solving, anger management, community responsibility, increased impulse control, and appropriate peer relations, etc.); and individual, group and family psychotherapy. The service shall be provided two or more hours per day in order to provide therapeutic interventions. Services are limited annually to 780 units: one unit of service is defined as a minimum of two hours but less than three hours in a given day. Two units of service shall be defined as a minimum of three but less than five hours in a given day. Three units of service shall be defined as five or more hours of service in a given day.

3. Crisis Intervention - Crisis intervention shall provide immediate mental health care, available 24 hours a day, seven days per week, to assist individuals who are experiencing acute psychiatric dysfunction requiring immediate clinical attention. Crisis intervention activities, are limited annually to 720 units per year (a unit equals 15 minutes) and shall include assessing the crisis situation, providing short-term counseling designed to stabilize the individual, providing access to further immediate assessment and follow-up, and linking the individual and family with ongoing care to prevent future crises. Crisis intervention services may include office visits, home visits, preadmission screenings, telephone contacts, and other client- related activities for the prevention of institutionalization.

4. Case Management - Case management services for youth at risk of serious emotional disturbance and who meet the definition of Seriously Emotionally Disturbed. Case management services assist youth at risk of serious emotional disturbance and with a diagnosis of Serious Emotional Disturbance in accessing needed medical, psychiatric, social, educational, vocational, and other supports essential to meeting basic needs. Services to be provided include: Assessment and planning, linking the individual

STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

STATE: Virginia Page 6-28

Effective Date: 07/01/05

28 Approval Date: _____________/06 directly to services and supports, assisting the individual directly for the purpose of locating, developing or obtaining needed service and resources, coordinating services and service planning, enhancing community integration, making collateral contacts, follow up and monitoring, and education and counseling.

6.2.12. ⌧ Durable medical equipment and other medically-related or remedial devices (such as prosthetic devices, implants, eyeglasses, hearing aids, dental devices, and adaptive devices). (Section 2110(a)(12)) Durable medical equipment, prosthetic devices, hearing aids, and eyeglasses are covered when medically necessary with certain limitations. 6.2.13. ⌧ Disposable medical supplies. (Section 2110(a)(13))

Medically necessary disposable medical supplies provided in an inpatient or outpatient setting are covered.

6.2.14. ⌧ Home and community-based health care services (See instructions) (Section 2110(a)(14))

Includes coverage of up to 90 visits per calendar year. Includes nursing and personal care services, home health aides, physical therapy, occupational therapy, and speech, hearing, and inhalation therapy.

6.2.15. ⌧ Nursing care services (See instructions) (Section 2110(a)(15))

Nurse practitioner services, nurse midwife services, and private duty nursing services are covered. Skilled nursing services provided for special education students are covered with limitations.

6.2.16. ⌧ Abortion only if necessary to save the life of the mother or if the pregnancy is the result of an act of rape or incest (Section 2110(a)(16) Abortion only if necessary to save the life of the mother. 6.2.17. ⌧ Dental services (Section 2110(a)(17)) Coverage includes diagnostic, preventive, primary, prosthetic and complex restorative services. Coverage does not include routine bases under restorations.

Coverage shall include full-banded orthodontics and related services to correct abnormal and correctable malocclusion for enrollees. Post-treatment stabilization retainers and follow-up visits are included in the orthodontic

STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

STATE: Virginia Page 6-29

Effective Date: 07/01/05

29 Approval Date: _____________/06 services. Effective 12/1/02, the benefit limits for orthodontic services increased to mirror Medicaid. 6.2.18. ⌧ Inpatient substance abuse treatment services and residential substance abuse treatment services (Section 2110(a)(18)) Other than (a) services furnished in a state-operated mental hospital, (b) services furnished in IMDs, or (c) residential services or other 24-hour therapeutically planned structural services. Inpatient rehabilitation in a substance abuse treatment facility up to 90 days, maximum lifetime benefit. 6.2.19. ⌧ Outpatient substance abuse treatment services (Section 2110(a)(19)) Outpatient substance abuse treatment services, other than services furnished in a state-operated mental hospital. Substance abuse services and psychiatric services are limited to no more than a combined total of 50 medically necessary visits for treatment with a licensed mental health or substance abuse professional each calendar year. 6.2.20. ⌧ Case management services (Section 2110(a)(20))

The State may elect to offer benefits for an approved, alternative treatment plan for a recipient who would otherwise require more expensive services. These services will be offered on a case-by-case-basis. 6.2.21. Care coordination services (Section 2110(a)(21))

6.2.22. ⌧ Physical therapy, occupational therapy, and services for individuals with speech, hearing, and language disorders (Section 2110(a)(22))

Medically necessary services used to treat or promote recovery from an illness or injury are covered with limitations.

6.2.23. ⌧ Hospice care (Section 2110(a)(23))

Hospice services include a program of a home and inpatient care provided directly under the direction of a licensed hospice. Hospice care programs include palliative and supportive physician, psychological, psychosocial, and other health services to individuals utilizing a medically directed interdisciplinary team. Hospice care services are available if the enrollee is diagnosed with a terminal illness with a life expectancy of six months or fewer.

6.2.24. ⌧ Any other medical, diagnostic, screening, preventive, restorative,

STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

STATE: Virginia Page 6-30

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30 Approval Date: _____________/06 remedial, therapeutic, or rehabilitative services. (See instructions) (Section 2110(a)(24))

Coverage of chiropractic and vision services with benefit limitations. Effective 12/1/02, the vision co-payments levels for each FPL will decrease. Reimbursement levels for frames and trifocal lenses will increase.

6.2.25. ⌧ Premiums for private health care insurance coverage (Section 2110(a)(25))

Premiums for private health care insurance coverage will be covered as outlined in § 3.1.

6.2.26. ⌧ Medical transportation (Section 2110(a)(26))

Professional ambulance services under certain conditions are covered when used locally to or from a covered facility or provider’s office. Ambulance services if prearranged by the Primary Care Physician and authorized by the Company if, because of enrollee’s medical condition, the enrollee cannot ride safely in a car when going to the provider’s office or to the outpatient department of the hospital. Ambulance services will be covered if the enrollee’s condition suddenly becomes worse and must go to a local hospital’s emergency room.

For coverage of ambulance services, the following three conditions must be met: (a) The trip to the facility or office must be to the nearest one recognized by the health plan administrator as having services adequate to treat the condition; (b) The services received in that facility or provider's office are covered services; and (c) If the health plan administrator requests it, the attending provider must explain why transportation could not occur in a private car or by any other less expensive means. 6.2.27. Enabling services (such as transportation, translation, and outreach services (See instructions) (Section 2110(a)(27))

6.2.28. ⌧ Any other health care services or items specified by the Secretary and not included under this section (Section 2110(a)(28))

Enhanced Services Provided Beyond Secretary-approved coverage modeled after the state employee plan:

The services described above are the services included in the Key Advantage State Employee Benefit Package in effect in June 2000. FAMIS Secretary- approved coverage modeled after the state employee plan will include all of the

STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

STATE: Virginia Page 6-31

Effective Date: 07/01/05

31 Approval Date: _____________/06 Key Advantage benefits plus the additional benefits listed below:

1. Well-child care from age 6 through 18 including visits, laboratory services as recommended by the American Academy of Pediatrics Advisory Committee, and any immunizations as recommended by the Advisory Committee on Immunization Practice (ACIP). (Well-child care from age birth through age 5 is covered under Key Advantage.)

2. Physical therapy, occupational therapy, speech language pathology, psychology/psychiatry services and skilled nursing services for special education students are covered under this state plan. The Department reimburses the school divisions directly for the services provided pursuant to the student’s Individualized Education Program (IEP) plan.

3. Blood lead testing.

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STATE: Virginia Page 6-32

Effective Date: 07/01/05

32 Approval Date: _____________/06 Coverage offered for Secretary-approved coverage through the fee-for-service program and the PCCM program is summarized in the checklist below.

6.2.1.A ⌧ Inpatient services (Section 2110(a)(1))

A. Payment based upon DRG shall be made for medically necessary stays in acute general care facilities within the limits of coverage prescribed with the Title XIX State Plan and state regulations. B. Medically necessary inpatient psychiatric care rendered in a psychiatric unit of a general acute care hospital shall be covered for all children within the limits of coverage prescribed in the Title XIX State Plan and state regulations. C. Payment will not be made for inpatient hospitalization for those surgical and diagnostic procedures listed on the mandatory outpatient surgery list unless the inpatient stay is medically justified or meets one of the exceptions. D. For purposes of organ transplantation, all similarly situated individuals will be treated alike. Transplant services shall be limited to procedures that are not experimental. Transplants are covered when determined medically necessary and preauthorized. E. Coverage for a normal, uncomplicated vaginal delivery shall be limited to the day of delivery plus an additional two days unless additional days are medically justified. Coverage for cesarean births shall be limited to the day of delivery plus an additional four days unless additional days are medically justified. F. Coverage for a radical or modified radical mastectomy for treatment of disease or trauma of the breast shall be limited to 48 hours unless additional days are medically justified. Coverage for a total or partial mastectomy with lymph node dissection for treatment of disease or trauma of the breast shall be limited to 24 hours unless additional days are medically justified.

6.2.2.A ⌧ Outpatient services (Section 2110(a)(2)) A. Outpatient hospital means preventive, diagnostic, therapeutic, rehabilitative or palliative services that are furnished to outpatients, by or under the direction of a physician or dentist, except in the case of nurse mid-wife services.

STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

STATE: Virginia Page 6-33

Effective Date: 07/01/05

33 Approval Date: _____________/06 B. Are furnished by an institution that is licensed or formally approved by the Virginia Department of Health and except in the case of medical supervision of nurse-midwife services, meets the requirements for participation in Medicare. C. Emergency hospital services provided without limitation. D. Coverage of outpatient observation beds. The following limits and requirements shall apply to DMAS coverage of outpatient observation beds. These services must be billed as outpatient care and may be provided for up to 23 hours. A patient stay of 24 hours or more shall require inpatient precertification and admission.

6.2.3.A ⌧ Physician services (Section 2110(a)(3))

A. Physician’s services whether furnished in the office, the patient’s home, a hospital, a skilled nursing facility or elsewhere. Elective surgery as defined by the Program is surgery that is not medically necessary to restore or materially improve a body function. Elective and cosmetic surgical procedures are not covered unless performed for physiological reasons and require prior approval by DMAS. B. Routine physicals and immunizations are not covered except when the services are provided under the EPSDT Program and when a well child examination is performed in a private physician’s office for a foster child of the local social services department on specific referral from those departments. B. Psychiatric services are limited to an initial availability of 26 sessions without prior authorization during the first year of treatment. An additional extension of up to 47 sessions during the first treatment year must be prior authorized by DMAS. The availability is further restricted to no more than 26 sessions each succeeding year when approved by DMAS. Psychiatric services are further restricted to no more than three sessions in any given seven-day period. Consistent with the Omnibus Budget Reconciliation Act of 1989 §6403, medically necessary psychiatric services shall be covered when prior authorized by DMAS for individuals younger than 19 year of age when the need for such services has been identified through an EPSDT screen. D. Physician visits to inpatient hospital patients are limited to medically necessary days of inpatient hospitalization. E. Psychological testing and psychotherapy by clinical psychologists licensed by the State Board of Medicine.

STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

STATE: Virginia Page 6-34

Effective Date: 07/01/05

34 Approval Date: _____________/06 F. Reimbursement will not be provided for physician services performed in the inpatient setting for those surgical or diagnostic procedures listed on the mandatory outpatient surgery list unless the service is medically justified or meets one of the exceptions. G. For purposes of organ transplantation, all similarly situated individuals will be treated alike. Experimental or investigational procedures are not covered.

6.2.4.A ⌧ Surgical services (Section 2110(a)(4))

A. Medical surgical services - Medically necessary surgical services are covered. Elective surgery is defined as procedures not medically necessary to restore or materially improve a body function. Elective and cosmetic surgical procedures are not covered unless performed for physiological reasons and require preauthorization. B. See physician services above for organ transplantation. Breast reconstruction/prostheses following mastectomy and breast reduction may be covered if preauthorized following the medically necessary complete or partial removal of a breast for any medical reason. Breast reductions shall be covered, if prior authorized for all medically necessary indications. Such procedures shall be considered non-cosmetic. 6.2.5.A ⌧ Clinic services (including health center services) and other ambulatory health care services. (Section 2110(a)(5))

Clinic services means preventive, diagnostic, therapeutic, rehabilitative, or palliative items of services that are provided to outpatients by a facility that is not part of a hospital but is organized and operated to provide medical care to outpatients and are furnished by or under the direction of a physician or dentist.

6.2.6.A ⌧ Prescription drugs (Section 2110(a)(6)) A. Drugs for which Federal Financial Participation is not available pursuant to the requirements of §1927 of the Social Security Act shall not be covered. Legend drugs, with the exception of the drugs or classes of drugs provided for in Supplement 5 of the Medicaid State Plan are covered. Coverage of drugs used for weight loss requires prior authorization. Prescriptions for recipients for specific multiple source drugs shall be filled with generic drug products unless the physician or other practitioners so licensed and certified to prescribe drugs certifies “brand necessary”. The number of refills shall be limited pursuant to the Drug Control Act, Code of Virginia Title §54.1-3411.

STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

STATE: Virginia Page 6-35

Effective Date: 07/01/05

35 Approval Date: _____________/06 B. Coverage includes home infusion therapy which is covered consistent with limits and requirements set out within home health services.

C. Effective June 1, 2004, pursuant to § 1927 of the Act and 42 CFR § 440.230, the Department shall require the prior authorization of legend drugs when both institutionalized and non-institutionalized FAMIS enrollees are prescribed high numbers of legend drugs. Over-the-counter drugs and legend drug refills shall not count as a unique prescription for the purposes of prior authorization as it relates to the threshold program.

Prior authorization shall be required for non-institutionalized FAMIS enrollees whose current volume of prescriptions meet the identified threshold limits as defined by the agency’s guidance documents for pharmacy utilization review, limitations, and the prior authorization program. All recipients subject to these prior authorization limits shall be given advance notice of such limits and shall be advised of their rights to appeal. Such appeals shall be considered and responded to pursuant to 12 VAC 30-110-10 et. seq.

Prior authorization shall be required for institutionalized FAMIS enrollees whose current volume of prescriptions meet the identified threshold limits as defined by the agency’s guidance documents for pharmacy utilization review, limitations, and prior authorization program. All recipients subject to these prior authorization limits shall be given advance notice of such limits and shall be advised of their rights to appeal. Such appeals shall be considered and responded to pursuant to 12 VAC 30-110-10 et. seq.

Prior authorization shall consist of prospective and retrospective drug therapy review by a licensed pharmacist to ensure that all predetermined clinically appropriate criteria, as established by the department, have been met before the prescription may be dispensed. Prior authorization shall be obtained through a call center staffed with appropriate clinicians, or through written or electronic communications (e.g., faxes, mail). Responses by telephone or other telecommunications device within 24 hours of a request for prior authorization shall be provided. The dispensing of 72-hour emergency supplies of the prescribed drug may be permitted and dispensing fees shall be paid to the pharmacy for such emergency supply.

Exclusion of protected institutions from pharmacy threshold prior authorization. For the purposes of threshold prior authorization, nursing facility residents do not include residents of the Commonwealth’s mental retardation training centers. For the purposes of threshold prior

STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

STATE: Virginia Page 6-36

Effective Date: 07/01/05

36 Approval Date: _____________/06 authorization, non-institutionalized recipients do not include recipients of services at Hiram Davis Medical Center.

6.2.7.A ⌧ Over-the-counter medications (Section 2110(a)(7)) Non-legend drugs shall be covered for insulin, syringes and needles, and diabetic test strips and family planning supplies. Designated non-legend drugs which are prescribed by licensed prescribers to be used as less expensive therapeutic alternatives to covered legend drugs are also covered. Designated categories of non-legend drugs for recipients in nursing homes are covered.

6.2.8.A ⌧ Laboratory and radiological services (Section 2110(a)(8))

Services must be ordered or prescribed and directed or performed within the scope of a license of the practitioner of the healing arts.

Effective 08-01-03, prior authorization of the following specific high-cost non- emergency outpatient procedures is required: Magnetic Resonance Imaging (MRI), Computer Axial Tomography (CAT) Scans and Positron Emission Tomography (PET) Scans.

6.2.9.A ⌧ Prenatal care and prepregnancy family services and supplies (Section 2110(a)(9)) A. Family planning services and supplies for individuals of child-bearing age must be ordered or prescribed and directed or performed within the scope of the license of a practitioner of the healing arts. Family planning services shall be defined as those services which delay or prevent pregnancy. Such services shall not include services to treat infertility or services to promote fertility. B. Pregnancy-related and postpartum services shall be covered for any medical condition that may complicate pregnancy if otherwise covered under the Title XXI state plan. Enhanced prenatal care services include nutrition, patient education, homemaker services, blood glucose meters (including test strips). 6.2.10.A ⌧ Inpatient mental health services, other than services described in 6.2.18., but including services furnished in a state-operated mental hospital and including residential or other 24-hour therapeutically planned structural services (Section 2110(a)(10)) Inpatient mental health services will be offered in general acute care hospitals.

STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

STATE: Virginia Page 6-37

Effective Date: 07/01/05

37 Approval Date: _____________/06 6.2.11.A ⌧ Outpatient mental health services, other than services described in 6.2.19, but including services furnished in a state-operated mental hospital and including community-based services (Section 2110(a)(11)

A. Psychiatric services are limited to an initial availability of 26 sessions without prior authorization during the first year of treatment. An additional extension of up to 47 sessions during the first treatment year must be prior authorized by DMAS. The availability is further restricted to no more than 26 sessions each succeeding year when approved by DMAS. Psychiatric services are further restricted to no more than three sessions in any given seven-day period. Consistent with the Omnibus Budget Reconciliation Act of 1989 §6403, medically necessary psychiatric services shall be covered when prior authorized by DMAS for individuals younger than 19 year of age when the need for such services has been identified through an EPSDT screen. B. Community Mental Health Services: 1. Intensive in-home services to children and adolescents under age 19 - Shall be time-limited interventions provided typically but not solely in the residence of a child who is at risk of being moved into an out-of-home placement or who is being transitioned to home from out-of-home placement due to a documented medical need of the child. These services provide crisis treatment; individual and family counseling; and communication skills (e.g., counseling to assist the child and his parents to understand and practice appropriate problem- solving, anger management, and interpersonal interaction, etc.); case management activities and coordination with other required services; and 24- hour emergency response. These services shall be limited annually to 26 weeks. Services must be directed toward the treatment of the eligible child and delivered primarily in the family's residence with the child present.

2 Therapeutic day treatment for children and adolescents - Provides evaluation; medication; education and management; opportunities to learn and use daily living skills and to enhance social and interpersonal skills (e.g., problem-solving, anger management, community responsibility, increased impulse control, and appropriate peer relations, etc.); and individual, group and family psychotherapy. The service shall be provided two or more hours per day in order to provide therapeutic interventions. Services are limited annually to 780 units: one unit of service is defined as a minimum of two hours but less than three hours in a given day. Two units of service shall be defined as a minimum of three but less than five hours in a given day. Three units of service shall be defined as five or more hours of service in a given day.

3. Day Treatment/Partial Hospitalization - Day treatment/partial

STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

STATE: Virginia Page 6-38

Effective Date: 07/01/05

38 Approval Date: _____________/06 hospitalization services shall be provided in sessions of two or more consecutive hours per day, which may be scheduled multiple times per week, to groups of individuals in a nonresidential setting. These services, limited annually to 780 units, include the major diagnostic, medical, psychiatric, psychosocial and psychoeducational treatment modalities designed for individuals who require coordinated, intensive, comprehensive, and multidisciplinary treatment but who do not require inpatient treatment

4. Psychosocial Rehabilitation - Psychosocial rehabilitation shall be provided at least two or more hours per day to groups of individuals in a nonresidential setting. These services, limited annually to 936 units, include assessment, education to teach the patient about the diagnosed mental illness and appropriate medications to avoid complication and relapse, opportunities to learn and use independent living skills and to enhance social and interpersonal skills within a supportive and normalizing program structure and environment.

5. Crisis Intervention - Crisis intervention shall provide immediate mental health care, available 24 hours a day, seven days per week, to assist individuals who are experiencing acute psychiatric dysfunction requiring immediate clinical attention. Crisis intervention activities, are limited annually to 720 units per year (a unit equals 15 minutes) and shall include assessing the crisis situation, providing short-term counseling designed to stabilize the individual, providing access to further immediate assessment and follow-up, and linking the individual and family with ongoing care to prevent future crises. Crisis intervention services may include office visits, home visits, preadmission screenings, telephone contacts, and other client-related activities for the prevention of institutionalization.

6. Mental Health Crisis Stabilization - Crisis stabilization services for non- hospitalized individuals shall provide direct mental health care to individuals experiencing an acute psychiatric crisis which may jeopardize their current community living situation. The maximum limit on this service is up to eight hours (with a unit being one hour) per day up to 60 days annually.

7. Mental Health Support - Mental health support services shall be defined as training and supports to enable individuals to achieve and maintain community stability and independence in the most appropriate, least restrictive environment. These services may be authorized for six consecutive months. This program shall provides the following services: training in or reinforcement of functional skills and appropriate behavior related to the individual's health and safety, activities of daily living, and use of community resources; assistance with medication management; and monitoring health, nutrition, and physical

STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

STATE: Virginia Page 6-39

Effective Date: 07/01/05

39 Approval Date: _____________/06 condition. The yearly limit for mental health support services is 372 units.

8. Intensive Community Treatment- Medical psychotherapy, psychiatric assessment, medication management, and case management activities offered to outpatients outside the clinic, hospital, or office setting for individuals who are best served in the community. The annual unit limit shall be 130 units.

9. Case Management - Case management services for youth at risk of serious emotional disturbance and who meet the definition of Seriously Emotionally Disturbed. Case management services assist youth at risk of serious emotional disturbance and with a diagnosis of Serious Emotional Disturbance in accessing needed medical, psychiatric, social, educational, vocational, and other supports essential to meeting basic needs. Services to be provided include: Assessment and planning, linking the individual directly to services and supports, assisting the individual directly for the purpose of locating, developing or obtaining needed service and resources, coordinating services and service planning, enhancing community integration, making collateral contacts, follow up and monitoring, and education and counseling. 6.2.12.A ⌧ Durable medical equipment and other medically-related or remedial devices (such as prosthetic devices, implants, eyeglasses, hearing aids, dental devices, and adaptive devices) (Section 2110(a)(12)) Prosthetic devices for the replacement of missing arms, legs and breasts and the provision of any internal (implant) body part shall be covered. Prosthetic devices (artificial arms and legs, and their necessary supportive attachments; implants and breasts) are provided when prescribed by a physician or other licensed practitioner of the healing arts within the scope of their professional license. This service when provided by an authorized vendor, must be medically necessary and preauthorized for the minimum applicable component necessary for the activities of daily living.

6.2.13.A ⌧ Disposable medical supplies (Section 2110(a)(13))

Medical supplies, equipment and appliances suitable for use in the home. All medically necessary medical supplies, equipment, and appliances are covered for recipients. Unusual amounts, types and duration of usage must be authorized by DMAS. When cost-effective, payment may be made for rental of the equipment in lieu of purchase. Prosthetics which are preauthorized shall be covered. Supplies, equipment that are not covered are: space conditioning equipment, equipment and supplies for any hospital or nursing facility resident, except for ventilators and associated supplies for nursing facility residents; furniture or

STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

STATE: Virginia Page 6-40

Effective Date: 07/01/05

40 Approval Date: _____________/06 appliances not defined as medical equipment; items that are only for the recipient’s comfort and convenience.

6.2.14.A ⌧ Home and community-based health care services (See instructions) (Section 2110(a)(14)) A. Home Health Services: Intermittent or part-time nursing service provided by a home health agency or by a registered nurse when no home health agency exists in the area. Effective 08-01-2003, home health services are limited to five visits without prior authorization in each state fiscal year. Service extensions beyond the initial five visits must be prior-authorized. Limits are per recipient, regardless of the number of providers rendering services. If services beyond these limitations are determined by the physician to be required, then the provider shall request prior authorization from DMAS for additional services. B. Home Health Aide services provided by a home health agency. Home health aides must function under the supervision of a professional nurse. Home health aides must meet the federal certification requirements. Patient may receive up to 32 visits annually.

6.2.15.A ⌧ Nursing care services (See instructions) (Section 2110(a)(15))

Intermittent or part-time nursing service provided by a home health agency; Nurse mid-wife services allowed under licensure requirements of Virginia and federal law; skilled nursing services provided in schools to special education students.

Private duty nursing services are not covered.

6.2.16.A ⌧ Abortion only if necessary to save the life of the mother or if the pregnancy is the result of an act of rape or incest (Section 2110(a)(16) Abortion only if necessary to save the life of the mother.

6.2.17.A ⌧ Dental services (Section 2110(a)(17)) A. Routine diagnostic, preventive or restorative procedures necessary for oral health provided by or under the direct supervision of a dentist in accordance with the State Dental Practice Act. B. Initial, periodic and emergency examinations; required radiography necessary to develop a treatment plan; patient education; dental prophylaxis;

STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

STATE: Virginia Page 6-41

Effective Date: 07/01/05

41 Approval Date: _____________/06 fluoride treatments; routine amalgam and composite restorations; stainless steel crowns, prefabricated steel post, temporary (polycarbonate crowns) and stainless steel bands; crown recementation; pulp capping; sedative fillings; therapeutic apical closure; topical palliative treatment for dental pain; removal of foreign body; simple extractions; root recovery; incision and drainage of abscess; surgical exposure of the tooth to aid eruption; sequestrectomy for osteomyelitis; and oral antral fistula closure are dental services covered without preauthorization. C. All covered dental services not referenced above require preauthorization by DMAS. The following services are also covered through preauthorization: medically necessary full banded orthodontics, tooth guidance appliances, complete and partial dentures, surgical preparation (alveoloplasty for prosthetics, single permanent crowns and bridges. D. Routine bases under restorations and inhalation analgesia are not covered. E. Examinations prophylaxis, fluoride treatment (one each six months); space maintenance appliance; bitewing x-ray - two films each 12 months; routine amalgam and composite restorations once each three years; dentures once each five years; extractions, orthodontics, tooth guidance appliances, permanent crowns and bridges, endodontics, patient education and sealants - one time. F. Limited oral surgery procedures, as defined and covered by Medicare when preauthorized. G. Provided only as a result of EPSDT and subject to medical necessity and preauthorization requirements specified under Dental Services.

6.2.18.A ⌧ Inpatient substance abuse treatment services and residential substance abuse treatment services (Section 2110(a)(18)) Residential treatment for pregnant women. The treatment facility shall not be an institution for mental disease.

6.2.19.A ⌧ Outpatient substance abuse treatment services (Section 2110(a)(19)) Group and individual counseling. Limitation of up to 26 sessions annually. If medically necessary, additional sessions may be preauthorized. Services must be rendered by a certified or licensed provider. Day treatment for pregnant women.

STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

STATE: Virginia Page 6-42

Effective Date: 07/01/05

42 Approval Date: _____________/06

6.2.20.A ⌧ Case management services (Section 2110(a)(20)) Targeted case management for high risk pregnant women and infants up to age 2; individuals with mental retardation; children with serious emotional disturbance and youth at risk for serious emotional disturbance; and children with behavioral disorder or emotional disturbances who are referred to treatment foster care by the Family Assessment and Planning Team of Comprehensive Services Act for Youth and Family.

6.2.21.A Care coordination services (Section 2110(a)(21))

May be a component of another service.

6.2.22.A ⌧ Physical therapy, occupational therapy, and services for individuals with speech, hearing, and language disorders (Section 2110(a)(22))

Effective 08-01-03, home health and outpatient rehabilitation services are limited to five visits for each rehabilitative therapy without prior authorization in each state fiscal year. Service extensions beyond the initial five visits must be prior- authorized. A. Under home health, physical therapy, occupational therapy, or speech pathology and audiology services provided by a home health agency or medical rehabilitation facility covered as ordered by a physician in consultation with a physical therapist who has been licensed by the Board of Medicine. Limits shall apply per recipient regardless of the number of providers rendering services. Annually shall be defined as July 1 through June 30 for each recipient. If the physician determines that additional services are needed, the provider shall request prior authorization. B. Physical therapy and related services:

1. Services for individuals requiring physical therapy are provided only as an element of hospital inpatient or outpatient services, nursing facility service, home health service, or when otherwise included as an authorized service by a cost provider who provides rehabilitation services.

2. The services shall be of a level of complexity and sophistication, or the condition of the patient shall be of a nature that the services can

STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

STATE: Virginia Page 6-43

Effective Date: 07/01/05

43 Approval Date: _____________/06 only be performed by a physical therapist licensed by the Board of Medicine or a physical therapy assistant who is licensed by the Board of Medicine and under the supervision of a qualified physical therapist who makes an onsite supervisory visit at least once every 30 days. This visit shall not be reimbursable. C. Occupational therapy: Services for individuals requiring occupational therapy are provided only as an element of hospital inpatient or outpatient service, nursing facility service, home health service, or when otherwise included as an authorized service by a provider who provides rehabilitation services. Services shall meet all of the following conditions: services shall be directly and specifically related to an active written plan of care designed by a physician after consultation with an occupational therapist registered and certified by the American Occupational Therapy Certification Board; shall be of a level of complexity and sophistication, or the condition of the patient shall be of a nature that the services can only be performed by a qualified occupational therapist. The amount, frequency and duration of the services shall be reasonable. D. Services for individuals with speech, hearing and language disorders. Services must be provided by or under the supervision of a speech pathologist or an audiologist only as an element of hospital inpatient or outpatient service, nursing facility service, home health service, or when otherwise included as an authorized service by a cost provider who provides rehabilitative services. Services shall be directly and specifically related to an active written treatment plan designed by a physician after any needed consultation with a speech-language pathologist licensed by the Board of Speech/Language Pathology, or, if exempt from state licensure, meets the requirements in 42 CFR 405.1719(c). The services shall be of a level of complexity and sophistication or the patient’s condition be of a nature that the services can only be performed by or under the direction of a qualified speech- language pathologist. The amount, frequency and duration of the services shall be reasonable.

6.2.23.A ⌧ Hospice care (Section 2110(a)(23)) A. Defined as those services allowed under the provisions of Medicare law and regulations as they relate to hospice benefits and as specified in the Code of Federal Regulations, Title 42, Part 418. Hospice services shall entail the following four categories of daily care: 1. Routine home care (at-home care that is not continuous). 2. Continuous home care consists of at-home care that is

STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

STATE: Virginia Page 6-44

Effective Date: 07/01/05

44 Approval Date: _____________/06 predominantly nursing care and is provided as short-term crisis care. A registered or licensed practical nurse must provide care for more than half of the period of the care. Home health aide or homemaker services may be provided in addition to nursing care. A minimum of 8 hours of care per day must be provided to qualify as continuous home care. 3. Inpatient respite care, which is short-term inpatient care, provided in an approved facility to relieve the primary caregiver. Respite care is limited to not more than five consecutive days. 4. General inpatient care may be provided in an approved freestanding hospice, hospital, or nursing facility. This care is usually for pain control or acute or chronic symptom management which cannot be successfully treated in another setting. B. The hospice must provide all or substantially all of the “core” services applicable for the terminal illness which are nursing care, social work and counseling. Other services are drugs and biologicals, home health aide and homemaker services, inpatient care, medical supplies, and occupational and physical therapies and speech-language pathology services. C. Other services available for the terminal illness that shall be available but are not considered “core” services are physician services, drugs and biologicals, home health aide and homemaker services, inpatient care, medical supplies, and occupational and physical therapies and speech-language/pathology services, and any other item or service which is specified under the plan and which is reasonable and necessary for the palliation and management of terminal illness and for which payment may otherwise be made under Title XIX. These other services may be arranged, such as by contractual agreement, or provided directly by the hospice. D. A certification that the person is terminally ill must have been completed by the physician and hospice services must be reasonable and necessary for the palliation or management of the terminal illness and related conditions. The individual must elect hospice care and the plan of care must be established before the services are provided.

6.2.24.A ⌧ Any other medical, diagnostic, screening, preventive, restorative, remedial, therapeutic, or rehabilitative services. (See instructions) (Section 2110(a)(24)) A. Intensive physical rehabilitation in facilities certified as rehabilitative hospitals or rehabilitation hospitals which meet the requirements to be excluded from the Medicare PPS system and in CORFs. An intensive physical rehabilitation program provides intensive skilled rehabilitation, nursing, physical therapy, occupational therapy, and speech therapy, cognitive rehabilitation,

STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

STATE: Virginia Page 6-45

Effective Date: 07/01/05

45 Approval Date: _____________/06 prosthetic-orthotic services, psychology, social work, and therapeutic recreation.

B. Optometrist: Diagnostic examination and optometric treatment procedures and services by ophthalmologists, optometrists, and opticians, as allowed by the Code of VA and by regulations of the Boards of Medicine and of Optometry, are covered. Routine refractions are limited to once in 24 months except as may be authorized by DMAS. C. Podiatrists: Covered podiatry services are defined as reasonable and necessary diagnostic, medical, or surgical treatment of disease, injury, or defects of the human foot. These services must be within the scope of the license of the podiatrists’ profession and defined by State law. The following services are not covered: preventive health care, including routine foot care: treatment of structural misalignment not requiring surgery; cutting or removal of corns, warts, or calluses; experimental procedures; acupuncture. D. Nursing facility services in a Medicaid certified facility (other than in an IMD). E. Nurse-midwife services- defined as those services allowed under the licensure requirements of the state statute and as specified in the Social Security Act. F. Disease Management Program with benefits that are essentially the same as the state’s Title XIX Plan.

6.2.25.A ⌧ Premiums for private health care insurance coverage (Section 2110(a)(25))

6.2.26.A ⌧ Medical transportation (Section 2110(a)(26)) Transportation services are provided to ensure that recipients have necessary access to and from providers of all covered medical services. Transportation to both emergency and nonemergency services are covered. 6.2.27.A Enabling services (such as transportation, translation, and outreach services (See instructions) (Section 2110(a)(27))

6.2.28.A ⌧ Any other health care services or items specified by the Secretary and not included under this section (Section 2110(a)(28))

STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

STATE: Virginia Page 6-46

Effective Date: 07/01/05

46 Approval Date: _____________/06

A. Early and Periodic Screening, Diagnosis, and Treatment (EPSDT). Consistent with the Omnibus Budget Reconciliation Act of 1989 §6403, Early and Periodic Screening, Diagnostic, and Treatment services means the following services: screening services, vision services, dental services, hearing services, and such other necessary health care, diagnostic services, treatment, and other measures described in Social Security Act §1905(a) to correct or ameliorate defects and physical and mental illnesses and conditions discovered by the screening services and which are medically necessary, whether or not such services are covered under the Virginia Title XIX State Plan subject to the requirements and limits of Title XXI.

B. Physical therapy, occupational therapy, speech language pathology, skilled nursing services, and psychology/psychiatry services for special education students. The Department reimburses the school divisions directly for these services.

6.3 The state assures that, with respect to pre-existing medical conditions, one of the following two statements applies to its plan: (42CFR 457.480)

6.3.1. ⌧ The state shall not permit the imposition of any pre-existing medical condition exclusion for covered services (Section 2102(b)(1)(B)(ii)); OR

6.3.2. The state contracts with a group health plan or group health insurance coverage, or contracts with a group health plan to provide family coverage under a waiver (see Section 6.4.2. of the template). Pre-existing medical conditions are permitted to the extent allowed by HIPAA/ERISA (Section 2103(f)). Please describe: Previously 8.6

STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

STATE: Virginia Page 6-47

Effective Date: 07/01/05

47 Approval Date: _____________/06 6.4 Additional Purchase Options. If the state wishes to provide services under the plan through cost effective alternatives or the purchase of family coverage, it must request the appropriate option. To be approved, the state must address the following: (Section 2105(c)(2) and(3)) (42 CFR 457.1005 and 457.1010)

6.4.1. Cost Effective Coverage. Payment may be made to a state in excess of the 10% limitation on use of funds for payments for: 1) other child health assistance for targeted low-income children; 2) expenditures for health services initiatives under the plan for improving the health of children (including targeted low-income children and other low-income children); 3) expenditures for outreach activities as provided in section 2102(c)(1) under the plan; and 4) other reasonable costs incurred by the state to administer the plan, if it demonstrates the following (42CFR 457.1005(a)):

6.4.1.1. Coverage provided to targeted low-income children through such expenditures must meet the coverage requirements above. Describe the coverage provided by the alternative delivery system. The state may cross reference section 6.2.1 - 6.2.28. (Section 2105(c)(2)(B)(i)) (42CFR 457.1005(b))

6.4.1.2. The cost of such coverage must not be greater, on an average per child basis, than the cost of coverage that would otherwise be provided for the coverage described above. Describe the cost of such coverage on an average per child basis. (Section 2105(c)(2)(B)(ii)) (42CFR 457.1005(b))

6.4.1.3. The coverage must be provided through the use of a community-based health delivery system, such as through contracts with health centers receiving funds under section 330 of the Public Health Service Act or with hospitals such as those that receive disproportionate share payment adjustments under section 1886(c)(5)(F) or 1923 of the Social Security Act. Describe the community based delivery system. (Section 2105(c)(2)(B)(iii)) (42CFR 457.1005(a))

6.4.2. Purchase of Family Coverage. Describe the plan to purchase family coverage. Payment may be made to a state for the purpose of family coverage under a group health plan or health insurance coverage that includes coverage of targeted low- income children, if it demonstrates the following: (Section 2105(c)(3)) (42CFR 457.1010)

STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

STATE: Virginia Page 6-48

Effective Date: 07/01/05

48 Approval Date: _____________/06

The families of targeted low-income children who have access to health insurance through their employer may be eligible for premium assistance for the purchase of their employer-sponsored health insurance if certain conditions are met. However, the goal of the FAMIS Plan is to provide coverage for eligible children under their parents' employer-sponsored plan. Any coverage of individuals not eligible for FAMIS is incidental.

6.4.2.1. Purchase of family coverage is cost-effective relative to the amounts that the state would have paid to obtain comparable coverage only of the targeted low-income children involved; and (Describe the associated costs for purchasing the family coverage relative to the coverage for the low income children.) (Section 2105(c)(3)(A)) (42CFR 457.1010(a))

6.4.2.2. The state assures that the family coverage would not otherwise substitute for health insurance coverage that would be provided to such children but for the purchase of family coverage. (Section 2105(c)(3)(B)) (42CFR 457.1010(b))

6.4.2.3. The state assures that the coverage for the family otherwise meets title XXI requirements. (42CFR 457.1010(c))

STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

STATE: Virginia Page 7-49

Effective Date: 07/01/05

49 Approval Date: _____________/06 Section 7. Quality and Appropriateness of Care

Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan, and continue on to Section 8.

7.1. Describe the methods (including external and internal monitoring) used to assure the quality and appropriateness of care, particularly with respect to well-baby care, well-child care, and immunizations provided under the plan. (2102(a)(7)(A)) (42CFR 457.495(a))

The Commonwealth will use numerous methods to assure that FAMIS recipients receive quality services that are appropriate to their needs. These methods may include the following:

• Verification that the health insurers develop and maintain quality assurance and quality improvement programs. • Verification that health insurers have sufficient network providers and procedures to ensure that children have access to routine, urgent, and emergency services. • Verification that health insurers maintain a member complaint system and provide access to a grievance process to appeal a plan action.

Will the state utilize any of the following tools to assure quality? (Check all that apply and describe the activities for any categories utilized.)

7.1.1. ⌧ Quality standards

Health insurers are required to follow standards established by the Commonwealth in the development and maintenance of their quality improvement programs.

7.1.2. ⌧ Performance measurement

A. Submission of a quality improvement plan.

B. Adherence to NCQA, JCAHO, or other nationally recognized accrediting organization.

C. Results of HEDIS or other.

D. CAHPS Survey.

E. Clinical focus studies.

STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

STATE: Virginia Page 7-50

Effective Date: 07/01/05

50 Approval Date: _____________/06

7.1.3. ⌧ Information strategies

Each managed care organization will establish a system to monitor compliance with access standards set forth by DMAS and a data management system to meet DMAS data collection requirements. DMAS annually requires managed care organization to report the percentage of children who received all expected well- child care visits according to the benefits schedule, during the period that each child was enrolled and the percent of two-year old children who have received each immunization specified in the most current ACIP recommendations.

7.1.4. ⌧ Quality improvement strategies

Health insurers may perform the following:

A. Documentation of current MCHIP quality certification or documentation of a comparable accreditation

B. Develop and maintain a Quality Improvement Program (QIP) which meets standards and reporting requirements set out by the Commonwealth.

C. Cooperate and show compliance with the DMAS Quality Improvement Program, which may require calculation and reporting of performance measures and the implementation of performance improvement projects as well as cooperate with DMAS or a designated agent in conducting quality reviews. Managed care organizations are required to have a written utilization management (UM) program that reflects the National Committee for Quality Assurance standards to include mechanisms to detect under-utilization and/or over-utilization of care. Managed care organizations must show implementation of an approved system to monitor and address complaints and grievances.

7.2. Describe the methods used, including monitoring, to assure: (2102(a)(7)(B)) (42CFR 457.495)

7.2.1 Access to well-baby care, well-child care, well-adolescent care and childhood and adolescent immunizations. (Section 2102(a)(7)) (42CFR 457.495(a))

Each MCO and PCCM provider will meet the requirements by the contract with DMAS to ensure access to well baby care, well adolescent care, and childhood immunizations. By contract MCOs and PCCM providers are responsible for arranging and administering

STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

STATE: Virginia Page 7-51

Effective Date: 07/01/05

51 Approval Date: _____________/06 covered services to enrollees and ensuring that the delivery system provides available, accessible and adequate numbers of facilities, locations and personnel for the provision of covered services. The MCO and PCCM provider provides or otherwise arranges care by providers specializing in early childhood youth services. MCOs and PCCM providers provide services as established by recognized clinically approved guidelines for standards of care. MCOs and PCCM providers ensure that immunizations are rendered in accordance with the most current Advisory Committee on Immunization Practices (ACIP) or the American Academy of Pediatrics Advisory Committee recommendations.

7.2.2 Access to covered services, including emergency services as defined in 42 CFR 457.10. (Section 2102(a)(7)) 42CFR 457.495(b))

Health insurers are required to demonstrate their ability to monitor network capacity throughout their service area for routine, urgent, and emergency care. The Commonwealth establishes standards and reporting requirements for access to routine, urgent, and emergency care. The health plans are solely responsible for arranging for and administering covered services to enrollees and ensuring that its delivery system provides available, accessible and adequate numbers of facilities, locations and personnel for the provision of covered services. The health plan must include in its network or otherwise arrange care by providers specializing in early childhood, youth services.

7.2.3 Appropriate and timely procedures to monitor and treat enrollees with chronic, complex, or serious medical conditions, including access to an adequate number of visits to specialists experienced in treating the specific medical condition and access to out-of-network providers when the network is not adequate for the enrollee’s medical condition. (Section 2102(a)(7)) (42CFR 457.495(c))

The State’s Disease Management program monitors and promotes appropriate and timely treatment for enrollees with chronic, complex or serious medical conditions.

The State monitors complaints pertaining to access to care received by DMAS, the Central Processing Unit, the MCOs or the PCCM providers with regard to access to care.

Children with special health care needs are not considered a separate population or as a special population under the FAMIS State Plan. MCOs and PCCM providers provide access to all covered services, including specialty service to any child regardless of the medical condition

Each provider must arrange to provide care according to established appointment standards and meet requirements determined by the contract for the monitoring and reporting access to services, timeliness of services, appropriateness of services for all enrollees including those with chronic, complex or serious medical conditions. The

STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

STATE: Virginia Page 7-52

Effective Date: 07/01/05

52 Approval Date: _____________/06 MCO or PCCM provider is responsible for the provision of services regardless if a medical condition and/or diagnosis was present prior to being assigned the enrollee, thus the MCO or PCCM provider will manage all pre-existing conditions. The health plans provide access to all covered services, including specialty services, to any child regardless of medical condition. MCOs cover and pay for services furnished in facilities or by practitioners outside the plan’s network if the needed medical services or necessary supplementary resources are not available in the plan’s network.

MCOs and PCCM providers are not permitted to refuse an assignment or disenroll a patient or otherwise discriminate against a patient based on physical or mental handicap or type of illness or condition.

7.2.4 Decisions related to the prior authorization of health services are completed in accordance with state law or, in accordance with the medical needs of the patient, within 14 days after the receipt of a request for services. (Section 2102(a)(7)) (42CFR 457.495(d))

Prior authorization of health decisions will be made in accordance with State law consistent with the standards set by the regulations governing managed care health insurance plans.

STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

STATE: Virginia Page 8-53

Effective Date: 07/01/05

53 Approval Date: _____________/06 Section 8. Cost Sharing and Payment (Section 2103(e))

Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan, and continue on to Section 9.

8.1. Is cost-sharing imposed on any of the children covered under the plan? (42CFR 457.505)

8.1.1. ⌧ YES 8.1.2. NO, skip to question 8.8.

STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

STATE: Virginia Page 8-54

Effective Date: 07/01/05

54 Approval Date: _____________/06 8.2. Describe the amount of cost-sharing, any sliding scale based on income, the group or groups of enrollees that may be subject to the charge and the service for which the charge is imposed or time period for the charge, as appropriate. (Section 2103(e)(1)(A)) (42CFR 457.505(a), 457.510(b) &(c), 457.515(a)&(c))

No cost-sharing will be charged to American Indians and Alaska Natives.

8.2.1. Premiums:

None.

8.2.2. Deductibles:

None.

8.2.3. Coinsurance or copayments:

Co-payments shall not be imposed on any of the children covered under the Secretary- approved coverage offered through the fee-for service program and the PCCM program. No co-payments are required for well-baby and well-child and other preventive services, and families for Secretary-approved coverage modeled after the state employee plan.

Income levels are provided as a percentage of Federal Poverty Level ("FPL") based on gross income. The FPL reflects changes made effective February 13, 2004.

Copayments for Secretary-approved coverage modeled after the state employee plan are:

Description of Service ≤ 150% FPL > 150% FPL Outpatient $2 per visit $5 per visit Prescription Drugs $2 per prescription $5 per prescription Inpatient $15 per admission $25 per admission Non-Emergency use of Emergency Room $10 per visit $25 per visit

Poverty Levels ≤ 150% FPL > 150% FPL Maximum Yearly Co- Payment Limit Per Family

$180

$350

Total cost-sharing for each year (or 12-month eligibility period) is limited to: (1) for a

STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

STATE: Virginia Page 8-55

Effective Date: 07/01/05

55 Approval Date: _____________/06 family with an annual income equal to or less than 150% of the FPL, the lesser of (a) 2.5% of a family’s income, and (b) $180.00; and (2) for a family with an annual income greater than 150% of the FPL, the lesser of (a) 5% of a family’s income, and (b) $350.00.

The co-payment and coinsurance maximums are set at thresholds that are well below the maximum allowable per CMS for families with annual incomes equal to or below 150% of FPL and for those with annual incomes above 150%. The maximum yearly co- payment limit for families in FAMIS with annual incomes at or below 150% FPL is $180.00 per year. Families enrolled in FAMIS and receiving benefits through FAMIS contracted health plans are advised of the amount of maximum allowable cost-sharing that they may be responsible for during the year. Families are required to submit documentation to DMAS or its contractor, showing that the co-payment cap is met for the year. Once the cap is met, DMAS or its contractor will issue a new card excluding families from paying additional co-pays.

Enrollees are not held liable for any additional costs, beyond the standard co-payment amount for emergency services furnished outside of the individual’s managed care network. Only one co-payment charge is imposed for a single office visit.

The proposed cost sharing caps to be applied toward copayments and/or coinsurance ($180 and $350) were included in the Plan document.

No cost-sharing will be charged to American Indians and Alaska Natives.

8.2.4. Other

8.3. Describe how the public will be notified, including the public schedule, of this cost- sharing (including the cumulative maximum) and changes to these amounts and any differences based on income. (Section 2103(e)((1)(B)) (42CFR 457.505(b))

The public is notified of FAMIS’ cost-sharing requirements, including differences based on income and plans, in the outreach and enrollment materials.

• Web site; • Handbook; • The public also has the opportunity to become involved during the regulatory process. Implementing regulations must go through a mandatory 60-day comment period consistent with the Code of Virginia; • Outreach Oversight Committee; • Managed care organization member handbooks; and • Outreach grantees.

STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

STATE: Virginia Page 8-56

Effective Date: 07/01/05

56 Approval Date: _____________/06 No cost-sharing is charged to American Indians and Alaska Natives. The application form requests racial information on each child for whom application for child health insurance is made. No cost-sharing is imposed on those children who are reported to be Native American or Alaska Native. The applicant’s statement on the application form is sufficient to exempt the child from any cost-sharing obligations. The FAMIS automated eligibility determination system codes the case records for children listed on the application form as Alaska Natives or American Indians and the automated record will exempt such children from any cost-sharing obligations.

FAMIS accommodates the federal requirement that Native American families are exempt from any cost-sharing provisions under CHIP. The FAMIS application inquires as to a child’s race. If a family declares that a child is a Native American or Alaska Native, the family will be exempt from cost-sharing obligations.

Virginia has no federally recognized Indian tribes; however, ongoing communication will occur with Indian tribes in Virginia to ensure that Indian families understand the program and can access the provider network to secure covered services.

Effective April 15, 2002, Virginia temporarily suspended premiums until further notice. FAMIS families were notified by letter, informing them of the suspension of premiums and copies of such letters were posted on the DMAS web site. Effective September 1, 2002, the FAMIS program no longer charged premiums.

STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

STATE: Virginia Page 8-57

Effective Date: 07/01/05

57 Approval Date: _____________/06 8.4. The state assures that it has made the following findings with respect to the cost sharing in its plan: (Section 2103(e))

8.4.1. ⌧ Cost-sharing does not favor children from higher income families over lower income families. (Section 2103(e)(1)(B)) (42CFR 457.530) 8.4.2. ⌧ No cost-sharing applies to well-baby and well-child care, including age-appropriate immunizations. (Section 2103(e)(2)) (42CFR 457.520) 8.4.3 ⌧ No additional cost-sharing applies to the costs of emergency medical services delivered outside the network. (Section 2103(e)(1)(A)) (42CFR 457.515(f))

8.5. Describe how the state will ensure that the annual aggregate cost-sharing for a family does not exceed 5 percent of such family’s income for the length of the child’s eligibility period in the State. Include a description of the procedures that do not primarily rely on a refund given by the state for overpayment by an enrollee: (Section 2103(e)(3)(B)) (42CFR 457.560(b) and 457.505(e))

Virginia has structured the cost sharing levels to make it highly unlikely that any family will exceed the allowable cost sharing levels.

Virginia ensures that the annual aggregate cost sharing for all FAMIS enrollees in a family does not exceed 5% of a family’s income as required by § 2103(e)(3)(b) of Title XXI. Co-payments are capped at levels that are extremely unlikely to exceed the upper limit. The tables below demonstrate that the maximum cost sharing for families under the Secretary-approved coverage modeled after the state employee plan falls within the required caps: For families with income equal to or below 150% of FPL, cost-sharing is capped at slightly less than 2.5% of income for a family of one at 100% of FPL. For families with income above 150% of FPL, cost-sharing is capped at slightly less than 5% of income for a family of one at 150% of FPL. (As mentioned earlier, families under the Secretary-approved coverage offered through the fee-for-service program are not subject to any cost-sharing.)

Table 1: Aggregate Cost Sharing for Families under Secretary-approved coverage modeled after the state employee plan Poverty Levels *100% 135% 150% 175% 200% Maximum Yearly Co-Payments Limit N/A $180 $350 $350 $350

Total Cost Sharing by Enrollees N/A $180 $350 $350 $350 FPL for family of one

$9,310

$12,569

$13,965

$16,293

$18,620

STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

STATE: Virginia Page 8-58

Effective Date: 07/01/05

58 Approval Date: _____________/06 Poverty Levels *100% 135% 150% 175% 200%

2.5% ≤ 150% of FPL 5% > 150% at FPL

$ $233

$314

$698

$815

$931

*Used for comparative purposes only.

* Figures in this column are for illustration purposes and are rounded.

Families are required to submit documentation to DMAS or its contractor, showing that the co- payment is met for the year. Once the cap is met, the managed care organization will issue a new card excluding families from paying additional co-pays.

Finally, Title XXI requires that cost-sharing for families with incomes below 150 percent of FPL not exceed an amount that is “nominal” under Medicaid law, with appropriate adjustment for inflation or other reasons as the Secretary determines to be reasonable. The maximum co- payments for a service costing over $50 is $3 under Medicaid law and was established in 1978. Virginia’s co-payment for families under 150% of FPL is $2, which is well below the $3 federal cap.

8.6 Describe the procedures the state will use to ensure American Indian (as defined by the Indian Health Care Improvement Act of 1976) and Alaska Native children will be excluded from cost-sharing. (Section 2103(b)(3)(D)) (42CFR 457.535)

No cost-sharing will be charged to American Indians and Alaska Natives. The application form requests racial information on each child for whom application for child health insurance is made. No cost-sharing is imposed on those children who are reported to be Native American or Alaska Native. The applicant’s statement on the application form is sufficient to exempt the child from any cost-sharing obligations. The FAMIS automated eligibility determination system codes the case records for children listed on the application form as Alaska Natives or American Indians and the automated record will exempt such children from any cost-sharing obligations.

Virginia has no federally recognized Indian tribes; however, ongoing communication will occur with Indian tribes in Virginia to ensure that Indian families understand the program and can access the provider network to secure covered services.

8.7 Please provide a description of the consequences for an enrollee or applicant who does not pay a charge. (42CFR 457.570 and 457.505(c))

Not applicable.

STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

STATE: Virginia Page 8-59

Effective Date: 07/01/05

59 Approval Date: _____________/06 8.7.1 Please provide an assurance that the following disenrollment protections are being applied:

⌧ State has established a process that gives enrollees reasonable notice of and an opportunity to pay past due premiums, copayments, coinsurance, deductibles or similar fees prior to disenrollment. (42CFR 457.570(a)) ⌧ The disenrollment process affords the enrollee an opportunity to show that the enrollee’s family income has declined prior to disenrollment for non payment of cost-sharing charges. (42CFR 457.570(b)) ⌧ In the instance mentioned above, that the state will facilitate enrolling the child in Medicaid or adjust the child’s cost-sharing category as appropriate. (42CFR 457.570(b)) ⌧ The state provides the enrollee with an opportunity for an impartial review to address disenrollment from the program. (42CFR 457.570(c))

8.8 The state assures that it has made the following findings with respect to the payment aspects of its plan: (Section 2103(e))

8.8.1. ⌧ No Federal funds will be used toward state matching requirements. (Section 2105(c)(4)) (42CFR 457.220)

8.8.2. ⌧ No cost-sharing (including premiums, deductibles, copays, coinsurance and all other types) will be used toward state matching requirements. (Section 2105(c)(5) (42CFR 457.224) (Previously 8.4.5)

8.8.3. ⌧ No funds under this title will be used for coverage if a private insurer would have been obligated to provide such assistance except for a provision limiting this obligation because the child is eligible under this title. (Section 2105(c)(6)(A)) (42CFR 457.626(a)(1))

8.8.4. ⌧ Income and resource standards and methodologies for determining Medicaid eligibility are not more restrictive than those applied as of June 1, 1997. (Section 2105(d)(1)) (42CFR 457.622(b)(5))

8.8.5. ⌧ No funds provided under this title or coverage funded by this title will include coverage of abortion except if necessary to save the life of the mother or if the pregnancy is the result of an act of rape or incest. (Section 2105)(c)(7)(B)) (42CFR 457.475)

STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

STATE: Virginia Page 8-60

Effective Date: 07/01/05

60 Approval Date: _____________/06

8.8.6. ⌧ No funds provided under this title will be used to pay for any abortion or to assist in the purchase, in whole or in part, for coverage that includes abortion (except as described above). (Section 2105)(c)(7)(A)) (42CFR 457.475)

STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

STATE: Virginia Page 9-61

Effective Date: 07/01/05

61 Approval Date: _____________/06 Section 9. Strategic Objectives and Performance Goals and Plan Administration (Section 2107)

9.1. Describe strategic objectives for increasing the extent of creditable health coverage among targeted low-income children and other low-income children: (Section 2107(a)(2)) (42CFR 457.710(b))

Objective One: To reduce the number of uninsured children

Objective Two: To improve the health care status of children

Objective Three: To conduct effective outreach to encourage enrollment in health insurance plans.

9.2. Specify one or more performance goals for each strategic objective identified: (Section 2107(a)(3)) (42CFR 457.710(c))

See § 9.3.

9.3. Describe how performance under the plan will be measured through objective, independently verifiable means and compared against performance goals in order to determine the state’s performance, taking into account suggested performance indicators as specified below or other indicators the state develops: (Section 2107(a)(4)(A),(B)) (42CFR 457.710(d))

Strategic Objective One “To Reduce the Number of Uninsured Children.” The first Goal is to “Increase the number of Medicaid eligible children enrolled in Medicaid.” DMAS expects an increase in Medicaid enrollment as a result of FAMIS outreach activities. The Central Processing Unit and the State Department of Social Services will track the number of children who apply for FAMIS but are eligible for Medicaid.

The second goal under this Strategic Objective is to “Enroll 61,200 children in FAMIS by the close of the FFY 2004.” This Goal is based on an analysis of uninsured children in Virginia. The Measurement Strategy utilized will be the FAMIS file, where an indicator of FAMIS enrollment will be counted over time.

The third goal under Strategic Objective One is to “Reduce the percentage of uninsured children.” The measurement strategy is to track changes in the percentage of uninsured children using a health access survey. Virginia conducted health access surveys in 1993, 1996, 1999, and 2001, and anticipates conducting future surveys to assess changes in the number of uninsured children.

Strategic Objective One -- Reduce the Number of Uninsured Children:

STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

STATE: Virginia Page 9-62

Effective Date: 07/01/05

62 Approval Date: _____________/06

Performance Goal Measurement Strategy Increase the number of Medicaid eligible children enrolled in Medicaid Data from the Central Processing Unit and DSS; DMAS enrollment data Enroll 61,200 children in Title XXI: FAMIS (and Medicaid Expansion )by the close of FFY2004 DMAS enrollment data Reduce the percentage of uninsured children Health access survey

Strategic Objective Two “To Improve the Health Status of Children” This objective encompasses three performance goals. The first goal is to “Increase the number of children with a usual source of care.” A usual source of care is critical to meeting the ongoing health needs of children in allowing for continuity of services. Most children in FAMIS will be enrolled in the Managed Care Organization Program, facilitating the establishment of a medical home and accountability for the quality of care.

The second goal is to “Increase the percentage of children who receive immunizations.” Performance is measured via an annual clinical focus study performed by an external quality review organization that utilizes DMAS data and medical chart review to estimate the percentage of children who are fully immunized. The Virginia SCHIP’s aggregate compliance rate for each of the selected individual immunizations is presented immediately below (Delmarva Foundation for Medical Care, Inc., 2003):

DTP OPV MMR HIb HBV VZV 4:3:1 88.9% 92.3% 92.3% 88.0% 96.6% 90.6% 86.3%

The statewide results demonstrate that FAMIS care providers have performed well in meeting their obligations to provide vaccines to children in Virginia. The compliance level was well above 85% for all indicators.

The third Goal is to “Increase the number of children receiving appropriate well-child care.” The Measurement Strategy is to perform a clinical focus study to estimate the number of children receiving appropriate well-child care. The study will focus on office-based visits. DMAS well- child care data may be used for comparison purposes. Administrative data may be supplemented by medical chart review.

Strategic Objective Two -- To Improve the Health Status of Children:

STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

STATE: Virginia Page 9-63

Effective Date: 07/01/05

63 Approval Date: _____________/06

Performance Goal Measurement Strategy Increase the number of children with a usual source of care DMAS enrollment data Increase the percentage of children with immunization Clinical focus study Increase the number of children receiving appropriate well-child care Clinical focus study

Comparing DMAS internal figures for April of 2003 with those for April of 2004 shows that enrollment in SCHIP in the last year rose from 50,336 to 54,581. Those same figures show that the number of SCHIP enrollees with a usual source of care rose from 44,121 to 48,471. This trend is expected to continue as enrollment grows.

DMAS anticipates receiving from the MCOs and other health insurers participating under FAMIS summary reports on usual source of care, immunizations, well-child care, and other measures reflective of access and quality.

Strategic Objective Three “To Conduct Effective Outreach to Encourage Enrollment in Health Insurance Plans” encompasses five Performance Goals. The first Goal is to “Develop and implement a comprehensive, statewide, community-based outreach plan”. This outreach plan was specified in the Virginia enabling legislation for FAMIS. The plan allows for a coherent and structured means to encourage enrollment in FAMIS. The Measurement Strategy is a published plan and administrative records from the outreach campaign. These records will indicate a broad range of involvement by members of the community and ensure a comprehensive, statewide plan. The remaining Performance Goals address obtaining the active participation of community-based organizations, other states agencies, the business community, and school districts. The Measurement Strategy for each of these is to utilize the administrative records from the outreach campaign. The records will document meetings, media contacts and events, publications, presentations, collaborations among organizations, and other activities to promote outreach.

Strategic Objective Three- To Conduct Effective Outreach to Encourage Enrollment in Health Insurance Plans:

Performance Goal Measurement Strategy Develop and implement a comprehensive, statewide community- based outreach plan Published outreach plan and administrative records from outreach campaign Obtain the active participation of community-based organizations Administrative records from outreach campaign and quarterly reports from outreach grantees and trainer

STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

STATE: Virginia Page 9-64

Effective Date: 07/01/05

64 Approval Date: _____________/06 Obtain the active participation of other state agencies Administrative records from outreach campaign Obtain the active participation of the business community Administrative records from outreach campaign Obtain the active participation of school districts Administrative records from outreach campaign

STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

STATE: Virginia Page 9-65

Effective Date: 07/01/05

65 Approval Date: _____________/06

Check the applicable suggested performance measurements listed below that the state plans to use: (Section 2107(a)(4))

9.3.1. ⌧ The increase in the percentage of Medicaid-eligible children enrolled in Medicaid.

9.3.2. ⌧ The reduction in the percentage of uninsured children.

9.3.3. ⌧ The increase in the percentage of children with a usual source of care.

9.3.4. The extent to which outcome measures show progress on one or more of the health problems identified by the state. 9.3.5. HEDIS Measurement Set relevant to children and adolescents younger than 19. 9.3.6. Other child appropriate measurement set. List or describe the set used.

9.3.7. ⌧ If not utilizing the entire HEDIS Measurement Set, specify which measures will be collected, such as: 9.3.7.1. ⌧ Immunizations 9.3.7.2. ⌧ Well child care 9.3.7.3. Adolescent well visits 9.3.7.4. ⌧ Satisfaction with care 9.3.7.5. Mental health 9.3.7.6. Dental care 9.3.7.7. Other, please list: 9.3.8. Performance measures for special targeted populations.

9.4. ⌧ The state assures it will collect all data, maintain records and furnish reports to the

Secretary at the times and in the standardized format that the Secretary requires.

(Section 2107(b)(1)) (42CFR 457.720)

9.5. ⌧ The state assures it will comply with the annual assessment and evaluation required

under Section 10. Briefly describe the state’s plan for these annual assessments and

reports. (Section 2107(b)(2)) (42CFR 457.750)

STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

STATE: Virginia Page 9-66

Effective Date: 07/01/05

66 Approval Date: _____________/06 DMAS complies with subsection 10.1 in assessing the operation of FAMIS and submitting a report to the Secretary by January 1 following the end of the fiscal year. This includes the reduction in the number of uninsured low-income children and the results of the program assessment.

9.6. ⌧ The state assures it will provide the Secretary with access to any records or information relating to the plan for purposes of review of audit. (Section 2107(b)(3)) (42CFR 457.720)

9.7. ⌧ The state assures that, in developing performance measures, it will modify those measures to meet national requirements when such requirements are developed. (42CFR 457.710(e))

9.8. The state assures, to the extent they apply, that the following provisions of the Social Security Act will apply under Title XXI, to the same extent they apply to a state under Title XIX: (Section 2107(e)) (42CFR 457.135)

9.8.1. ⌧ Section 1902(a)(4)(C) (relating to conflict of interest standards) 9.8.2. ⌧ Paragraphs (2), (16) and (17) of Section 1903(i) (relating to limitations on payment) 9.8.3. ⌧ Section 1903(w) (relating to limitations on provider donations and taxes) 9.8.4. ⌧ Section 1132 (relating to periods within which claims must be filed)

9.9. Describe the process used by the state to accomplish involvement of the public in the design and implementation of the plan and the method for insuring ongoing public involvement. (Section 2107(c)) (42CFR 457.120(a) and (b))

In order to accomplish public involvement in the administration, outreach, and access to the FAMIS program, ongoing meetings are held with several advocacy, retail, business, and community organizations to seek direction and request involvement. These organizations include the Virginia Coalition for Children’s Health, Virginia Association of Health Plans, the Covering Kids & Families Statewide Coalition, the Virginia Hospital and Healthcare Association, the Virginia Poverty Law Center, and the Virginia League of Social Services Executives, as well as other advocacy organizations that represent the interests of the uninsured. Meetings are also held with other state agencies to seek their assistance. Ongoing meetings are held with legislators, with legislative commissions, and with local human service directors to review and discuss FAMIS.

The Department held five Town Hall meetings during the Spring 2002 across the State to hear ways to improve the FAMIS program. These meetings were attended by approximately 200 persons. To ensure public involvement, DMAS advises and consults with the Joint Commission on Health Care and provide quarterly reports on enrollment, benefit levels, and outreach efforts. The public also has the opportunity to become involved during the regulatory process.

STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

STATE: Virginia Page 9-67

Effective Date: 07/01/05

67 Approval Date: _____________/06 Implementing regulations must go through a mandatory 60-day comment period consistent with the Code of Virginia.

Another method for insuring ongoing public involvement is the Outreach Oversight Committee. The Outreach Oversight Committee is composed of representatives from community-based organizations engaged in outreach activities, social services eligibility workers, the provider community, health plans, and consumers. The Committee meets quarterly to discuss strategies to improve outreach activities. The Committee may offer recommendations regarding state-level outreach activities, the coordination of regional and local outreach activities, and procedures for streamlining and simplifying the application process, brochures, other printed materials, forms, and applicant correspondence.

9.9.1 Describe the process used by the state to ensure interaction with Indian Tribes and organizations in the state on the development and implementation of the procedures required in 42 CFR 457.125. (Section 2107(c)) (42CFR 457.120(c))

Virginia has no federally recognized Indian tribes; however, ongoing communication occurs with Indian tribes in Virginia to ensure that Indian families understand the program and can access the provider network to secure covered services.

No cost-sharing will be charged to American Indians and Alaska Natives. The application form requests racial information on each child for whom application for child health insurance is made. The applicant is requested to indicate if the child is White, Black, Hispanic, Other, Native American, Alaska Native or Asian/Pacific Islander. No cost sharing is imposed on those children who are reported to be Native American or Alaska Native.

9.9.2 For an amendment relating to eligibility or benefits (including cost sharing and enrollment procedures), please describe how and when prior public notice was provided as required in 457.65(b) through (d).

9.10. Provide a one year projected budget. A suggested financial form for the budget is attached. The budget must describe: (Section 2107(d)) (42CFR 457.140) Planned use of funds, including -- - Projected amount to be spent on health services; - Projected amount to be spent on administrative costs, such as outreach, child health initiatives, and evaluation; and - Assumptions on which the budget is based, including cost per child and expected enrollment.

- Projected sources of non-Federal plan expenditures, including any requirements for

STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

STATE: Virginia Page 9-68

Effective Date: 07/01/05

68 Approval Date: _____________/06 cost-sharing by enrollees.

SCHIP Budget Plan Template

Federal Fiscal Year Costs – FFY 2007 Enhanced FMAP rate 65% Benefit Costs

Insurance payments

Managed care 89,151,050 per member/per month rate @ # of eligibles $119.50 @ 748,851 months Fee for Service $62,816,498 Total Benefit Costs

(Offsetting beneficiary cost sharing payments)

Net Benefit Costs $151,967,547

Administration Costs

Personnel $1,525,467 General administration $206,750 Contractors/Brokers (e.g., enrollment contractors) $7,083,500 Claims Processing $50,000 Outreach/marketing costs $1,603,002 Other $290,865 Total Administration Costs $10,759,584 10% Administrative Cost Ceiling $16,885,283

Federal Share (multiplied by enh-FMAP rate) $179,238 State Share $96,513 TOTAL PROGRAM COSTS $162,727,131

Note: The Federal Fiscal Year (FFY) runs from October 1st through September 30th.

Funding:

State funding comes from two sources: State General Funds, and the Family Access to Medical

STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

STATE: Virginia Page 9-69

Effective Date: 07/01/05

69 Approval Date: _____________/06 Insurance Security Plan Trust Fund. The 1997 General Assembly established the Virginia Children’s Medical Security Insurance Plan Trust Fund (the fund was renamed the Family Access to Medical Insurance Security Plan Trust Fund in legislation enacted in 2000) in anticipation that a children’s health insurance program would be enacted by the 1998 General Assembly. The Assembly directed that the Fund be used to pay in part the Commonwealth’s share of expenditures under the new children’s health insurance program. Income to the Fund is derived from increased health insurance premium tax revenue. In 1997, the Commonwealth repealed a partial tax exemption enjoyed by the Blue Cross and Blue Shield Companies which no longer provide insurance of last resort as a result of HIPAA reforms. Payments into the trust fund are expected to be between $9 and $10 million a year. The remainder of the Commonwealth’s share is paid from State General Funds.

STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

STATE: Virginia Page 10-1

Effective Date: 07/01/05

70 Approval Date: _____________/06 Section 10. Annual Reports and Evaluations (Section 2108)

10.1. Annual Reports. The state assures that it will assess the operation of the state plan under this Title in each fiscal year, including: (Section 2108(a)(1),(2)) (42CFR 457.750)

10.1.1. ⌧ The progress made in reducing the number of uncovered low-income children and report to the Secretary by January 1 following the end of the fiscal year on the result of the assessment, and

Below is a chart listing the types of information that the state’s annual report might include. Submission of such information will allow comparisons to be made between states and on a nationwide basis.

Attributes of Population

Number of Children with Creditable Coverage XIX OTHER CHIP

Number of Children without Creditable Coverage

TOTAL

Income Level

< 100%

< 133%

< 185%

< 200%

> 200%

Age

0 – 1

1 – 5

6 – 12

13 - 18

Race and Ethnicity

American Indian or Alaskan

Asian or Pacific Islander

Black, not of Hispanic origin

Hispanic

White, not of Hispanic origin

STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

STATE: Virginia Page 10-1

Effective Date: 07/01/05

71 Approval Date: _____________/06

Location

MSA

Non-MSA

10.2. ⌧ The state assures it will comply with future reporting requirements as they are developed. (42CFR 457.710(e))

10.3. ⌧ The state assures that it will comply with all applicable Federal laws and regulations, including but not limited to Federal grant requirements and Federal reporting requirements.

STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

STATE: Virginia Page 11-1

Effective Date: 07/01/05

72 Approval Date: _____________/06 Section 11. Program Integrity (Section 2101(a))

Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan, and continue to Section 12.

11.1 ⌧ The state assures that services are provided in an effective and efficient manner through free and open competition or through basing rates on other public and private rates that are actuarially sound. (Section 2101(a)) (42CFR 457.940(b))

11.2. The state assures, to the extent they apply, that the following provisions of the Social Security Act will apply under Title XXI, to the same extent they apply to a state under Title XIX: (Section 2107(e)) (42CFR 457.935(b)) The items below were moved from section 9.8. (Previously items 9.8.6. - 9.8.9)

11.2.1. ⌧ 42 CFR Part 455 Subpart B (relating to disclosure of information by providers and fiscal agents) 11.2.2. ⌧ Section 1124 (relating to disclosure of ownership and related information) 11.2.3. ⌧ Section 1126 (relating to disclosure of information about certain convicted individuals) 11.2.4. ⌧ Section 1128A (relating to civil monetary penalties) 11.2.5. ⌧ Section 1128B (relating to criminal penalties for certain additional charges) 11.2.6. ⌧ Section 1128E (relating to the National health care fraud and abuse data collection program)

STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

STATE: Virginia Page 11-1

Effective Date: 07/01/05

73 Approval Date: _____________/06 Section 12. Applicant and enrollee protections (Sections 2101(a))

Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan.

Eligibility and Enrollment Matters

12.1 Please describe the review process for eligibility and enrollment matters that complies with 42 CFR 457.1120.

For reviews involving adverse eligibility actions taken by the Department of Medical Assistance Services (“DMAS”), the local department of social services, or the Central Processing Unit (“CPU), the following procedures shall apply.

1. DMAS, the local department of social services, and/or the CPU must send written notification of adverse actions affecting an individual’s request for or receipt of FAMIS coverage. Adverse actions include:

a. Denial of eligibility;

b. Failure to make a timely determination;

c. Suspension or termination of enrollment, including disenrollment for failure to pay cost sharing.

2. The written notification must include the reasons for the determination, an explanation of rights to request a review and how to request a review, the standard and expedited time frames for review, and the circumstances under which enrollment may continue pending review. The notice must be sent to applicants/enrollees within 10 days after the date of denial or at least 10 days prior to suspension or termination of enrollment.

3. To be considered timely, a request for review shall be received by DMAS no later than 30 calendar days from the date of the DMAS, the local department of social services, or CPU notice of adverse action.

4. A review shall not be granted if the sole basis for the adverse determination is a state or federal provision requiring an automatic change in eligibility or enrollment that affects all applicants or enrollees or a group of applicants or enrollees without regard to their individual circumstances.

5. A request for review shall be heard and decided by an agent of DMAS who has not been directly involved in the adverse action under review.

STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

STATE: Virginia Page 11-1

Effective Date: 07/01/05

74 Approval Date: _____________/06 6. All applicants/enrollees shall have the right to have personal and medical information and records maintained as confidential.

7. All applicants/enrollees shall have an opportunity to:

a) Represent themselves or have representation of their choosing during the review process;

b) Timely review their files and other applicable information relevant to review of the decision;

c) Fully participate in the review process, including an opportunity to present supplemental information during the review process; and

d) Receive continued coverage if the enrollee requests a review prior to the effective date of the suspension or termination of the enrollment.

8. If an expedited review decision is not mandated, a request for review shall result in a written final decision within 90 calendar days of receipt of the request for review unless the applicant, enrollee, or authorized representative requests or causes a delay. An expedited review decision will be mandated whenever the State receives, from the managed care organization or the primary health provider, information indicating that taking the time for a standard resolution of the review request could seriously jeopardize the enrollee’s life or health or ability to attain, maintain, or regain maximum function. If an expedited review decision is mandated, then a request for review shall result in a written final decision within 3 business days after the State receives, from the managed care organization or the primary health provider, the case record and information indicating that taking the time for a standard resolution of the review request could seriously jeopardize the enrollee’s life or health or ability to attain, maintain, or regain maximum function, unless the applicant, enrollee, or authorized representative requests or causes a delay.

Health Services Matters

12.2 Please describe the review process for health services matters that complies with 42 CFR 457.1120.

For reviews involving health services matters for FAMIS enrollees receiving services through Managed Care Organizations (MCOs), the following procedures shall apply.

1. The MCO shall provide a written notification within 10 days after a decision is made and provide the opportunity for external review whenever an enrollee’s request for covered services is delayed, denied, reduced, suspended, or terminated, in whole or in part including a determination

STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

STATE: Virginia Page 11-1

Effective Date: 07/01/05

75 Approval Date: _____________/06 about the type or level of services; or whenever there has been the failure to approve, furnish or provide payment for health services in a timely manner.

2. Written notification must include the reasons for the determination, an explanation of rights to request a review and how to request a review, and the standard and expedited time frames for review. In addition, it shall inform the enrollee about his or her opportunity to file a grievance or a request for review with the MCO, and include the phone number and name of the contact person at the MCO’s office.

3. The MCO shall comply with the Department’s hearing process, no more or less, and in the same manner as is required for all other FAMIS evidentiary hearings.

4. The MCO shall have written policies and procedures which describe the informal and formal grievance and review process and how it operates, and the process must be in compliance with federal and State regulations. The procedures must provide for prompt resolution of the issue and involve the participation of individuals with the authority to require corrective action.

5. A review shall not be granted if the sole basis for the adverse determination is a state or federal provision requiring an automatic change that affects all applicants or enrollees or a group of applicants or enrollees without regard to their individual circumstances.

6. The MCO shall offer an internal grievance review procedure. The MCO shall issue grievance decisions within fourteen (14) days from the date of initial receipt of the grievance and after all pertinent information has been received. The decision must be in writing and shall include but not be limited to:

a. The decision reached by the MCO;

b. The reasons for the decision;

c. The policies or procedures which provide the basis for the decision; and

d. A clear explanation of further review rights and the time frame for filing a request for review.

7. The enrollee may request an external review of any formal grievance decision by the MCO. An external review organization shall manage the external review procedure. The external review organization provides an independent external review, because the external review organization is the State or a contractor other than the contractor responsible for the matter subject to external review. If an enrollee wishes to file an appeal with the external review organization, the appeal must be filed within 30 days of the enrollee’s receipt of notice of the final decision from the MCO.

STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

STATE: Virginia Page 11-1

Effective Date: 07/01/05

76 Approval Date: _____________/06

8. The MCO shall provide to the external review organization all information necessary for any enrollee appeal within the time frame established by the Department.

9. All applicants/enrollees shall have the right to have personal and medical information and records maintained as confidential.

10. All applicants/enrollees shall have an opportunity to:

a. Represent themselves or have representation of their choosing during the review process;

b. Timely review their files and other applicable information relevant to review of the decision;

c. Fully participate in the review process, whether the review is in person or in writing, including an opportunity to present supplemental information during the review process; and

d. Receive continued coverage if the enrollee requests a review prior to the effective date of the reduction or termination of services or payment for services.

11. Unless an expedited review decision is mandated, the external review organization shall complete the external review process and issue a decision within ninety (90) calendar days of the date an enrollee requests an internal review. If the enrollee’s physician or health plan determines that operating under the standard time frame could seriously jeopardize the enrollee’s life or health or ability to attain, maintain, or regain maximum function, then the external review organization must complete the external review process and issue a decision within seventy-two (72) hours of the time an enrollee requests external review.

12. The MCO shall comply with the external review decision. The external review organization's decision in these matters shall be final and shall not be subject to appeal by the MCO.

13. The external review organization’s decision must be in writing and shall include but not be limited to:

STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

STATE: Virginia Page 12-1

Effective Date: 07/01/05

77 Approval Date: _____________/06 a. The decision reached by the external review organization;

b. The reasons for the decision;

c. The policies or procedures which provide the basis for the decision.

For reviews involving health services matters for FAMIS enrollees receiving services through fee-for- service, the following procedures shall apply.

1. The State or its contractor shall provide a written notification within 10 days after a decision is made and provide the opportunity for external review whenever an enrollee’s request for covered services is delayed, denied, reduced, suspended, or terminated, in whole or in part including a determination about the type or level of services; or whenever there has been the failure to approve, furnish or provide payment for health services in a timely manner.

2. Written notification must include the reasons for the determination, an explanation of rights to request a review and how to request a review, and the standard and expedited time frames for review.

3. A review shall not be granted if the sole basis for the adverse determination is a state or federal provision requiring an automatic change that affects all applicants or enrollees or a group of applicants or enrollees without regard to their individual circumstances.

4. The external review must be conducted by the State or a contractor other than the contractor responsible for the matter subject to external review.

5. If an enrollee wishes to request an external review, the request must be filed within 30 days of the enrollee’s receipt of notice of the final decision from the State or its contractor.

6. All applicants/enrollees shall have the right to have personal and medical information and records maintained as confidential.

7. All applicants/enrollees shall have an opportunity to:

a. Represent themselves or have representation of their choosing during the review process;

b. Timely review their files and other applicable information relevant to review of the decision;

c. Fully participate in the review process, whether the review is in person or in writing, including an opportunity to present supplemental information during the review process; and

STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

STATE: Virginia Page 12-1

Effective Date: 07/01/05

78 Approval Date: _____________/06 d. Receive continued coverage if the enrollee requests a review prior to the effective date of the reduction or termination of services or payment for services.

8. Unless an expedited review decision is mandated, the external review process shall be completed and a written decision shall be issued within ninety (90) calendar days of the date an enrollee requests an external review, unless the applicant, enrollee, or authorized representative requests or causes a delay. If the enrollee’s physician or health plan determines that operating under the standard time frame could seriously jeopardize the enrollee’s life or health or ability to attain, maintain, or regain maximum function, then the external review process must be completed and a written decision must be issued within seventy-two (72) hours of the time an enrollee requests external review, unless the applicant, enrollee, or authorized representative requests or causes a delay.

Premium Assistance Programs

12.3 If providing coverage through a group health plan that does not meet the requirements of 42 CFR 457.1120, please describe how the state will assure that applicants and enrollees have the option to obtain health benefits coverage other than through the group health plan at initial enrollment and at each redetermination of eligibility.

STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

STATE: Virginia Attachment A

Effective Date: 07/01/05

79 Approval Date: _____________/06

VIRGINIA TITLE XXI STATE PLAN FACT SHEET

Name of Plan: Family Access to Medical Insurance Security Plan (FAMIS)

Date Plan Submitted: June 15, 1998 Date Plan Approved: October 22, 1998 Effective Date: October 26, 1998

Date First Amendment Submitted: June 23, 2000 Date First Amendment Approved: December 22, 2000 Amendment Effective Date:

December 22, 2000

Date Second Amendment Submitted: November 15, 2001 Date Second Amendment Approved: January 23, 2002 Amendment Effective Date:

December 1, 2001

Date Third Amendment Submitted: June 28, 2002 Date Third Amendment Approved: September 26, 2002 Amendment Effective Date:

December 1, 2001

Date Fourth Amendment Submitted: August 30, 2002 Date Fourth Amendment Approved: December 23, 2002 Amendment Effective Date:

September 1, 2002

Date Fifth Amendment Submitted: June 15, 2004 Date Fifth Amendment Approved: September 13, 2004 Amendment Effective Date:

August 1, 2003 and June 1, 2004

Date Sixth Amendment Submitted: June 29, 2004 Date Sixth Amendment Disapproved: April 16, 2007

Date Seventh Amendment Submitted: July 3, 2006 Date Seventh Amendment Approved: September 26, 2006 Amendment Effective Dates: Vary as follows:

• August 1, 2005 pregnant applicants no longer

subject to the waiting period; and removes reference

to premium assistance program. • August 1, 2006 retroactive eligibility for

newborns; • July 1, 2006 adds disease management benefit to

the fee-for-service delivery system

Background:

• On June 15, 1998, Virginia submitted a proposal for a separate child health program, known as the Virginia Children's Medical Security Insurance Plan (VCMSIP).

• The initially approved plan covered children up to age 19 with family incomes up to 185 percent of the Federal poverty level (FPL).

Amendments

• Virginia submitted its first amendment on June 23, 2000, to change the name of the title XXI program to the Family Access to Medical Insurance Security Plan (FAMIS). The program covers children from birth through age 18 with family incomes up to 200 percent of the FPL. This amendment also made the following changes:

• Changed the benefit package from Medicaid look-alike to coverage based upon the state employee health plan, with the addition of physical therapy, occupational therapy, speech language pathology, and skilled nursing services for special needs children.

• Established a premium assistance program for children in families that meet FAMIS eligibility requirements and who have access to health insurance coverage through their parent's employer. Under the program, the State may pay the employee's share of the premium for dependent coverage if certain requirements are met. (The State no longer has approval to operate its premium assistance program through its State plan. See Amendment # 7).

• Incorporated cost sharing in the form of premiums and co-payments.

• Virginia submitted its second amendment on November 15, 2001, to allow the State to offer two different benefits packages to FAMIS enrollees based upon their geographic location in the State. Enrollees obtaining care through a managed care entity receive an enhanced benefit package based upon the State employee health plan. Enrollees in geographic areas of the State where there is not yet a contract with a managed care entity continue to obtain services through the Primary Care Case Management (PCCM) program and receive a Medicaid look-alike package, until such time as a contract with a managed care entity is implemented. This amendment also allowed the State to exempt children receiving services through the PCCM program from paying co-payments.

• On June 28, 2002, Virginia submitted its third amendment to update and amend the SCHIP State plan to indicate the State's compliance with the final SCHIP regulations. This amendment also suspended premiums and added case management and hospice services to the State plan for the benefit package modeled on the state employee health plan. These services were always included in the benefit package and provided to enrollees but were inadvertently omitted from earlier SCHIP State plan amendments.

• On August 30, 2002, Virginia submitted its fourth amendment to establish a SCHIP Medicaid expansion program, in addition to the existing separate child health program. Children ages 6 through 18 with family income equal to or less than 133 percent of the FPL moved from the separate child health program into the Medicaid expansion program. This move makes all children below 133 percent of the FPL eligible for Medicaid and allows all of the children in one family to be covered in the same program. This amendment also increased dental, vision, and other services in the state employee health plan benefit package, eliminated premiums from cost-sharing requirements, changed procedures to improve coordination with Medicaid on eligibility determination for FAMIS, and added additional good cause exceptions to the 6-month waiting period requirement.

• Virginia submitted its sixth amendment on June 29, 2004. The amendment requested the addition of new school based health services to the State’s SCHIP (FAMIS) benefit package. This Amendment was disapproved. In the absence of a response from the State, it was not possible to ascertain whether the amendment met the statutory and regulatory requirements of the State Children’s Health Insurance Program (SCHIP), including the definition of “child health assistance” at section 2110(a) of the Act, the coverage requirements under section 2103 of the Act, and Section 2101(a), which requires the provision of child health assistance in an effective and efficient manner. Therefore the SPA was disapproved.

• This seventh amendment was submitted on July 3, 2006 with additional changes made on August 7, 2006. It made the following changes to the State plan: • Excludes the State’s four-month period of uninsurance if an applicant is pregnant at the time of application; • Permits 90-day retroactive coverage for newborns; • Adds disease management to the benefit package provided to enrollees in the fee-for- service delivery system; and • Removes all references to its previously approved SCHIP state plan premium assistance program, since the State currently operates its premium assistance program through an SCHIP Section 1115 demonstration.

Children Covered Under Program

• The State reported that 65,536 children were ever enrolled in the Medicaid expansion and 71,646 children were ever enrolled in the separate child health program in FFY 2006.

Administration

• Virginia's Department of Medical Assistance Services administers both the FAMIS and Medicaid programs.

Health Care Delivery System

• Enrollees in the Medicaid expansion program receive services through the established Medicaid delivery system, which includes mandatory managed care plans in certain geographic areas and PCCM in others.

• In the separate child health program, enrollees living in geographic areas of the state with more than one managed care entity must choose a managed care entity. Enrollees in geographic areas of the State without a contracted managed care entity receive services through the PCCM until such time as a contract with a managed care entity is implemented.

Benefit Package

• Enrollees in the Medicaid expansion program receive the Medicaid benefit package.

• Enrollees in the separate child health program living in geographic areas of the State where a managed care entity has not yet been identified receive a Secretary-approved benefit package that is a Medicaid look-alike, with the addition of substance abuse services.

• Enrollees in the separate health program living in geographic areas of the State where a managed care entity has been identified receive a Secretary-approved benefit package based upon the State employee health plan, with the addition of certain mental health services and blood lead testing.

• The State provides supplemental coverage for children in the premium assistance program if the employer plan does not provide services included in the benchmark plan.

Cost Sharing

• Premiums were suspended in the separate program on April 15, 2002, and eliminated from cost-sharing requirements effective September 1, 2002.

• Families at or below 150 percent of the FPL are subject to co-payments ranging from $2 per outpatient visit to $15 per inpatient admission with an annual co-payment cap of $180. For families with incomes above 150 percent of the FPL, co-payments range from $5 to $25 with an annual co-payment cap of $350. Families track the amount they spend on co-payments and notify the State when the annual co-payment cap is met. A new card is then issued excluding these families from additional co-payments.

• American Indian and Alaska Native children are not subject to cost sharing.

State Action to Avoid Crowd Out

• If a child has had health care coverage within 4 months of application for or receipt of FAMIS services, the child will be ineligible unless good cause for discontinuing the coverage is demonstrated or if the child is pregnant.

Coordination between SCHIP and Medicaid

• A joint Medicaid/FAMIS application, which addresses specific questions about health insurance coverage or available coverage, can either be mailed to a central processing unit

(CPU) or taken to a local Department of Social Services office for determination. Medicaid eligibility staff is co-located at the CPU. Applicants are not required to have a face-to-face interview or contact.

Outreach Activities

• Virginia’s comprehensive marketing and outreach efforts promote both Medicaid and FAMIS. The State coordinates activities with other state agencies, community-based organizations, the business community, and health care associations and providers.

• Virginia also has a Central Processing Unit that provides a toll-free help line number, serves as a distribution point for applications, assists callers with completing applications, serves as a source for answering questions, and provides eligibility status.

• A contract with a public relations firm is used to assist with the development of a statewide marketing plan, development of multimedia marketing materials, and evaluation of activities to promote application and enrollment.

• Other strategies include coordination with school districts and other agencies/organizations, a toll-free hotline number, the use of a simplified application, and direct-marketing techniques.

Financial Information

Total FY 2007 SCHIP Allotment -- $94,070,318 FY 2007 Enhanced Federal Matching Rate -- 65 %

Date last updated: May 4, 2007

_____________________________________________________________________________ Table of Contents State/Territory Name: Virginia State Plan Amendments (SPA) #: VA-13-0015 This file contains the following documents in the order listed: 1) Approval Letter 2) SPA Summary Form 3) Approved SPA Pages The complete title XXI state plan for Massachusetts consists of the most recent state plan posted on Medicaid.gov under CHIP and State Plan Amendments. The link is provided below. The following approved templates are in addition to, or replace sections of the state’s posted current state plan. The attached approval letter(s) explain how these templates fit into that state plan. Link to state title XXI state plans and amendments: http://medicaid.gov/Medicaid-CHIP-Program-Information/By- Topics/Childrens-Health-Insurance-Program-CHIP/CHIP-State-Program-Information.html

ie

DEPARTMENT OF HEALTH & HUMAN SERVICES

Centers for Medicare & Medicaid Services ( € . RA ay,

7500 Security Boulevard, Mail Stop: S2-01-16 CENTERS FOR MEDICARE & MEDICAID SERVICES Baltimore, Maryland 21244-1850 CENTER FOR MEDICAID & CHIP SERVICES

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Children and Adults Health Programs Group

DEC 2 4 2013

Rebecca Mendoza

Director, Maternal and Child Health Division Virginia Department of Medical Assistance Services 600 East Broad Street, Suite 1300

Richmond, VA 23219

Dear Ms. Mendoza:

I am pleased to inform you that your Title XXI Children’s Health Insurance Program (CHIP) state plan amendment (SPA) number VA-13-15, submitted on October 4, 2013, and related to Modified Adjusted Gross Income (MAGI) Eligibility has been approved with an effective date of January 1, 2014.

MAGI Eligibility & Methods:

SPA number VA-13-15 provides assurance on page CS15 that the state will apply methodologies based on MAGI for all separate CHIP covered groups; using the approved MAGI conversion plan income thresholds, the state indicates on page CS7 that it will cover targeted low-income children; and on page CS13 the state elects to cover as deemed newborns children born to mothers enrolled as targeted low-income children in CHIP or enrolled in the section 1115 demonstration, FAMIS MOMS. A copy of the approved CS15 is attached and should be incorporated within a separate subsection under Section 4.3 of the state’s approved CHIP state plan.

A copy of the approved CS7 is attached and supersedes the current Geographic Area, Age and Income Sections 4.1.1, 4.1.2 and 4.1.3 of the current CHIP state plan. A copy of the approved CS13 is attached and should be incorporated under Section 4.3 of the state’s approved CHIP state plan.

Your Title XX] project officer is Ms. Ticia Jones. She is available to answer questions concerning this amendment. Ms. Jones’s contact information is as follows:

Centers for Medicare & Medicaid Services Center for Medicaid & CHIP Services

7500 Security Boulevard, Mail Stop S2-01-16 Baltimore, MD 21244-1850

Telephone: (410) 786-8145

Facsimile: (410) 786-5882

E-mail: Ticia.Jones@cms.hhs.gov

Page 2 - Ms. Rebecca Mendoza Official communications regarding program matters should be sent simultaneously to Ms. Jones and Mr. Francis McCullough, Associate Regional Administrator, Division of Medicaid and Children's Health Operations, in our Philadelphia Regional Office. Mr. McCullough's address 1s: Centers for Medicare & Medicaid Services Division of Medicaid and Children's Health Operations The Public Ledger Building, Suite 216 150 South Independence Mall West Philadelphia, PA 19106 If you have additional questions, please contact Ms. Linda Nablo, Director, Division of State Coverage Programs, at (410) 786-5143. We look forward to continuing to work with you and your staff toward the approval of your remaining MAGI Eligibility SP As. Enclosures Sincerely, Eliot Fishman Director cc: Francis McCullough, ARA, CMS Region III, Philadelphia

Control Panel

General Information

File Management

Tribal Input

Summary

Children's Health Insurance

Program Eligibility

Children’s Health Insurance Program Eligibility: Summary Page

State/Territory Virginia

name: Transmittal Number: Please enter the Transmittal Number (TN) in the format ST- ¥Y-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number

with leading zeros. The dashes must also be entered. |VA-13-15 |

Type of SPA: “1 MAGI Eligibility & Methods XXI Medicaid Expansion | Establish 2101(f) Group Eligibility Processing Non-Financial Eligibility

Proposed Effective Date

(nm aa/ yyy)

Federal Statute/ Regulation Citation

[Section 1902(e)(14) of the Social Security Act

Federal Budget Impact

| This SPA has a budget impact. Total budget impact:

State Funds: $ Federal Funds: $

Subject of Amendment

Please provide a brief summary of SPA changes. Character Count:232 out of 2000

cS7 — Eligibility for targeted low-income children under a separate CHIP; C513 -Eligibility for deemed newborns under a separate CHIP; C515 — Modified Adjusted Gross Income (MAGI) based methodologies for separate CHIP covered groups

Signature of State Agency Official

Submitted By: Brian McCormick

Last Revision Dec 16, 2013 Date:

Submit Date: Oct 4, 2013

coms CHIP Eligibility

OMB Control Number: 0938-1148

Expiration date: 10/31/2014

2102(b)(1)(B)(v) of the SSA and 42 CFR 457.315

The CHIP Agency will apply Modified Adjusted Gross Income methodologies for all separate CHIP covered groups, as described below, and consistent with 42 CFR 457.315 and 435.603(b) through (i).

In the case of determining ongoing eligibility for enrollees determined eligible for CHIP on or before December 31, 2013, MAGI- based income methodologies will not be applied until March 31, 2014 or the next regularly-scheduled renewal of eligibility, whichever is later.

If the state covers pregnant women, in determining family size for the eligibility determination of a pregnant woman, she is counted as herself plus each of the children she is expected to deliver.

In determining family size for the eligibility determination of the other individuals in a household that includes a pregnant woman: @ The pregnant woman is counted just as herself. C The pregnant woman is counted just as herself, plus one. C The pregnant woman is counted as herself, plus the number of children she is expected to deliver. Financial eligibility is determined consistent with the following provisions: When determining eligibility for new applicants, financial eligibility is based on current monthly income and family size. When determining eligibility for current beneficiaries, financial eligibility is based on: @ Current monthly household income and family size. © Projected annual household income for the remaining months of the current calendar year and family size. In determining current monthly or projected annual household income, the state will use reasonable methods to: (J Include a prorated portion of the reasonably predictable increase in future income and/or family size. Account for a reasonably predictable decrease in future income and/or family size.

Except as provided at 42 CFR 457.315 and 435.603(d)(2) through (d)(4), household income is the sum of the MAGI-based income of every individual included in the individual's household.

Household income includes actually available cash support. exceeding nominal amounts. provided by the person claiming an individual described at §435.603(f)(2)(i) as a tax dependent.

0

The CHIP Agency certifies that it has submitted and received approval for the conversion for all separate CHIP covered group income standards to MAGI-equivalent standards.

An attachment is submitted.

PRA Disclosure Statement

SPA# VA-13-15 Approval Date: Effective Date: January 1, 2014 Page 1 of 2

Cems CHIP Eligibility

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of

the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

SPA# VA-13-15 Approval Date: Effective Date: January 1, 2014 Page 2 of 2

CHEK FOE MEDICAED Au ARE RESIICRS

CHIP Eligibility

OMB Control Number: 0938-1148

Separate Eligibili

2102(b)(1)(B)(v) of the SSA and 42 CFR 457.310, 315 and 320

rl Targeted Low-Income Children - Uninsured children under age 19 whose household income is within standards established by the state.

The CHIP Agency operates this covered group in accordance with the following provisions: Age

Must be under age 19.

Income Standards

Income standards are applied statewide.

Are there any exceptions, e.g. populations in a county which may qualify under either a statewide income No standard or a county income standard?

Statewide Income Standards

Begin with lowest age range first.

Please note that the lower bound for CHIP eligibility should be the highest standard used for Medicaid poverty- level children for the same age group or groups entered here.

From Age To Age Above (% FPL) Up to & including (% FPL)

+ |io 19 143 200 xX

Age ranges may overlap. If there is an overlap, provide an explanation. Include the age ranges for each income standard that has overlapping ages and the reason for having different income standards.

Special Program for Children with Disabilities

Does the state have a special program for children with disabilities?

PRA Disclosure Statement

SPA# VA-13-15 Approval Date: Effective Date: January 1, 2014 Page 1 of 2

CHIP Eligibility

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of

the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

V.20130709|

SPA# VA-13-15 Approval Date: Effective Date: January 1, 2014

Page 2 of 2

coms CHIP Eligibility

OMB Control Number: 0938-1148

Section 2112(e) of the SSA and 42 CFR 457.360

iw Deemed Newborns - Children born to targeted low-income pregnant women are deemed to have applied for and be eligible for CHIP or Medicaid until the child turns one.

The state operates this covered group in accordance with the following provisions: [B] The child was born to an eligible targeted low-income pregnant woman under section 2112 of the SSA.

rl The child is deemed to have applied for and been found eligible for CHIP or Medicaid, as appropriate, as of the date of the child's birth, and remains eligible without regard to changes in circumstances until the child's first birthday.

The state elects the following option(s):

Rl The state elects to cover as a deemed newborn a child born to a mother who is covered as a targeted low-income child under the state's separate CHIP on the date of the newborn's birth.

The state elects to recognize a child's deemed newborn status from another state and provides benefits in accordance with the requirements of section 2112(e) of the SSA.

The state elects to cover as a deemed newborn a child born to a mother who is covered under Medicaid or CHIP through the authority of the state’s section 1115 demonstration on the date of the newborn’s birth.

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of

the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer. Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

SPA# VA-13-15 Approval Date:. Effective Date: January 1, 2014

Page | of 1

_____________________________________________________________________________ Table of Contents State/Territory Name: Virginia State Plan Amendments (SPA) #: VA-13-0017 This file contains the following documents in the order listed: 1) Approval Letter 2) SPA Summary Form 3) Approved SPA Pages The complete title XXI state plan for Massachusetts consists of the most recent state plan posted on Medicaid.gov under CHIP and State Plan Amendments. The link is provided below. The following approved templates are in addition to, or replace sections of the state’s posted current state plan. The attached approval letter(s) explain how these templates fit into that state plan. Link to state title XXI state plans and amendments: http://medicaid.gov/Medicaid-CHIP-Program-Information/By- Topics/Childrens-Health-Insurance-Program-CHIP/CHIP-State-Program-Information.html

DEPARTMENT OF HEALTH & HUMAN SERVICES aaa Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop: 82-26-12 Baltimore, Maryland 21244-1850

CENTERS FOR MEDICARE & MEDICAID SERVICES CENTER FOR MEDICAID & CHIP SERVICES

Children and Adults Health Programs Group

NOV 18 2013

Rebecca Mendoza

Director, Division of Maternal and Child Health Virginia Department of Medical Assistance Services 600 East Broad Street, Suite 1300

Richmond, VA 23219

Dear Ms. Mendoza:

I am pleased to inform you that your Title XXI Children’s Health Insurance Program (CHIP) state plan amendments (SPA) VA-13-0017 and VA-13-19 submitted on October 6, 2013 and related to Modified Adjusted Gross Income (MAGI) Eligiblity have been approved with an effective date of January 1, 2014.

Establish 2101(f) Group:

SPA number VA-13-0017 provides coverage in Virginia’s separate CHIP, as specified in the state’s submission of CS14: Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards. A copy of the approved state plan page (CS14) is attached, and should be incorporated within a separate subsection under Section 4.1 of Virginia’s approved CHIP state plan.

Non-Financial Eligibility:

SPA number VA-13-19 is approved to clarify the state’s non-financial eligibility policies on residency; citizenship; social security numbers; and other eligbility standards. We are approving this SPA in the absence of state plan page CS20. The state's non-financial eligibility policy on substitution of coverage will be submitted when the state legislature has met and approved the change to the waiting period: Copies of the approved state plan pages are attached and these approved pages supersede sections of Virginia’s current state plan as laid out below:

New State Plan Page Impact on Current State Plan Section

CS17: Non-Financial Eligibility — Residency Section 4.1.5

CS18: Non-Financial Eligibility — Citizenship Section 4.1.0; and 4.1-LR

CS19: Non-Financial Eligibility — Social Security | Section 4.1.9.1 Number

C823: Other Eligibility Standards Section 4.1.6; 4.1.7; 4.1.8; 4.1.9

Page 2 - Ms. Rebecca Mendoza Your Title XXI project officer is Ms. Ticia Jones. She is available to answer questions concerning these amendments and other CHIP-related issues. Ms. Jones' contact information is as follows: Centers for Medicare & Medicaid Services Center for Medicaid & CHIP Services Mail Stop: S2-01-16 7500 Security Boulevard Baltimore, MD 21244-1850 Telephone: (410) 786-8145 Facsimile: (410) 786-5882 E-mail: Ticia.Jones@cms.hhs.gov If you have questions or wish to discuss this determination further, please contact Mr. Francis McCullough, Associate Regional Administrator (ARA) in our Philadelphia Regional Office. Mr. McCullough's address is: Centers for Medicare & Medicaid Services Division of Medicaid and Children's Health Operations Suite 216, The Public Ledger Building 150 Independence Mall West Philadelphia, PA 19106 Congratulations on the approval. We look forward to continuing to work with you and your staff toward the approval of your remaining MAGI Eligibility SPAs. If you have additional questions, please contact Ms. Linda Nablo, Director of the Division of State Coverage Programs, at (410) 786-5143. We look forward to continuing to work with you and your staff. Enclosure Sincerely,
 Eliot Fishman Director cc: Francis McCullough, ARA, CMS Region III, Philadelphia

03, 2014)

Children's Health Insurance Program Eligibility

Control Panel

General Information

File Management Tribal Input

Summary

Children's Health Insurance Program Eligibility: Summary Page

State/Territory Virginia

name: Transmittal Number: Please enter the Transmittal Number (TN) in the format ST- YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number

with leading zeros. The dashes must also be entered. |VA-14-0025 |

Type of SPA: MAGI Eligibility & Methods XXI Medicaid Expansion “| Establish 2101(f) Group Eligibility Processing Non-Financial Eligibility

Proposed Effective Date

(nmn/aa/yyyy)

Federal Statute/ Regulation Citation

| Section 1902(e)(14) of the Social Security Act

Federal Budget Impact

This SPA has a budget impact. Total budget impact:

State Funds: $ Federal Funds: $

Subject of Amendment

Please provide a brief summary of SPA changes.

Character Count:&89 out of 2000

C514 Children ineligible for Medicaid as a result of the elimination of income disregards

Signature of State Agency Official

Submitted By: Brian McCormick

Last Revision Sep 10, 2014 Date:

Submit Date: Jun 26, 2014

coms. CHIP Eligibility

OMB Control Number: 0938-1148 Expiration date: 10/31/2014

Section 2101(f) of the ACA and 42 CFR 457.310(d)

{Mi Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards The CHIP agency provides coverage for this group of children as follows:

The state has received approval from CMS to maintain Medicaid eligibility for children who would otherwise be subject to Section 2101(f) such that no child in the state will be subject to this provision.

The state assures that separate CHIP coverage will be provided for children ineligible for Medicaid due to the elimination of income disregards in accordance with 42 CFR 457.310(d). Coverage for this population will cease when the last child protected from loss of Medicaid coverage as a result of the elimination of income disregards has been afforded 12 months of coverage in a separate CHIP (expected to be no later than April 1, 2016 ).

C

Describe the methodology used by the state to identify and enroll children in a separate CHIP who are subject to the protection afforded by Section 2101(f) of the Affordable Care Act:

The state has demonstrated and CMS has agreed that all children qualifying for section 2101(f) protection will qualify for the state’s existing separate CHIP.

The state will enroll all children in a separate CHIP who lose Medicaid eligibility because of an increase in family income at their ‘first renewal applying MAGI methods.

The state will enroll children in a separate CHIP whose family income falls above the converted MAGI Medicaid FPL but at or below the following percentage of FPL. The state has demonstrated and CMS has agreed that all or almost all the children who would have maintained Medicaid eligibility if former disregards were applied will be within this income range and therefore covered in the separate CHIP.

be FPL

The state will enroll children in a separate CHIP who are found to be ineligible for Medicaid based on MAGI but whose family income has not increased since the child’s last determination of Medicaid eligibility or who would have remained eligible for Medicaid (based on the 2013 Medicaid income standard) if the value of their 2013 disregards had been applied to the family income as determined by MAGI methodology.

Cc

C Other.

Describe the benefits provided to this population:

C This population will be provided the same benefits as are provided to children in the state’s Medicaid program. @ This population will be provided the same benefits as are provided to children in the state's separate CHIP.

C Other (consistent with Section 2103 of the SSA and 42 CFR 457 Subpart D).

Describe premiums and cost sharing required of this population:

C Cost sharing is the same as for children in the Medicaid program.

* ae SPA # VA-13-0017 Approval Date: NGY i o auld Effective Date: January 1, 2014 NOY 1 6 Page 1 of 2

ccms CHIP Eligibility

(@ Premiums and cost sharing are the same as for targeted low-income children in the state's separate CHIP.

C No premiums, copayments, deductibles, coinsurance or other cost sharing is required.

C Other premiums and/or cost-sharing requirements (consistent with Section 2103(e) of the SSA and 42 CFR 457 Subpart E).

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

NOV 18 2013

SPA # VA-13-0017 Approval Date: Effective Date: January 1, 2014 Page 2 of 2

_____________________________________________________________________________

Table of Contents

State/Territory Name: Virginia

State Plan Amendment (SPA) #: VA-13-0018

This file contains the following documents in the order listed:

1) Approval Letter 2) SPA Summary Form 3) Approved SPA Pages 4) Additional Attachments that are part of the state plan

The complete title XXI state plan for Virginia consists of the most recent state plan posted on Medicaid.gov under CHIP and State Plan Amendments. The link is provided below. The following approved templates are in addition to, or replace sections of the state’s posted current state plan. The attached approval letter(s) explain how these templates fit into that state plan. Link to state title XXI state plans and amendments: http://medicaid.gov/Medicaid-CHIP-Program-Information/By- Topics/Childrens-Health-Insurance-Program-CHIP/CHIP-State-Program-Information.html

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services (“CMS 7500 Security Boulevard, Mail Stop: S2-26-12 CM Ss

Baltimore, Maryland 21244-1850 CENTER FOR MEDICAID & CHIP SERVICES

Children and Adults Health Programs Group

JUN 17 2014

Rebecca Mendoza ;

Director, Maternal and Child Health Division Virginia Department of Medical Assistance 600 East Broad Street, Suite 1300 Richmond, VA 23219

Dear Ms. Mendoza:

I am pleased to inform you that the Centers for Medicare & Medicaid Services (CMS) has * approved Virginia’s Children’s Health Insurance Program (CHIP) State Plan Amendment (SPA), VA-13-0018 submitted on October 6, 2013. This SPA incorporates the MAGI-based eligibility process requirements in accordance with the Affordable Care Act. The effective date of this SPA is October 1, 2013.

The approval of CHIP SPA VA-13-0018 includes full approval of your State’s alternative single streamlined paper application. The State is using an interim alternative single streamlined online application used to apply for multiple human service programs. By December 31, 2014, Virginia will implement a revised alternative online application that addresses CMS concerns outlined in the companion letter issued with this SPA approval.

Enclosed is a copy of the following CS24 state plan pages and attachments to be incorporated within a separate section at the end of Virginia’s approved state plan:

CS24 Attachment 1 — Statement of use with respect to the alternative single streamlined online application Alternative single streamlined paper application e Statement related to coordination of eligibility and enrollment

This approval and the attachments supercede the following sections of the current CHIP State Plan:

e Section 4.3: Single Streamlined Application Screen and Enroll Process e Section 4.4: Renewals, Screening by Other Insurance Affordability Programs

The CMS appreciates the significant amount of work your staff dedicated to preparing this State Plan Amendment. Your title XXI project officer is Ms. Ticia Jones. She is available to answer questions concerning this amendment and other CHIP-related issues. Ms. Jones’ contact information is as follows:

Page 2 — Ms. Rebecca Mendoza

Centers for Medicare & Medicaid Services Center for Medicaid and CHIP Services Mail Stop: S2-01-16

7500 Security Blvd.

Baltimore, MD 21244-1850

Telephone: (410) 786-8145

Facsimile: (410) 786-5882

E-mail: Ticia. Jones@cms.hhs.gov

Official communications regarding program matters should be sent simultaneously to Ms. Jones and to Francis McCullough, Associate Regional Administrator (ARA) in our Philadelphia Regional Office. Mr. McCullough’s address is:

Francis McCullough

Office of the Regional Administrator Suite 216, The Public Ledger Building 150 S. Independence Mall West Philadelphia, PA 19106

If you have additional questions, please contact Barbara K. Richards, Acting Director, Division of State Coverage Programs at 410-786-5920.

We look forward to continuing to work with you and your staff.

Sincerely,

10t Fishman Director

Enclosure

ce: Mr. Francis McCullough, ARA, CMS Region III, Philadelphia

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services

7500 Security Boulevard, Mail Stop: S2-26-12 Baltimore, Maryland 21244-1850

Children and Adults Health Programs Group

CCMS

CENTERS FOR MEDICARE & MEDICAID SERVICES CENTER FOR MEDICAID & CHIP SERVICES

JUN 17 2014

Rebecca Mendoza

Director, Maternal and Child Health Division Virginia Department of Medical Assistance 600 East Broad Street, Suite 1300 Richmond, VA 23219

RE: CS24 — Eligibility Process State Plan Amendment (SPA), VA-13-0018

Dear Ms. Mendoza:

This letter is being sent as a companion to Centers for Medicare & Medicaid Services (CMS) approval of Virginia’s state plan amendment (SPA) transmittal VA-13-0018. Our review of this submission included a review of the online and paper alternative single streamlined applications

developed by the state.

Until December 31, 2014, the State is using an interim, alternative single streamlined online application used to apply for multiple human service programs. This interim application needs

to be revised to reflect the following changes.

household members live together) e All citizenship and immigration questions

Medicare MCO Selection

only.)

e Residency questions (other than information needed to determine whether

e Non-MAGI screening questions related to blindness, disability, and

The attestation which states "I understand that my signature on this application certifies, under penalty of perjury, that I am a U.S. Citizen or alien in lawful immigration status (unless applying for emergency services

Completion Necessary changes Date The following questions will not appear for household members not seeking any December benefits: 31, 2014

Page 2 — Ms. Rebecca Mendoza

Completion Necessary changes Date The following questions will not appear on application for health coverage only. December 31, 2014 ¢ Questions regarding roomer/boarder © Questions regarding income not countable under MAGI, such as SSI and child support income (Note: SSI may be asked as a yes/no question of applicants only as a non-MAGI screening question) Questions regarding dependent care bills Questions regarding school enrollment status and grade completed, except for 18-22 year-olds as needed. Questions about the cost of the employer-sponsored coverage premium will be moved to follow the question regarding the name of the lowest cost plan. ae

Please submit the revised alternative single streamline online application to CMS for review no later than December 1, 2014, to ensure approval by December 31, 2014. We continue to be available to provide technical assistance. If you have any questions about your application, please contact Victoria Collins at Victoria.Collins@cms.hhs.gov or (410) 786-2167.

We look forward to continuing to work with you and your staff.

Sincerely,

Barbara K. Richards Acting Director Division of State Coverage Programs

ce: Mr. Francis McCullough, AR A, CMS Region III, Philadelphia

logged in as TONIABROWN(CMS CO Staff) read only mode application rev p01 Children's Health Insurance Program Eligibility VA.0405.R00.00 - Oct 01, 2013 Home Logout Finder Save Validate Print Help Control Panel General Information File Management Tribal Input Summary State/Territory name: Virginia State Funds: $ Federal Funds: $ Submitted By: Brian McCormick Last Revision Date: Oct 17, 2014 Submit Date: Oct 6, 2013 Children's Health Insurance Program Eligibility: Summary Page Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. VA-13-0018 Type of SPA: MAGI Eligibility & Methods XXI Medicaid Expansion Establish 2101(f) Group Eligibility Processing Non-Financial Eligibility Proposed Effective Date 10/01/2013 (mm/dd/yyyy) Federal Statute/Regulation Citation Section 1902(e)(14) of the Social Security Act Federal Budget Impact This SPA has a budget impact. Total budget impact: Subject of Amendment Please provide a brief summary of SPA changes. Character Count:286 out of 2000 CS24 - Submission of the alternative single, streamlined Medicaid/CHIP application developed by Virginia, the eligibility redetermination process, and confirmation of coordination of eligibility and enrollment between Medicaid, CHIP, Exchanges and other insurance affordability programs Signature of State Agency Official Page 1 of 2 Children's Health Insurance Program Eligibility: CMS 179 11/02/2014 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

FAQs | Site Map | Contact | Medicaid.gov | CMS.gov Page 2 of 2 Children's Health Insurance Program Eligibility: CMS 179 11/02/2014 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

USE OF THE ALTERNATIVE SINGLE STREAMLINED APPLICATION

O Paper Application 1] Online Application TRANSMITTAL NUMBER: STATE: VA-13-0018 Virginia

Through December 31, 2014, the state is using an interim alternative single streamlined application. After December 31, 2014, the state will use a revised alternative single streamlined application. The revised application will address the issues outlined in the CMS letter, which was issued with the approval of this state plan amendment, concerning the state’s application. The revised application will be incorporated by reference

into the state plan.

COORDINATION OF ELIGIBILITY AND ENROLLMENT

TRANSMITTAL NUMBER:

VA-13-0018

STATE:

Virginia

Notwithstanding the final checked statement on page 2, the single state agency has not entered into an agreement with the Federally-facilitated Marketplace to date. The single state agency will make a good faith effort to enter into a memorandum of agreement with the Federally-facilitated Marketplace as soon as possible. At such time the agreement is signed, it will be incorporated by reference into this attachment

Cems CHIP Eligibility

OMB Control Number: 0938-1148 Expiration date: 10/31/2014

2102(b)(3) & 2107(e)(1)(O) of the SSA and 42 CFR 457, subpart C

The CHIP Agency meets all of the requirements of 42 CFR 457, subpart C for application processing, eligibility screening and enrollment.

4)

Application Processing

Indicate which application the agency uses for individuals apply ing for coverage who may be eligible based on the applicable modified adjusted gross income standard:

Oo The single, streamlined application developed by the Secretary in accordance with section 1413(b)(1)(A) of the Affordable Care Act.

An alternative single, stream lined application developed by the state and approved by the Secretary in accordance with

“ section 1413(b)(1)(B) of the Affordable Care Act.

An alternative application used to apply for multiple human service programs approved by the Secretary, provided that the ‘RX agency makes readily available the single or alternative application used only for insurance affordability programs to individuals seeking assistance only through such programs.

The agency's procedures permit an individual, or authorized person acting on behalf of the individual, to submit an application via the internet website described in CF R 457.340(a), by telephone, via mail, in person and other commonly available electronic means.

The agency accepts applications in the following other electronic means. (1) Other electronic means: Screen and Enroll Process

The CHIP Agency has coordinated eligibility and enrollment screening procedures in place that are applied at time of initial application, periodic redeterminations, and follow-up eligibility determinations. The procedures ensure that only targeted low-

income children are provided CHIP coverage and that enrollment is facilitated for applicants found to be potentially eligible for other insurance affordability programs.

Procedures include:

Screening of application to identify all individuals eligible or potentially eligible for CHIP or other insurance affordability il programs; and

wl Income eligibility test, with calculation of household income consistent with 42 CFR 457.315 for individuals identified as potentially eligible for Medicaid or other insurance affordability programs based on household income; and

JUNT7 2014

SPA# VA-13-0018 Approval Date: Effective Date: October 1, 2013 Page 1 of 2

cCEMs CHIP Eligibility

ia Screening process for individuals who may qualify for Medicaid on a basis other than having household income at or below the applicable MAGI standard, based on information in the single streamlined application.

The CHIP agency has entered into an arrangement with the Exchange to make eligibility determinations for advanced

premium tax credits in accordance with section 1943(b)(2) of the SSA. No

Redetermination Processing

Redeterm inations of eligibility for individuals whose financial eligibility is based on the applicable modified adjusted gross income standard are performed as follows, consistent with 42 CFR 457.343:

[Ml] Once every 12 months.

ry Without requiring information from the individual if able to do so based on reliable information contained in the individual's account or other more current information available to the agency.

If the agency cannot determine eligibility solely on the basis of the information available to it, or otherwise needs additional [Mf] information to complete the redetermination, it provides the individual with a pre-populated renewal form containing the information already available.

Screening by Other Insurance Affordability Programs

The CHIP Agency provides assurance that it has adopted procedures to accept and process electronic accounts of individuals screened as potentially eligible for CHIP by other insurance affordability programs in accordance with the requirements of 42 CFR 457.348(b) and to determine eligibility in accordance with 42 CFR 457.340 in the same manner as if the application had been submitted directly to, and processed by the state.

The CHIP Agency elects the option to accept CHIP eligibility decisions made by the Exchange or other agencies administering Be insurance affordability programs as provided in 42 CFR 457.348 and to furnish CHIP in accordance with requirem ents of 42 CFR 457.340 to the same extent and in the same manner as if the applicant had been determined by the state to be eligible for

CHIP.

Check all types of agencies that apply:

(1 The Exchange

EX] Medicaid

(C1) Other agency administering insurance affordability programs

The CHIP Agency has entered into an agreement with agencies administering other insurance affordability programs to fulfill the O requirements of 457.348(b) and will provide this agreement to the Secretary upon request.

PRA Disclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

V.20130709

JUN 147 2014

SPA# VA-13-0018 Approval Date: Effective Date: October 1, 2013 Page 2 of 2

< e %) ,; COVE!

R VIRGINIA

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mek feast

Application for Health Coverage & Help Paying Costs

THINGS TO KNOW

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Use this application to see what coverage choices you qualify for

Who can use this application?

Apply faster online

What you may need to apply

Why do we ask for this information?

What happens next?

Get help with this application

* Free or low-cost insurance from Medicaid, FAMIS or Plan First

«Affordable private health Insurance plans that offer comprehensive coverage to help you stay well

* Anew tax credit that can immediately help pay your premiums for health coverage

You may qualify for a low-cost program even if you earn as much as $94,000 a year (for a family of 4).

* Use this application to apply for anyone in your family.

* Apply even if you or your child already has health coverage. You could be eligible for lower-cost or free coverage.

* Families that include immigrants can apply. You can apply for your child even if you aren't eligible for coverage. Applying won't affect your immigration status or chances of becoming a permanent resident or citizen.

* if someone is helping you fill out this application, you may need to complete Appendix C.

+ Ifyou are disabled and/or need assistance with nursing home or community based care, you may need to complete Appendix D.

Apply faster online at commonheip.virginia.gov. For more information about Medicaid, FAMIS and Plan First visit

goverva.org.

* Social Security Numbers (or document numbers for any legal immigrants who need insurance)

* Employer and income Information for everyone in your family (for example, from paystubs, W-2 forms, or wage and tax statements)

* Policy numbers for any current health insurance

* Information about any job-related health insurance available to your family

We ask about income and other information to let you know what coverage you qualify for and if you can get any help paying for it. We'll keep all the information you provide private and secure, as required by law.

If you use this paper application, send your complete, signed application to the local Department of Social Services in the city or county where

you live. They will follow up with you to obtain additional information. Your application should be processed within 45 days from the date it was received,

* Phone: Call Cover Virginia at 1-855-242-8282,

* In person: There may be application assisters in your area who can help. Visit our website at coverva.org or call 1-855-242-8282 for more information.

* £n Espaftol: Llame a nuestro centro de ayuda gratis al 1-855-242-8282.

NEED HELP WITH YOUR APPLICATION? Visit coverva.org or call us at 1-855-242-8282. Para obtener una copia de este formulario en Espafiol, lame 1-855-242-8282. If you need help in a language other than English, call 1-855-242-8282 and tell the customer service representative the language you need. We'll get you help at no cost to you. TTY users should call 1-888-221-1590,

10/1/2013

vod

Cover Page Effective Date: 10/01/2013

Gi

G i P 1 | Tell us about yourself.

(We need one adult in the family to be the contact person for your application.)

1. First name, Middle name, Last name, & Suffix

2. Home address (Leave blank if you don't have one.) 3. Apartment or suite number 4, City 5. State 6. ZIP code 7. County

8. Mailing address (if different from home address) ” 9, Apartment or suite number 10, City 11, State 12. ZIP code 13. County

14, Phone number 15. Other phone number

( ) - ( ) =

16, Do you want to get information about this application by email? [Yes [No

Email address:

17, What is your preferred spoken or written language (if not English)?

| STEP 2 | Tell us about your family.

Who do you need to include on this application? Tell us about all the family members who live with you. If you file taxes, we need to know about everyone on your tax return. (You don’t need to file taxes to get health coverage).

DO Include: You DON'T have to include: * Yourself * Your unmarried partner who doesn't need health coverage » Your spouse * Your unmarried partner's children * Your children under 21 who live with you * Your parents who live with you, but file their own tax return * Your unmarried partner who needs health coverage (if you're over 21) * Anyone you include on your tax return, even if they don't * Other adult relatives who file their own tax return live with you * Anyone else under 21 who you take care of and lives with you

The amount of assistance or type of program you qualify for depends on the number of people in your family and their incomes. This information helps us make sure everyone gets the best coverage they can.

Complete Step 2 for each person in your family. Start with yourself, then add other adults and children. if you have more than 2 people in your family, you'll need to include copies of the Additional Person single page supplement form and attach them. You don't need to provide immigration status or a Social Security Number (SSN) for family members who don't need health coverage. We'll keep all the information you provide private and secure as required by law. We'll use personal information only to check if you're eligible for health coverage.

NEED HELP WITH YOUR APPLICATION? Visit the Cover Virginia website at coverva.org or call us at 1-855-242-8282, Para obtener una copia de este formulario en Espafiol, llame 1-855-242-8282. If you need help in a language other than English, call 1-855-242-8282 and tell the customer service representative the language you need. We'll get you help at no cost to you. TTY users should call 1-888-221-1590. Tor innee Page 1 of 8 Effective Date: 10/01/2013 Virg Al :

Sia ee ele (Start with yourself)

' papaueuey norms suapmammmersaermeeramamns rasan Complete Step 2 for yourself, your spouse/partner and children who Tvewith you and/or anyone on your same federal Income tax return if you file one. See page 1 for more ‘formation about who to include. if you dont file a tax return, remember to still add family members who live

with you. 7. First name, Middle name, Last name, & Suffix 2. Relationship to you? SELF 3. Date of birth (mm/dd/yy) 4. Sex CF] Mate (] Female _ 5. Social Security number (SSN) —. + ee

We need this If you want health coverage and have an SSN. Providing your SSN can be helpful if you don’t want health coverage too since it can speed up the application pracess. We use SSNs to check income and other information to see who's eligible for heip with health coverage costs. if someone wants help getting an SSN, call 1-800-772-1213 or visit snclalsecurity.gay. TTY users should call 1-800-325-0778.

6. Do you pian to file a federal income tax return NEXT YEAR? —________{You-can-stilLapply fer health insurance everf yo i (1 Yes. if yes, please answer questions a-c. C1 No. tf no, skip to question c. a. Will you file jointly with a spouse? [Yes [No Hyes, name of spouse: b, Will you claim any dependents on your tax return? []yes CINo ee _—____htyes, list name(s) of dependents: _. ¢. Will you be daimed as a dependent on someone's tax return? [Yes []No If yes, please list the name of the tax filer: How are you related to the tax filer?

7. Are you pregnant? ([]Yes []No a. if yes, how many babies are expected during this pregnancy? —___ Expected due date: —.._

CO ves. tfyes, answer all the questions below. 4)

(1 NO. t? no, SKIP to the income questions on page 3. (1 YES. if not eligible for full coverage, do you wish to be Leave the rest of this page blank. 6 evaluated for Plan First (family planning coverage only)?

9. Do you have a physical, mental, or emotional heaith condition that causes limitations in activities (like bathing, dressing, daily —-—-—-----__cheres, ete} oF live in-a medical facility or nursing heme? [}¥es—(] Ne- —-

10, Are you a US. citizen or U.S. national? ClYes [INo 11. Ifyou aren't a U.S, citizen or U.S. national, do you have eligible immigration status? (ves. Fill in your document type and 1D number below. a, Immigration document type —_.________ b. Document ID number

¢. Have you lived in the U.S. since 1996? Clyes [No d, Are you, or your spouse or parent a veteran or an active-duty rs member of te US. military? Llves LINo

12, Do you want help paying for medical bills from the last 3 months? [JYes [C]No 13. Do you live with at least one child under the age of 19, and are you the main person taking care of this chiid? [lyes [No

i = ewe a tava aa saa Please answer the following questions [f you are 18 or younger: ______.___14,_Did you have Insurance that ended within the past 4 months? []ves []No _ reer a ist of ee a. ifyes, enddate:__...._ sb, Reason the Insurance ended: see aes 6. 15. Are you a full-time student? []¥es []No 16. Were you in foster care in Virginia at age 18 or older? Clyes [].No

17. If Hispanic/Latino, ethnicity (OPTIONAL—check all that apply.) Cimexican []MexicanAmerican (Ichicano/a (C]Puerto Rican Clcuban Clother

White oO American indian or Alaska Filipino Vietnamese Guamanian or Chamorro

Black or African Native Japanese Other Asian Samoan

American Asian indian C] Korean Native Hawalian Other Pacific stander Chinese - Other.

NEED HELP WITH YOUR APPLICATION? Visit the Cover Virginia website at Coverva.org or call us at 1-855-242-8282. Para obtener una copia de este formulario en Espafiol, lame 1-855-242-8282, If you need help in a language other than English, call 1-855-242-8282 and tell the eed_We'll pet you help at no-cost to}

customer service representative the janguage youn

10/1/2013 Page 2 of 8

Effective Date: 10/01/2013 virgita Attemative Single ouvenn.. , «per Application-3

* asee) Nap (Continue with yourself) Current job & income Information

(2 Employed (1 Not employed OO Self-employed If you're currently employed, tell us Skip to question 29. Skip to question 28. about your income. Start with question 19, CURRENT JOB 1: 19. Employer name and address 20. Employer phone number

21. Wages/tips (before taxes) [“JHourly [_]Weekly [lévery2weeks [ltwiceamonth []Monthly Clearly ~~ $ _— 22. Average hours worked each WEEK

CURRENT JOB 2: (If you have more jobs and need more space, attach another sheet of paper.) 23. Employer name and address ic Employer phone number

( ) -

25. Wages/tips (before taxes) [Hourly []Weekly []évery2 weeks []twicea month (] Monthly [yearly $e 26. Average hours worked each WEEK

27.1n the past year, did you: [[] Change jobs (] Stop working [7] Start working fewer hours {_] None of these

28. If self-employed, answer the following questions:

a. Type of work b. How much net income (profits once business expenses are paid) wilt you get from this self-employment this month?

$2

29. OTHER INCOME THIS MONTH: Check all that apply, and give the amount and how often you get it. NOTE: You don't need to tell us about child support, veteran’s payment, or Supplemental Security income (SSI). Cl None

[Unemployment $ How often? C1 net farming/fishing $ How often? ClPensions $ How often? _ Cnet rental/royalty $ How often? O)sociat Security $___ Howoften?_______—»— LJ Other income $ How often? CJRetirement accounts $______ Howoften?____ Type:

ClAlimony received $_.___. How often? .____

30. DEDUCTIONS: Check all that apply, and give the amount and how often you get it.

If you pay for certain things that can be deducted on a federal income tax return, telling us about them could make the cost of health coverage alittle lower.

NOTE: You shouldn't include a cost that you already considered in your answer to net self-employment (question 27b). CAlimony paid $—.._. How often? ___ (Clother deductions $ How often? Cistudent loan interest = $ __ How often? Type:

31. YEARLY INCOME: Complete only if your income changes fram month to month. If you don’t expect changes to your monthly income, skip to the next person. ©}

Your total income this year Your total income next year (if you think it will be different)

$ $ THANKS! This is all we need to know about you.

NEED HELP WITH YOUR APPLICATION? Visit the Cover Virginia website at coverva,org or call us at 1-855-242-8282. Para obtener una copia de este formulario en Espafiol, lame 1-855-242-8282. If you need help in a language other than English, call 1-855-242-8282 and tell the customer service representative the language you need. We'll get you help at no cost to you. TTY users should call 1-888-221-1590. 10/1/9972 Page 3 of 8 wees . Effective Date: 10/01/2013 Virginia Alternative Single Streamlined Paper Application-4

STEP 2: PERSON 2

Complete Step 2 for your spouse/partner, and children who live with you and/or anyone on your same federal income tax return if you file one. See page 1 for more information about who to include. if you dontt file a tax return, remember to still add family members who live with you.

“T First name, Middle name, Last name, & Suffix 2. Relationship to you?

SE bate oF bin immniddiyyy) f4.Sex ClMale C]female -

{ 5, Social Security number (SSN) —— — — - _. - We need this if you want health coverage and have an SSN. 6, Does PERSON 2 live at the same address as you? Clyes []No if na, list address: 7, 2008 PERSON 2 plan to file a federal income tax return NEXT YEAR? {You can still apply for health insurance even if you don't file a federal income tax return.) (YES. if yes, please answer questions a-c. CINO. If no, skip to question c. a. Will PERSON 2 file jointly with a spouse? [Yes [No ff yes, name of spouse: b. Will PERSON 2 claim any dependents on his or her tax return? Clyes [JNo ¢. Will PERSON 2 be claimed as a dependent on someone's tax retum? []Yes CINo i yes, please list the name of the tax filer: How is PERSON 2 related to the tax filer?

8. ts PERSON 2 pregnant? [Yes []No a. if yes, how many babies are expected during this pregnancy?

9, Does PERSON 2 need health coverage? {Even if they have Insurance, there might be a program with better coverage or lower costs.)

(1) ves. ityes, answer all the questions below. 4) 1 No. tf no, SKIP to the income questions on page 5. >]

C1 VES. tf not eligible for full coverage, do you wish to be Leave the rest of this page blank, evaluated for Plan First (farnily planning coverage only)?

€xpected due date:

10, Does PERSON 2 have a physical, mental, or emotional health condition that causes limitations in activities (like bathing, dressing, daily ________ chores, etc) or live in.a medical facility or nursing home? [lyes_[1No 11, Is PERSON 2 a US. citizen or U.S. national? Cl¥es C1No 12. Hf PERSON 2 isn’t a US. citizen or U.S, national, do they have eligible immigration status? 1 Yes. Fill in their document type and ID number betow. a. Document type b. Document ID number

c. Has PERSON 2 lived in the U.S, since 1996? C]yes [1] No d. Is PERSON 2, or their spouse or parent a veteran or an active- _. duty. member in the U.S_ military? Clyes_(CiNo

13, Does PERSON 2 want help paying for 14. Does PERSON 2 live with at least one child under | 15. Was PERSON 2 in foster care in medical bills from the last 3 months? the age of 19, and are they the main person Virginia at age 18 or older? Clves CINo taking care of this child? ves [No Oyes CINo Please answer the following questions if PERSON 2 Is 18 or younger: __... 16. Did PERSON. 2 have insurance that ended within the past 4 months? ([]ves []No *For a list of a. yes, end date; sb. Reason the insurance ended: reasons, pease

17. Is PERSON 2 a full-time student? Clyes CINo

18. if Hispanic/Latino, ethnicity (OPTIONAL—check all that apply.) (Cimexican [Mexican American []chicanofa (Puerto Rican [Jcuban (] other

19, Race (OPTIONAL —check aff that apply.)

() white (J American indian or Alaska [1] Filipino (1 Vietnamese CJ Guamanian or Chamorro C1 Black or African Native D Japanese C1 Other Asian (1 Samoan American CO Asian indian ( Korean (CI Native Hawaiian (1 Other Pacific slander (1 Chinese (1 other

NEED HELP WITH YOUR APPLICATION? Visit the Cover Virginia website at coverva.org or call us at 1-855-242-8282. Para obtener una copia de este formulario en Espafiol, lame 1-855-242-8282. If you need help in a language other than English, call 1-855-242-8282 and tell the

_..._ Customer senvice representative the language you need, We'll get you help at no.cost to you. TTY users should call 4-888-221-1590 VO/V/INIA Page 4 of 8

Effective Date: 10/01/2013 Virginia Altemative Single Streamlined Paper Appucation-5

@

TEP 2: PERSON 2 Current Job & Income Information

C1 Employed 1 Not employed O Self-employed \f PERSON 2 is currently employed, Skip to question 30. Skip to question 29, tell us about their income. Start with question 20.

CURRENT JOB 1: 20. Employer name and address fa Employer phone number

22, Wages/tips (before taxes) []Hourly []Weekly [Every 2 weeks [] Twice a month [] Monthly o Yearly :

23, Average hours worked each WEEK

CURRENT JOB 2: (if PERSON 2 has more jobs and needs more space, attach another sheet of paper.) 24, Employer name and address 25. Employer phone number

26. Wages/tips (before taxes) []Hourly []Weekly Cl every 2 weeks, Oo Twice a month CI Monthly [] Yearly oo $

27. Average hours worked each WEEK

28. in the past year, did PERSON 2: [1] Change jobs [1 Stop working [1 Start working fewer hours [_] None of these

29. if self-employed, answer the following questions:

a. Type of work b. How much net income {profits once business expenses are paid) will PERSON 2 get from this self-employment this month?

$

30. OTHER INCOME THIS MONTH: Check ail that apply, and give the amount and how often they get it. NOTE: You don’t need to tell us about child support, veteran's payment, or Supplemental Security Income (SSi). None

(1 Unemployment $__..._ Howoften?_._____. _ _(C)Net farming/fishing $$ How often? CPensions $____ Howoften?_.__——t—<t«é‘~dSS Nett reentai/rcnyzaalty $ How often?

(Social Security $____._ How often? _. (1 other incorne $ How often? (Retirement accounts $_....._.._ How often? ___._=_ Type: ———____________..__

CJaAlimony received $_.__- Howoften?_

31. DEDUCTIONS: Check all that apply, and give the amount and how often they get it.

If PERSON 2 pays for certain things that can be deducted on a federal income tax return, telling us about them could make the cost of health coverage a little lower.

NOTE: You shouldn't include a cost that you already considered in the answer to net self-employment (question 29b). ClAlimony paid $_______ How often? ._=>_E (Other deductions $ How often? Cistudent foan interest $.—.._ How often? Type:

32. YEARLY INCOME: Complete only if PERSON 2's income changes from month to month. If you don’t expect changes to PERSON 2‘s monthly income, add another person or skip to the next section.

“PERSON 2's total income this year PERSON 2's total income next year (if you think it will be different) $ $

THANKS! This is all we need to know about PERSON 2. tf you have more than two people to include, complete the Additional Person single page supplement form.

NEED HELP WITH YOUR APPLICATION? Visit the Cover Virginia website at Coverva.org or call us at 1-855-242-8282. Para obtener una copia de este formulario en Espafiol, llame 1-855-242-8282, if you need help in a language other than English, call 1-855-242-8282 and tell the customer service representative the language you need. We'll get you help at no cost to you. TTY users should call 1-888-221-1590.

10/1/2012 Page 5 of 8

Effective Date: 10/01/2013 Virginia Altemative Single Streamlined Paper Application-6

American Indian or Alaska Native (Al/AN) family member(s)

1. Are you or is anyone in your family American indian or Alaska Native? CII No, skip to Step 4. CO Yes. if yes, go to Appendix B.

| STEP 4 | Your Family's Health Coverage

Answer these questions for anyone who needs health coverage.

1. Is anyone enrolled in health coverage now from the following? (Es. If yes, check the type of coverage and write the person(s)’ name(s) next to the coverage they have. (INO.

C1 Medicaid CI Employer insurance ~

0 Famis Name of health insurance:

CO Plan First Policy number:

; Is this COBRA coverage? [les [No

C1 Medicare Is this a retiree health plan? (JYes CINo

C1 TRICARE (Don't check if you have direct care or Line of Duty) O other Name of health insurance:

( veterans Administration health care programs Policy number: is this a limited-benefit plan (like a school accident policy)? Cves CINo

O Peace Corps

O Marketplace.

2. Is anyone listed on this application offered health coverage from a job? Check yes even if the coverage is from someone else's job, such as a parent or spouse.

CVVEs. if yes, you'll need to complete and include Appendix A. Is this a state employee benefit plan? Clyes (] No CINO. if no, continue to Step 5.

* REASONS CHILD'S HEALTH INSURANCE ENDED: 1 Parent or stepparent changed jobs or stopped employment and no other employer contributes to the cost of family coverage. 2 Parent or stepparent’s employer stopped contributing to the cost of family coverage and no other employer contributes to the cost of family coverage. 3 insurance company discontinued coverage because child is uninsurable. 4 Cost of insurance exceeded 10% of monthly income (before taxes). 5 insurance stopped/dropped by someone other than parent or stepparent living with child. 6 Stopped/dropped a COBRA policy. 7 Other.

PRA Disclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number, The valid OMB control number for this information collection is 0938-1191, The time required to complete this information collection is estimated to average {insert Time (hours or minutes} per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. ff you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

NEED HELP WITH YOUR APPLICATION? Visit the Cover Virginia website at Coverva.org or call us at 1-855-242-8282. Para obtener una copia de este formulario en Espafiol, Ilame 1-855-242-8282. if you need help in a language other than English, call 1-855-242-8282 and tell the customer service representative the language you need. We'll get you help at no cost to you. TTY users should call 1-888-221-1590. 10/1/2013 Page 6 of 8 Effective Date: 10/01/2013 Virginia Altemative Singie ouvarmnted Paper Application-7

| STEP 5 | Read & sign this application.

+ I'm signing this application under penalty of perjury which means I've provided true answers to all the questions on this form to the best of my knowledge. | know that | may be subject to penalties under federal law if t provide false and or untrue information,

* understand that for individuals enrolled in managed care, a premium is paid each month to the MCO for the person's coverage. If the child or pregnant woman is not eligible for FAMIS, FAMIS Plus, FAMIS MOMS, or Medicaid because | did not report truthful information or failed to report required changes in my family size or income, | may have to repay the monthly premiums paid to the MCO. | may have to repay these premiums even if no medical services were received during those months.

+ [know that | must tell the local Department of Social Services if anything changes and is different than what | wrote on this application. | can visit www.commonhelp to report any changes. | understand that a change in my information could affect the eligibility for member(s) of my household.

* know that under federal law, discrimination isn’t permitted on the basis of race, color, national origin, sex, age, sexual orientation, gender identity, or disability. | can file a complaint of discrimination by visiting www.hhs,gov/ocr/office/file.

» | confirm,that no one applying for health insurance on this application is incarcerated (detained or jailed). If not,

is incarcerated.

(name of person) We need this information to check your eligibility for help paying for health coverage if you choose to apply. We'll check your

answers using information in our electronic databases and databases from the Internal Revenue Service (IRS), Social Security, the

Department of Homeland Security, and/or a consumer reporting agency. If the information doesn’t match, we may ask you to send us proof,

Renewal of coverage in future years

To make it easier to determine my eligibility for help paying for health coverage in future years, | agree to allow the Medicaid or FAMIS programs or the Marketplace to use income data, including information from tax returns. | understand that | will receive notification of the outcome of my renewal. | understand that | can opt out at any time.

Yes, renew my eligibility automatically for the next

O15 years (the maximum number of years allowed), or for a shorter number of years:

04 years (13 years O2 years Otyear O)Don't use information from tax returns to renew my coverage.

if anyone on this application is eligible for Medicaid

* {am giving to the Medicaid agency our rights to pursue and get any money from other health insurance, legal settlements, or other third parties. | am also giving to the Medicaid agency rights to pursue and get medical support from a spouse or parent.

» Does any child on this application have a parent living outside of the home? Oyes CNo

* Ifyes, | know | will be asked to cooperate with the agency that collects medical support from an absent parent. if | think that cooperating to collect medical support will harm me or my children, | can tell Medicaid and | may not have to cooperate.

My right to appeal If think Medicaid, FAMIS or Plan First has made a mistake | can contact them at www.coverva.org or call 1-855-242-8282. Instructions for filing an appeal will be included on my notice and are also available on the coverva.org website.

If | think the Health Insurance Marketplace has made a mistake, | can appeal its decision. To appeal means to tell someone at the Health insurance Marketplace that | think the action is wrong, and ask for a fair review of the action. | know that | can find out how to appeal by contacting the Marketplace at 1-800-318-2596. | know that I can be represented in the process by someone other than myself, My eligibility and other important information will be explained to me.

Sign this application. The person who filled out Step 1 should sign this application. if you're an authorized representative you " may sign here, as long as you have provided the information required in Appendix C.

Signature Date (mm/dd/yyyy)

Gos Mail completed application.

Mail your signed application to: The local Department of Social Services in the city or county in which you live

As a citizen of the Commonwealth of Virginia, we are required to provide you with the opportunity to register to vote when applying for benefits. if you are not already registered and you want to register to vote, you can complete a voter registration form at www.sbe.virginia.gov.

NEED HELP WITH YOUR APPLICATION? Visit the Cover Virginia website at Coverva.org or call us at 1-855-242-8282. Para obtener una copia de este formulario en Espafiol, lame 1-855-242-8282. If you need help in a language other than English, call 1-855-242-8282 and tell the customer service representative the language you need. We'll get you help at no cost to you. TTY users should call 1-888-221-1590. oye 7042 Page 7 of 8 : Effective Date: 10/01/2013 Virginia Altemative Single Streamlined Paper Application-8

nsent to Share User Profile Information The Virginia Department of Social Services (VDSS) would like to use some of the personal information that you have provided on your application about you and your dependents to create your User Profile. VDSS is asking for permission to share your User

Profile electronically with the state agencies listed below. Each agency will be told when you make a change to the information in your User Profile. This will allow you to save time by only providing User Profile information once when visiting these agencies.

Legal notice The data being shared

Your User Profile will only be created if you agree to share it and you are eligible for assistance. Your User Profile will contain first name, last name, middle initial, suffix (r., Sr., etc.), current home address, date of birth, Social Security Number and Medicaid identification number (if applicable), email address, home phone, driver's license ID and cell phone number. However, you can share your User Profile without sharing your Social Security number; this will not affect your eligibility. Your Medicaid identification number will only be shared with VDSS and your local department of social services. Because the User Profile is based on your application for assistance, the agencies named below also will know that you are receiving assistance.

Agencies included and Allowed Use

Below are the agencies that will get your information. The reasons they have requested your User Profile and what they will be allowed to do with your User Profile are listed.

Sharing your User Profile will allow them to update the information in their computers, saving taxpayer dollars. It may save you a visit to one of these agencies because your information has been changed electronically.

The Department of Motor Vehicles (DMV) would Ike a copy of your User Profile when it changes. DMV can change your address for cars you own or driver's license/identification card information they have for you. They will send you a card automatically through the mail to complete this update.

The Virginia Information Technologies Agency (VITA) operates an electronic system known as Enterprise Data Management (EDM). EDM contains data that you have already provided to DMV for your driver's license or identification card. If you give permission to share your User Profile, EDM will match the DMV data and your User Profile, and share this information with your focal department of social services and DMV. If the data does not match, DMV or your lacal department of social services may contact you to confirm the information. Email address, home phone number, cell phone number and Medicaid identification number may be reviewed by a local department of social services worker inside EDM to identify possible duplicate User Profiles.

If you choose not to share your User Profile

Your information will remain only with the Department of Social Services, Choosing not to share your User Profile will not affect your eligibilityfor assistance.

Social Security Number

Including your Social Security Number (SSN) in your User Profile is your choice. The SSN is used to match your User Profile with DMV data in EDM easily. Your SSN is kept confidential.

Dependents

This request is for your own User Profile and for the User Profile of any person who is your legal dependent, including your children under age 18, any person for whom you serve as legal guardian, or any other person for whom you have the authority to agree to share information.

To stop sharing of your User Profile

You can stop sharing your User Profile at any time by going to www.commonhelp.virginia.gov and changing your decision to share. You can also change your decision to share your User Profile by visiting your local department of social services.

How long consent to share lasts

Your permission to share your User Profile will remain active for one (1) year from the date you approve, unless you change your decision to share sooner. Your agreement for any minor child who turns 18 will be stopped on the date of the child’s 18th birthday. That individual then will be asked to agree to share his information.

You will be asked to share your information every time you make a change to the information that is used in your User Profile.

Giving Consent

| have reviewed the Consent language contained here and hereby authorize the Commonwealth to:

O Share my User Profile with the specified agencies. include Social Security Number when creating my User Profile.

C1 My User Profile can be shared with the specified agencies, but do not include Social Security Number when creating my User Profile.

(1) Do not allow my User Profile to be shared.

NEED HELP WITH YOUR APPLICATION? Visit the Cover Virginia website at Coverva.org or Call us at 1-855-242-8282. Para obtener una

copia de este formulario en Espafiol, llame 1-855-242-8282. If you need help in a language other than English, call 1-855-242-8282 and tell the

customer service representative the language you need. We'll get you help at no cost to you. TTY users should call 1-888-221-1590.

10/1/2013 Page 8 of 8 “ ” Effective Date: 10/01/2013

Virginia Altemative Single Streamlined Paper Application-9

APPENDIX A Ce rc

Health Coverage from Jobs

You DONT need to answer these questions unless someone in the household is eligible for health coverage from a job. Attach a copy of this page for each job that offers coverage.

Tell us about the job that offers coverage.

Take the Employer Coverage Tool on the next page to the employer who offers coverage to help you answer these questions. You only need to include this page when you send in your application, not the Employer Coverage Tool.

EMPLOYEE Information

1. Employee name (First, Middle, Last)

2. Employee Social Security number

EMPLOYER Information 3, Employer name

4, Employer Identification Number (EIN)

6. Employer phone number C ) - 7. City 8, State 9, ZIP code

5, Employer address

10. Who can we contact about employee health coverage at this job?

11, Phone number (if different from above) 12. Email address

C ) =

13. Are you currently eligible for coverage offered by this employer, ar will you become eligible in the next 3 months? Cl yes (continue)

13a. If you're in a waiting or probationary period, when can you enrolt in coverage? we on (mm/dd/yyyy) List the names of anyone else who is eligible for coverage from this job.

Name: Name: Name:

Ono (Stop here and go to Step 5 in the application)

Tell us about the health pian offered by this employer.

14. Does the employer offer a health plan that meets the minimum value standard*? [Jyes (No

15. For the lowest-cost plan that meets the minimum value standard* offered only to the employee (don't include family plans): ” if the employer has wellness programs, provide the premium that the employee would pay if he/ she received the maximum discount for any tobacco cessation programs, and did not receive any other discounts based on wellness programs.

a, How much would the employee have to pay in premiums for this plan? $ b. How often? Cl weekly Clevery2 weeks Cltwicea month Clonceamonth Cl quarterly Cl yearly

16, What change will the employer make for the new plan year (if known)? C1 employer won't offer health coverage

Clempioyer will start offering health coverage to employees or change the premium for the lowest-cost plan available only.to the employee that meets the minimum value standard.

* (Premium should reflect the discount for wellness programs. See question 15.) a. How much will the employee have to pay in premiums for that plan? $

b. How often? Cl weekly Clevery 2 weeks Ctwicea month Clonceamonth (1) quarterly OH yeariy Date of change (mm/dd/yyyy):

*an employer-sponsored health plan meets the “minimum value standard" if the plan's share of the total allowed benefit costs covered by the plan is no less than 60 percent of such costs (Section 368(c)(2)(CXii) of the Internal Revenue Code of 1986)

NEED HELP WITH YOUR APPLICATION? Visit the Cover Virginia website at coverva.org or call us at 1-855-242-8282, Para obtener una copia de este formulario en Espaiiol, llame 1-855-242-8282, If you need help in a language other than English, call 1-855-242-8282 and tell the customer service representative the language you need. We'll get you help at no cost to you. TTY users should call 1-888-221-1590.

10/1/2013

Effective Date: 10/01/2013 virginia Altemative Single Streamlined Paper Application-10

EMPLOYER COVERAGE TOOL Ceram,

Use this tool to help answer questions in Appendix A about any employer health coverage that you're eligible for (even if it's from another person's job, like a parent-or spouse). The information in the numbered boxes below match the boxes on Appendix A. For example, the answer to question 14 on this page should match question 14 on Appendix A.

Write your name and Social Security number in boxes 1 and 2 and ask the employer to fill out the rest of the form. Complete one tool for each employer that offers health coverage.

EMPLOVEE information The employee needs to fill out this section. 1. Employee name (First, Middle, Last) 2. Social Security Number EMPLOYER information Ask the employer for this information. 3. Employer name 4. Employer Identification Number (EIN) 5, Employer address (the Marketplace will send notices to this address) 6, Employer phone number — ( ) - 7. City 8. State 9. ZIP code

10, Who can we contact about employee health coverage at this job?

11, Phone number (if different from above) | 12. Emall address () -

13. Is the employee currently eligible for coverage offered by this employer, or will the employee be eligible in the next 3 months? CJ ¥es (continue)

13a. If the employee is not eligible today, including as a result of a waiting or probationary period, when is the employee eligible for coverage? (mmidd/yyyy) (Continue)

Cino (STOP and return this form to employee)

Tell us about the health plan offered by this employer.

Does the employer offer a health plan that covers an employee's spouse or dependent? CYes. Which people? []Spouse [] Dependents) [No (Go to question 14)

14. Does the employer offer a health plan that meets the minimum value standard*? (Yes (Go to question 15) [1] No (STOP and return form to employee)

15, For the lowest-cost plan that meets the minimum value standard* offered only to the employee (don't include family plans): If the employer has wellness programs, provide the premium that the employee would pay if he/ she received the maximum discount for any tobacco cessation programs, and didn’t receive any other discounts based on wellness programs.

a. How much would the employee have to pay in premiums for this plan? $ b. How often? C] weekly Cl every 2weeks Citwicea month CJonceamonth [] Quarterly [1 Yearly

if the plan year will end soon and you know that the health plans offered will change, go to question 16. If you don't know, STOP and return

form to employee.

46. What change will the employer make for the new pian year?

Cl employer won't offer health coverage

Cemployer will start offering health coverage to employees or change the premium for the lowest-cost plan available only to the employee that meets the minimum value standard.

* (Premium should reflect the discount for wellness programs. See question 15.} a. How much will the employee have to pay in premiums for that plan? $_-__ b. How often? Cl weekly Clevery 2weeks C]twicea month Clonceamonth Cl quarterly 0 yearly Date of change (mmv/dd/yyyy):

*An employer-sponsored health plan meets the “minimum value standard” if the plan’s share of the total allowed benefit costs covered by the plan is no less than 60 percent of such costs (Section 36B(c2\(CXii) of the Internal Revenue Code of 1986) NEED HELP WITH YOUR APPLICATION? Visit the Cover Virginia website at coverva.org or call us at 1-855-242-8282. Para obtener una copia de este formulario en Espafiol, lame 1-855-242-8282. If you need help in a language other than English, call 1-855-242-8282 and tell the customer service representative the language you need. We'll get you help at no cost to you. TTY users should call 1-888-221-1590. 10/1/2013 . Effective Date: 10/01/2013 virginia Altemative Single Streamined Paper Application-11

APPENDIX B Ghee

American Indian or Alaska Native Family Member (AI/AN)

Complete this appendix if you or a family member are American Indian or Alaska Native. Submit this with your Application for Health Coverage & Help Paying Costs.

Tell us about your American indian or Alaska Native family member(s).

American Indians and Alaska Natives can get services from the Indian Health Services, tribal health programs, or urban Indian health programs. They also may not have to pay cost sharing and may get special monthly enroliment periods. Answer the following questions to make sure your family gets the most help possible.

NOTE: If you have more peopie to include, make a copy of this page and attach.

AI/AN PERS AI/AN PERSON 2 1. Name First Middle First Middle (First name, Middle name, Last name) Last Last 2. Member of a federally recognized tribe? Clyes Clves if yes, tribe name If yes, tribe name CINo (CINo 3. Has this person ever gotten a service fromthe | []yes Clves Indian Health Service, a tribal health program, or urban Indian health program, or thraugha | CJNo CiNno referral from one of these programs? If no, is this person eligible to get If no, is this person eligible to get services from the Indian Health Service, services from the indian Health Service, tribal health programs, or urban Indian tribal health programs, or urban Indian health programs, or through a referral health programs, or through a referral from one of these programs? from one of these programs? Oyes CINo Oves CINo 4. Certain money received may not be counted $ $ for Medicaid, FAMIS or Plan First. List any income (amaunt and how often) reported on How often?___._. How often? __

your application that includes money from

these sources:

+ Per capita payments fram a tribe that come from natural resources, usage rights, leases, or royalties

* Payments from natural resources, farming, ranching, fishing, leases, or royalties from land designated as Indian trust land by the Department of Interior (including reservations and former reservations)

+ Money from selling things that have cultural significance

NEED HELP WITH YOUR APPLICATION? Visit the Cover Virginia website at coverva.org or call us at 1-855-242-8282. Para obtener una copia de este formulario en Espanol, lame 1-855-242-8282. If you need help in a language other than English, call 1-855-242-8282. and tell the customer service representative the language you need. We'll get you help at no cost to you. TTY users should call 1-888-221-1590 .

1/2013

: Effective Date: 10/01/2013 Virginia Altemative Single Streamuned Paper Application-12

APPENDIX C erm.

Assistance with Completing this Application You can choose an authorized representative.

You can give a trusted person permission to talk about this application with us, see your information, and act for you on matters related to this application, including getting information about your application and signing your application on your behalf. This person is called an “authorized representative.” If you ever need to change your authorized representative, contact the local

Department of Social Services. If you're a legally appointed representative far someone on this application, submit proof with the application,

1, Name of authorized representative (First name, Middle name, Last name)

2. Address 3. Apartment or suite numper

4. City 5. State 6. ZIP code

7, Phone number () -

8. Organization name

9. ID number (if applicable)

By signing, you allow this person to sign your application, get official information about this application, and act for you on all future matters with this agency.

10. Your signature 11. Date (mm/dd/yyyy)

For certified application counselors, navigators, agents, and brokers only.

Complete this section if you're a certified application counselor, navigator, agent, or broker filling out this application for somebody else.

1, Application start date (mm/dd/yyyy)

2. First name, Middle name, Last name, & Suffix

3. Organization name 4. 1D number (if applicable)

NEED HELP WITH YOUR APPLICATION? Visit the Cover Virginia website at coverva.org or Call us at 1-855-242-8282. Para obtener una copia de este farmulario en Espafiol, ame 1-855-242 8282. if you need help in a language other than English, call 1-855-242-8282 and tell the customer service representative the language you need. We'll get you help at no cost to you. TTY users should call 1-888-221-1590.

1/701

aa Effective Date: 10/01/2013 Virginia Altemative Single sveamiineu Paper Application-13

ma STEP 2: ADDITIONAL PERSON

Name from STEP 1

Complete Step 2 for your spouse/partner, and children who five with you and/or anyone on your same federal income tax return if you file one. See page 1 for more information about who to Include, if you don't file a tax return, remember to still add farnily members who live with you.

7 First name, Middie name, Last name, & Suffix

2. Relationship to you?

3, Bate of birth-(mmiddfyyyy)———

ta. sex hare Ci remate

5. Social Security number (SSN) —_. —_ — - —. +. -- We need this H you want health coverage and have an SSN, 6. Does this PERSON live at the same address as you? []yes []No i no, list address: —————_# Boes this PERSON pint to file a federat income tax return NEXT YEAR? — {You can still apply for health insurance even if you don't file a federal income tax return.) CIVES. if yes, please answer questions a-c. a. Will this PERSON file jointly with a spouse? []yes [No if yes, name of spouse: b. Will this PERSON claim any dependents on his or her tax return? [Jves (No iF yas, list name(s) of dependants:

CINO. if no, skip to question c.

¢. Will this PERSON be claimed as a dependent on someone's tax return? [Yes []No if yes, please list the name of the tax filer:

How is this PERSON related to the tax filer?

8. Is this PERSON pregnant? [] Yes [[]No a. tf yes, how many babies are expected during this pregnancy? 2

(Even If they have insurance, there might be a program with better coverage or lower costs.)

(1 ves. tyes, answer all the questions below.

Expected due date;

C1 No. if no, SKIP to the income questions on next page. to» ] ve tl st of this page blank. C1 ves. if not eligible for full coverage, do you wish to be Leave the rest of this page blan!

evaluated for Pian First (farnily planning coverage only)?

10. Does this PERSON have a physical, mental, or emotional health condition that causes limitations in activities (like bathing, dressing, dally — ----cheres; ete} ortivein-a- medicalfaeility-or-nursing-ho

Ne

11. { this PERSON a U.S. citizen or U.S. national? [Yes (no :

12. I this PERSON isn’t a U.S. citizen or U.S. national, do they have eligible immigration status? (1 ves. Fill in their document type and 1D number below. a, Document type

¢. Has this PERSON lived in the U.S. since 19967 [Yes []no

b. Document iD number

d. Is this PERSON, or their spouse or Parent a veteran or an active-

duty member-in the-US-military? E] es—E]} No 13. Does this PERSON want help paying for | 14. Does this PERSON live with at least one child 15. Was this PERSON in foster care in medical bills from the last 3 months? under the age of 19, and are they the main Virginia at age 18 or older? Dlves CONno person taking care of this child? Cves (No Clves CINo Please answer the following questions if this PERSON ts 18 or younger:

-—-46--Did-this PERSON-have insurance-that ended-within the past 4- months? Cly¥es_L] No a. if yas, end date:

*For a list of b. Reason the insurance ended:

reasons, please see page 6. 17. Is this PERSON a full-time student? Llyes (]No 18. iF Hispanic/Latino, ethnicity (OPTIONAL—check ‘ail that apply.) Cimexican (J MexicanAmerican []Chicano‘a (puerto rican C]cuban (Jother oe 19, Race (OPTIONAL —check afi that apply.) ( white (1 american indian or Alaska (J Filipino (J Vietnamese (J) Guamanian or Chamorro (0 Black or African Native 1 Japanese - (1 other Asian (J samoan American (0 Asian indian ( Korean (1 Native Hawaiian (1 other Pacific slander C1 Chinese 01 other NEED HELP WITH YOUR APPLICATION? Visit the Cover Virginia website at coverva.org or call us at 1-855-242-8282. Para obtener una

copia de-este formulario en Espaftol, lame 1-855-242-8282, if you need help in a language other than English, call 1-855-242-8282 and tell the ___....—-qustomer service representative the language you need_Welll get you help at no_cost-to you. TTY users should call 4-888-221-1590,____ 10/1/2013

Effective Date: 10/01/2013 virginia Additional Person Supplemental Application-1

TEP 2: ADDITIONAL PERSON

Current Job & Income Information

C Employed (1 Not employed O Self-employed If this PERSON is currently employed, Skip to question 30. Skip to question 29. tell us about their income. Start with question 20.

CURRENT JOB 1: 20. Employer name and address 21, Employer phone number

( ) -

22. Wages/tips (before taxes) []Hourly []Weekly []évery 2weeks [] Twice amonth [Monthly [Yearly 23. Average hours worked each WEEK

CURRENT JOB 2; (If they have more jobs and need more space, attach another sheet of paper.) 24. Employer name and address 25. Employer phone number

26, Wages/tips (before taxes) [J Hourly []Weekly [Jevery 2weeks [] Twice amonth [] Monthly [yearly $ : 27. Average hours worked each WEEK

28. In the past year, did this PERSON: [[] Change jobs [7] Stop working [[] Start working fewer hours [] None of these

29. If self-employed, answer the following questions:

a. Type of work b. How much net income (profits once business expenses are paid) will this person get from this self-employment this month?

30. OTHER INCOME THIS MONTH: Check ail that apply, and give the amount and how often they get it. NOTE: You don't need to tell us about child support, veteran’s payment, or Supplemental Security Income (SSI). Cl None

Cl unempioyment $.. How often? __. Cnet farming/fishing —$. How often? O)Pensions $.._.. _Howoften?_.. (1 Net rental/royalty $ How often? Csociat Security $_ ss Howoften?__ (1 other income $ How often? Ciretirement accounts $_--__._ How often?____ Type: ——____._-___.

QAlimony received $ How often? —___ —

31. DEDUCTIONS: Check all that apply, and give the amount and how often they get it.

If this PERSON pays for certain things that can be deducted on a federal income tax return, telling us about them could make the cost of health coverage a little lower.

NOTE: You shouldn't include a cost that you already considered in your answer to net self-employment (question 29b). DAlimony paid $._.- How often? __ Clother deductions $ How often? Cistudenttoan interest $____.__ How often? Type:

32. YEARLY INCOME: Complete only If this PERSON’s Income changes from month to month. If you don’t expect changes to this PERSON's monthly income, add another person or skip to the next section.

This PERSON's total income this year This PERSON's total income next year (if you think it will be different) $ $

THANKS! This is all we need to know about this PERSON. if you have more people to include, complete another Additional Person single page supplement form.

NEED HELP WITH YOUR APPLICATION? Visit the Cover Virginia website at coverva.org or call us at 1-855-242-8282. Para obtener una copia de este formulario en Espafioi, lame 1-855-242-8282. If you need help in a language other than English, call 1-855-242-8282 and tell the customer service representative the language you need. We'll get you help at no cost to you. TTY users should call 1-888-221-1590. 10/1/2072

- ; Effective Date: 10/01/2013 Virginia Additional Person Supplemental Application-2

_____________________________________________________________________________ Table of Contents State/Territory Name: Virginia State Plan Amendment (SPA) #: VA-13-0019 This file contains the following documents in the order listed: 1) Approval Letter 2) SPA Summary Form 3) Approved SPA Pages The complete title XXI state plan for Massachusetts consists of the most recent state plan posted on Medicaid.gov under CHIP and State Plan Amendments. The link is provided below. The following approved templates are in addition to, or replace sections of the state’s posted current state plan. The attached approval letter(s) explain how these templates fit into that state plan. Link to state title XXI state plans and amendments: http://medicaid.gov/Medicaid-CHIP-Program-Information/By- Topics/Childrens-Health-Insurance-Program-CHIP/CHIP-State-Program-Information.html

DEPARTMENT OF HEALTH & HUMAN SERVICES aaa Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop: 82-26-12 Baltimore, Maryland 21244-1850

CENTERS FOR MEDICARE & MEDICAID SERVICES CENTER FOR MEDICAID & CHIP SERVICES

Children and Adults Health Programs Group

NOV 18 2013

Rebecca Mendoza

Director, Division of Maternal and Child Health Virginia Department of Medical Assistance Services 600 East Broad Street, Suite 1300

Richmond, VA 23219

Dear Ms. Mendoza:

I am pleased to inform you that your Title XXI Children’s Health Insurance Program (CHIP) state plan amendments (SPA) VA-13-0017 and VA-13-19 submitted on October 6, 2013 and related to Modified Adjusted Gross Income (MAGI) Eligiblity have been approved with an effective date of January 1, 2014.

Establish 2101(f) Group:

SPA number VA-13-0017 provides coverage in Virginia’s separate CHIP, as specified in the state’s submission of CS14: Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards. A copy of the approved state plan page (CS14) is attached, and should be incorporated within a separate subsection under Section 4.1 of Virginia’s approved CHIP state plan.

Non-Financial Eligibility:

SPA number VA-13-19 is approved to clarify the state’s non-financial eligibility policies on residency; citizenship; social security numbers; and other eligbility standards. We are approving this SPA in the absence of state plan page CS20. The state's non-financial eligibility policy on substitution of coverage will be submitted when the state legislature has met and approved the change to the waiting period: Copies of the approved state plan pages are attached and these approved pages supersede sections of Virginia’s current state plan as laid out below:

New State Plan Page Impact on Current State Plan Section

CS17: Non-Financial Eligibility — Residency Section 4.1.5

CS18: Non-Financial Eligibility — Citizenship Section 4.1.0; and 4.1-LR

CS19: Non-Financial Eligibility — Social Security | Section 4.1.9.1 Number

C823: Other Eligibility Standards Section 4.1.6; 4.1.7; 4.1.8; 4.1.9

Page 2 - Ms. Rebecca Mendoza Your Title XXI project officer is Ms. Ticia Jones. She is available to answer questions concerning these amendments and other CHIP-related issues. Ms. Jones' contact information is as follows: Centers for Medicare & Medicaid Services Center for Medicaid & CHIP Services Mail Stop: S2-01-16 7500 Security Boulevard Baltimore, MD 21244-1850 Telephone: (410) 786-8145 Facsimile: (410) 786-5882 E-mail: Ticia.Jones@cms.hhs.gov If you have questions or wish to discuss this determination further, please contact Mr. Francis McCullough, Associate Regional Administrator (ARA) in our Philadelphia Regional Office. Mr. McCullough's address is: Centers for Medicare & Medicaid Services Division of Medicaid and Children's Health Operations Suite 216, The Public Ledger Building 150 Independence Mall West Philadelphia, PA 19106 Congratulations on the approval. We look forward to continuing to work with you and your staff toward the approval of your remaining MAGI Eligibility SPAs. If you have additional questions, please contact Ms. Linda Nablo, Director of the Division of State Coverage Programs, at (410) 786-5143. We look forward to continuing to work with you and your staff. Enclosure Sincerely,
 Eliot Fishman Director cc: Francis McCullough, ARA, CMS Region III, Philadelphia

Children’s Health Insurance Program Eligibility

Control Panel

General Information

File Management Tribal Input

Summary

Children's Health Insurance Program Eligibility: Summary Page

State/Territory Virginia name: Transmittal Number:

Please enter the Transmittal Number (TN) in the format ST- YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and OOOO = a four digit number

with leading zeros. The dashes must also be entered. |VA-13-19 |

Type of SPA: MAGI Eligibility & Methods XXI Medicaid Expansion Establish 2101(f) Group Eligibility Processing “| Non-Financial Eligibility

Proposed Effective Date

(nm/aa/yyyy)

Federal Statute/ Regulation Citation

[Section 1902(e)(14) of the Social Security Act

Federal Budget Impact

This SPA has a budget impact. Total budget impact:

State Funds: $ Federal Funds: $

Subject of Amendment

Please provide a brief summary of SPA changes.

Character Count:286 out of 2000 CS17 Separate CHIP Eligibility —- Non-Financial Eligibility - Residency; C518 AcAA Citizenship requirements for separate CHIP covered groups; C513 AcAASocial security number requirement for separate CHIP covered groups; C523 AcAA Other requirements for separate CHIP covered groups

Signature of State Agency Official

Submitted By: Brian McCormick

Last Revision Aug 6, 2015 Date:

Submit Date: Jun 27, 2014

coms. CHIP Eligibility

OMB Control Number: 0938-1148 Expiration date: 10/31/2014

Section 2101(f) of the ACA and 42 CFR 457.310(d)

{Mi Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards The CHIP agency provides coverage for this group of children as follows:

The state has received approval from CMS to maintain Medicaid eligibility for children who would otherwise be subject to Section 2101(f) such that no child in the state will be subject to this provision.

The state assures that separate CHIP coverage will be provided for children ineligible for Medicaid due to the elimination of income disregards in accordance with 42 CFR 457.310(d). Coverage for this population will cease when the last child protected from loss of Medicaid coverage as a result of the elimination of income disregards has been afforded 12 months of coverage in a separate CHIP (expected to be no later than April 1, 2016 ).

C

Describe the methodology used by the state to identify and enroll children in a separate CHIP who are subject to the protection afforded by Section 2101(f) of the Affordable Care Act:

The state has demonstrated and CMS has agreed that all children qualifying for section 2101(f) protection will qualify for the state’s existing separate CHIP.

The state will enroll all children in a separate CHIP who lose Medicaid eligibility because of an increase in family income at their ‘first renewal applying MAGI methods.

The state will enroll children in a separate CHIP whose family income falls above the converted MAGI Medicaid FPL but at or below the following percentage of FPL. The state has demonstrated and CMS has agreed that all or almost all the children who would have maintained Medicaid eligibility if former disregards were applied will be within this income range and therefore covered in the separate CHIP.

be FPL

The state will enroll children in a separate CHIP who are found to be ineligible for Medicaid based on MAGI but whose family income has not increased since the child’s last determination of Medicaid eligibility or who would have remained eligible for Medicaid (based on the 2013 Medicaid income standard) if the value of their 2013 disregards had been applied to the family income as determined by MAGI methodology.

Cc

C Other.

Describe the benefits provided to this population:

C This population will be provided the same benefits as are provided to children in the state’s Medicaid program. @ This population will be provided the same benefits as are provided to children in the state's separate CHIP.

C Other (consistent with Section 2103 of the SSA and 42 CFR 457 Subpart D).

Describe premiums and cost sharing required of this population:

C Cost sharing is the same as for children in the Medicaid program.

* ae SPA # VA-13-0017 Approval Date: NGY i o auld Effective Date: January 1, 2014 NOY 1 6 Page 1 of 2

ccms CHIP Eligibility

(@ Premiums and cost sharing are the same as for targeted low-income children in the state's separate CHIP.

C No premiums, copayments, deductibles, coinsurance or other cost sharing is required.

C Other premiums and/or cost-sharing requirements (consistent with Section 2103(e) of the SSA and 42 CFR 457 Subpart E).

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

NOV 18 2013

SPA # VA-13-0017 Approval Date: Effective Date: January 1, 2014 Page 2 of 2

cCcMs CHIP Eligibility

OMB Control Number: 0938-1148 Expiration date: 10/31/2014

42 CFR 457.320

Residency

The CHIP Agency provides CHIP to otherwise eligible residents of the state, including residents who are absent from the state under certain conditions.

A child is considered to be a resident of the state under the following conditions:

Ir A non-institutionalized child, if capable of indicating intent and who is emancipated or married, if the child is living in the state and:

1. Intends to reside in the state, including without a fixed address, or

2. Has entered the state with a job commitment or seeking employment, whether or not currently employed. [iM A non-institutionalized child not described above and a child who is not a ward of the state:

1. Residing in the state, with or without a fixed address, or

2. The state of residency of the parent or caretaker, in accordance with 42 CFR.435.403(h)(1), with whom the individual resides.

iw An institutionalized child, who is not a ward of the state, if the state is the state of residence of the child's custodial parent or caretaker at the time of placement, or

[Im] A child who is a ward of the state regardless of where the child lives, or

A child physically located in the state when there is a dispute with one or more states as to the child's actual state of a residence.

If the state covers pregnant women, a pregnant woman is considered to be a resident under the following conditions: [Ml] A non-institutionalized pregnant woman who is living in the state and: 1. Intends to reside in the state, including without a fixed address, or if incapable of indicating intent, is living in the state, or 2. Entered with a job commitment or seeking employment, whether or not currently employed.

ol An institutionalized pregnant woman placed in an out-of-state-institution, as defined in 42 CFR 435.1010, including foster care homes, by an agency of the state, or

ia] An institutionalized pregnant woman residing in an in-state-institution, as defined in 42 CFR 435.1010, whether or not the individual established residency in the state prior to entering the institution, or

Ir A pregnant woman physically located in the state when there is a dispute with one or more states as to the pregnant woman's actual state of residence.

The state has in place related to the residency of children and pregnant women (if covered by the state):

SPA # VA-13-19 Approval Date: NOV { 8 203 Effective: January 1, 2014 Page | of 2

ceomMs. CHIP Eligibility

One or more interstate agreement(s). No

A policy related to individuals in the state only for educational purposes. No

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of

the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

NGV 1% 2018

SPA # VA-13-19 Approval Date: Effective: January 1, 2014 Page 2 of 2

ccms CHIP Eligibility

OMB Control Number: 0938-1148 Expiration date: 10/31/2014

Sections 2105(c)(9) and 2107(e)(1)(J) of the SSA and 42 CFR 457.320(b)(6), (c) and (d)

Citizenship

The CHIP Agency provides CHIP eligibility to otherwise eligible citizens and nationals of the United States and certain non-citizens, including the time period during which they are provided with reasonable opportunity to submit verification of their citizenship, national status or satisfactory immigration status.

[ml] The CHIP Agency provides eligibility under the Plan to otherwise eligible individuals:

Who are citizens or nationals of the United States; or

Who are qualified non-citizens as defined in section 431 of the Personal Responsibility and Work Opportunity Reconciliation

Act (PRWORA) (8 U.S.C. §1641), or whose eligibility is required by section 402(b) of PRWORA (8 U.S.C. §1612(b)) and is not prohibited by section 403 of PRWORA (8 U.S.C. §1613); or

Who have declared themselves to be citizens or nationals of the United States, or an individual having satisfactory immigration status, during a reasonable opportunity period pending verification of their citizenship, nationality, or satisfactory immigration status consistent with requirements of 1903(x), 1137(d), and 1902(ee) of the Act, and 42 CFR 435.406, 407, 956 and 457.380.

The reasonable opportunity period begins on and extends 90 days from the date the notice of reasonable opportunity is received by the individual.

The agency provides for an extension of the reasonable opportunity period if the individual is making a good faith effort

to resolve any inconsistencies or obtain any necessary documentation, or the agency needs more time to complete the Yes verification process.

The agency begins to furnish benefits to otherwise eligible individuals during the reasonable opportunity period on a date Yes earlier than the date the notice is received by the individual.

The date benefits are furnished is: @ The date of application containing the declaration of citizenship or immigration status. ( The date the reasonable opportunity notice is sent.

C Other date, as described:

The CHIP Agency elects the option to provide CHIP coverage to otherwise eligible children up to age 19, lawfully residing Yes in the United States, as provided in Section 2107(e)(1)(J) of the SSA (Section 214 of CHIPRA 2009, P.L. 111-3).

Otherwise eligible children means children meeting the eligibility requirements of targeted low-income children with the exception of non-citizen status.

The CHIP Agency provides assurance that lawfully residing children are also covered under the state's Medicaid program.

SPA # VA-13-19 Approval Date! Effective Date: January 1, 2014

Page 1 of 3

CHIP Eligibility

The CHIP Agency elects the option to provide CHIP coverage to otherwise eligible pregnant women, lawfully residing in the United States, as provided in Section 214 of CHIPRA 2009, P.L. 111-3. The state may not select this option unless the state also elects to cover lawfully residing children. A state may not select this option unless the state also covers Targeted Low- Income Pregnant Women.

An individual is considered to be lawfully residing in the United States if he or she is lawfully present and meets state residency requirements.

(a) {| An individual is considered to be lawfully present in the United States if he or she is: 1. A qualified non-citizen as defined in 8 U.S.C. 1641(b) and (c);

2. A non-citizen in a valid nonimmigrant status, as defined in 8 U.S.C. 1101(a)(15) or otherwise under the immigration laws (as defined in 8 U.S.C. 1101{a)(17));

3. A non-citizen who has been paroled into the United States in accordance with 8 U.S.C.1182(d)(5) for less than 1 year, except for an individual paroled for prosecution, for deferred inspection or pending removal proceedings;

4. A non-citizen who belongs to one of the following classes: (i) Granted temporary resident status in accordance with 8 U.S.C.1160 or 1255a, respectively;

(ii) Granted Temporary Protected Status (TPS) in accordance with 8 U.S.C. §1254a, and individuals with pending applications for TPS who have been granted employment authorization;

(iii) Granted employment authorization under 8 CFR 274a.12(c);

(iv) Family Unity beneficiaries in accordance with section 301 of Pub. L. 101-649, as amended;

(v) Under Deferred Enforced Departure (DED) in accordance with a decision made by the President; (vi) Granted Deferred Action status;

(vii) Granted an administrative stay of removal under 8 CFR 241;

(viii) Beneficiary of approved visa petition who has a pending application for adjustment of status;

5. Is an individual with a pending application for asylum under 8 U.S.C. 1158, or for withholding of removal under 8 U.S.C.1231,or under the Convention Against Torture, who:

(i) Has been granted employment authorization; or

(ii) Is under the age of 14 and has had an application pending for at least 180 days; 6. Has been granted withholding of removal under the Convention Against Torture; 7. Is a child who has a pending application for Special Immigrant Juvenile status as described in 8 U.S.C.1101(a)(27)(J); 8. Is lawfully present in American Samoa under the immigration laws of American Samoa; or

9. Is a victim of severe trafficking in persons, in accordance with the Victims of Trafficking and Violence Protection Act of 2000, Pub. L. 106-386, as amended (22 U.S.C. 7105(b)).

SPA # VA-13-19 Approval pate NOV 1 8 2013 Effective Date: January 1, 2014 Page 2 of 3

cCCmMS CHIP Eligibility

10. Exception: An individual with deferred action under the Department of Homeland Security's deferred action for the childhood arrivals process, as described in the Secretary of Homeland Security's June 15, 2012 memorandum, shall not be considered to be lawfully present with respect to any of the above categories in paragraphs (1) through (9) of this definition.

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments conceming the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

SPA # VA-13-19 Approval Date: NOV \ 8 203 Effective Date: January 1, 2014 Page 3 of 3

CCMS CHIP Eligibility

Erreneueirven netraniee mers

OMB Control Number: 0938-1148 Expiration date: 10/31/2014

Separate Child He

42 CFR 457.340(b)

Social Security Number

As a condition of eligibility, the CHIP Agency must require individuals who have a social security number or are eligible for one as determined by the Social Security Administration, to furnish their social security number, or numbers if they have more than one number.

The CHIP Agency requires individuals, as a condition of eligibility, to furnish their social security number(s), with the following exceptions:

Individuals refusing to obtain a social security number (SSN) because of well established religious objections, or Individuals who are not eligible for an SSN, or Individuals who are issued an SSN only for a valid non-work purpose.

rl The CHIP Agency assists individuals, who are required to provide their SSN, to apply for or obtain an SSN from the Social , Security Administration if the individual does not have or forgot their SSN.

[i] The CHIP Agency informs individuals required to provide their SSN: By what statutory authority the number is solicited; and

How the state will use the SSN.

The CHIP Agency provides assurance that it will verify each SSN furnished by an applicant or beneficiary with the Social Security Administration, not deny or delay services to an otherwise eligible applicant pending issuance or verification of the individual's SSN by the Social Security Administration and that the state's utilization of the SSNs is consistent with sections 205

and 1137 of the Social Security Act and the Privacy Act of 1974.

The state may request non-applicant household members to voluntarily provide their SSN, if the state meets the requirements below.

The state requests non-applicant household members to voluntarily provide their Yes SSN.

When requesting an SSN for non-applicant household members, the state assures that:

a At the time such SSN is requested, the state informs the non-applicant that this information is voluntary and provides information regarding how the SSN will be used; and

ia The state only uses the SSN for determination of eligibility for CHIP or other insurance affordability programs, or for a purpose directly connected with the administration of the state plan.

PRA Disclosure Statement

SPA # VA-13-19 Approval patelOV 18 2ot3

: Effective Date: January 1, 2014 Page 1 of 2

ccmMs CHIP Eligibility

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of

the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

SPA # VA-13-19 Approval pateNOV { 8 2013

Effective Date: January 1, 2014 Page 2 of 2

CemMs CHIP Eligibility

OMB Control Number: 0938-1148 Expiration date: 10/31/2014

Other eligibility standards:

Name of eligibility standard: [Third party liability Remove To which covered group(s) does this standard apply? Targeted Low-Income Children

(1 Targeted Low-Income Pregnant Women (FJ Coverage from Conception to Birth (11 Children with Access to Public Employee Coverage (7 Pregnant Women with Access to Public Employee Coverage (7 Children Eligible for Dental Only Supplemental Coverage (1) Deemed Newborns

Describe how this standard affects eligibility:

Children are not eligible for the Separate CHIP if their parent or other authorized representative does not meet the requirements on assignment of rights to benefits or cooperation with the agency in identifying and providing information to assist the Commonwealth in pursuing any liable third party.

Add

PRA Disclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

V.20130709

SPA # VA-13-19 Approval DateNOY i 8 2013 Effective Date: January 1, 2014

Page | of 1

_____________________________________________________________________________ Table of Contents State/Territory Name: Virginia State Plan Amendments (SPA) #: VA-14-0002 This file contains the following documents in the order listed: 1) Approval Letter 2) SPA Summary Form 3) Approved SPA Pages The complete title XXI state plan for Massachusetts consists of the most recent state plan posted on Medicaid.gov under CHIP and State Plan Amendments. The link is provided below. The following approved templates are in addition to, or replace sections of the state’s posted current state plan. The attached approval letter(s) explain how these templates fit into that state plan. Link to state title XXI state plans and amendments: http://medicaid.gov/Medicaid-CHIP-Program-Information/By- Topics/Childrens-Health-Insurance-Program-CHIP/CHIP-State-Program-Information.html

DEPARTMENT OF HEALTH & HUMAN SERVICES

Centers for Medicare & Medicaid Services (CMs

7500 Security Boulevard, Mail Stop: S2-26-12 Cc M Ss (CENTERS FOR MEDICARE & MEDICAID SERVICES

Baltimore, Maryland 21244-1850

CENTER FOR MEDICAID & CHIP SERVICES

Children and Adults Health Programs Group

MAR 14 2014

Rebecca Mendoza, Director

Maternal and Child Health Division Virginia Department of Medical Assistance 600 East Broad Street, Suite 1300 Richmond, VA 23219

Dear Ms. Mendoza:

Tam pleased to inform you the Centers for Medicare & Medicaid Services has approved your title XXI Children’s Health Insurance Program (CHIP) state plan amendment (SPA) number VA-14- 0002, submitted on March 10, 2014, and related Modified Adjusted Gross Income (MAGI) Eligibility with an effective date of January 1, 2014.

The SPA number VA-14-0002 converts the state’s existing income eligibility standards to MAGI-equivalent standards, by age group, for children covered in its title XXI-funded Medicaid program. A copy of the approved state plan page (CS3) is attached, and should be incorporated into the state’s approved CHIP state plan. This page supersedes the current Medicaid expansion section (4.0) of the current CHIP state plan.

Your title XXI project officer is Ms. Ticia Jones. She is available to answer questions concerning this amendment and other CHIP-related issues.

Ms. Jones’ contact information is as follows:

Centers for Medicare & Medicaid Services Center for Medicaid & CHIP Services Mail Stop S2-01-16

7500 Security Boulevard

Baltimore, MD 21244-1850

Telephone: (410) 786-8145

Facsimile: (410) 786-5943

E-mail: Ticia.Jones@cms.hhs.gov

Official communications regarding program matters should be sent simultaneously to Ms. Jones and to Mr. Francis McCullough, Associate Regional Administrator (ARA) in our Philadelphia Regional Office.

Page 2 - Ms. Rebecca Mendoza Mr. McCullough address is: Centers for Medicare and Medicaid Services Division of Medicaid and Children's Health Operations Suite 216, The Public Ledger Building 150 Independence Mall West Philadelphia, PA 19106 If you have additional questions, please contact Ms. Linda Nab lo, Director, Division of State Coverage Programs, at (410) 786-5143. We look forward to continuing to work with you and your staff toward the approval of your remaining MAGI Eligibility SP As. Enclosures cc: Sincerely, Eliot Fishman Director Mr. Francis McCullough, CMS Region III, Philadelphia

Children's Health Insurance Program Eligibility

= = iran ann ae cs at a a =

Control P l ; none i . sbi — Children's Health Insurance Program Eligibility: Summary Page

General

Information

File Management name: Transmittal Number:

se Please enter the Transmittal Number (TN) in the format ST- Tribal Input YY-0000 where ST= the state abbreviation, YY = the last two

digits of the submission year, and 0000 = a four digit number

with leading zeros. The dashes must also be entered. |VA-14-0002

Summary

Type of SPA: MAGI Eligibility & Methods “i XXI Medicaid Expansion Establish 2101(f) Group Eligibility Processing Non-Financial Eligibility Proposed Effective Date

(nm da/ yyy)

Federal Statute/ Regulation Citation

[Section 1902(e)(14) of the Social Security Act

Federal Budget Impact This SPA has a budget impact. Total budget impact: State Funds: $ Federal Funds: $

Subject of Amendment

Please provide a brief summary of SPA changes. Character Count:48 out of 2000

C53 — Eligibility for Medicaid Expansion Program

Signature of State Agency Official

Submitted By: Brian McCormick

Last Revision Mar 10, 2014 Date:

Submit Date: Mar 10, 2014

ccm AAP SRNR

CHIP Eligibility

OMB Control Number: 0938-1148 Expiration date: 10/31/2014

42 CFR 457.320(a)(2) and (3)

Age and Household Income Ranges

There should be no overlaps or gaps for the ages entered.

Income eligibility for children under the Medicaid Expansion is determined in accordance with the following income standards:

From Age

To Age

Above (% FPL)

Up to & including (% FPL)

19

109

143

PRA Disclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a

valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete

this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data

resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance

Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

SPA# VA-14-0002

Approval Date:

MAR 14 2014

Effective Date: January 1, 2014

Page 1 of 1

_____________________________________________________________________________ Table of Contents State/Territory Name: Virginia State Plan Amendment (SPA) #: VA-17-0012 This file contains the following documents in the order listed: 1) Approval Letter 2) State Plan

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop: 52-01-16 Baltimore, Maryland 21244-7850 Children and Adults Health Programs Group rvts ctNtt¡s foß Mtotc^rc & Mfotc¡tD sfnvtc€s CEÑTEß fON M¡DICAID & CHIP SEIVICCS AUG 0 3 ?0t7 Ms. Rebecca Anderson Public Policy Manager Virginia Department of Medical Assistance Services 600 East Broad St. Richmond, VA232I9 Dear Ms. Anderson: I am pleased to inform you that Virginia's Children's Health Insurance Program (CHIP) state plan amendment (SPA) number VA-17-0012, submitted June 8,2017, has been approved. Effective April 1, 2017, this SPA expands Virginia's outpatient substance abuse treatment services to include intensive outpatient, partial hospitalization, medication assisted treatment, and case management. Effective July 1,2017, this SPA adds peer support services to its benefits package. In addition, the state is removing the prior authorization requirement for outpatient mental health services. This SPA also makes minor updates to other sections of the CHIP state plan to reflect current practices. The Centers for Medicare &. Medicaid Services (CMS) has finalized regulations to implement mental health and substance use disorder parity requirements consistent with section 2103(c)(6) of the Social Security Act that become effective on October 2,2017. After that date, states will need to demonstrate compliance with the parity regulations through the CHIP state plan amendment process. Your title XXI project officer, Ms. Ticia Jones, is available to answer questions concerning this amendment and other CHlP-related issues. Ms. Jones' contact information is as follows: Centers for Medicare & Medicaid Services Center for Medicaid and CHIP Services Mail Stop: 32-01-16 7500 Security Boulevard Baltimore, MD 21244-1 850 Telephone: (al0) 786-8145 E-mail:'['icia.Jones@cms.hhs.qov Offrcial communication regarding program matters should be submitted simultaneously to Ms. Jones and Mr. Francis McCullough, Associate Regional Administrator (ARA) for the Division of Medicaid and Children's Health Operations in the CMS Philadelphia Regional Office. Mr. McCullough's contact information is as follows:

Page2 - Ms. Rebecca Anderson Centers for Medicare & Medicaid Services Philadelphia Regional Office Division of Medicaid and Children's Health Operations The Public Ledger Building, Suite 216 150 South Independence Mall West Philadelphia, PA 19106 If you have additional questions, please contact Ms. Amy Lutzky, Director, Division of State Coverage Programs, at (410) 786-0721. Anne Marie Costello Director cc Mr. Francis McCullougho ARA, CMS Region III, Philadelphia / Anne Marie Costello/

Model Application Template for the State Children’s Health Insurance Program

Effective Date: 0107/01/17

1 Approval Date_______08/03/17

OMB #: 0938-0707 Exp. Date:

MODEL APPLICATION TEMPLATE FOR STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT STATE CHILDREN’S HEALTH INSURANCE PROGRAM

Preamble

Section 4901 of the Balanced Budget Act of 1997 (BBA) amended the Social Security Act (the Act) by adding a new title XXI, the State Children’s Health Insurance Program (SCHIP). Title XXI provides funds to states to enable them to initiate and expand the provision of child health assistance to uninsured, low-income children in an effective and efficient manner. To be eligible for funds under this program, states must submit a state plan, which must be approved by the Secretary. A state may choose to amend its approved state plan in whole or in part at any time through the submittal of a plan amendment.

This model application template outlines the information that must be included in the state child health plan, and any subsequent amendments. It has been designed to reflect the requirements as they exist in current regulations, found at 42 CFR part 457. These requirements are necessary for state plans and amendments under Title XXI.

The Department of Health and Human Services will continue to work collaboratively with states and other interested parties to provide specific guidance in key areas like applicant and enrollee protections, collection of baseline data, and methods for preventing substitution of Federal funds for existing state and private funds. As such guidance becomes available, we will work to distribute it in a timely fashion to provide assistance as states submit their state plans and amendments.

Model Application Template for the State Children’s Health Insurance Program

Effective Date: 0107/01/17

2 Approval Date_______08/03/17 Form CMS-R-211

MODEL APPLICATION TEMPLATE FOR STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT STATE CHILDREN’S HEALTH INSURANCE PROGRAM

(Required under 4901 of the Balanced Budget Act of 1997 (New section 2101(b)))

State/Territory:___________________Virginia____________________________ (Name of State/Territory)

As a condition for receipt of Federal funds under Title XXI of the Social Security Act, (42 CFR 457.40(b))

________________________________________________________________________ William A. Hazel, Jr. M.D., Secretary of Health and Human Resources

submits the following State Child Health Plan for the State Children’s Health Insurance Program and hereby agrees to administer the program in accordance with the provisions of the approved State Child Health Plan, the requirements of Title XXI and XIX of the Act (as appropriate) and all applicable Federal regulations and other official issuances of the Department.

The following state officials are responsible for program administration and financial oversight (42 CFR 457.40(c)):

Name: William A. Hazel, Jr. M.D.

Position/Title: Secretary of Health and Human Resources Name: Cynthia B. Jones

Position/Title: Director, Department of Medical Assistance Services Name: Rebecca Mendoza

Position/Title: Director, Division of Child Health Insurance

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0707. The time required to complete this information collection is estimated to average 160 hours per response, including the time to review instructions, search existing data resources, and gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, N2-14-26, Baltimore, Maryland 21244.

STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

STATE: Virginia Page 2-3

Effective Date: 0107/01/17

3 Approval Date_______08/03/17 Section 1. General Description and Purpose of the State Child Health Plans and State Child Health Plan Requirements (Section 2101)

1.1 The state will use funds provided under Title XXI primarily for (Check appropriate box) (42 CFR 457.70):

1.1.1 

Obtaining coverage that meets the requirements for a separate child health program (Section 2103); OR

1.1.2. 

Providing expanded benefits under the State’s Medicaid plan (Title XIX); OR

1.1.3.  A combination of both of the above. (Effective 09/01/02)

1.2  Please provide an assurance that expenditures for child health assistance will not be claimed prior to the time that the State has legislative authority to operate the State plan or plan amendment as approved by CMS. (42 CFR 457.40(d))

1.3  Please provide an assurance that the state complies with all applicable civil rights requirements, including title VI of the Civil Rights Act of 1964, title II of the Americans with Disabilities Act of 1990, section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, 45 CFR part 80, part 84, and part 91, and 28 CFR part 35. (42CFR 457.130)

Guidance: The effective date as specified below is defined as the date on which the State begins to incur costs to implement its State plan or amendment. (42 CFR 457.65) The implementation date is defined as the date the State begins to provide services; or, the date on which the State puts into practice the new policy described in the State plan or amendment. For example, in a State that has increased eligibility, this is the date on which the State begins to provide coverage to enrollees (and not the date the State begins outreach or accepting applications).

1.4 Provide the effective (date costs begin to be incurred) and implementation (date services begin to be provided) dates for this SPA (42 CFR 457.65). A SPA may only have one effective date, but provisions within the SPA may have different implementation dates that must be after the effective date.

Original Plan - Effective Date: 10/26/98 Implementation Date: 10/26/98 Effective date: Plan: 10/26/98; Amend. 1: 7/01/01; Amend. 2: 12/01/01; Amend. 3: 7/01/01; Amend. 4: 09/01/02; Amend. 5: 08/01/03; Amend. 6: Withdrawn; Amend.7: [(delete ESHI premium assistance program and exempt pregnant children from waiting period 8/01/05; allow for disease management in fee-for-service program 7/01/06)];

STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

STATE: Virginia Page 2-4

Effective Date: 0107/01/17

4 Approval Date_______08/03/17 Amend. 8: Changes to the CHIP State Plan to outline coverage of school services and to add language regarding private funding; Amend. 9 FAMIS MOMS to 200% FPL and MCO opt in: 07/01/09, and Medicaid Expansion Immigrants: 04/01/09; Amend. No. 10: Translation for Dental Care: 7/1/09; Hospice Concurrent with Treatment: 3/23/10; Early Intervention and prospective payment for FQHCs and RHCs: 10/01/09; Citizenship Documentation: 01/01/10; Mental Health Parity and No Cost Sharing for Pregnancy-Related Assistance: 07-01-10. Amend. No. 11: Administrative Renewal Process: 10/01/10; and Virginia Health Care Fund: 07/01/10. Amend. No. 16: Behavioral Therapies added 7/1/16. Amend. No. 17: Temporary Adjustments to Enrollment and Redetermination for Individuals Living or Working in a Declared Disaster Area at the Time of a Disaster Event.

Implementation date: 10/26/98; Amend. 1: 8/01/01; Amend. 2: 12/01/01; Amend. 3: 12/01/01; Amend. 4: 09/01/02; Amend. 5: 08/01/03; Amend. 6: Withdrawn; Amendment 7: 7/01/06; Amend. 8: 07/01/07, and 02/14/09 implementation date of language regarding the RWJ Grant funding and private funding; Amend. 9: 07/01/09, and Medicaid Expansion Immigrants: 04/01/09; Amend. No. 10: Translation for Dental Care: 7/1/09; Hospice Concurrent with Treatment: 3/23/10; Early Intervention and prospective payment for FQHCs and RHCs: 10/01/09; Citizenship Documentation: 01/01/10; and Mental Health Parity, No Cost Sharing for Pregnancy-Related Assistance, and Virginia Health Care Fund: 07-01-10. Amend. No. 11: Administrative Renewal Process: 10/01/10; and Virginia Health Care Fund: 07/01/10. Amend. No. 12: Discontinue primary care case management: 5/1/12; Expand eligibility under lawfully residing option: 7/1/12; Add coverage for early intervention case management: 10/1/11; and Discontinue Virginia Health Care Fund funding: 7/1/12. Amend. No. 13: Outreach Procedures 07/01/12; and Performance Plan: 07/01/12. Amend. No. 14: Delivery system change (Sec. 6 and 12) Behavioral Health Service Administrator: 01/01/14. Amend. No. 16: Behavioral Therapies 7/1/16. Amend. No. 17: Temporary Adjustments to Enrollment and Redetermination for Individuals Living or Working in a Declared Disaster Area at the Time of a Disaster Event.

Transmittal Number SPA Group PDF Description Superseded Plan Section(s) VA-13-15

Effective/Implementation Date: January 1, 2014

MAGI Eligibility & Methods CS7

CS13

Eligibility – Targeted Low Income Children

Eligibility - Deemed Newborns

Supersedes the current sections Geographic Area 4.1.1; Age 4.1.2; and Income 4.1.3

Incorporate under section 4.3

STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

STATE: Virginia Page 2-5

Effective Date: 0107/01/17

5 Approval Date_______08/03/17 Transmittal Number SPA Group PDF Description Superseded Plan Section(s)

VA-14-0020

Effective/Implementation Date: January 1, 2015

CS15

CS10

MAGI-Based Income Methodologies

Eligibility – Children Who Have Access to Public Employee Coverage Incorporate within a separate subsection under section 4.3

Supersedes language in regard to dependents of public employees in Section 4.1.9

VA-14-0002

Effective/Implementation Date: January 1, 2014

XXI Medicaid Expansion CS3 Eligibility for Medicaid Expansion Program Supersedes the current Medicaid expansion section 4.0 VA-14-0025

Effective/Implementation Date: January 1, 2014 Establish 2101(f) Group CS14 Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards Incorporate within subsection 4.4.1 VA-13-0018

Effective/Implementation Date: October 1, 2013 Eligibility Processing CS24 Eligibility Process Supersedes the current sections 4.3 and 4.4 VA-13-19

Effective/Implementation Date: January 1, 2014

VA-13-19-01 Non- Financial Eligibility CS17

CS18

CS19

CS23

Non-Financial Eligibility – Residency

Non-Financial – Citizenship

Non-Financial – Social Security Number

Other Eligibility Standards

Supersedes the current section 4.1.5

Supersedes the current sections 4.1.0; 4.1.1-LR

Supersedes the current section 4.1.9

Supersedes the current section 4,1.6, 4.1.7, 41.8, 4.1.9

STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

STATE: Virginia Page 2-6

Effective Date: 0107/01/17

6 Approval Date_______08/03/17 Transmittal Number SPA Group PDF Description Superseded Plan Section(s) Effective/Implementation Date: July 3, 2014 CS20 Substitution of Coverage

Supersedes the current section 4.4.4

SPA #15, Purpose of SPA Update for SFY 2015 Proposed effective date: 7/1/14

Proposed implementation date: Eligibility: Remove waiting period: 07/03/014; Allow eligibility for dependents of state employees: 01/01/15

SPA #16, Purpose of SPA Update for SFY 2016

Proposed effective date: 7/1/15

Proposed implementation date:

Benefits: Add Behavioral Therapy services: 7/1/16

SPA #17:

Temporary Adjustments to Enrollment and Redetermination for Individuals Living or Working in a Declared Disaster Area at the Time of a Disaster Event.

Proposed effective date: 1/1/2017

VA – 17-0012: Purpose of SPA Update for SFY 2017

Proposed effective date of SPA: 7/1/17 SUD amendments (not including peer supports) have an effective date of 4/1/2017. All other items (including peer supports) have an effective date of 7/1/2017.

STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

STATE: Virginia Page 2-7

Effective Date: 0107/01/17

7 Approval Date_______08/03/17

Section 2. General Background and Description of State Approach to Child Health Coverage and Coordination (Section 2102 (a)(1)-(3)) and (Section 2105)(c)(7)(A)- (B))

2.1. Describe the extent to which, and manner in which, children in the state including targeted low-income children and other classes of children, by income level and other relevant factors, such as race and ethnicity and geographic location, currently have creditable health coverage (as defined in 42 CFR 457.10). To the extent feasible, make a distinction between creditable coverage under public health insurance programs and public-private partnerships (See Section 10 for annual report requirements). (42 CFR 457.80(a))

The Virginia Health Care Foundation conducted two surveys of health access in Virginia. The latest survey was conducted in the Spring of 1997 for the year 1996 of a representative sample of 1,861 households representing 4,694 individuals. The Department of Medical Assistance Services (DMAS) used estimates derived from this survey and census data for its planning purposes rather than from the national Current Population Survey. DMAS' administrative data were used to estimate Medicaid insured children.

HEALTH INSURANCE STATUS OF VIRGINIA CHILDREN 0-18, BY POVERTY LEVEL 1996

Insured Uninsured

Poverty Level Medicaid Private Total Insured Medicaid Eligible Other Uninsured Total Uninsured Total Children Under 100% 206,550 2,430 208,980 34,020 0 34,020 243,000 100% to 125% 33,450 3,570 37,020 10,980 9,000 19,980 57,000 125% to 150% 31,500 4,860 36,360 12,920 12,720 25,640 62,000 150% to 175% 37,500 9,140 46,640 22,080 17,280 39,360 86,000 175% to 200% 6,000 44,000 50,000 2,000 33,000 35,000 85,000 200% to 250% 0 57,000 57,000 0 20,000 20,000 77,000 Above 250% 0 979,000 979,000 0 40,000 40,000 1,019,000 Totals 315,000 1,100,000 1,415,000 82,000 132,000 214,000 1,629,000

DMAS assumes that insured/uninsured individuals are evenly distributed by age below 100% of poverty. Above 100% of poverty more of the uninsured are ages 6-18. Virginia Medicaid covers children 0 through 5 up to 133% and covers children ages 6 through 18 up to 100% of poverty. Effective 9/01/02, Virginia’s Medicaid Program was expanded through Title XXI to cover additional targeted low-income children ages 6 through 18 with family income equal to or less than 133% of FPL. Effective January 1, 2014, this changed to 143% of FPL.

STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

STATE: Virginia Page 2-8

Effective Date: 0107/01/17

8 Approval Date_______08/03/17

2.2. Describe the current state efforts to provide or obtain creditable health coverage for uncovered children by addressing: (Section 2102)(a)(2) (42CFR 457.80(b))

2.2.1. The steps the state is currently taking to identify and enroll all uncovered children who are eligible to participate in public health insurance programs (i.e. Medicaid and state-only child health insurance):

Prior to October 1, 2013, determinations of eligibility for the state child health insurance program, The Family Access to Medical Insurance Security (FAMIS) Plan (Title XXI), were completed at a Central Processing Unit or Local Department of Social Services (LDSS). The Central Processing Unit screened applicants for Medicaid eligibility prior to completing a FAMIS eligibility determination. LDSS determines eligibility for Medicaid first and then determines FAMIS eligibility for children denied Medicaid due to excess income. Families may apply by mail, by phone, fax or web; there is no requirement for a face-to-face interview.

In addition, many community groups have trained volunteers to help parents of potential Medicaid (Title XIX) and FAMIS (Title XXI) eligible individuals by answering questions and helping to complete applications and gather verifications needed to process cases.

Effective October 1, 2013, DMAS launched the Cover Virginia Call Center. This call center accepts the new MAGI single streamlined application and signature by telephone. At the same time, the existing Central Processing Unit stopped handling new applications for FAMIS. The call center answered eligibility and covered services questions for the general Medicaid and FAMIS population. The Cover Virginia website (www.coverva.org) also went live to provide users a self-directed eligibility screener, based on MAGI methodologies, and a link to an on-line application.

FAMIS provides comprehensive health benefits for children from birth through age 18 who are not covered under health insurance. Effective July 3, 2014, children no longer need a four-month uninsured waiting period to be eligible for FAMIS. Effective January 1, 2015, dependents of state employees who have access to subsidized health insurance may enroll in FAMIS. The application addresses specific questions about other current health insurance coverage.

In April 2015, Cover Virginia began processing and determining eligibility for telephonic applications, again functioning as a Central Processing Unit. A family may contact Cover Virginia by phone or on-line to apply. Additionally, a paper

STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

STATE: Virginia Page 2-9

Effective Date: 0107/01/17

9 Approval Date_______08/03/17 application can be completed, signed, and returned via mail or fax to LDSS for determination of eligibility for Medicaid and FAMIS. Expenditures for children who meet Medicaid eligibility criteria are claimed at the Commonwealth’s regular Medicaid FMAP. Effective 9/01/02, the Commonwealth began claiming enhanced funding for optional targeted low-income children who qualify under the Medicaid expansion. Expenditures for the children determined eligible under the Family Access to Medical Insurance Security Plan are claimed at the State’s enhanced FMAP.

No Entitlement: In accordance with § 2102(b)(4) of the Social Security Act (42 U.S.C. § 1397bb(b)(4)) and § 32.1-353 of the Code of Virginia, the Family Access to Medical Insurance Security Plan shall not create any individual entitlement for payment of medical services or any right or entitlement to participation.

2.2.2. The steps the state is currently taking to identify and enroll all uncovered children who are eligible to participate in health insurance programs that involve a public- private partnership:

Virginia currently has no health insurance programs that involve a public-private partnership.

2.3. Describe the procedures the state uses to accomplish coordination of SCHIP with other public and private health insurance programs, sources of health benefits coverage for children, and relevant child health programs, such as title V, that provide health care services for low-income children to increase the number of children with creditable health coverage. (Previously 4.4.5.) (Section 2102)(a)(3) and 2102(c)(2) and 2102(b)(3)(E)) (42CFR 457.80(c))

The FAMIS program coordinates with the Virginia Department of Health, including Children’s Specialty Services and the Maternal and Child Health programs, with State teaching hospitals serving indigent families, and with local government health delivery programs which serve low income children. The Commonwealth’s goal is to provide all targeted low-income children with an accessible and comprehensive system of care that secures a medical home for children. This coordination is directed to ensuring that FAMIS does not supplant or replace existing programs. Rather, the goal of coordination is the close cooperation between these programs to enhance the health care resources available to low income children. DMAS, the single State agency that administers the Medicaid program, also administers FAMIS. Thus, Virginia ensures that the plan is closely coordinated with Medicaid in identifying and facilitating enrollment in the respective programs.

DMAS is responsible for the coordination of outreach and education efforts for all children whether they qualify for Medicaid or for FAMIS. Community-based organizations participating

STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

STATE: Virginia Page 2-10

Effective Date: 0107/01/17

10 Approval Date_______08/03/17 in this effort inform families about the programs and assist them with applying. The Cover Virginia Call Center provides customer service, assists callers with program information, selection of a managed care organization, and referrals to other sources of care if not eligible. Public programs that have established networks serving families who would meet either FAMIS or Medicaid’s income eligibility requirements are used as a resource in reaching eligible children.

DMAS has developed an interagency committee specifically to address the health care needs of children, pregnant women, and special needs populations. The group meets periodically to discuss issues of mutual concern, solicit support, and cooperation, and share creative approaches to serving these unique populations. Information regarding FAMIS as well as Medicaid is routinely shared and discussed with these individuals. A part of this group effort is the identification and coordination of Title V children. In addition, through its many other committees comprised of non-agency membership (e.g., Board of Directors, Managed Care Advisory Committee, Provider Advisory Council), DMAS solicits input and advice from public and private entities on its programs.

DMAS shall issue a settlement notice at the time of the reconciliation that denotes the amount due to or from the Local Education Agency (LEA) provider. If the interim payments exceed the FFP of the certified costs of an LEA’s Medicaid, Medicaid Expansion, or FAMIS services, DMAS will recoup the overpayment using the methods outlined in the Virginia Medicaid State Plan, Attachment 4.19-B, Pages 9a of 15 through 9f of 15 and subsequent revisions to this section. If the FFP of the certified costs exceeds interim payments, DMAS will pay the difference to the LEA provider.

At the end of each settlement, interim rates for each LEA provider will be determined by dividing total medical services cost and special transportation service cost by an estimate of the number of units of service. For the initial interim rates or for new providers, interim rates will be based on pro forma cost data. Interim rates are provisional in nature pending completion of the cost report.

STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

STATE: Virginia Page 3-11

Effective Date: 0107/01/17

11 Approval Date_______08/03/17 Section 3. Methods of Delivery and Utilization Controls (Section 2102)(a)(4))

Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan, and continue on to Section 4.

Guidance: In Section 3.1., discussion may include, but is not limited to: contracts with managed health care plans (including fully and partially capitated plans); contracts with indemnity health insurance plans; and other arrangements for health care delivery. The State should describe any variations based upon geography, as well as the State methods for establishing and defining the delivery systems.

Should the State choose to cover unborn children under the Title XXI State plan, the State must describe how services are paid. For example, some states make a global payment for all unborn children while other states pay for services on fee-for-services basis. The State’s payment mechanism and delivery mechanism should be briefly described here.

Section 2103(f)(3) of the Act, as amended by section 403 of CHIPRA, requires separate or combination CHIP programs that operate a managed care delivery system to apply several provisions of section 1932 of the Act in the same manner as these provisions apply under title XIX of the Act. Specific provisions include: section 1932(a)(4), Process for Enrollment and Termination and Change of Enrollment; section 1932(a)(5), Provision of Information; section 1932(b), Beneficiary Protections; section 1932(c), Quality Assurance Standards; section 1932(d), Protections Against Fraud and Abuse; and section 1932(e), Sanctions for Noncompliance. If the State CHIP program operates a managed care delivery system, provide an assurance that the State CHIP managed care contract(s) complies with the relevant sections of section 1932 of the Act. States must submit the managed care contract(s) to CMS’ Regional Office servicing them for review and approval.

In addition, states may use up to 10 percent of actual or estimated Federal expenditures for targeted low-income children to fund other forms of child health assistance, including contracts with providers for a limited range of direct services; other health services initiatives to improve children’s health; outreach expenditures; and administrative costs (See 2105(c)(2)(A)). Describe which, if any, of these methods will be used.

Examples of the above may include, but are not limited to: direct contracting with school- based health services; direct contracting to provide enabling services; contracts with health centers receiving funds under section 330 of the Public Health Service Act; contracts with hospitals such as those that receive disproportionate share payment adjustments under section 1886(d)(5)(F) or 1923 of the Act; contracts with other hospitals; and contracts with public health clinics receiving Title V funding.

STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

STATE: Virginia Page 3-12

Effective Date: 0107/01/17

12 Approval Date_______08/03/17

If applicable, address how the new arrangements under Title XXI will work with existing service delivery methods, such as regional networks for chronic illness and disability; neonatal care units, or early-intervention programs for at-risk infants, in the delivery and utilization of services. (42CFR 457.490(a))

3.1. Describe the methods of delivery of the child health assistance using Title XXI funds to targeted low-income children. Include a description of the choice of financing and the methods for assuring delivery of the insurance products and delivery of health care services covered by such products to the enrollees, including any variations. (Section 2102)(a)(4) (42CFR 457.490(a))

 Check here if the State child health program delivers services using a managed care delivery model. The State provides an assurance that its managed care contract(s) complies with the relevant provisions of section 1932 of the Act, including section 1932(a)(4), Process for Enrollment and Termination and Change of Enrollment; section 1932(a)(5), Provision of Information; section 1932(b), Beneficiary Protections; section 1932(c), Quality Assurance Standards; section 1932(d), Protections Against Fraud and Abuse; and section 1932(e), Sanctions for Noncompliance. The State also assures that it will submit the contract(s) to the CMS’ Regional Office for review and approval. (Section 2103(f)(3))

The Commonwealth of Virginia’s Title XXI State Plan utilizes two Secretary-approved benefit packages within FAMIS. One Secretary-approved coverage is a modified Medicaid look-alike component offered through a fee-for-service system under the State’s original Title XXI program, Virginia Children’s Medical Security Insurance Plan (VCMSIP). The other Secretary-approved coverage is modeled after the state employee plan in effect in June 2000 approved by the Centers for Medicare and Medicaid Services (CMS) December 22, 2000 and delivered by contracted (Managed Care Organizations) MCOs.

Newly eligible and enrolled FAMIS recipients are assigned to the fee-for-service program until they are enrolled into managed care. Effective July 1, 2012, all geographic areas are covered by two or more MCOs.

Financing

Effective October 1, 2009, the Commonwealth reimburses for services provided by Federally- qualified health centers (FQHCs) and rural health clinics (RHCs), applicable to CHIP, in the same manner it reimburses for services provided in the Title XIX (Medicaid) program as described in the Virginia State Plan for Medical Assistance, Attachment 4.19-B. Supplemental payments are made to FQHCs and RHCs for services reimbursed by MCOs as also described in the Virginia State Plan for Medical Assistance, Attachment 4.19-B. Coverage under the modified Medicaid look-alike component will be reimbursed on a fee-for-service basis by the

STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

STATE: Virginia Page 3-13

Effective Date: 0107/01/17

13 Approval Date_______08/03/17 Department.

The managed care organizations (MCOs) are at risk for all services provided. The plans have the discretion in reimbursing and contracting with providers and must ensure services are provided and a sufficient network exists. FAMIS rates are actuarially sound rates, and are established in a manner consistent with CMS regulations promulgated pursuant to the Balanced Budget Act of 1997. A managed care savings factor shall be applied to determine the final rates. The savings factor shall be determined annually.

FEE-FOR-SERVICE

Coverage under the modified Medicaid look-alike component is based on the fee-for- service program and providers are reimbursed by the Department. Reimbursement rates for services under FAMIS are the same as those for Medicaid. Children newly eligible for FAMIS receive services through the fee-for-service delivery system until they are enrolled in an MCO. Effective July 1, 2012, all localities have at least two MCOs.

COVERAGE PROVIDED UNDER MCOs

The second benefit package is Secretary-approved coverage modeled after the state employee plan in effect in June 2000, provided under the current Title XXI State Plan through contracted MCOs.

Secretary-approved coverage modeled after the state employee health plan provides a comprehensive array of health care benefits for eligible enrollees. DMAS has contracted with various managed care health insurers that meet certain requirements and standards in order to provide a comprehensive health benefits plan to FAMIS enrollees on a regional basis. The plans have the discretion in reimbursing and contracting with providers and must ensure services are provided and a sufficient network exists.

Effective July 1, 2012, all localities are served by more than one MCO, providing choice for enrollees.

3.2. Describe the utilization controls under the child health assistance provided under the plan for targeted low-income children. Describe the systems designed to ensure that enrollees receiving health care services under the state plan receive only appropriate and medically necessary health care consistent with the benefit package described in the approved state plan. (Section 2102)(a)(4) (42CFR 457.490(b))

A. FFS Utilization Controls

STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

STATE: Virginia Page 3-14

Effective Date: 0107/01/17

14 Approval Date_______08/03/17 Utilization controls for providers offering Secretary-approved coverage through the fee- for-service component are administrative mechanisms that are designed to ensure that children use only health care that is appropriate, medically necessary, and approved by DMAS. DMAS relies on the utilization controls already established and operational in the Title XIX program for eligibles under Title XXI. Administrative mechanisms to be employed include the following: prepayment reviews, prior authorizations and internal reviews, post payment and SURS reviews.

Managed Care Organization Utilization Controls

Managed care organizations providing the Secretary-approved coverage modeled after the State employee plan in effect in June 2000 are required by contract to manage service utilization and have in place a process of evaluating the necessity, appropriateness and efficiency of health care services against established guidelines and criteria. The utilization program may include drug formulary decisions and criteria. The UM program must demonstrate that enrollees have equitable access to care across the network and that UM decisions are made in a fair, impartial, and consistent manner that serves the best interest of the enrollees. The MCO’s UM program reflects standards for utilization management from the most current nationally accepted standards. The program must have mechanisms to detect over-utilization and/or under-utilization of care, including, but not limited to, provider profiling and disease management programs. MCOs must ensure that the preauthorization requirements do not apply to emergency care, family planning services, preventative services, and basic prenatal care.

For more information on utilization controls, please refer to the current Title XXI State Plan § 7 - Quality and Appropriateness of Care.

STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

STATE: Virginia Page 4-15

Effective Date: 0107/01/17

15 Approval Date_______08/03/17 Section 4. Eligibility Standards and Methodology. (Section 2102(b))

Note the following summary of approved amendments for this section:

 Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan, and continue on to Section 5.

4.1. The following standards may be used to determine eligibility of targeted low-income children for child health assistance under the plan. Please note whether any of the following standards are used and check all that apply. If applicable, describe the criteria that will be used to apply the standard. (Section 2102)(b)(1)(A)) (42CFR 457.305(a) and 457.320(a))

4.1.1.  Geographic area served by the Plan:

State wide.

4.1.2.  Age:

From birth through age 18.

4.1.3.  Income:

Effective September 1, 2002, the Commonwealth’s Medicaid program was expanded under Title XXI to provide coverage for children from age 6 through age 18 who live in families with income in excess of 100% of FPL, but less than or equal to 133% FPL. The income limit prior to this date was less than or equal to 100% FPL for children age 6 through 18. All Medicaid income disregards, deductions and methodologies used for the Poverty Level group of Medicaid eligible children in the State’s Title XIX plan apply to this expanded group. The Commonwealth claims enhanced funding for optional targeted low-income children who qualify under the Medicaid expansion. Regular FMAP is claimed for those children who do not meet the definition of optional targeted low-income child. The Family Access to Medical Insurance Security Plan, Virginia’s separate Title XXI plan, was also revised to cover children from birth through age 18 in families with gross incomes at or below 200% of the FPL, but in excess of 133% of the federal poverty level. Formerly, FAMIS covered children from birth through age 5 in families with gross income in excess of 133% of the FPL but at or below 200% of the FPL and children from age 6 through 18 in families with gross incomes in excess of 100% of the

STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

STATE: Virginia Page 4-16

Effective Date: 0107/01/17

16 Approval Date_______08/03/17 FPL but at or below 200% of the FPL.

The former Title XXI program, CMSIP, covered children up to 185% of the FPL and used the same income methodologies applied under the Virginia State Plan for Medical Assistance that are applied to children in the poverty income related groups.

Children who were enrolled in CMSIP on the date of FAMIS implementation, August 2001, were automatically enrolled in FAMIS. The income methodology for these children is protected. In the event that their gross family income exceeds the FAMIS limits, their eligibility will be determined using the income requirements of the CMSIP program for as long as they remain continuously eligible.

Effective October 1, 2013, MAGI-based income methodologies are in force. Effective January 1, 2014, the upper limit of eligibility for Medicaid Expansion increased from 133% to 143% FPL; the lower limit of eligibility for the Separate CHIP program also increased to 143% FPL. See approved templates effective January 1, 2014: CS3 (Eligibility for Medicaid Expansion Program), and CS7 (Eligibility – Targeted Low- Income Children).

4.1.4. 

Resources (including any standards relating to spend downs and disposition of resources):

4.1.5.  Residency (so long as residency requirement is not based on length of time in state):

Eligible children must be Virginia residents. See approved template effective January 1, 2014: CS17 (Non-Financial Eligibility – Residency).

4.1.6. 

Disability Status (so long as any standard relating to disability status does not restrict eligibility):

4.1.7.  Access to or coverage under other health coverage:

Any child covered under a group health plan or under health insurance coverage, as defined in § 2791 of the Public Health Service Act (42 U.S.C. § 300gg-91(a) and (b)(1)) shall not be eligible for the program.

4.1.8.  Duration of eligibility:

STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

STATE: Virginia Page 4-17

Effective Date: 0107/01/17

17 Approval Date_______08/03/17

Children enrolled in FAMIS are eligible for coverage as of the first day of the month in which a completed application is received at either the local department of social services in the locality where the child resides or electronically or telephonically through Cover Virginia. Effective 08-01- 06, if a child enrolled in FAMIS is born within the three months prior to the month in which a signed application is received, coverage is effective retroactive to their date of birth if they would have met all eligibility criteria during that time.

Effective 08-01-03, enrollment is for 12 continuous months, unless one of the following events occurs before the annual renewal: 1) an increase in gross monthly income to above 200% FPL; 2) a child moves out of state; 3) a child turns age 19; 4) the family requests cancellation; or 5) the family reports a change and the child is determined eligible for Medicaid. Families must report the following changes before the annual renewal: 1) an increase in gross monthly income or change in family size resulting in a family income above 200% FPL; or 2) an enrolled child moving out of the Commonwealth of Virginia. If none of the above changes is reported, eligibility will be renewed annually. See approved template effective January 1, 2014: CS27 (General Eligibility – Continuous Eligibility).

4.1.9.  Other standards (identify and describe):

Prior to January 1, 2015, children were not eligible for the Family Access to Medical Insurance Security Plan: (1) if they are a member of a family eligible for employer-sponsored dependent health insurance coverage under any Virginia State Employee Health Insurance Plan, (2) if they are inmates of public institutions, (3) if they are inpatients in an institution for mental disease, or (4) if their parent or other authorized representative does not meet the requirements on assignment of rights to benefits or cooperation with the agency in identifying and providing information to assist the Commonwealth in pursuing any liable third party. As of January 1, 2015, dependents of state employees able to access subsidized health insurance are eligible to enroll in FAMIS, if they otherwise qualify. See attached approved template effective January 1, 2015: CS10 (Eligibility – Children Who Have Access to Public Employee Coverage). All other eligibility requirements noted above remain in effect. The Commonwealth performed an analysis of public employee coverage costs for 20165 – 176, and confirms that the previously approved Hardship Exception still applies. See attachment Hardship Exception Analysis 20165-176. Effective 01-01-10, upon signing the declaration of citizenship or nationality required by § 1137(d) of the Social Security Act, the applicant

STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

STATE: Virginia Page 4-18

Effective Date: 0107/01/17

18 Approval Date_______08/03/17 or recipient is required under § 2105(c)(9) to furnish satisfactory documentary evidence of U.S. citizenship or nationality and documentation of personal identity unless citizenship or nationality has been verified by the Commissioner of Social Security or unless otherwise exempt. Applicants who otherwise meet eligibility requirements are enrolled and are permitted a reasonable opportunity to provide the required verification. See approved templates effective January 1, 2014: CS16 (Spenddowns); CS18 (Citizenship); CS19 (Social Security Number); CS21 (Non-Payment of Premiums; CS23 (Other Eligibility Standards); and, CS28 (Presumptive Eligibility for Children). Guidance: States have the option to cover groups of “lawfully residing” children and/or pregnant women. States may elect to cover (1)“lawfully residing” children described at section 2107(e)(1)(J) of the Act; (2) “lawfully residing” pregnant women described at section 2107(e)(1)(J) of the Act; or (3) both. A state electing to cover children and/or pregnant women who are considered lawfully residing in the U.S. must offer coverage to all such individuals who meet the definition of lawfully residing, and may not cover a subgroup or only certain groups. In other words, a State that chooses to cover pregnant women under this option must otherwise cover pregnant women under their State plan as described in 4.1.11. In addition, states may not cover these new groups only in CHIP, but must also extend the coverage option to Medicaid. States will need to update their budget to reflect the additional costs for coverage of these children. If a State has been covering these children with State only funds, it is helpful to indicate that so CMS understands the basis for the enrollment estimates and the projected cost of providing coverage. Please remember to update section 9.10 when electing this option.

4.1- LR

Lawfully Residing Option (Sections 2107(e)(1)(J) and 1993(v)(4)(A);

This section is replaced by approved template CS18 (Citizenship).

4.2. The state assures that it has made the following findings with respect to the eligibility standards in its plan: (Section 2102)(b)(1)(B)) (42CFR 457.320(b))

4.2.1.  These standards do not discriminate on the basis of diagnosis. 4.2.2.  Within a defined group of covered targeted low-income children, these standards do not cover children of higher income families without covering children with a lower family income. 4.2.3.  These standards do not deny eligibility based on a child having a pre- existing medical condition.

4.3. Describe the methods of establishing eligibility and continuing enrollment. (Section 2102)(b)(2)) (42CFR 457.350)

STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

STATE: Virginia Page 4-19

Effective Date: 0107/01/17

19 Approval Date_______08/03/17 Section 4.3 is superseded by the attached approved template CS24 and associated attachments.

Effective September 1, 2002, the State intensified efforts to enroll children in health care coverage through both its FAMIS and Medicaid programs. The Medicaid income limits for poverty level children were increased to 133% of the federal poverty level for children ages 6-19, thereby creating a single income limit for all poverty level children. A Title XIX State Plan Amendment effective September 1, 2002 was submitted to expand this income limit. Note: Children with income in excess of 100% FPL but equal to or less than 133% FPL who were currently enrolled in FAMIS became Medicaid eligible effective on this date. Families of these children were notified of this change, the different benefit package available to Medicaid recipients, and the fact that their children’s cases would be transferred to and maintained by the local department of social services in the locality where they reside. As noted in section 4.1.3, effective January 1, 2014, the income eligibility level changed from 133% to 143% FPL.

See also approved templates effective January 1, 2014: CS13 (Deemed Newborns) and CS15 (MAGI-Based Income Methodologies).

A single child health insurance application form was implemented September 2002. October 1, 2013 Virginia began using the new single streamlined application.

Historically, the Commonwealth contracted with a private entity to operate a Central Processing Unit for receipt and review of applications, for conducting a screen for Medicaid eligibility and for making FAMIS eligibility determinations for those children who did not appear to be eligible for Medicaid. Families were able to apply by mail, by phone, by fax or on the FAMIS.org website. Effective July 2010, new and renewal applications made through the FAMIS.org website could be signed with an electronic signature. Effective January 2011, new and renewal applications could be signed over the telephone with an electronically recorded signature. Approved Medicaid cases were then transferred to the local department of social services in the city or county where the child resides for on-going case maintenance. Children eligible for FAMIS were enrolled in the FAMIS program and their cases transferred to the FAMIS Central Processing Unit for ongoing case maintenance.

Effective October 1, 2013, the Central Processing Unit ceased to process new applications, and began transitioning management of active FAMIS cases to local departments of social services. At that time, Virginia began accepting the new MAGI single streamlined application telephonically and electronically. The Central Processing Unit ceased operations on January 31, 2014.

FAMIS cases are reviewed annually to determine continued eligibility. Effective 08-01-

STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

STATE: Virginia Page 4-20

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20 Approval Date_______08/03/17 03, enrollment is for 12 continuous months, unless one of the following events occurs before the annual renewal: 1) an increase in gross monthly income to above 200% FPL; 2) a child moves out of state; 3) a child turns age 19; 4) the family requests cancellation; or 5) the family reports a change and the child is determined eligible for Medicaid. Families must report the following changes before annual renewal: 1) an increase in gross monthly income or change in family size that results in family income above 200% FPL; or 2) an enrolled child moves out of the Commonwealth of Virginia. Medicaid cases are reviewed in accordance with established Medicaid policy. At the time of redetermination and/or renewal, a child found ineligible for either Medicaid or FAMIS will have his eligibility automatically determined in the other program.

A series of eligibility process enhancements occurred in 2010 – 2011 as follows: • Beginning in July 2010, recipients up for renewal received a renewal packet in the mail with a PIN and Family ID number with the option to log into the FAMIS.org website and view/submit a renewal application pre-populated with family information, including income information from the most recent eligibility determination. • On October 1, 2010, the FAMIS CPU implemented an administrative renewal process. Additional fields were added to both the paper and the electronic renewal pre-populated application to allow the recipient to attest that the income had not changed from the previous reporting period. In addition, families could report any changes in income. If the responsible person did not confirm or report a change in income source, the CPU attempted to electronically verify the household income through the Department of Social Service’s data warehouse. When the CPU could not verify income either though electronic means or other documentation, a letter went to the family requesting the verification. If the CPU did not receive the requested verifications, a letter notified the family that coverage would be canceled in accordance with the procedure described in Section 12.1. • Application options expanded with the addition of telephonic signature capability. Effective January 1, 2011, new applicants could obtain application assistance and sign the application over the telephone. • In an effort to reach more recipients on a monthly basis, DMAS added text messaging to the automated outreach performed at the CPU. Those who opted into the service received a reminder text message prior to an automated outbound phone call that all enrollees currently receive. The triggers for reminders included: upcoming renewal, newborn birth needs to be reported, deficiency in application and cancellation due to not returning renewal. Reminders were in both English and Spanish.

The Medicaid and FAMIS programs aligned with the open enrollment period of October 1, 2013. DMAS modified an existing contract with Xerox (now Conduent) to launch the

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STATE: Virginia Page 4-21

Effective Date: 0107/01/17

21 Approval Date_______08/03/17 Cover Virginia Call Center to accept the single streamlined application used to make determinations of eligibility and enrollment in all insurance affordability programs. This call center supports electronic and telephonic application and signature. Cover Virginia also processes hospital reports to expedite electronic enrollment for deemed newborns. The call center answers eligibility and covered services questions for the general Medicaid and FAMIS population. The Cover Virginia website (www.coverva.org) went live to provide users a self-directed eligibility screener, based on MAGI methodologies, and a link to an on-line application. In August 2014, the eligibility system (VaCMS) incorporated an automated determination for those applications that were complete.

Beginning with renewals due in April 2014, FAMIS cases were converted monthly into the new eligibility system, renewed by the LDSS where the child resides, and maintained by the LDSS where the child resides. Due to the volume of applications received from the federally facilitated marketplace (FFM), it was determined that the local LDSS staff did not have the capacity to process FFM case transfer applications. Steps were taken during the remainder of 2014 to reinstate a Central Processing Unit function through Cover Virginia through the state's new eligibility system resulting in a determination of eligibility for MAGI cases. This process is monitored by col-located state staff. Cover Virginia now processes telephonic and FFM applications. The Virginia Department of Social Services (VDSS) has subsequently added capacity for a limited central processing unit as well.

No Entitlement: In accordance with § 2102(b)(4) of the Social Security Act and § 32.1- 353 of the Code of Virginia, the Family Access to Medical Insurance Security Plan shall not create any individual entitlement for payment of medical services or any right or entitlement to participation.

Beginning January 1, 2017, in the event that all or a portion of the Commonwealth is declared a disaster area by the Governor or FEMA, the Virginia FAMIS program, in consultation with the Departments of Health and Social Services, will have the option of extending the renewal grace period an additional 90 days for families living and/or working in the affected disaster area during the time of the disaster.

DMAS will notify CMS in the event of a declared disaster and Virginia's intent to implement this policy modification. The CMS notification will include the intent to modify the renewal process, the areas affected by the disaster, and the effective dates of the policy modification. The next twelve-month continuous eligibility period will begin the month after the renewal completion date.

4.3.1 Describe the state’s policies governing enrollment caps and waiting lists (if any). (Section 2106(b)(7)) (42CFR 457.305(b))

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22 Approval Date_______08/03/17

 Check here if this section does not apply to your state.

4.4. Describe the procedures that assure that:

4.4.1. Through the screening procedures used at intake and follow-up eligibility determination, including any periodic redetermination, that only targeted low- income children who are ineligible for Medicaid or not covered under a group health plan or health insurance coverage (including access to a state health benefits plan) are furnished child health assistance under the state child health plan. (Sections 2102(b)(3)(A) and 2110(b)(2)(B)) (42 CFR 457.310(b) (42CFR 457.350(a)(1)) 457.80(c)(3))

Section 4.4 is superseded by approved template CS24 and associated attachments.

The application asks for employer information and whether children currently have health insurance. The screening question regarding access to state employee insurance was removed in accordance with the January 2015 policy change.

As described in §4.3 above, all applications for child health insurance coverage are screened for completeness of information, the presence of other health insurance, verification of income, and Medicaid eligibility. Beginning January 1, 2014, children who will lose Medicaid due to changes in income at their first renewal applying MAGI standards will be provided coverage under FAMIS. See template CS14 (Eligibility – Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards). Those children with employer-sponsored or private insurance have the option to enroll in FAMIS Select to avoid termination at their next annual eligibility review. 4.4.2. The Medicaid application and enrollment process is initiated and facilitated for children found through the screening to be potentially eligible for medical assistance under the state Medicaid plan under Title XIX. (Section 2102)(b)(3)(B)) (42CFR 457.350(a)(2))

Prior to October 1, 2013, applications received at the FAMIS Central Processing Unit were screened for Medicaid eligibility and, if found to be potentially eligible for Medicaid, transferred directly by the FAMIS staff to Medicaid eligibility workers co-located at the FAMIS Central Processing Unit. Medicaid workers, either at the Central Processing Unit, or at local departments of social

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STATE: Virginia Page 4-23

Effective Date: 0107/01/17

23 Approval Date_______08/03/17 services completed a Medicaid eligibility determination on all applications.

As of October 1, 2013, the Cover Virginia Call Center supports telephonic application and signature. At the same time, the existing Central Processing Unit stopped processing new applications for FAMIS. The call center answers eligibility and covered services questions for the general Medicaid and FAMIS population. The Cover Virginia website (www.coverva.org) also went live to provide users a self-directed eligibility screener, based on MAGI methodologies, and a link to an on-line application.

4.4.3. The State is taking steps to assist in the enrollment in SCHIP of children determined ineligible for Medicaid. (Sections 2102(a)(1) and (2) and 2102(c)(2)) (42CFR 431.636(b)(4))

A single streamlined application and process facilitates eligibility determination and enrollment of children in the appropriate program, either Medicaid or FAMIS. As noted above, beginning January 1, 2014, children who will lose Medicaid due to changes in income at their first renewal applying MAGI standards will be provided coverage under FAMIS.

4.4.4 The insurance provided under the state child health plan does not substitute for coverage under group health plans. Check the appropriate box. (Section 2102)(b)(3)(C)) (42CFR 457.805) (42 CFR 457.810(a)-(c))

4.4.4.1.  Coverage provided to children in families at or below 200% FPL: describe the methods of monitoring substitution.

Only uninsured children shall be eligible for FAMIS. The single streamlined application requests information on health insurance coverage the child may have.

DMAS will conduct a focused survey of applicants every five years to determine the percentage of enrollees who have dropped employer-based health insurance for enrollment in FAMIS. See template effective July 2014: CS20 (Substitution of Coverage). Assignment of rights to medical support is a condition of eligibility.

4.4.4.2. 

Coverage provided to children in families over 200% and up to 250% FPL: describe how substitution is monitored and identify specific strategies to limit substitution if levels become

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STATE: Virginia Page 4-24

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24 Approval Date_______08/03/17 unacceptable.

4.4.4.3. Coverage provided to children in families above 250% FPL: describe how substitution is monitored and identify specific strategies in place to prevent substitution.

4.4.4.4 If the state provides coverage under a premium assistance program, describe:

The minimum period without coverage under a group health plan, including any allowable exceptions to the waiting period.

The minimum employer contribution.

The cost-effectiveness determination.

4.4.5 Child health assistance is provided to targeted low-income children in the state who are American Indian and Alaska Native. (Section 2102)(b)(3)(D)) (42 CFR 457.125(a))

American Indian and Alaska Native children are eligible for the Family Access to Medical Insurance Security Plan on the same basis as any other children in the Commonwealth, and are served statewide by Marketing and Outreach efforts. At this time Virginia has one federally recognized Indian tribe. The geographic region that is home to the Pamunkey Indian Tribe is currently served by Outreach staff who act as resources to ensure that Indian families understand the program and can access the provider network to secure covered services.

No cost sharing is imposed on American Indian and Alaska Native children.

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STATE: Virginia Page 5-25

Effective Date: 0107/01/17

25 Approval Date_______08/03/17 Section 5. Outreach (Section 2102(c)) Describe the procedures used by the state to accomplish:

Outreach to families of children likely to be eligible for child health assistance or other public or private health coverage to inform them of the availability of the programs, and to assist them in enrolling their children in such a program: (Section 2102(c)(1)) (42CFR 457.90)

Pursuant to the 2004 amendment to § 32.1-351.2 of the Code of Virginia, DMAS has established the Children’s Health Insurance Advisory Committee. The Committee consists of no more than 20 members and shall include membership from appropriate entities, as follows: one representative of the Joint Commission on Health Care, the Department of Social Services, the Department of Health, the Department of Education, the Department of Behavioral Health and Developmental Services, the Virginia Health Care Foundation, various provider associations and children's advocacy groups; and other individuals with significant knowledge and interest in children's health insurance. The Committee may report on the current status of FAMIS and FAMIS Plus and make recommendations as deemed necessary to the Director of the Department of Medical Assistance Services and the Secretary of Health and Human Resources. The Committee is staffed by DMAS Marketing and Outreach staff.

DMAS maintains Marketing and Outreach staff to conduct statewide outreach, oversee campaigns, attend community events, sit on coalitions, and design and print flyers, brochures, posters, and other support materials in English and Spanish. This staff also oversees content for the Cover Virginia website and FAMIS and Cover Virginia Facebook pages and Cover Virginia You Tube and Twitter Accounts. The marketing and outreach efforts promote FAMIS and Medicaid and may include the following:

Coordination with Other State Agencies -- Assistance is sought from other agencies, including Virginia’s Department of Education, Department of Health, and Department of Social Services to promote the program to potential new enrollees. Utilizing the highly successful annual Back to School Campaign in conjunction with the Free and Reduced School Lunch Program, school systems are a primary vehicle for sending information home to parents about the FAMIS program. This campaign usually results in a 25% increase in applications during the month of September. In addition, State agencies are routinely educated and trained about the program, informed of any changes or new initiatives, and are provided with informational fact sheets, website links, and other materials.

Coordination with other Community Based Organizations -- The Commonwealth actively encourages participation of a wide range of organizations, including, but not limited to, those organizations that target high concentrations of uninsured children.

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STATE: Virginia Page 5-26

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26 Approval Date_______08/03/17 DMAS has partnered with a network of Community Based Organizations (CBO) to promote and facilitate enrollment of children in the FAMIS and Medicaid programs. DMAS will continue to build coalitions and infrastructure at the state and local level that will provide awareness and application assistance in both FAMIS and Medicaid. DMAS continues to work closely with its contractor, the Virginia Health Care Foundation, in coordinating local outreach efforts through various CBO that have expertise in providing outreach and application assistance, including translation services to reach eligible families with limited English speaking abilities. All outreach materials are available in both English and Spanish. DMAS continues to provide these organizations with the support and tools needed to reach these families.

In 20165, DMAS again contracted with a marketing firm to launch a media campaign aimed solely at increasing enrollment of eligible uninsured children in FAMIS and Medicaid. The campaign went into production in summer 2015 to create expanded on the TV and radio spots, digital and Spanish print ads, posters, and brochures that were created in 2015. It launched in August 20165 in conjunction with the annual Back to School campaign. A second “cold and flu” media buy took place in January 20176 and a third spring media buy took place in April/May 20176.

Coordination with the Business Community -- DMAS will contact Virginia businesses and business associations to request their cooperation in enrolling employees’ children, sponsorship opportunities, advertising partnerships, and support of the State’s child health insurance programs. These groups will be provided with materials outlining the importance and benefits of the program so that they can make informed decisions on their ability and level of participation.

Coordination with the Health Care Associations and Providers -- The Commonwealth partners with health care associations and requests their cooperation in performing outreach for Virginia’s child health insurance programs. Outreach information is provided to health care associations and health care providers so that they can distribute FAMIS and Medicaid information to their members.

Cover Virginia Call Center– Effective October 2013, the Commonwealth, through a contractor, provides a call center with a toll-free number that provides general program information, assists callers with completing new and renewal applications, documents reported changes in status, provides status updates on pending application, and helps enrollees with selecting a MCO as needed. On-line resources are available to support customer service representatives in assisting callers and making referrals to other programs. DMAS continues to coordinate outreach efforts in conjunction with the call center and works to develop better outreach evaluation methods. The call center provides translation services for non-English speaking callers in 148 of the most commonly spoken languages around the world.

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27 Approval Date_______08/03/17

www.coverva.org – This web site, in tandem with the Cover Virginia Call Center, provides program information as well as information about DMAS contracted MCOs. The site is a resource for consumers, patient navigators, and community partners. It provides information on eligibility, training for community partners who assist with enrollment, and features a News section for timely updates and notices. Providers and partners can order materials. The site provides an on-line eligibility screening tool using MAGI income methodologies, and if the user is found eligible, a link to the CommonHelp application. If the user is not eligible, information on other sources of care is available, as is a link to the FFM. The site is also a source of health information for populations served by public insurance.

FAMIS and Cover Virginia Facebook -- DMAS monitors and updates weekly FAMIS and Cover Virginia Facebook and Cover Virginia Twitter accounts which were established to capitalize on social media as a method of communicating with applicants and enrollees. They serve as great tools for promoting current health related messages to pregnant women, families with children, and teens themselves.

The Commonwealth has not received any gifts or in-kind contributions from the business community to support the Commonwealth’s Child Health Insurance Program. Any gifts, donations, or in-kind contributions that have been provided have been given directly to the outreach efforts (as described above) or have been provided directly to the grantees providing/supporting the outreach efforts. As stated above, none of these funds are used to draw-down the Title XXI federal match.

Virginia currently has no health insurance programs that involve a public-private partnership.

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28 Approval Date_______08/03/17 Section 6. Coverage Requirements for Children’s Health Insurance (Section 2103)

 Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan, and continue on to Section 7.

6.1. The state elects to provide the following forms of coverage to children: (Check all that apply.) (42CFR 457.410(a))

6.1.1. 

Benchmark coverage; (Section 2103(a)(1) and 42 CFR 457.420) 6.1.1.1. 

FEHBP-equivalent coverage; (Section 2103(b)(1)) (If checked, attach copy of the plan.) 6.1.1.2. 

State employee coverage; (Section 2103(b)(2)) (If checked, identify the plan and attach a copy of the benefits description.) 6.1.1.3. 

HMO with largest insured commercial enrollment (Section 2103(b)(3)) (If checked, identify the plan and attach a copy of the benefits description.)

6.1.2. 

Benchmark-equivalent coverage; (Section 2103(a)(2) and 42 CFR 457.430) Specify the coverage, including the amount, scope and duration of each service, as well as any exclusions or limitations. Please attach a signed actuarial report that meets the requirements specified in 42 CFR 457.431. See instructions.

6.1.3. 

Existing Comprehensive State-Based Coverage; (Section 2103(a)(3) and 42 CFR 457.440) [Only applicable to New York; Florida; Pennsylvania] Please attach a description of the benefits package, administration, date of enactment. If existing comprehensive state-based coverage is modified, please provide an actuarial opinion documenting that the actuarial value of the modification is greater than the value as of 8/5/97 or one of the benchmark plans. Describe the fiscal year 1996 state expenditures for existing comprehensive state-based coverage.

6.1.4.  Secretary-Approved Coverage. (Section 2103(a)(4)) (42 CFR 457.450) 6.1.4.1.  Coverage the same as Medicaid State plan 6.1.4.2.  Comprehensive coverage for children under a Medicaid

Section 1115 demonstration project 6.1.4.3.  Coverage that either includes the full EPSDT benefit or

that the state has extended to the entire Medicaid population 6.1.4.4.  Coverage that includes benchmark coverage plus additional coverage 6.1.4.5. 

Coverage that is the same as defined by existing comprehensive state-based coverage

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29 Approval Date_______08/03/17 6.1.4.6. 

Coverage under a group health plan that is substantially equivalent to or greater than benchmark coverage through a benefit by benefit comparison (Please provide a sample of how the comparison will be done) 6.1.4.7.  Other (Describe)

Secretary-approved coverage through a modified Title XIX look-alike (a fee-for-service component) is the delivery system provided for newly eligible children until they are enrolled in an MCO.

Secretary-approved coverage modeled after the state employee plan provides coverage using the Key Advantage Plan. This plan is the PPO option for state employees that was offered statewide in June 2000. Several enhanced benefits are added to the plan. The services under the Key Advantage Member Handbook are briefly outlined in the checklist in § 6.2. The enhanced benefits that are provided in addition to the Key Advantage Plan are listed at the end of this checklist. This coverage is provided for children enrolled in an MCO.

6.2. The state elects to provide the following forms of coverage to children: (Check all that apply. If an item is checked, describe the coverage with respect to the amount, duration and scope of services covered, as well as any exclusions or limitations) (Section 2110(a)) (42CFR 457.490)

Secretary-approved coverage modeled after the state employee, Virginia’s Key Advantage State Employee Benefit Plan in effect in June 2000, is summarized in the checklist below (6.2.1 --6.2.28). The additional coverage provided is listed separately at the bottom of the checklist. NOTE: The FAMIS program has two separate health care services delivery systems, described immediately below and at 6.2.1.A – 6.2.28.A, below.

6.2.1.  Inpatient services (Section 2110(a)(1))

365 days per confinement; includes ancillary services.

6.2.2.  Outpatient services (Section 2110(a)(2))

Outpatient services include emergency services, surgical services, and professional provider services in a physician’s office or outpatient hospital department. Facility charge for outpatient department of a

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STATE: Virginia Page 6-30

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30 Approval Date_______08/03/17 hospital or hospital emergency room, separate from physician or diagnostic services.

6.2.3.  Physician services (Section 2110(a)(3))

Physician services include services while admitted in the hospital, or in a physician’s office, or outpatient hospital department.

6.2.4.  Surgical services (Section 2110(a)(4))

Surgical services include services provided in §§ 6.2.1, 6.2.2, and 6.2.3.

6.2.5.  Clinic services (including health center services) and other ambulatory health care services. (Section 2110(a)(5))

Clinic services include services provided in §§ 6.2.2 and 6.2.3.

6.2.6.  Prescription drugs (Section 2110(a)(6))

Covered for outpatient prescription drugs. Mandatory generic program.

6.2.7.  Over-the-counter medications (Section 2110(a)(7))

Optional - May be covered at the discretion of the health plan.

6.2.8.  Laboratory and radiological services (Section 2110(a)(8))

Outpatient diagnostic tests, X-rays, and laboratory services covered in a physician's office, hospital, independent and clinical reference lab.

6.2.9.  Prenatal care and prepregnancy family services and supplies (Section 2110(a)(9))

Maternity service including routine prenatal care is covered. Prepregnancy family services include coverage for prescription drugs and devices approved by the U.S. Food and Drug Administration for use as contraceptives. Contraceptive drugs and devices eligible for reimbursement are oral contraceptives, depo provera, cervical caps, diaphragms, intrauterine devices and transdermal implants.

6.2.10.  Inpatient mental health services, other than services described in 6.2.18., but including services furnished in a state-operated mental hospital and including residential or other 24-hour therapeutically planned structural services. (Section 2110(a)(10))

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31 Approval Date_______08/03/17

Inpatient acute mental health services other than those (a) services furnished in a state-operated mental hospital, (b) services furnished by IMDs, or (c) residential services or other 24-hour therapeutically planned structural services.