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

JFK Federal Building. Government Center Room 2275 CENTERS for MEDICARE & MEDICAID SERVICES Boston. Massachusetts 02203

Division of Medicaid and Children's Health Operations / Boston Regional Office

December 21. 2011

Douglas A. Racine, Secretary Department of Vermont Health Access 103 South Main Street

Waterbury. VT 05671-0204

Dear Secretary Racine:

We are pleased to enclose a copy of approved State plan amendment (SPA) No. 11-008 with an effective date of July 1, 2011, as requested by your Agency.

This SPA transmitted a proposed amendment to your approved Title XIX State plan to elect the option provided by §214 of the Children’s Health Insurance Program Reauthorization Act of 2009, Public Law 111-3. This option provides States, at their option; to grant full Medicaid coverage to all otherwise eligible alien children or pregnant women fully residing in the United States.

We are approving this SPA as revised. As we agreed to, you submitted the latest revised draft

version of the State plan pages. In addition, we revised boxes 8 and 9 to indicate the correct

page number of the plan attachment and the page number of the superseded plan attachment,

respectively.

If there are questions. please contact Robert Cruz. He can be reached at (617) 565-1257. Sincerely,

S

Richard R. McGreal Associate Regional Administrator

Enclosure ce: Mark Larson. Commissioner Afsar Sultana, Program Tech II

Suzanne Santarcangelo, Ph.D., Director, AHS Healthcare Operations, Compliance & Improvement

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED

Centers For Medicare & Medicaid Services OMB NO. 0938-0193 TRANSMITTAL AND NOTICE OF APPROVAL OF 1. TRANSMITTAL NUMBER: 2. STATE: STATE PLAN MATERIAL 14-08 Vermont FOR: HEALTH CARE FINANCING ADMINISTRATION 3. PROGRAM IDENTIFICATION: TITLE XIX, SSA (MEDICAID) TO: REGIONAL ADMINISTRATOR . 4. PROPOSED EFFECTIVE DATE(S) CENTERS FOR MEDICARE & MEDICAID SERVICES JULY 1, 2011

DEPARTMENT OF HEALTH AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL (CHECK ONE):

im NEW STATE PLAN ia] AMENDMENT TO BE CONSIDERED AS NEW PLAN | AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate Transmittal for each amendment)

6. FEDERAL STATUTE/REGULATION CITATION: 7. FEDERAL BUDGET IMPACT:

Children’s Health Insurance Program Reauthorization Act of | @. FFY 2011.2 $__tbd___

2009, P.L. 111-3, Section 214 (2009) b. FFY 2012. 2 = 898 $_tbd

8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: . 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION : OR ATTACHMENT (if Applicable):

ATTACHMENT 2.6 A, PAGE 2, 2a, 2b, 2c, 3 Attachment 2.6-A, Page 2 and 3

10. SUBJECT OF AMENDMENT: ADDITION OF LANGUAGE TO STATE PLAN REGARDING THE OPTIONAL GROUP AUTHORIZED BY SEC. 214 OF CHIPRA (2009)HAT wilt PROVIDE COVERAGE FOR LEGAL IMMIGRANT CHILDREN AND PREGNANT WOMEN

°

11. GOVERNOR'S REVIEW (Check One):

[&GovERNOR'S OFFICE REPORTED NO COMMENT (J oTHER, AS SPECIFIED (_] COMMENTS OF GOVERNOR'S OFFICE ENCLOSED Aeerinem mann STITT AT ee CCAR [1 No REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL ee Ree A 12. SIGNATURE OF STATE AGENCY OFFICIAL: 16. RETURN TO: —=> \ . ; AFSAR SULTANA DEPT. OF CHILDREN AND FAMILIES ECONOMIC SERVICES DIVISION 103 SOUTH MAIN STREET

WATERBURY, VT 05671-1201

13. TYPED NAME: DOUGLAS RACINE 14, TITLE: SECRETARY, AGENCY OF HUMAN SERVICES

15. DATESUBMITTED: 7 XA

i FOR REGIONAI. OFFICE USE ONLY 17. DATE RECEIVED: g/99/44 18. DATE APPROVED: 42/21/11 :

PLAN APPROVED - ONE COPY ATTACHED 19, EFFECTIVE DATE OF APPROVED MATERIAL: 7/444 \ T20, SIGNATURE OR2FGINNA!l nero =

21. TYPEDNAME: Richard R. McGreal 22, TITLE Associate Regiort Adininitrator, Division of Medicaid and = Children's Health Operations, Boston Regional Office

23. REMARKS State and Federal officials agree via e-mail dated 12/13/2011 to pen & ink changes to Boxes 8 and 9 to reflect the actual new and superseded pages.

FORM CMS-179 (07-82) Instructions on Back

Revision: CMS-PM-

State:

ATTACHMENT 2.6-A Page 2 OMB No.:

VERMONT.

Citation(s)

Condition or Requirement

1905 (p) of the Act

1905(s) of the Act

42 CFR 435.406

a.

For the medically needy, meets the non-financial eligibility conditions of 42 CFR Part 435.

For financially eligible qualified Medicare beneficiaries covered under section 1902(a)(10)(E)(i) of the Act, meets the non-financial criteria of section 1905(p) of the Act.

For financially eligible qualified disabled and working individuals covered under section 1902(a)(10)(E)(ii) of the Act, meets the non-financial criteria of section - 1905(s).

. Is residing in the United States (U.S), and—

Is a citizen or national of the United States;

Is a qualified alien (QA) as defined in section 431 of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA) as amended, and the QA’s eligibility is required by section 402(b) of PRWORA as amended, and is not prohibited by section 403 of PRWORA as amended;

Is a qualified alien subject to the 5-year bar as described in section 403 of PRWORA, so that eligibility is limited to treatment of an emergency medical condition as defined in section 401 of PRWORA;

Is a non-qualified alien, so that eligibility is limited to treatment of an emergency medical condition as defined in section 401 of PRWORA;

TN No. __ 11-08

Supersedes Approval Date:

TN No. __ 91-12

12/21/11 Effective Date: 07/1/11

Revision: CMS-PM- ATTACHMENT 2.6-A Page 2a OMB No.:

State: VERMONT

Citation(s) Condition or Requirement

e. IsaQA whose eligibility is authorized under section 402(b) of PRWORA as amended, and is not prohibited by section 403 of PRWORA as amended. XX. State covers all authorized QAs. .

___ State does not cover authorized QAs.

f. State elects CHIPRA option to provide full Medicaid coverage to otherwise eligible pregnant women or children as specified belew who are aliens lawfully residing in the United States; including the following:

1. A qualified alien as defined in section 431 of PRWORA (8 U.S.C. §1641);

2. An alien in nonimmigrant status who has not violated the terms of the status under which he or she was admitted or to which he or she has changed after admission;

3. An alien who has been paroled into the United States pursuant to section 212(d)(5) of the Immigration and Nationality Act (INA) (8 U.S.C. §1182(d)(5)) for less than 1 year, except for an alien paroled for prosecution, for deferred inspection or pending removal proceedings;

4. An alien who belongs to one of the following classes:

TN No. __11-08 . Supersedes Approval Date: 12/21/11 Effective Date: 07/1/11 TN No. __ None

Revision: CMS-PM- ATTACHMENT 2.6-A Page 2b OMB No.:

State: VERMONT.

Citation(s) Condition or Requirement

(i) Aliens currently in temporary resident status pursuant to section 210 or 245A of the INA (8 U.S.C. §§1160 or 1255a, respectively);

(ii) Aliens currently under Temporary Protected Status (TPS) pursuant to section 244 of the INA (8 U.S.C. §1254a), and pending applicants for TPS who have been granted employment authorization;

(iii) Aliens who have been granted employment authorization under 8 CFR 274a.12(c)(9), (10), (16), (18), (20), (22), or (24);

(iv) Family Unity beneficiaries pursuant to section 301 of Pub. L. 101-649, as amended;

(v) Aliens currently under Deferred Enforced Departure (DED) pursuant to a decision made by the President;

(vi) Aliens currently in deferred action status; or

(vii) Aliens whose visa petition has been approved and who have a pending application for adjustment of status;

' 5. A pending applicant for asylum under section 208(a) of the INA (8 U.S.C. § 1158) or for withholding of removal under section 241(b)(3) of the INA (8 U.S.C. § 1231) or under the Convention Against Torture who has been granted employment authorization, and such an applicant under the age of 14 who has had an application pending for at least 180 days;

TN No. __11-08 Supersedes Approval Date: 12/21/11 Effective Date: 07/1/11 TN No. __None

Revision: HCFA-PM-91-4 (BPD) ATTACHMENT 2.6-A

AUGUST 1991 Page 3 OMB NO.: 0938 - State: VERMONT Citation Condition or Requirement

42 CFR 435.403 4. Isa resident of the State, regardless of whether or not the individual 1902(b) of the Act maintains the residence permanently or maintains it at a fixed address.

[_] State has interstate residency agreement with the following states:

([] State has open agreement(s).

[Not applicable; no residency requirement. *

TN No. __11-08 Approval Date: 12/21/11 Effective Date: 07/1/11 Supersedes

TN No. __ 91-12 HCFA ID: 7985E

Table of Contents

’ State/Territory Name: Vermont

State Plan Amendment (SPA) #: 11-023B

This file contains the following documents in the order listed:

1) Approval Letter(s)

2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES : Centers for Medicare & Medicaid Services CAIs JFK Federal Building, Government Center er eer

Room 2275 CENTERS for MEDICARE & MEDICAID SERVICES

Boston, Massachusetts 02203

Division of Medicaid and Children’s Health Operations / Boston Regional Office

April 30, 2012

Douglas A. Racine, Secretary Department of Vermont Health Access 208 Hurricane Lane, Suite 103 Williston, VT 05495

Dear Secretary Racine:

On April 26, 2012, our Central Office sent you a letter approving your proposed State Plan Amendment (SPA) No. 11-023B effective July 1, 2011. This letter transmits the Transmittal and Notice of Approval of State Plan Material (CMS-179) and the approved State Plan pages.

SPA 11-023B amends the State’s approved Title XIX State Plan to reduce the current Medicaid reimbursement methodology for limited distribution specialty pharmacies from average wholesale price (AWP) minus 14.2 percent to 16.5 percent, cover generic over-the-counter drugs when medically necessary without the option of prior authorization for brand name drugs and cover active pharmaceutical

ingredient (API) drugs.

Changes are reflected in the following sections of your approved State Plan: e Attachment 3.1-A, page 5a and Sb e Attachment 4.19-B, page 4a and 4b

If you have any questions regarding this matter you may contact Robert Cruz (617) 565-1257 or by e-mail at Robert.Cruz @cms.bhs.gov.

Sincerely,

Richard R. Associate Regional Administrator

cc: Mark Larson, Commissioner Suzanne Santarcangelo, Ph.D., Director, AHS Healthcare Operations, Compliance & Improvement Lindsey Wells, Health Programs Administrator, Department of Vermont Health Access

Enclosure/s

Department of Health & Human Services Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-14-26 Baltimore, Maryland 21244-1850

Center for Medicaid and CHIP Services

CMTS,

CENTERS for MEDICARE & MEDICAID SERVICES

April 26, 2012

Douglas A. Racine, Secretary Department of Vermont Health Access Agency of Human Services

208 Hurricane Lane, Suite 103 Williston, Vermont 05495

Attention: Lindsey Wells

Dear Mr. Racine:

Disabled and Elderly Health Programs Group

We have reviewed Vermont State Plan Amendment (SPA) 11-023B received in the Boston Regional Office on September 30, 2011. Under this SPA, the State proposes to reduce the current Medicaid reimbursement methodology for limited distribution specialty pharmacies from average wholesale price (AWP) minus 14.2 percent to 16.5 percent, cover generic over-the-counter drugs when medically necessary without the option of prior authorization for brand name drugs and cover active pharmaceutical ingredient (API) drugs. The effective date for this SPA is July 1, 2011.

We are pleased to inform you that Vermont SPA 11-023B is approved, effective July 1, 2011. The Boston Regional Office will forward to you a copy of the CMS-179 form, as well as the pages approved for incorporation into the Vermont Medicaid State Plan. If you have any questions regarding this amendment, please contact Bernadette Leeds at (410) 786-9463.

Sincerely,

/s/

Larry Reed Director Division of Pharmacy

ce: Richard McGreal, ARA, Boston Regional Office Mark Larson, Department of Vermont Health Access

Robert Cruz, Boston Regional Office

TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL FOR: CENTERS FOR MEDICARE AND MEDICAID SERVICES

4. TRANSMITTAL NUMBER: 2. STATE:

11 --023-B 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID)

VERMONT

TO: REGIONAL ADMINISTRATOR CENTERS FOR MEDICARE & MEDICAID SERVICES DEPARTMENT OF HEALTH ANO HUMAN SERVICES

4. PROPOSED EFFECTIVE DATE(S) dJucy 1, 2011

5. TYPE OF PLAN MATERIAL (CHECK ONE):

(]_ NEW STATE PLAN

[] AMENDMENT TO BE CONSIDERED AS NEW PLAN

1X) AMENDMENT

COMPLETE BLOCKS 6 THRU 10 JF THIS IS AN AMENDMENT (Separate Transmittal for each amendment)

6. FEDERAL STATUTE/REGULATION CITATION: ~ 42 CFR §430.12(c)(ii)

7. FEDERAL BUDGET IMPACT: a. FFY 2011 $ (62,960) savings b. FFY 2012 $ (249,225) savings

8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: ATT 3.1-A PG 5A & 58 ATT 4.19-B PG -----— 4A & 48

9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable) : Art 3.1-A PG 5A & 58

AIT 4.19-B PG ---—--—~ 4A

40. SUBJECT OF AMENDMENT: Pharmacy

11. GOVERNOR'S REVIEW (Check Ona): [MZ GOVERNOR'S OFFICE REPORTED NO COMMENT {] COMMENTS OF GOVERNOR'S OFFICE ENCLOSED {| NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL

KK oTHER, AS SPECIFIED " "SIGNATURE OF SECRETARY OF ADMINISTRATION

42. oo OF STATE AGENCY OFFICIAL:

16, RETURN TO:

13. TYPED N. LAS A. RACINE

LINDSEY WELLS

14. TITLE: SECRETARY, AGENCY FOR HUMAN SERVICES

DEPARTMENT OF VERMONT HEALTH ACCESS 312 HURRICANE LANE, SUITE 207

DATE SUBM p09/30/2011

ag original SPA submission 11-023 into three smaller SPAs AC) at CMS request.

WILLISTON, VT 05495

FORM CMS-179 (07-92)

Instructions on Back

TITLE XIX Attachment 3.1-A State: VERMONT Page 5a

ITEM 12. PRESCRIBED DRUGS, DENTURES, AND PROSTHETIC DEVICES; EYEGLASSES PRESCRIBED BY A PHYSICIAN SKILLED IN DISEASES OF THE EYE OR BY AN OPTOMETRIST

A. Prescribed Drugs

1. Drugs listed by the FDA as less than effective are not covered by Medicaid, nor are the generic equivalents of the listed drugs covered.

2. Physicians and Pharmacists are required to conform to Act 127 (18 VSA Chapter 91), otherwise known as the Vermont Generic Drug Law. In those cases where the Generic Drug Law permits substitution, only the lowest priced equivalent in stock at the pharmacy shall be considered medically necessary. Medicaid will not pay if the recipient refuses the substitution required by law.

3. A pharmacist must fill prescriptions in quantities of between 30 and 90 days supply for all drugs prescribed for continued regular use. The physician may prescribe for particular patients or conditions in lesser amounts and in these instances the pharmacist is required to fill as directed. Effective July 15, 2009, when the DVHA is the primary payer, pharmacies will be required to dispense designated classes of maintenance drugs in 90-day supplies after the first fill. The first fill allows prescribers to test for therapeutic effectiveness and patient tolerance.

4. Coverage for certain other drugs is limited to specific conditions, e.g. amphetamines for the treatment of narcolepsy cataplexy syndrome only.

5. Generic over-the-counter (OTC) drugs are covered when medically necessary; without the option of prior authorization for brand products; prescribed by a qualified Medicaid provider; and a federal rebate agreement with the manufacturer is in force. Some OTC medications already managed on the Preferred Drug list (PDL) may have additional restrictions. The PDL can be found at http://dvha.vermont.gov/for -providers/preferred-drug-list-clinical-criteria.

6. Contraceptive drugs are covered and claimed at the increased Federal match under Family Planning.

7. No coverage is provided for items such as:

® — topical antiseptics ® rubbing alcohol

8. [Reserved]

TN No. __11-023-B Effective Date: 07/01/11 Supersedes TN No. __ 09-009 Approval Date: __ 04/26/12

TITLE XIX Attachment 3.1-A State: VERMONT Page 5b

ITEM 12. PRESCRIBED DRUGS, DENTURES, AND PROSTHETIC DEVICES; EYEGLASSES PRESCRIBED BY A PHYSICIAN SKILLED IN DISEASES OF THE EYE OR BY AN OPTOMETRIST (Continued)

A. Prescribed Drugs (Continued)

10. Supplemental Rebate Agreements: Certain covered products in accordance with Section 1927 of the Social Security Act may not be among the baseline preferred drugs identified by the State of Vermont’s Drug Utilization Review (DUR) Board and/or the Pharmacy and Therapeutics (P & T) Committee for various therapeutic classes. The state may negotiate supplemental rebate agreements that would reclassify any drug not designated as preferred in the baseline listing for as long as the agreement is in effect.

In addition the State has the following policies for the supplemental rebate program for the Medicaid population:

* Supplemental rebate agreements are unique to each state. The supplemental rebate agreement submitted to CMS on June 6, 2009 amends the March 31, 2006 version of the “Vermont State Supplemental Drug Rebate Agreement” authorized under Transmittal 06-05. CMS has authorized this amended version of the “Vermont State Supplemental Drug Rebate Agreement.” The addendum to this agreement, approved by CMS, entitled “Sovereign States Drug Consortium, Addendum to Member States Agreements” is not changed by this amendment. The June 6, 2009 supplemental rebate agreement and the approved SSDC Addendum apply to drugs dispensed beginning January 1, 2009.

= Funds received from supplemental rebate agreements will be reported to CMS. The state will remit the federal portion of any supplemental rebates collected.

* Manufacturers with supplementa) rebate agreements are allowed to audit utilization data.

= The unit rebate amount is confidential and cannot be disclosed in accordance with Section 1927(b)(3)(D) of the Social Security Act.

* The Department of Vermont Health Access (DVHA) may require prior authorization for covered outpatient drugs. Non-preferred drugs are available with prior authorization.

= The prior authorization process for covered outpatient drugs will conform to the provisions of section 1927(d)(5) of the Social Security Act.

11. The DVHA covers select active pharmaceutical ingredients (API) and excipients used in extemporaneously compounded prescriptions when dispensed by a participating pharmacy provider and issued by a licensed prescriber following state and federal laws. Select APIs are published at http://dvha.vermont.gov/for-providers.

TN No. _11-023-B Effective Date: 07/01/11 Supersedes TN No. 09-007 Approval Date: __ 04/26/12

TITLE XIX Attachment 4.19-B State: Vermont Page 4a

METHODS AND STANDARDS OF ESTABLISHING PAYMENT RATES - OTHER MEDICAL CARE (Continued)

12 a. Prescribed Drugs (1) “Multiple Source” drugs are paid, as of 7/15/09, at the lowest of:

(a) AWP-14.2% + dispensing fee; (b) CMS Federal Upper Limit (FUL) + dispensing fee; (c) State Maximum Allowable Cost (MAC) + dispensing fee; or (4) the Usual and Customary (U&C) (includes dispensing fee). (2) “Single-source” drugs are paid, as of 07/15/09, at the lower of: (a) AWP-14.2% + dispensing fee; or (b) Usual and Customary (U&C) (includes dispensing fee). (3) “Physician Certified as Brand Necessary” are paid, as of 07/15/09, at the lower of: (a) AWP-14,2% + dispensing fee; or (b) the Usual and Customary (U&C) (includes dispensing fee). (4) All compounded prescriptions must contain more than one ingredient, and: (a) As of 07/15/09, ingredients will be priced at the lesser of AWP — 14.2%, the MAC, or the FUL (plus a dispensing fee). (b) The ingredients’ costs will be totaled and priced at the lesser of the calculated cost in (a) or the claim’s U&C cost. (5) Drugs dispensed by limited distribution pharmacies are paid, at the lower of (a) “Multiple Source” drugs are paid, at the lowest of: = AWP-16.5% + dispensing fee; = CMS Federal Upper Limit (FUL) + dispensing fee; = State Maximum Allowable Cost (MAC) + dispensing fee; or "the Usual and Customary (U&C) (includes dispensing fee). (b) “Single-source” drugs are paid, at the lower of: = AWP-16.5% + dispensing fee; or " Usual and Customary (U&C) (includes dispensing fee)

Effective July 1, 2009, the dispensing fee for all fills and refills will be: a. $4.75 for Vermont pharmacies,

b. $19.75 for compounded prescriptions at Vermont pharmacies,

c. $2.50 for out-of-state pharmacies, and

d. $17.50 for compounded prescriptions at out-of-state pharmacies.

TN# __11-023-B Effective Date: 07/01/11 Supersedes TN# _ 09-013 Approval Date: __ 04/26/12

TITLE XIX Attachment 4.19-B State: Vermont Page 4b

METHODS AND STANDARDS OF ESTABLISHING PAYMENT RATES - OTHER MEDICAL CARE (Continued)

‘MAC’ is acommonly utilized acronym in prescription drug management, translating to ‘maximum allowable cost’. MAC represents the highest price a pharmacy will be reimbursed for the dispensing of a specific dose and formulation of a generic medication when that medication is available from multiple manufacturers. The goal of MAC pricing is to establish a fair and equitable level of reimbursement for all pharmacies, while simultaneously assuring that our clients are paying the lowest possible cost for such drug products. For a MAC price to be established on any given product, there needs to be a minimum of three suppliers. This generally consists of the originator brand and at least two generic sources. MAC pricing is established through an in- depth review of the prices paid by a typical pharmacy for the generic sources of the product. From there, a MAC price is established using a formula that ensures an adequate balance of low cost to our clients, yet a reasonable profit for the dispensing pharmacy.

Our MAC list is fully updated on a quarterly basis, with mid-quarter changes routinely taking place when significant pricing changes arise or when new generics enter the market from multiple generic manufacturers. We also commit to a more expeditious and aggressive updating of our MAC list when the generic exclusivity period expires on key products. This helps to avoid any substantial lost savings opportunity that may result from delays in MAC list updating.

Limited Distribution Pharmacies dispense medications that may have special requirements for dosing or close lab monitoring. Because of these special requirements, drug manufacturers sometimes choose to limit the distribution of their drugs to only one or a few select pharmacies or, as part of the drug approval process, the Food and Drug Administration (FDA) may recommend this type of distribution. This type of restricted distribution allows the manufacturer to properly control the inventory of the drug; educating dispensing pharmacists about appropriate patient education and monitoring required; and ensure that any risks associated with the medication are minimized.

TN# __11-023-B Effective Date: 07/01/11 Supersedes

TN# _ None Approval Date: 04/26/12

Table of Contents (Cover Page) for one PDF to post on Medicaid.gov

Sample Template is below this line. Do not print the wording above this line.

Table of Contents State/Territory Name: Vermont State Plan Amendment (SPA) #: VT 11-0033 This file contains the following documents in the order listed:

1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES

Centers for Medicare & Medicaid Services CIOT. Ax JFK Federal Building. Government Center

Room 2275 CENTERS for MEDICARE & MEDICAID SERVICES

Boston. Massachusetts 02203

Division of Medicaid and Children's Health Operations / Boston Regional Office

March 2, 2012

Douglas A. Racine, Secretary Department of Vermont Health Access 103 South Main Street

Waterbury, VT 05671-0204

Dear Secretary Racine:

We are pleased to enclose a copy of approved State plan amendment (SPA) No. 11-033 with an effective date of January 1, 2012, as requested by your Agency.

This SPA transmitted a proposed amendment to your approved Title XIX State plan to address Section 6411 of the Affordable Care Act (ACA) regarding the Medicaid Recovery Audit Contractors (RAC) program.

We are approving this SPA as revised. The State requested an exemption from implementing a Medicaid RAC program because more than 95 percent of Vermont's Medicaid beneficiaries are enrolled in managed care. Therefore, a RAC program to monitor such a small Medicaid claims and beneficiary population would not be cost-beneficial to the State.

The State submitted a revised version of the State plan page to acknowledge the RAC program exemption, as requested by CMS during the review of this SPA. This SPA will be in effect as long as the current Global Commitment to Health Section 1115(a) Demonstration (project number 11-W-00194/1) is in effect. Prior to the expiration of the Demonstration’s renewal period on 12/31/2013, the State must submit to CMS either a SPA containing a new request for an exemption, or a SPA establishing a RAC program.

If there are questions, please contact Robert Cruz at (617) 565-1257. Sincerely, Ss

Richard R. McGreal Associate Regional Administrator Enclosure cc: Mark Larson, Commissioner Suzanne Santarcangelo, Ph.D., Director, AHS Healthcare Operations, Compliance & Improvement Lindsey Wells, Health Programs Administrator, Department of Vermont Health Access

TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL

FOR: CENTERS FOR MEDICARE AND MEDICAID SERVICES

1. TRANSMITTAL NUMBER: 2. STATE:

41 --033 VERMONT

3. PROGRAM IDENTIFICATION: . TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID)

TO: REGIONAL ADMINISTRATOR CENTERS FOR MEDICARE & MEDICAID SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES

4. PROPOSED EFFECTIVE DATE(S) JANUARY 1, 2012

&. TYPE OF PLAN MATERIAL (CHECK ONE):

(] NEW STATE PLAN

[_] AMENDMENT TO BE CONSIDERED AS NEW PLAN

(<] AMENDMENT

COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate Transmittal for each amendment)

6. FEDERAL STATUTE/REGULATION CITATION: 42 CFR 455.506(a)(1)

7. FEDERAL BUDGET IMPACT: a. FFY 2042 $0 b. FFY2013 «0

8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: 36B

9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (if Applicable) : 36B & 366

10. SUBJECT OF AMENDMENT: RECOVERY AUDIT CONTRACTOR (RAC) UPDATE

11, GOVERNOR'S REVIEW (Check One): O GOVERNOR'S OFFICE REPORTED NO COMMENT C COMMENTS OF GOVERNOR’S OFFICE ENCLOSED C] NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL

OTHER, AS SPECIFIED SIGNATURE OF SECRETARY OF ADMINISTRATION

12. SIGNATURE OF STATE AGENCY OFFICIAL:

. TYPED NAME: DOUGLAS A. RAGINE

16. RETURN TO:

LINDSEY WELLS

14. TILE: DEPARTMENT OF VERMONT HEALTH ACCESS SECRETARY, AGENCY FOR HUMAN SERVICES 312 HURRICANE LANE, SUITE 201 WILLISTON, VT 05495 15. DATE SUBMITTED: AAJ IQ/AN 2 y 3 4 4 Tr ANTES She : gait eth Ch ONAL IRE é Y irate 12/12/11 03/02/12 ath ft HR ) 9 ev aye Hie 01/01/12 i : Ahi Otani F : ssociate Regional Administrator, Division of Medicaid and Sitar eats ‘Richard R. McGreal Children’s Health Operations, Boston Regional Office eh ; i ( SsjiiPlease note: "t z a This SPA will be in effect as long as the current Global Commitment to Health Section 1115(a) Demonstration (project number 11- i i -00194/1) is in effect. Prior to the expiration of the Demonstration's renewal period on 12/31/2013, the State must submit to CMS either ee a SPA containing a new request for an exemption, or a SPA establishing a RAC program. ACEO Cp 3 i pe beats nase PA SUA RU AT AR IDR ENN ACR AN TEAS FE SARAH SE OATES GEN ERGO

FORM CMS-179 (07-92)

Instructions on Back

New: December 31. 2010

36b

Vermont

4.5b Medicaid Recovery Audit Contractor Program

Citation

Section 1902(a)(42)(B)(i) of the Social Security Act

Section 1902(a)(42)(B)(ii)() of the Act

Section 1902 (a)(42)(B)(ii)(11)(aa) of the Act

TN No. __ 11-033 Supersedes TN No. __ 11-005

(J The State has established a program under which it will contract with one or more recovery audit contractors (RACs) for the purpose of identifying underpayments and overpayments of Medicaid claims under the State plan and under any waiver of the State plan.

DX] The State is seeking an exception to establishing such program for the following reasons:

More than 95% of Vermont’s Medicaid beneficiaries are enrolled

in managed care. The number of Vermont Medicaid beneficiaries

and the associated claims expenditures in non-managed care

programs is too low to attract a Recovery Audit Contractor

compensated on a contingency fee basis.

This SPA will be in effect as long as the current GC Waiver is in effect. At the expiration of the waiver’s renewal period, Vermont must submit to CMS either:

a) A new request for an exemption; or

b) A SPA establishing a Medicaid RAC program.

O The State/Medicaid agency has contracts of the type(s) listed in section 1902(a)(42)(B)(ii)(I) of the Act. All contracts meet the requirements of the statute. RACs are consistent with the statute.*

Place a check mark to provide assurance of the following:

(J The State will make payments to the RAC(s) only from amounts recovered.

(_] The State will make payments to the RAC(s) on a contingent basis for collecting overpayments.

The following payment methodology shall be used to determine State payments to Medicaid RACs for identification and recovery of overpayments (c.g., the percentage of the contingency fee):

im The State attests that the contingency fee rate paid to the Medicaid RAC will not exceed the highest rate paid to Medicare RACs, as published in the Federal Register.

(_] The State attests that the contingency fee rate paid to the Medicaid RAC will exceed the highest rate paid to Medicare RACs, as published in the Federal Register. The State will only submit for FFP up to the amount equivalent to that published rate.

Effective Date: 01/01/12

Approval Date: 3/2/12

Table of Contents (Cover Page) for one PDF to post on Medicaid.gov

Sample Template is below this line. Do not print the wording above this line.

Table of Contents State/Territory Name: Vermont State Plan Amendment (SPA) #: VT 11-0035 This file contains the following documents in the order listed:

1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

DEPARTMENT OF HEALTU & HUMAN SERVICES wy Centers for Medicare & Medicaid Services Ay JFK Federal Building. Government Center

Room 2275 CENTERS tor LIEDICARE & MEDICMD SERVICES Boston, Massachusetts 02203

Division of Medicaid and Children's Health Operations / Boston Regional Office

March 23, 2012

Douglas A. Racine, Secretary Department of Vermont Health Access 103 South Main Street

Waterbury. VT 05671-0204

Dear Secretary Racine:

We are pleased to enclose a copy of approved State plan amendment (SPA) No. 11-035 with an effective date of February 10. 2012. as requested by your Agency.

This SPA transmitted a proposed amendment to your approved Title XIX State plan to implement section 4107 of the Affordable Care Act (ACA). This ACA provision amended section 1905(a)(4) of the Social Security Act to add a new subsection (D) to provide Medicaid coverage of comprehensive tobacco cessation services for pregnant women. including both counseling and pharmacotherapy. without cost sharing.

If there are questions. please contact Robert Cruz at (617) 565-1257.

Sincerely,

Ss

Richard R. McGreal

Associate Regional Administrator Enclosure cc: Mark Larson. Commissioner

Suzanne Santarcangelo. Ph.D.. Director. AHS Healthcare Operations. Compliance &

Improvement Lindsey Wells. Health Programs Administrator. Department of Vermont Health Access

TRANSMITTAL AND NOTICE OF APPROVAL OF 1. TRANSMITTAL NUMBER: 2. STATE: STATE PLAN MATERIAL 14--035 ; __| VERMONT

FOR: CENTERS FOR MEDICARE AND MEDICAID SERVICES 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID)

TO: REGIONAL ADMINISTRATOR 4. PROPOSED EFFECTIVE DATE(S) CENTERS FOR MEDICARE & MEDICAID SERVICES OCTOBER 1, 2012 . DEPARTMENT OF HEALTH AND HUMAN SERVICES

5. TYPE OF PLAN MATERIAL (CHECK ONE):

CI NEWSTATEPLAN [2] AMENDMENT TO BE CONSIDERED AS NEW PLAN [1 AMENOMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate Transmiltal for each amendment) 6. FEDERAL STATUTE/REGULATION CITATION: 7. FEDERAL BUDGET IMPACT: Section 1905(a)(4)(D) of the SSA/Section 4107 of the a. FFY 2012 $150.94 Patient Protection and Affordable Care Act b, FFY 2013 $229.76 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION ATT. 3.1-APG 2C1 OR ATTACHMENT (if Applicable) Att. 3.4-A, pg 5a(1) and 5a(2) Att. 3.1-A, pg 5a(1) and 5a(2) Att. 4.19B, pg 11 Att. 4.19B, pg 11 10. SUBJECT OF AMENDMENT: TOBACCO CESSATION 11. GOVERNOR'S REVIEW (Check One): iJ OTHER, AS SPECIFIED 7 (] GoOVERNOR’S OFFICE REPORTED NO COMMENT SIGNATURE OF SECRETARY OF ADMINISTRATION

Cl COMMENTS OF GOVERNOR'S OFFICE ENCLOSED [| No REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL 12. SIGNATURE OF STATE,AGENCY OFFICIAL:

LINDSEY WELLS

13. TYPED NAME DOUGLAS A. RACINE 14. TITLE: DEPARTMENT OF VERMONT HEALTH ACCESS SECRETARY, AGENCY FOR HUMAN SERVICES 312 HURRICANE LANE, SUITE 201 WILLISTON, VT 05495

15. DATE SUBMITTED:

PSIATET SEG URAC aie ERD EET TG NNER aK

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Ss : ke PERROVEDS 03/23/12 ens

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aR ae AEC RASEPBS PAT gta tice Sadat bound ; BTN Ca etctinleal 5 § ‘ ST

ty i fi 5 . eR RGHsRE REY Sih | HOAGIYORD: amet teehee : ii4Associate Regional Administrator, Division of Medicaid and |

fr g Richard R. McGreal . HS Children's Health Operations, Boston Regicnal Office

ENS rf y “ k oT (Lis iee Sea a poate 4

is 3 Per agreement with State staff, the following pen and ink changes were made to the 179:

ay is is Y , - updated Box 4 to reflect the day after the public notice was published

Wivavavoneienl. added financial impact to Box 7

es Bae eae added Att. 4.19B, pg 11 and Att. 3.1-A pages Sa(1) and 5a(2) to Box 8

Ras Gest gt - added Att. 4.19B, pg 11 and Att. 3.1-A pages Sa(1) and 5a(2) to Box 9 y ME AS CHEA BEETS ss rausaaranuscmauusewe myn unininonanacvestica nus TAA AuNE/AC (MISMO DENI H ecient paon Reve SRAgNN TUNER SE SATE STS SNR ADRTIAAIE

FORM CMS-179 (07-92)° Instructions on Back

TITLE XIX Attachment 3.1-A State: VERMONT Page 2cl

4.D 1) Face-to-Face Tobacco Cessation Counseling Services provided (by): (i) By or under supervision of a physician; & (ii) By any other health care professional who is legally authorized to furnish such services under State law and who is authorized to provide Medicaid coverable services other than tobacco cessation services; * or (iii) Any other health care professional legally authorized to provide tobacco cessation services under State law and who is specifically designated by the Secretary in regulations. (None are designated at this time; this item is reserved for future use.) 2) Face-to-Face Tobacco Cessation Counseling Services Benefit Package for Pregnant Women

Provided: | ([] No limitations With limitations*

Face-to-face smoking cessation counseling is covered for pregnant Vermont Medicaid beneficiaries. The maximum number of visits allowed per calendar year is 16.

TN No.__ 11-035 Effective Date: __ 02/10/12 Supersedes TN No. __ None Approval Date: __ 03/23/12

TITLE XIX

Attachment 3.1-A State: VERMONT Sal.

Page Sal

ITEM 12. | PRESCRIBED DRUGS, DENTURES, AND PROSTHETIC DEVICES; EYEGLASSES

PRESCRIBED BY A PHYSICIAN SKILLED IN DISEASES OF THE EYE OR BY AN OPTOMETRIST (Continued)

A. Prescribed Drugs (Continued)

9. Medicaid Program: Requirements Relating To Covered Outpatient Drugs For The Categorically Needy

Citation (s) Provision (s)

1935(d)(I) Effective January 1, 2006, the Medicaid agency will not cover any Part D drug for full-benefit dual eligible individuals who are entitled to receive Medicare benefits under Part A or Part B.

The Medicaid agency will cover the following classes of excluded drugs as listed below:

{XJ (a) Drugs for anorexia, weight loss, or weight gain: Some drug categories covered under the drug class: Hormone therapy is covered when used for anorexia or weight gain.

No drugs are covered for weight loss.

(b) Some prescription vitamins and mineral products, except prenatal vitamins and fluoride: Single vitamins or minerals when prescribed for the treatment of a specific disease;

(c) All drug categories covered under the drug class: Barbiturates and

] @) All drug categories covered under the drug class: Benzodiazepines

(e) Nonprescription Drugs: Some drug categories covered under the drug class:

analgesics; antihistamines; decongestants; cough suppressants; dermatological agents; fluoride dental products; gastrointestinal agents; hematopoietic agents; insulin; ophthalmics; otics and all smoking cessation products.

& (@ All prescription smoking cessation drugs (except dual eligibles as Part D will cover):

Nicotine replacement and oral therapies are covered when prescribed for smoking cessation.

TN No. __ 11-035 Effective Date: 02/10/12 Supersedes TN No. _ 06-01 Approval Date: _03/23/12

TITLE XIX Attachment 3.1-A State: VERMONT Page 5a2

ITEM 12. PRESCRIBED DRUGS, DENTURES, AND PROSTHETIC DEVICES; EYEGLASSES PRESCRIBED BY A PHYSICIAN SKILLED IN DISEASES OF THE EYE OR BY AN OPTOMETRIST (Continued)

A. Prescribed Drugs (Continued)

9. Medicaid Program: Requirements Relating To Covered Outpatient Drugs For The Categorically Needy (Continued)

Some drugs when used for the symptomatic relief of coughs and colds e Decongestants e Antihistamines e Cough suppressants

(1 Drugs when used for cosmetic purposes or hair growth

() Drugs when used to promote fertility

These services provided are identical in the amount, duration and scope of services as provided to the medically needy for prescription drugs.

TN No. __ 11-035 Effective Date: 02/10/12 Supersedes

TN No. __ 06-01 Approval Date: __03/23/12

TITLE XIX Attachment 4.19-B State: Vermont Page 11

METHODS AND STANDARDS OF ESTABLISHING PAYMENT RATES - OTHER MEDICAL CARE (Continued)

27. Tobacco Cessation Counseling for Pregnant Women Tobacco Cessation Counseling for Pregnant Women is defined as diagnostic, therapy, counseling services, and pharmacotherapy for cessation of tobacco use by pregnant women who use tobacco products or who are being treated for tobacco use; by or under supervision of a physician; or by any other health care professional who is legally authorized to furnish such services under State law and who is authorized to provide Medicaid coverable services other than tobacco cessation services.

Qualifying providers are reimbursed in accordance with the standard Medicaid reimbursement methodology.

Payment is made at the lower of the actual charge or the Medicaid rate. The agency’s rates were set as of 02/10/12 and are effective for services on or after that date. All rates are published at www.dvha.vermont.gov/for-providers. Except as otherwise noted in the plan, State developed fee schedule rates are the same for both governmental and private.

TN# __ 11-035 Effective Date: 02/10/12 Supersedes TN# _ None Approval Date: __ 03/23/12

Table of Contents (Cover Page) for one PDF to post on Medicaid.gov

Sample Template is below this line. Do not print the wording above this line.

Table of Contents State/Territory Name: Vermont State Plan Amendment (SPA) #: VT 12-005 This file contains the following documents in the order listed:

1) Approval Letter

2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services CHF. Ay JFK Federal Building. Government Center

Room 2275 CENTERS for MEDICARE & MEDICAID SERVICES Boston. Massachusetts 02203

Division of Medicaid and Children's Health Operations / Boston Regional Office

April 26, 2012

Douglas A. Racine, Secretary Department of Vermont Health Access 103 South Main Street

Waterbury, VT 05671-0204

Dear Secretary Racine:

We are pleased to enclose a copy of approved State plan amendment (SPA) No. 12-005 with an effective date of March 31, 2012, as requested by your Agency.

This SPA transmitted a proposed amendment to your approved Title XIX State plan to implement Section 6401 (a) of the Affordable Care Act (ACA). This ACA provision amended section 1866(j) of the Social Security Act to add a new paragraph “(2) Provider Screening.”

Section 1866(j)(2)(A) of the Act requires the Secretary, in consultation with the Department of Health and Human Services’ Office of the Inspector General, to establish procedures under which screening is conducted with respect to providers of medical or other items or services and suppliers under Medicare, Medicaid, and CHIP.

If there are questions, please contact Robert Cruz at (617) 565-1257. Sincerely, Ss

Richard R. McGreal Associate Regional Administrator

Enclosure

ce: Mark Larson, Commissioner Suzanne Santarcangelo, Ph.D., Director, AHS Healthcare Operations, Compliance & Improvement

Lindsey Wells, Health Programs Administrator, Department of Vermont Health Access

TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL

FOR: CENTERS FOR MEDICARE AND MEDICAID SERVICES ~

1. TRANSMITTAL NUMBER: 2. STATE:

12 -- 005 VERMONT

3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID)

TO: REGIONAL ADMINISTRATOR CENTERS FOR MEDICARE & MEDICAID SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES

4, PROPOSED EFFECTIVE DATE(S) MARCH 31, 2012

5. TYPE OF PLAN MATERIAL (CHECK ONE):

(]_ NEW STATE PLAN

oOo AMENDMENT TO BE CONSIDERED AS NEW PLAN

AMENDMENT

COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate Transmilfal for each amendment)

6. FEDERAL STATUTE/REGULATION CITATION: 42 CFR §455

7, FEDERAL BUDGET IMPACT: a FFY2012 $0 b. FFY2013. $0

8, PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: PAGE 79CC AND 79DD

9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable}

10. SUBJECT OF AMENDMENT: PROVIDER SCREENING AND ENROLLEMENT

11. GOVERNOR'S REVIEW (Check One): CJ Governor's OFFICE REPORTED NO COMMENT (] COMMENTS OF GOVERNOR'S OFFICE ENCLOSED LJ No REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL

1K] OTHER, AS SPECIFIED SIGNATURE OF SECRETARY OF ADMINISTRATION

DouGiAs A. RACINE

44. TITLE: SECRETARY, AGENCY FOR HUMAN SERVICES

15. DATE SUBMITTED: 5/29 [1a . ORT

16. RETURN TO:

LINDSEY WELLS

DEPARTMENT OF VERMONT HEALTH ACCESS 312 HURRICANE LANE, SUITE 201 WILLISTON, VT 05495

FORM GMS-179 (07-02)

Instructions on Back

79¢c

STATE PLAN UNDER ‘TITLE XIX OF THE SOCIAL SECURITY ACT

State/Territory: Vermont

4.46 Provider Screening and Enrollinent

‘The State-Medicaid agency gives the following assurances:

Citation 1902(a)(77) 1902(a)(39) Adds 1902(kk); PLT. 111-148 And PLL, 111-152 fi2 CFR 455 PROVIDER SCREENING Subpart E X__Assures that the State Medicaid agency complies with the process for jscrccning providers under section 1902(a)(39), 1902(a)(77) and_1902(kk) of the Act. 42 CIR 455.410 ENROLLMENT AND SCREENING OF PROVIDERS X__ Assures enrolled providers will be screened in accordance with 42 CFR [55.400 et seq. : X__Assures that the State Medicaid agency requires all ordering or referring hysicians or other professionals to be enrolled under the State plan or under a waiver of the Plan as a participating provider. 42 CFR 455.412 VERIFICATION OF PROVIDER LICENSES X__Assures that the State Medicaid agency has a method for verifying providers licensed by a State and that such providers licenses have not expired or have no urrent limitations. a2 CFR 455.414 IREVALIDATION OF ENROLLMENT

X__Assures that providers will be revalidated regardless of provider type at least every 5 years.

42 CFR 455.416

TERMINATION OR DENIAL OF ENROLLMENT

X__Assures that the State Medicaid agency will comply with section 1902(a)(39) of the Act and with the requirements outlined in 42 CFR 455.416 for all terminations or denials of provider enrollment.

12 CFR 455.420 REACTIVATION OF PROVIDER ENROLLMENT X__Assures that any reactivation of a provider will include re-screening and payment of application fees as required by 42 CFR 455.460. TN No.__ 12-005 Effective Date: 03/31/12 Supersedes Approval Date: 4/26/12

‘TINNo,_None

79dd

2 CFR 455.422

~VAPPEAL RIGIITS

X__Assures that all terminated providers and providers denicd enrollment as a result of the requirements of 42 CFR 455.416 will have appcal rights available under rocedures established by State law or regulation.

42 CFR 455.432

SITE VISITS . j X__Assures that pre-enrollment and post cnrollment site visits of providers who jare in “moderate” or “high risk” categorics will occur.

42 CFR 455.434

CRIMINAL BACKGROUND CHECKS

X_Assures that providers as a condition of enrollment will be required to consent to criminal background checks including fingerprints if required to do so under State law or by the level of screening based on risk of fraud, waste or abuse for that catcgory of provider.

42 CFR 455.436

FEDERAL DATABASE CHECKS

X__Assures that the State Medicaid agency will perform Federal database checks on all providers or any person with an ownership or controlling interest or who is an jagent or managing employce of the provider.

42 CIR 455.440

NATIONAL PROVIDER IDENTIFIER X__Assures that the State Medicaid agency requires the National Provider (dentifier of any ordering or referring physician or other professional to be specified

pn any claim for payment that is based on an order or referral of the physician or other professional.

42 CFR 455.450

SCREENING LEVELS FOR MEDICAID PROVIDERS

X__Assurcs that the State Medicaid agency complies with 1902(a)(77)and 1902(kk) of the Act and with the requirements outlined in 42 CFR 455.450 for screening levels based upon the categorical risk level determined for a provider.

A2 CFR 455.460

APPLICATION FEE X__Assures that the State Medicaid agency complies with the requirements for

collection of the application fee sct forth in section 1866({)(2)(C) of the Act and 42 CIR 455.460. ;

2 CFR 455.470

TEMPORARY MORATORIUM ON ENROLLMENT OF NEW PROVIDERS OR SUPPLIERS X__Assurcs that the State Medicaid agency complies with any temporary oratorium on the enrollment of new providers or provider types imposed by the ecretary under section 1866(j)(7) and 1902(kk)(4) of the Act, subject to any letermination by the State and written notice to the Secretary that such a temporary oratorium would not adversely impact beneficiarics’ access to medical assistance.

‘IN No.__12-005 Supersedes TN No.__ None

Effective Date: __ 03/31/12 Approval Date:__ 4/26/12

_____________________________________________________________________________

Table of Contents State/Territory Name: Vermont State Plan Amendment (SPA) #:13-0002-MM1 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Superseding Pages Notice 4) Approved SPA Pages 5) Additional Attachments that are part of the state plan

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services JFK Federal Building, Government Center Room 2275 Boston, Massachusetts 02203

Division of Medicaid and Children’s Health Operations / Boston Regional Office

March 10, 2014

Douglas A. Racine, Secretary Agency of Human Services 208 Hurricane Lane, Suite 103 Williston, VT 05495

Dear Secretary Racine:

Enclosed is an approved copy of Vermont’s state plan amendment (SPA) 13-0002MM1, which was submitted to CMS on December 2, 2013, approved on December 13, 2013 and effective on January 1, 2014. SPA 13- 0002MM1 implements the Modified Adjusted Gross Income (MAGI) eligibility process for both mandatory and optional populations.

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

• S14, Pages S14-1 through S14-7 • S25, Pages S25-1 through S25-3 • S28, Pages S28-1 through S28-2 • S30, Pages S30-1 through S30-5 • S32, Pages S32-1 through S32-2 • S33, Page S33-1 • S50, Page S50-1 • S51, Page S51-1 • S52, Page S52-1 • S53, Page S53-1 • S54, Page S54-1 • S55, Page S55-1 • S57, Page S57-1 • S59, Page S59-1

In addition, enclosed is a summary of the state plan pages which are superseded by SPA 13-0004MM6 which should also be incorporated into a separate section in the front of the state plan.

• Superseding pages of state plan material, SPA 13-0002MM1

CMS appreciates the significant amount of work your staff dedicated to preparing this state plan amendment. We apologize in the delay of getting this approval package to you due to ACA implementation. If you have any questions about this letter or need any additional information, please contact Lynn Wolfsfeld of my staff at 1-410- 999-4004 or by email at Lynn.Wolfsfeld@cms.hhs.gov.

Sincerely,

/s/

Richard R. McGreal Associate Regional Administrator

Enclosure

cc: Mark Larson, Commissioner

Ashley Berliner, DVHA Health Programs Administrator

State/Territory name: Vermont Submitted By: Ashley Berliner Last Revision Date: Dec 11, 2013 Submit Date: Dec 2, 2013 Medicaid State Plan Eligibility: Summary Page (CMS 179) 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. VT 13-002 Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation 42 CFR §430.12(c)(ii) Federal Budget Impact Federal Fiscal Year Amount First Year 2014 $ 0.00 Second Year 2015 $ 0.00 Subject of Amendment MAGI-Based Eligibility Groups Governor's Office Review Governor's office reported no comment Comments of Governor's office received Describe: No reply received within 45 days of submittal Other, as specified Describe: Signature of State Agency Official Date Received: 12/02/2013 Effective Date of Approved Material: 01/01/2014 Typed Name: Richard R. McGreal Plan Approved - One Copy Attached Date Approved: 12/13/2013 Signature of Regional Official

Division of Medicaid & Children's Health Operations Boston, MA -s-

1

SUPERSEDING PAGES OF STATE PLAN MATERIAL

TRANSMITTAL NUMBER:

13-0002MM1

STATE:

Vermont

Pages or sections of pages being superseded by S25, S28, S30, S51, S52, S53, S55, and S14 and related pages or sections of pages being deleted as obsolete

State Plan Section

Complete Pages Removed

Partial Pages Removed Attachment 2.2-A

Page 1 Page 3 Page 3a Page 4 Page 4a Page 12 Page 13 Page 13a Page 14 Page 14a Page 21 Page 23

Page 2, A.2.b Page 2, A.2.c Page 2a, A.3 Page 5, A.10 Page 9c, B.1 remove “Caretaker relatives” and “Pregnant women”; Remove reference to treatment of CR & minor children at the bottom of the page. Page 20, B.14 Page 25, C.4

Supplement 1 to Attachment 2.2-A

Page 1

Attachment 2.6-A

Page 3b Page 11a Page 19 Page 19a Page 19b Page 21

Page 1, A.2.a(i) and (iii) Page 6 related to AFDC recipients, pregnant women, infants, and children Page 7, 1.a(1) and (2) Page 12, C.1.e(2) Page 18, C.5.e Page 25, 11.a(3) Supplement 1 to Attachment 2.6-A Pages 1, 2, 2a, 3, 3a and 4

Supplement 2 to Attachment 2.6-A

Pages 1-5

Supplement 8a to Attachment 2.6-A

Page 1 – language related to pregnant women and infants.

2

Page 2 – language related to pregnant women, infants and children. Page 4 – language related to pregnant women, infants and children.

Supplement 8b to Attachment 2.6-A

Page 1-language related to pregnant women. Supplement 12 to Attachment 2.6-A Page 1 for 1931 eligibility (dup. page #) Page 2

Supplement 14 to Attachment 2.6-A Page 1

Page 1 of 7 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 AFDC Income Standards S14 Enter the AFDC Standards below. All states must enter: MAGI-equivalent AFDC Payment Standard in Effect As of May 1, 1988 and AFDC Payment Standard in Effect As of July 16, 1996 Entry of other standards is optional. MAGI-equivalent AFDC Payment Standard in Effect As of May 1, 1988 Income Standard Entry - Dollar Amount - Automatic Increase Option S13a The standard is as follows: Statewide standard Standard varies by region Standard varies by living arrangement Standard varies in some other way Enter the standard by region Remove Region Name of region Chittenden County Description Largest population area in the state Household size Standard ($) + 1 623 x + 2 795 x + 3 977 x + 4 1,120 x + 5 1,282 x Additional incremental amount Yes No Increment amount $ Remove Region TN 13-0002MM1 Vermont Approval Date: 12/13/2013 S14-1 Effective Date: 01/01/2014 OFFICIAL

Page 2 of 7 Medicaid Eligibility Name of region All other counties Description Household size Standard ($) + 1 570 x + 2 741 x + 3 923 x + 4 1,065 x + 5 1,227 x Additional incremental amount Yes No Increment amount $ Add Region The dollar amounts increase automatically each year Yes No AFDC Payment Standard in Effect As of July 16, 1996 Income Standard Entry - Dollar Amount - Automatic Increase Option S13a The standard is as follows: Statewide standard Standard varies by region Standard varies by living arrangement Standard varies in some other way Enter the standard by region Remove Region Name of region Chittenden County Description Largest population area in the state TN 13-0002MM1 Vermont Approval Date: 12/13/2013 S14-2 Effective Date: 01/01/2014 OFFICIAL

Page 3 of 7 Medicaid Eligibility Household size Standard ($) + 1 436 x + 2 536 x + 3 636 x + 4 715 x + 5 802 x Additional incremental amount Yes No Increment amount $ Remove Region Name of region All other counties Description Household size Standard ($) + 1 396 x + 2 496 x + 3 597 x + 4 676 x + 5 762 x Additional incremental amount Yes No Increment amount $ Add Region The dollar amounts increase automatically each year Yes No MAGI-equivalent AFDC Payment Standard in Effect As of July 16, 1996 Income Standard Entry - Dollar Amount - Automatic Increase Option S13a The standard is as follows: Statewide standard Standard varies by region TN 13-0002MM1 Vermont Approval Date: 12/13/2013 S14-3 Effective Date: 01/01/2014 OFFICIAL

Page 4 of 7 Medicaid Eligibility Standard varies by living arrangement Standard varies in some other way The dollar amounts increase automatically each year Yes No AFDC Need Standard in Effect As of July 16, 1996 Income Standard Entry - Dollar Amount - Automatic Increase Option S13a The standard is as follows: Statewide standard Standard varies by region Standard varies by living arrangement Standard varies in some other way The dollar amounts increase automatically each year Yes No AFDC Payment Standard in Effect As of July 16, 1996, increased by no more than the percentage increase in the Consumer Price Index for urban consumers (CPI-U) since such date. Income Standard Entry - Dollar Amount - Automatic Increase Option S13a The standard is as follows: Statewide standard Standard varies by region Standard varies by living arrangement Standard varies in some other way The dollar amounts increase automatically each year Yes No MAGI-equivalent AFDC Payment Standard in Effect As of July 16, 1996, increased by no more than the percentage increase in the Consumer Price Index for urban consumers (CPI-U) since such date TN 13-0002MM1 Vermont Approval Date: 12/13/2013 S14-4 Effective Date: 01/01/2014 OFFICIAL

Page 5 of 7 Medicaid Eligibility Income Standard Entry - Dollar Amount - Automatic Increase Option S13a The standard is as follows: Statewide standard Standard varies by region Standard varies by living arrangement Standard varies in some other way The dollar amounts increase automatically each year Yes No TANF payment standard Income Standard Entry - Dollar Amount - Automatic Increase Option S13a The standard is as follows: Statewide standard Standard varies by region Standard varies by living arrangement Standard varies in some other way The dollar amounts increase automatically each year Yes No MAGI-equivalent TANF payment standard Income Standard Entry - Dollar Amount - Automatic Increase Option S13a The standard is as follows: Statewide standard Standard varies by region Standard varies by living arrangement Standard varies in some other way Enter the standard by region Remove Region TN 13-0002MM1 Vermont Approval Date: 12/13/2013 S14-5 Effective Date: 01/01/2014 OFFICIAL

Page 6 of 7 Medicaid Eligibility Name of region Chittenden County Description Largest population area in state Household size Standard ($) + 1 524 x + 2 649 x + 3 777 x + 4 885 x + 5 999 x + 6 1,084 x + 7 1,215 x + 8 1,327 x Additional incremental amount Yes No Increment amount $ Remove Region Name of region All other counties Description Household size Standard ($) + 1 502 x + 2 626 x + 3 754 x + 4 863 x + 5 977 x + 6 1,062 x + 7 1,193 x TN 13-0002MM1 Vermont Approval Date: 12/13/2013 S14-6 Effective Date: 01/01/2014 OFFICIAL

Page 7 of 7 Medicaid Eligibility + 8 1,306 x Additional incremental amount Yes No Increment amount $ Add Region The dollar amounts increase automatically each year Yes 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 40 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. TN 13-0002MM1 Vermont Approval Date: 12/13/2013 S14-7 Effective Date: 01/01/2014 OFFICIAL

Page 1 of 3 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups - Mandatory Coverage Parents and Other Caretaker Relatives S25 42 CFR 435.110 1902(a)(10)(A)(i)(I) 1931(b) and (d) Parents and Other Caretaker Relatives - Parents and other caretaker relatives of dependent children with household income at or below a standard established by the state. ■ The state attests that it operates this eligibility group in accordance with the following provisions: ✔ Individuals qualifying under this eligibility group must meet the following criteria: ■ Are parents or other caretaker relatives (defined at 42 CFR 435.4), including pregnant women, of dependent children (defined at 42 CFR 435.4) under age 18. Spouses of parents and other caretaker relatives are also included. ■ The state elects the following options: This eligibility group includes individuals who are parents or other caretakers of children who are 18 years old, provided the children are full-time students in a secondary school or the equivalent level of vocational or technical training. Options relating to the definition of caretaker relative (select any that apply): The definition of caretaker relative includes the domestic partner of the parent or other caretaker relative, even after the partnership is terminated. Definition of domestic partner: The definition of caretaker relative includes other relatives of the child based on blood (including those of half-blood), adoption or marriage. Description of other relatives: The definition of caretaker relative includes any adult with whom the child is living and who assumes primary responsibility for the dependent child's care. Options relating to the definition of dependent child (select the one that applies): The state elects to eliminate the requirement that a dependent child must be deprived of parental support or care by reason of the death, physical or mental incapacity, or absence from the home or unemployment of at least one parent. The child must be deprived of parental support or care, but a less restrictive standard is used to measure unemployment of the parent (select the one that applies): TN No. 13-0002MM1 Vermont Approval Date: 12/13/2013 S25-1 Effective Date: 01/01/2014 OFFICIAL

Page 2 of 3 Medicaid Eligibility Have household income at or below the standard established by the state. ■ MAGI-based income methodologies are used in calculating household income. Please refer as necessary to S10 MAGI- Based Income Methodologies, completed by the state. ■ Income standard used for this group ■ Minimum income standard ■ The minimum income standard used for this group is the state's AFDC payment standard in effect as of May 1, 1988, converted to MAGI-equivalent amounts by household size. The standard is described in S14 AFDC Income Standards. The state certifies that it has submitted and received approval for its converted May 1, 1988 AFDC payment standard. ✔ An attachment is submitted. Maximum income standard ■ The state certifies that it has submitted and received approval for its converted income standard(s) for parents and other caretaker relatives to MAGI-equivalent standards and the determination of the maximum income standard to be used for parents and other caretaker relatives under this eligibility group. ✔ An attachment is submitted. The state's maximum income standard for this eligibility group is: The state's effective income level for section 1931 families under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size. The state's effective income level for section 1931 families under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL or amounts by household size. The state's effective income level for any population of parents/caretaker relatives under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size. The state's effective income level for any population of parents/caretaker relatives under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL or amounts by household size. Enter the amount of the maximum income standard: TN No. 13-0002MM1 Vermont Approval Date: 12/13/2013 S25-2 Effective Date: 01/01/2014 OFFICIAL

Page 3 of 3 Medicaid Eligibility A percentage of the federal poverty level: The state's AFDC payment standard in effect as of July 16, 1996, converted to a MAGI-equivalent standard. The standard is described in S14 AFDC Income Standards. The state's AFDC payment standard in effect as of July 16, 1996, increased by no more than the percentage increase in the Consumer Price Index for urban consumers (CPI-U) since such date, converted to a MAGI- equivalent standard. The standard is described in S14 AFDC Income Standards. The state's TANF payment standard, converted to a MAGI-equivalent standard. The standard is described in S14 AFDC Income Standards. Other dollar amount % Income standard chosen: ■ Indicate the state's income standard used for this eligibility group: The minimum income standard The maximum income standard The state's AFDC payment standard in effect as of July 16, 1996, increased by no more than the percentage increase in the Consumer Price Index for urban consumers (CPI-U) since such date. The standard is described in S14 AFDC Income Standards. Another income standard in-between the minimum and maximum standards allowed There is no resource test for this eligibility group. ■ Presumptive Eligibility ■ The state covers individuals under this group when determined presumptively eligible by a qualified entity. The state assures it also covers individuals under the Pregnant Women (42 CFR 435.116) and/or Infants and Children under Age 19 (42 CFR 435.118) eligibility groups when determined presumptively eligible. Yes 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 40 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. TN No. 13-0002MM1 Vermont Approval Date: 12/13/2013 S25-3 Effective Date: 01/01/2014 OFFICIAL

Page 1 of 2 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups - Mandatory Coverage Pregnant Women S28 42 CFR 435.116 1902(a)(10)(A)(i)(III) and (IV) 1902(a)(10)(A)(ii)(I), (IV) and (IX) 1931(b) and (d) 1920 Pregnant Women - Women who are pregnant or post-partum, with household income at or below a standard established by the state. ■ The state attests that it operates this eligibility group in accordance with the following provisions: ✔ Individuals qualifying under this eligibility group must be pregnant or post-partum, as defined in 42 CFR 435.4. ■ Pregnant women in the last trimester of their pregnancy without dependent children are eligible for full benefits under this group in accordance with section 1931 of the Act, if they meet the income standard for state plan Parents and Other Caretaker Relatives at 42 CFR 435.110. Yes No MAGI-based income methodologies are used in calculating household income. Please refer as necessary to S10 MAGI-Based Income Methodologies, completed by the state. ■ Income standard used for this group ■ Minimum income standard (Once entered and approved by CMS, the minimum income standard cannot be changed.) ■ The state had an income standard higher than 133% FPL established as of December 19, 1989 for determining eligibility for pregnant women, or as of July 1, 1989, had authorizing legislation to do so. Yes No Enter the amount of the minimum income standard (no higher than 185% FPL): 185 % FPL Maximum income standard ■ The state certifies that it has submitted and received approval for its converted income standard(s) for pregnant women to MAGI-equivalent standards and the determination of the maximum income standard to be used for pregnant women under this eligibility group. ✔ An attachment is submitted. The state's maximum income standard for this eligibility group is: The state's highest effective income level for coverage of pregnant women under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified pregnant women), 1902(a)(10)(A)(i)(IV) (mandatory poverty level- related pregnant women), 1902(a)(10)(A)(ii)(IX) (optional poverty level-related pregnant women), 1902(a)(10) (A)(ii)(I) (pregnant women who meet AFDC financial eligibility criteria) and 1902(a)(10)(A)(ii)(IV) (institutionalized pregnant women) in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. TN No. 13-0002MM1 Vermont Approval Date: 12/13/2013 S28-1 Effective Date: 01/01/2014 OFFICIAL

Page 2 of 2 Medicaid Eligibility The state's highest effective income level for coverage of pregnant women under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified pregnant women), 1902(a)(10)(A)(i)(IV) (mandatory poverty level- related pregnant women), 1902(a)(10)(A)(ii)(IX) (optional poverty level-related pregnant women), 1902(a)(10) (A)(ii)(I) (pregnant women who meet AFDC financial eligibility criteria) and 1902(a)(10)(A)(ii)(IV) (institutionalized pregnant women) in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. The state's effective income level for any population of pregnant women under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. The state's effective income level for any population of pregnant women under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. 185% FPL The amount of the maximum income standard is: 208 % FPL Income standard chosen ■ Indicate the state's income standard used for this eligibility group: The minimum income standard The maximum income standard Another income standard in-between the minimum and maximum standards allowed. There is no resource test for this eligibility group. ■ Benefits for individuals in this eligibility group consist of the following: ■ All pregnant women eligible under this group receive full Medicaid coverage under this state plan. Pregnant women whose income exceeds the income limit specified below for full coverage of pregnant women receive only pregnancy-related services. Presumptive Eligibility ■ The state covers ambulatory prenatal care for individuals under this group when determined presumptively eligible by a qualified entity. Yes 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 40 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. TN No. 13-0002MM1 Vermont Approval Date: 12/13/2013 S28-2 Effective Date: 01/01/2014 OFFICIAL

Page 1 of 5 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups - Mandatory Coverage Infants and Children under Age 19 S30 42 CFR 435.118 1902(a)(10)(A)(i)(III), (IV), (VI) and (VII) 1902(a)(10)(A)(ii)(IV) and (IX) 1931(b) and (d) Infants and Children under Age 19 - Infants and children under age 19 with household income at or below standards established by the state based on age group. ■ The state attests that it operates this eligibility group in accordance with the following provisions: ✔ Children qualifying under this eligibility group must meet the following criteria: ■ Are under age 19 ■ Have household income at or below the standard established by the state. ■ MAGI-based income methodologies are used in calculating household income. Please refer as necessary to S10 MAGI- Based Income Methodologies, completed by the state. ■ Income standard used for infants under age one ■ Minimum income standard ■ The state had an income standard higher than 133% FPL established as of December 19, 1989 for determining eligibility for infants under age one, or as of July 1, 1989, had authorizing legislation to do so. Yes No Enter the amount of the minimum income standard (no higher than 185% FPL): 185 % FPL Maximum income standard ■ The state certifies that it has submitted and received approval for its converted income standard(s) for infants under age one to MAGI-equivalent standards and the determination of the maximum income standard to be used for infants under age one. ✔ An attachment is submitted. The state's maximum income standard for this age group is: The state's highest effective income level for coverage of infants under age one under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(IV) (mandatory poverty level-related infants), 1902(a)(10)(A)(ii)(IX) (optional poverty level-related infants) and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI- equivalent percent of FPL. TN No. 13-0002MM1 Vermont Approval Date: 12/13/2013 S30-1 Effective Date: 01/01/2014 OFFICIAL

Page 2 of 5 Medicaid Eligibility The state's highest effective income level for coverage of infants under age one under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(IV) (mandatory poverty level-related infants), 1902(a)(10)(A)(ii)(IX) (optional poverty level-related infants) and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. The state's effective income level for any population of infants under age one under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. The state's effective income level for any population of infants under age one under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. 185% FPL Enter the amount of the maximum income standard: 312 % FPL Income standard chosen ■ The state's income standard used for infants under age one is: The maximum income standard If not chosen as the maximum income standard, the state's highest effective income level for coverage of infants under age one under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10) (A)(i)(IV) (mandatory poverty level-related infants), 1902(a)(10)(A)(ii)(IX) (optional poverty level-related infants) and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's highest effective income level for coverage of infants under age one under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10) (A)(i)(IV) (mandatory poverty level-related infants), 1902(a)(10)(A)(ii)(IX) (optional poverty level-related infants) and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's effective income level for any population of infants under age one under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's effective income level for any population of infants under age one under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. Another income standard in-between the minimum and maximum standards allowed, provided it is higher than the effective income standard for this age group in the state plan as of March 23, 2010. The amount of the income standard for infants under one is: 237 % FPL Income standard for children age one through age five, inclusive ■ TN No. 13-0002MM1 Vermont Approval Date: 12/13/2013 S30-2 Effective Date: 01/01/2014 OFFICIAL

Page 3 of 5 Medicaid Eligibility Minimum income standard ■ The minimum income standard used for this age group is 133% FPL. Maximum income standard ■ The state certifies that it has submitted and received approval for its converted income standard(s) for children age one through five to MAGI-equivalent standards and the determination of the maximum income standard to be used for children age one through five. ✔ An attachment is submitted. The state's maximum income standard for children age one through five is: The state's highest effective income level for coverage of children age one through five under sections 1931 (low- income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(VI) (mandatory poverty level- related children age one through five), and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. The state's highest effective income level for coverage of children age one through five under sections 1931 (low- income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(VI) (mandatory poverty level- related children age one through five), and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. The state's effective income level for any population of children age one through five under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. The state's effective income level for any population of children age one through five under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. Enter the amount of the maximum income standard: 312 % FPL Income standard chosen ■ The state's income standard used for children age one through five is: The maximum income standard If not chosen as the maximum income standard, the state's highest effective income level for coverage of children age one through five under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(VI) (mandatory poverty level-related children age one through five), and 1902(a)(10)(A)(ii) (IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's highest effective income level for coverage of children age one through five under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(VI) (mandatory poverty level-related children age one through five), and 1902(a)(10)(A)(ii) (IV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. TN No. 13-0002MM1 Vermont Approval Date: 12/13/2013 S30-3 Effective Date: 01/01/2014 OFFICIAL

Page 4 of 5 Medicaid Eligibility If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's effective income level for any population of children age one through five under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI- equivalent percent of FPL. If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's effective income level for any population of children age one through five under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI- equivalent percent of FPL. Another income standard in-between the minimum and maximum standards allowed, provided it is higher than the effective income standard for this age group in the state plan as of March 23, 2010. The amount of the income standard for children age one through five is: 237 % FPL Income standard for children age six through age eighteen, inclusive ■ Minimum income standard ■ The minimum income standard used for this age group is 133% FPL. Maximum income standard ■ The state certifies that it has submitted and received approval for its converted income standard(s) for children age six through eighteen to MAGI-equivalent standards and the determination of the maximum income standard to be used for children age six through age eighteen. ✔ An attachment is submitted. The state's maximum income standard for children age six through eighteen is: The state's highest effective income level for coverage of children age six through eighteen under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(VII) (mandatory poverty level-related children age six through eighteen) and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. The state's highest effective income level for coverage of children age six through eighteen under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(VII) (mandatory poverty level-related children age six through eighteen) and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. The state's effective income level for any population of children age six through eighteen under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. The state's effective income level for any population of children age six through eighteen under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. 133% FPL Enter the amount of the maximum income standard: 312 % FPL TN No. 13-0002MM1 Vermont Approval Date: 12/13/2013 S30-4 Effective Date: 01/01/2014 OFFICIAL

Page 5 of 5 Medicaid Eligibility Income standard chosen ■ The state's income standard used for children age six through eighteen is: The maximum income standard If not chosen as the maximum income standard, the state's highest effective income level for coverage of children age six through eighteen under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(VII) (mandatory poverty level-related children age six through eighteen) and 1902(a)(10)(A) (ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's highest effective income level for coverage of children age six through eighteen under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(VII) (mandatory poverty level-related children age six through eighteen) and 1902(a)(10)(A) (ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's effective income level for any population of children age six through eighteen under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI- equivalent percent of FPL. If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's effective income level for any population of children age six through eighteen under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI- equivalent percent of FPL. Another income standard in-between the minimum and maximum standards allowed, provided it is higher than the effective income standard for this age group in the state plan as of March 23, 2010. The amount of the income standard for children age six through eighteen is: 237 % FPL There is no resource test for this eligibility group. ■ Presumptive Eligibility ■ The state covers children when determined presumptively eligible by a qualified entity. Yes 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 40 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. TN No. 13-0002MM1 Vermont Approval Date: 12/13/2013 S30-5 Effective Date: 01/01/2014 OFFICIAL

Page 1 of 2 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups - Mandatory Coverage Adult Group S32 1902(a)(10)(A)(i)(VIII) 42 CFR 435.119 The state covers the Adult Group as described at 42 CFR 435.119. Yes No Adult Group - Non-pregnant individuals age 19 through 64, not otherwise mandatorily eligible, with income at or below 133% FPL. ■ The state attests that it operates this eligibility group in accordance with the following provisions: ✔ Individuals qualifying under this eligibility group must meet the following criteria: ■ Have attained age 19 but not age 65. ■ Are not pregnant. ■ Are not entitled to or enrolled for Part A or B Medicare benefits. ■ Are not otherwise eligible for and enrolled for mandatory coverage under the state plan in accordance with 42 CFR 435, subpart B. ■ Note: In 209(b) states, individuals receiving SSI or deemed to be receiving SSI who do not qualify for mandatory Medicaid eligibility due to more restrictive requirements may qualify for this eligibility group if otherwise eligible. Have household income at or below 133% FPL. ■ MAGI-based income methodologies are used in calculating household income. Please refer as necessary to S10 MAGI-Based Income Methodologies, completed by the state. ■ There is no resource test for this eligibility group. ■ Parents or other caretaker relatives living with a child under the age specified below are not covered unless the child is receiving benefits under Medicaid, CHIP or through the Exchange, or otherwise enrolled in minimum essential coverage, as defined in 42 CFR 435.4. ■ Under age 19, or A higher age of children, if any, covered under 42 CFR 435.222 on March 23, 2010: Under age 20 Under age 21 Presumptive Eligibility ■ The state covers individuals under this group when determined presumptively eligible by a qualified entity. The state assures it also covers individuals under the Pregnant Women (42 CFR 435.116) and/or Infants and Children under Age 19 (42 CFR 435.118) eligibility groups when determined presumptively eligible. Yes No TN No: 13-0002MM1 Vermont Approval Date: 12/13/2013 S32-1 Effective Date: 01/01/2014 OFFICIAL

Page 2 of 2 Medicaid Eligibility 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 40 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. TN No: 13-0002MM1 Vermont Approval Date: 12/13/2013 S32-2 Effective Date: 01/01/2014 OFFICIAL

Page 1 of 1 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups - Mandatory Coverage Former Foster Care Children S33 42 CFR 435.150 1902(a)(10)(A)(i)(IX) Former Foster Care Children - Individuals under the age of 26, not otherwise mandatorily eligible, who were on Medicaid and in foster care when they turned age 18 or aged out of foster care. ■ The state attests that it operates this eligibility group under the following provisions: ✔ Individuals qualifying under this eligibility group must meet the following criteria: ■ Are under age 26. ■ Are not otherwise eligible for and enrolled for mandatory coverage under the state plan, except that eligibility under this group takes precedence over eligibility under the Adult Group. ■ Were in foster care under the responsibility of the state or Tribe and were enrolled in Medicaid under the state's state plan or 1115 demonstration when they turned 18 or at the time of aging out of that state's or Tribe's foster care program. ■ The state elects to cover children who were in foster care and on Medicaid in any state at the time they turned 18 or aged out of the foster care system. Yes No The state covers individuals under this group when determined presumptively eligible by a qualified entity. The state assures it also covers individuals under the Pregnant Women (42 CFR 435.116) and/or Infants and Children under Age 19 (42 CFR 435.118) eligibility groups when determined presumptively eligible. Yes 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 40 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. TN No. 13-0002MM1 Vermont Approval Date: 12/13/2013 S33-1 Effective Date: 01/01/2014 OFFICIAL

Page 1 of 1 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups - Options for Coverage Individuals above 133% FPL S50 1902(a)(10)(A)(ii)(XX) 1902(hh) 42 CFR 435.218 Individuals above 133% FPL - The state elects to cover individuals under 65, not otherwise mandatorily or optionally eligible, with income above 133% FPL and at or below a standard established by the state and in accordance with provisions described at 42 CFR 435.218. Yes 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 40 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. TN No. 13-0002MM1 Vermont Approval Date: 12/13/2013 S50-1 Effective Date: 01/01/2014 OFFICIAL

Page 1 of 1 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups - Options for Coverage Optional Coverage of Parents and Other Caretaker Relatives S51 42 CFR 435.220 1902(a)(10)(A)(ii)(I) Optional Coverage of Parents and Other Caretaker Relatives - The state elects to cover individuals qualifying as parents or other caretaker relatives who are not mandatorily eligible and who have income at or below a standard established by the state and in accordance with provisions described at 42 CFR 435.220. Yes 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 40 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. TN No. 13-0002MM1 Vermont Approval Date: 12/13/2013 S51-1 Effective Date: 01/01/2014 OFFICIAL

Page 1 of 1 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups - Options for Coverage Reasonable Classification of Individuals under Age 21 S52 42 CFR 435.222 1902(a)(10)(A)(ii)(I) 1902(a)(10)(A)(ii)(IV) Reasonable Classification of Individuals under Age 21 - The state elects to cover one or more reasonable classifications of individuals under age 21 who are not mandatorily eligible and who have income at or below a standard established by the state and in accordance with provisions described at 42 CFR 435.222. Yes 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 40 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. TN No. 13-0002MM1 Vermont Approval Date: 12/13/2013 S52-1 Effective Date: 01/01/2014 OFFICIAL

Page 1 of 1 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups - Options for Coverage Children with Non IV-E Adoption Assistance S53 42 CFR 435.227 1902(a)(10)(A)(ii)(VIII) Children with Non IV-E Adoption Assistance - The state elects to cover children with special needs for whom there is a non IV-E adoption assistance agreement in effect with a state, who were eligible for Medicaid, or who had income at or below a standard established by the state and in accordance with provisions described at 42 CFR 435.227. Yes No The state attests that it operates this eligibility group in accordance with the following provisions: ✔ Individuals qualifying under this eligibility group must meet the following criteria: ■ The state adoption agency has determined that they cannot be placed without Medicaid coverage because of special needs for medical or rehabilitative care; ■ Are under the following age (see the Guidance for restrictions on the selection of an age): ■ Under age 21 Under age 20 Under age 19 Under age 18 MAGI-based income methodologies are used in calculating household income. Please refer as necessary to S10 MAGI- Based Income Methodologies, completed by the state. ■ The state covered this eligibility group in the Medicaid state plan as of December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013. Yes No The state also covered this eligibility group in the Medicaid state plan as of March 23, 2010. Yes No Individuals qualify under this eligibility group if they were eligible under the state's approved state plan prior to the execution of the adoption agreement. ■ The state used an income standard or disregarded all income for this eligibility group either in the Medicaid state plan as of March 23, 2010 or December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013. Yes No There is no resource test for this eligibility group. ■ 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 40 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. TN No. 13-0002MM1 Vermont Approval Date: 12/13/2013 S53-1 Effective Date: 01/01/2014 OFFICIAL

Page 1 of 1 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups - Options for Coverage Optional Targeted Low Income Children S54 1902(a)(10)(A)(ii)(XIV) 42 CFR 435.229 and 435.4 1905(u)(2)(B) Optional Targeted Low Income Children - The state elects to cover uninsured children who meet the definition of optional targeted low income children at 42 CFR 435.4, who have household income at or below a standard established by the state and in accordance with provisions described at 42 CFR 435.229. Yes 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 40 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. TN No. 13-0002MM1 Vermont Approval Date: 12/13/2013 S54-1 Effective Date: 01/01/2014 OFFICIAL

Page 1 of 1 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups - Options for Coverage Individuals with Tuberculosis S55 1902(a)(10)(A)(ii)(XII) 1902(z) Individuals with Tuberculosis - The state elects to cover individuals infected with tuberculosis who have income at or below a standard established by the state, limited to tuberculosis-related services. Yes 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 40 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. TN No. 13-0002MM1 Vermont Approval Date: 12/13/2013 S55-1 Effective Date: 01/01/2014 OFFICIAL

Page 1 of 1 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups - Options for Coverage Independent Foster Care Adolescents S57 42 CFR 435.226 1902(a)(10)(A)(ii)(XVII) Independent Foster Care Adolescents - The state elects to cover individuals under an age specified by the state, less than age 21, who were in state-sponsored foster care on their 18th birthday and who meet the income standard established by the state and in accordance with the provisions described at 42 CFR 435.226. Yes 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 40 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. TN No. 13-0002MM1 Vermont Approval Date: 12/13/2013 S57-1 Effective Date: 01/01/2014 OFFICIAL

Page 1 of 1 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups - Options for Coverage Individuals Eligible for Family Planning Services S59 1902(a)(10)(A)(ii)(XXI) 42 CFR 435.214 Individuals Eligible for Family Planning Services - The state elects to cover individuals who are not pregnant, and have household income at or below a standard established by the state, whose coverage is limited to family planning and related services and in accordance with provisions described at 42 CFR 435.214. Yes 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 40 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. TN No. 13-0002MM1 Vermont Approval Date: 12/13/2013 S59-1 Effective Date: 01/01/2014 OFFICIAL

Page 1 of 7 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 AFDC Income Standards S14 Enter the AFDC Standards below. All states must enter: MAGI-equivalent AFDC Payment Standard in Effect As of May 1, 1988 and AFDC Payment Standard in Effect As of July 16, 1996 Entry of other standards is optional. MAGI-equivalent AFDC Payment Standard in Effect As of May 1, 1988 Income Standard Entry - Dollar Amount - Automatic Increase Option S13a The standard is as follows: Statewide standard Standard varies by region Standard varies by living arrangement Standard varies in some other way Enter the standard by region Remove Region Name of region Chittenden County Description Largest population area in the state Household size Standard ($) + 1 623 x + 2 795 x + 3 977 x + 4 1,120 x + 5 1,282 x Additional incremental amount Yes No Increment amount $ Remove Region

Page 2 of 7 Medicaid Eligibility Name of region All other counties Description Household size Standard ($) + 1 570 x + 2 741 x + 3 923 x + 4 1,065 x + 5 1,227 x Additional incremental amount Yes No Increment amount $ Add Region The dollar amounts increase automatically each year Yes No AFDC Payment Standard in Effect As of July 16, 1996 Income Standard Entry - Dollar Amount - Automatic Increase Option S13a The standard is as follows: Statewide standard Standard varies by region Standard varies by living arrangement Standard varies in some other way Enter the standard by region Remove Region Name of region Chittenden County Description Largest population area in the state

Page 3 of 7 Medicaid Eligibility Household size Standard ($) + 1 436 x + 2 536 x + 3 636 x + 4 715 x + 5 802 x Additional incremental amount Yes No Increment amount $ Remove Region Name of region All other counties Description Household size Standard ($) + 1 396 x + 2 496 x + 3 597 x + 4 676 x + 5 762 x Additional incremental amount Yes No Increment amount $ Add Region The dollar amounts increase automatically each year Yes No MAGI-equivalent AFDC Payment Standard in Effect As of July 16, 1996 Income Standard Entry - Dollar Amount - Automatic Increase Option S13a The standard is as follows: Statewide standard Standard varies by region

Page 4 of 7 Medicaid Eligibility Standard varies by living arrangement Standard varies in some other way The dollar amounts increase automatically each year Yes No AFDC Need Standard in Effect As of July 16, 1996 Income Standard Entry - Dollar Amount - Automatic Increase Option S13a The standard is as follows: Statewide standard Standard varies by region Standard varies by living arrangement Standard varies in some other way The dollar amounts increase automatically each year Yes No AFDC Payment Standard in Effect As of July 16, 1996, increased by no more than the percentage increase in the Consumer Price Index for urban consumers (CPI-U) since such date. Income Standard Entry - Dollar Amount - Automatic Increase Option S13a The standard is as follows: Statewide standard Standard varies by region Standard varies by living arrangement Standard varies in some other way The dollar amounts increase automatically each year Yes No MAGI-equivalent AFDC Payment Standard in Effect As of July 16, 1996, increased by no more than the percentage increase in the Consumer Price Index for urban consumers (CPI-U) since such date

Page 5 of 7 Medicaid Eligibility Income Standard Entry - Dollar Amount - Automatic Increase Option S13a The standard is as follows: Statewide standard Standard varies by region Standard varies by living arrangement Standard varies in some other way The dollar amounts increase automatically each year Yes No TANF payment standard Income Standard Entry - Dollar Amount - Automatic Increase Option S13a The standard is as follows: Statewide standard Standard varies by region Standard varies by living arrangement Standard varies in some other way The dollar amounts increase automatically each year Yes No MAGI-equivalent TANF payment standard Income Standard Entry - Dollar Amount - Automatic Increase Option S13a The standard is as follows: Statewide standard Standard varies by region Standard varies by living arrangement Standard varies in some other way Enter the standard by region Remove Region

Page 6 of 7 Medicaid Eligibility Name of region Chittenden County Description Largest population area in state Household size Standard ($) + 1 524 x + 2 649 x + 3 777 x + 4 885 x + 5 999 x + 6 1,084 x + 7 1,215 x + 8 1,327 x Additional incremental amount Yes No Increment amount $ Remove Region Name of region All other counties Description Household size Standard ($) + 1 502 x + 2 626 x + 3 754 x + 4 863 x + 5 977 x + 6 1,062 x + 7 1,193 x

Page 7 of 7 Medicaid Eligibility + 8 1,306 x Additional incremental amount Yes No Increment amount $ Add Region The dollar amounts increase automatically each year Yes 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 40 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.

_____________________________________________________________________________

Table of Contents State/Territory Name: Vermont State Plan Amendment (SPA) #:13-0006-MM2 This file contains the following documents in the order listed: 1) Approval Letter 2) Additional Companion letter 3) CMS 179 Form/Summary Form (with 179-like data) 4) Superseding Pages Notice 5) Approved SPA Pages 6) Additional Attachments that are part of the state plan

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services JFK Federal Building, Government Center Room 2275 Boston, Massachusetts 02203

Division of Medicaid and Children’s Health Operations / Boston Regional Office

February 27, 2013

Douglas A. Racine, Secretary Agency of Human Services 208 Hurricane Lane, Suite 103 Williston, VT 05495

Dear Secretary Racine:

Enclosed is an approved copy of Vermont’s state plan amendment (SPA) 13-0006 MM2, which was submitted to CMS on December 2, 2013. SPA 13-0006 MM2 incorporates the MAGI-based eligibility process requirements, including the single streamlined application, into Vermont’s Medicaid state plan in accordance with the Affordable Care Act. The effective date of this SPA is October 1, 2013.

The approval of SPA 13-0006 MM2 includes the state’s use of the single streamlined paper application for all insurance affordability programs, developed by the Secretary in accordance with section 1413(b)(1)(A) of the Affordable Care Act. Also, the state is using an interim alternative single streamlined online application and by March 31, 2014 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 S94 state plan pages and attachments to be incorporated within a separate section at the end of Vermont’s approved state plan:

• S94, pages S94-1 and S94-2 • Attachment 1 – Statement of use with respect to the alternative single streamlined online application

In addition, enclosed is a summary of the state plan pages which are superseded by SPA 13-0006 MM2 which should also be incorporated into a separate section in the front of the state plan.

• Superseding pages of state plan material, SPA 13-0006 MM2.

CMS appreciates the significant amount of work your staff dedicated to preparing this state plan amendment. If you have any questions about this letter or need any additional information, please contact Lynn Wolfsfeld of my staff at 1-410-999-4004 or by email at Lynn.Wolfsfeld@cms.hhs.gov.

Sincerely,

/s/

Richard R. McGreal Associate Regional Administrator

Enclosure

cc: Mark Larson, Commissioner

Ashley Berliner, DVHA Health Programs Administrator

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Boston Regional Office JFK Federal Building 15 N Sudbury St, Rm 2325 Boston, Massachusetts 02203-0003

DIVISION OF MEDICAID & CHILDREN’S HEALTH OPERATIONS

March 4, 2014

Douglas A. Racine, Secretary Agency of Human Services 208 Hurricane Lane, Suite 103 Williston, VT 05495

Dear Secretary Racine:

This letter is being sent as a companion to Centers for Medicare & Medicaid Services (CMS) approval of state plan amendment (SPA) transmittal VT 13-0006-MM2, which was submitted to CMS on December 2, 2013. Our review of this submission included a review of the single streamlined online application developed by the state.

Until March 31, 2014, the state is using an interim alternative single streamlined online application. This interim application needs to be revised to reflect the following changes:

Necessary changes:

Completion Date:

The special enrollment period questions will be asked only of applicants exceeding the Medicaid and CHIP income thresholds unless applicants within the income thresholds request consideration for qualified health plan eligibility.

The following language will appear before the special enrollment questions until this change is made: "Your responses to the following questions do not affect medical assistance eligibility."

March 31, 2014

Please submit the revised alternative online application to CMS for review no later than March 13, 2014 to ensure approval by March 31, 2014. We continue to be available to provide technical assistance. If you have any questions about your application, please contact Dena Greenblum at Dena.Greenblum@cms.hhs.gov or (410) 999-4004. If you have any questions about this letter or need any additional information, please contact Lynn Wolfsfeld of my staff at (617) 682–9426 or by email at Lynn.Wolfsfeld@cms.hhs.gov.

Sincerely,

/s/

Richard R. McGreal Associate Regional Administrator

Enclosure

cc: Mark Larson, Commissioner

Ashley Berliner, DVHA Health Programs Administrator

State/Territory name: Vermont Submitted By: Ashley Berliner Last Revision Date: Feb 24, 2014 Submit Date: Dec 2, 2013 Medicaid State Plan Eligibility: Summary Page (CMS 179) 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. Vt 13-006 Proposed Effective Date 10/01/2013 (mm/dd/yyyy) Federal Statute/Regulation Citation 42 CFR §430.12(c)(ii) Federal Budget Impact Federal Fiscal Year Amount First Year 2014 $ 0.00 Second Year 2015 $ 0.00 Subject of Amendment VT Eligibility Process Governor's Office Review Governor's office reported no comment Comments of Governor's office received Describe: No reply received within 45 days of submittal Other, as specified Describe: Signature of State Agency Official Date Received: 12/02/2013 Effective Date of Approved Material: 10/01/2013 Typed Name: Richard R. McGreal Plan Approved - One Copy Attached Date Approved: 02/27/2014 Signature of Regional Official

Division of Medicaid & Children's Health Operations Boston, MA OFFICIAL -s-

SUPERSEDING PAGES OF STATE PLAN MATERIAL

TRANSMITTAL NUMBER:

VT 13-006 STATE:

VERMONT

PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:

S94 - Eligibility Process

PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable):

Section 2, Page 10, section 2.1(a), TN # 91-12, effective date: 11/1/91, approved: 4/27/92

Section 2, Page 11a, section 2.1(d), TN # 91-16 effective date: 7/1/91, approved: 12/5/71

Page 1 of 2 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 General Eligibility Requirements Eligibility Process S94 42 CFR 435, Subpart J and Subpart M Eligibility Process The state meets all the requirements of 42 CFR 435, Subpart J for processing applications, determining and verifying eligibility, and furnishing Medicaid. ✔ Application Processing Indicate which application the agency uses for individuals applying for coverage who may be eligible based on the applicable modified adjusted gross income standard. The single, streamlined application for all insurance affordability programs, developed by the Secretary in accordance with section 1413(b)(1)(A) of the Affordable Care Act An alternative single, streamlined application developed by the state in accordance with section 1413(b)(1)(B) of the Affordable Care Act and approved by the Secretary, which may be no more burdensome than the streamlined application developed by the Secretary. An attachment is submitted. An alternative application used to apply for multiple human service programs approved by the Secretary, provided that the agency makes readily available the single or alternative application used only for insurance affordability programs to individuals seeking assistance only through such programs. An attachment is submitted. Indicate which application the agency uses for individuals applying for coverage who may be eligible on a basis other than the applicable modified adjusted gross income standard: The single, streamlined application developed by the Secretary or one of the alternate forms developed by the state and approved by the Secretary, and supplemental forms to collect additional information needed to determine eligibility on such other basis, submitted to the Secretary. An attachment is submitted. An application designed specifically to determine eligibility on a basis other than the applicable MAGI standard which minimizes the burden on applicants, submitted to the Secretary. An attachment is submitted. 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 42 CFR 435.1200(f), by telephone, via mail, and in person. The agency also accepts applications by other electronic means: Yes No TN No. 13-0006MM2 Vermont Approval Date: 2/27/2014 S94-1 Effective Date: 10/01/2013

Page 2 of 2 Medicaid Eligibility The agency has procedures to take applications, assist applicants and perform initial processing of applications for the eligibility groups listed below at locations other than those used for the receipt and processing of applications for the title IV-A program, including Federally-qualified health centers and disproportionate share hospitals. ✔ Parents and Other Caretaker Relatives Pregnant Women Infants and Children under Age 19 Redetermination Processing Redeterminations 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 435.916: ✔ Once every 12 months ■ 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 information to complete the redetermination, it provides the individual with a pre-populated renewal form containing the information already available. ■ Redeterminations of eligibility for individuals whose financial eligibility is not based on the applicable modified adjusted gross income standard are performed, consistent with 42 CFR 435.916 (check all that apply): ■ Once every 12 months Once every 6 months Other, more often than once every 12 months Coordination of Eligibility and Enrollment The state meets all the requirements of 42 CFR 435, Subpart M relative to coordination of eligibility and enrollment between Medicaid, CHIP, Exchanges and other insurance affordability programs. The single state agency has entered into agreements with the Exchange and with other agencies administering insurance affordability programs. ✔ 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 40 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. TN No. 13-0006MM2 Vermont Approval Date: 2/27/2014 S94-2 Effective Date: 10/01/2013

10 Revision: HCFA-PM-91-4 (BPD)

OMB No. 0938

August 1991

State/Territory: __________VERMONT__________

SECTION 2 – COVERAGE AND ELIGIBILITY

Citation 42 CFR 435.10 and Subpart J

2.1 Application, Determination of Eligibility and Furnishing Medicaid

(a) The Medicaid agency meets all requirements of 42 CFR Part 435, Subpart J for processing applications, determining eligibility, and furnishing Medicaid.

______________________________________________________________________________ TN No. __91-12__ Supersedes

Approval Date: __04/27/92__

Effective Date: __11/01/91__ TN No. __75-13__

Effective 09/29/75

HCFA ID: 7982E

Approved 01/05/76

11a

Revision: HCFA-PM-91-6 (MB)

OMB No.

September 1991

State/Territory: _____________Vermont__________________________

Citation 1902(a)(55) of the Act

2.1(d) The Medicaid agency has procedures to take applications, assist applicants, and perform initial processing of applications from those low income pregnant women, infants, and children under age 19, described in §1902(a)(10)(A)(i)(IV), (a)(10)(A)(i)(VI), (a)(10)(A)(i)(VII), and (a)(10)(A)(ii)(IX) at locations other than those used by the title IV-A program including FQHCs and disproportionate share hospitals. Such application forms do not include the ADFC form except as permitted by HCFA instructions.

______________________________________________________________________________ TN No. __91-16__ Supersedes

Approval Date: __12/05/71__ Effective Date: __07/01/91__ TN No. __None__ HCFA ID: 7985E

USE OF THE ALTERNATIVE SINGLE STREAMLINED APPLICATION

 Paper Application  Online Application

TRANSMITTAL NUMBER:

VT-13-0006-MM2

STATE:

Vermont

Through March 31, 2014, the state is using an interim alternative single streamlined application. After March 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.

_____________________________________________________________________________

Table of Contents State/Territory Name: Vermont State Plan Amendment (SPA) #:13-0010-MM3 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Superseding Pages Notice 4) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services JFK Federal Building, Government Center Room 2275 Boston, Massachusetts 02203

Division of Medicaid and Children’s Health Operations / Boston Regional Office

March 6, 2014

Douglas A. Racine, Secretary Agency of Human Services 208 Hurricane Lane, Suite 103 Williston, VT 05495

Dear Secretary Racine:

Enclosed is an approved copy of Vermont’s state plan amendment (SPA) 13-0010MM3, which was submitted to CMS on December 2, 2013 and approved on January 10, 2014 with an effective date of January 1, 2014. SPA 13- 0010MM3 describes how the state will apply Modified Adjusted Gross Income (MAGI)-based methodologies consistent with 42 CFR §435.603.

Enclosed is a copy of the following S10 state plan pages to be incorporated within a separate section at the end of Vermont’s approved state plan:

• S10, Pages S10-1 to S10-2

In addition, enclosed is a summary of the state plan pages which are superseded by SPA 13-0010MM3 which should also be incorporated into a separate section in the front of the state plan.

• Superseding pages of state plan material, SPA 13-0010MM3

CMS appreciates the significant amount of work your staff dedicated to preparing this state plan amendment. We apologize for the delay in getting this approval letter to you secondary to ACA implementation. If you have any questions about this letter or need any additional information, please contact Lynn Wolfsfeld of my staff at 1-410- 999-4004 or by email at Lynn.Wolfsfeld@cms.hhs.gov.

Sincerely,

/s/

Richard R. McGreal Associate Regional Administrator

Enclosure

cc: Mark Larson, Commissioner

Ashley Berliner, DVHA Health Programs Administrator

State/Territory name: Vermont Submitted By: Ashley Berliner Last Revision Date: Dec 23, 2013 Submit Date: Dec 2, 2013 Medicaid State Plan Eligibility: Summary Page (CMS 179) 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. VT 13-010 Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation 1902(e)(14) / 42 CFR 435.603 Federal Budget Impact Federal Fiscal Year Amount First Year 2014 $ 0.00 Second Year 2015 $ 0.00 Subject of Amendment MAGI-Income Methodology Governor's Office Review Governor's office reported no comment Comments of Governor's office received Describe: No reply received within 45 days of submittal Other, as specified Describe: Signature of State Agency Official Date Received: 12/02/2013 Effective Date of Approved Material: 01/01/2014 Typed Name: Richard R. McGreal Plan Approved - One Copy Attached Date Approved: 01/10/2014 Signature of Regional Official

Division of Medicaid & Children's Health Operations Boston, MA OFFICIAL /s/

SUPERSEDING PAGES OF STATE PLAN MATERIAL

TRANSMITTAL NUMBER:

13-0010-MM3 STATE: Vermont

PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:

S10 - MAGI Income Methodology

PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable):

Notwithstanding any other provisions of the Vermont Medicaid State Plan, the financial eligibility methodologies described in State Plan Amendment 13-0010-MM3 will apply to all MAGI- based eligibility groups covered under Vermont’s Medicaid State Plan. The MAGI financial methodologies set forth in 42 CFR § 435.603 apply to everyone except those individuals described at 42 CFR § 435.603(j) for whom MAGI-based methods do not apply. This State Plan Amendment supersedes the current financial eligibility provisions of the Medicaid State Plan only with respect to the MAGI-based eligibility groups.

Page 1 of 2 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 MAGI-Based Income Methodologies S10 1902(e)(14) 42 CFR 435.603 The state will apply Modified Adjusted Gross Income (MAGI)-based methodologies as described below, and consistent with 42 CFR 435.603. ■ In the case of determining ongoing eligibility for beneficiaries determined eligible for Medicaid 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 application of such methods results in a determination of ineligibility prior to such date. 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. The pregnant woman is counted as herself, plus one. 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 and family size for the remaining months of the current calendar year In determining current monthly or projected annual household income, the state will use reasonable methods to: Include a prorated portion of a 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 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. In determining eligibility for Medicaid, an amount equivalent to 5 percentage points of the FPL for the applicable family size will be deducted from household income in accordance with 42 CFR 435.603(d). 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. Yes No TN No. 13-0010MM3 Vermont Approval Date: 01/10/2014 S10-1 Effective Date: 01/01/2014 OFFICIAL

Page 2 of 2 Medicaid Eligibility The age used for children with respect to 42 CFR 435.603(f)(3)(iv) is: ■ Age 19 Age 19, or in the case of full-time students, age 21 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 40 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. TN No. 13-0010MM3 Vermont Approval Date: 01/10/2014 S10-2 Effective Date: 01/01/2014 OFFICIAL

_____________________________________________________________________________

Table of Contents State/Territory Name: Vermont State Plan Amendment (SPA) #:13-0012-MM5 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Superseding Pages Notice 4) Approved SPA Pages

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

JFK Federal Building, Government Center

Room 2275

Boston, Massachusetts 02203

CMS

CENTERS FOR MEDICARE & MEDICAID SERVICES

Division of Medicaid and Children’s Health Operations / Boston Regional Office

March 5, 2014

Douglas A. Racine, Secretary Agency of Human Services 208 Hurricane Lane, Suite 103 Williston, VT 05495

Dear Secretary Racine:

Enclosed is an approved copy of Vermont’s state plan amendment (SPA) 13-0012MMS, which was submitted to CMS on December 2, 2013 and approved on February 27, 2014 with an effective date of January 1, 2014. SPA 13-0012MMS updates residency language in the State Plan and affirms that the state meets the requirements of 42 CFR §435.403 and provides Medicaid to otherwise eligible residents of the state, including residents who are absent from the state under certain conditions.

Enclosed is a copy of the following S88 state plan pages to be incorporated within a separate section at the end of Vermont’s approved state plan:

© S88, Pages S88-1 to S88-4

In addition, enclosed is a summary of the state plan pages which are superseded by SPA 13-0012MM5 which should also be incorporated into a separate section in the front of the state plan.

e Superseding pages of state plan material, SPA 13-0012MM5

CMS appreciates the significant amount of work your staff dedicated to preparing this state plan amendment. If you have any questions about this letter or need any additional information, please contact Lynn Wolfsfeld of my staff at 1-410-999-4004 or by email at Lynn. Wolfsfeld@cms.hhs.gov.

Sincerely, /s/

Richard R. McGreal Associate Regional Administrator

Enclosure

ce: Mark Larson, Commissioner Ashley Berliner, DVHA Health Programs Administrator

State/Territory name: Vermont Submitted By: Ashley Berliner Last Revision Date: Feb 24, 2014 Submit Date: Dec 2, 2013 Medicaid State Plan Eligibility: Summary Page (CMS 179) 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. 13-012 Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation 42 CFR §430.12(c)(ii) Federal Budget Impact Federal Fiscal Year Amount First Year 2014 $ 0.00 Second Year 2015 $ 0.00 Subject of Amendment Residency Governor's Office Review Governor's office reported no comment Comments of Governor's office received Describe: No reply received within 45 days of submittal Other, as specified Describe: Signature of State Agency Official Date Received: 12/02/2013 Effective Date of Approved Material: 01/01/2014 Typed Name: Richard R. McGreal Plan Appproved - One Copy Attached Date Approved: 02/27/2014 Signature of Regional Official

Division of Medicaid & Children's Health Operations Boston, MA OFFICIAL /s/

SUPERSEDING PAGES OF STATE PLAN MATERIAL

TRANSMITTAL NUMBER:

13-012

STATE:

Vermont

PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:

S88 Non-Financial Eligibility- State Residency Section 2.3, page 13 (Removed) Attachment 2.6-A, Page 3 (Removed)

PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable):

(New Page- None Superseded) Section 2.3, page 13, TN 87-9 Attachment 2.6-A: Page 3, TN 11-08

Page 1 of 4 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Non-Financial Eligibility State Residency S88 42 CFR 435.403 State Residency The state provides Medicaid to otherwise eligible residents of the state, including residents who are absent from the state under certain conditions. ✔ Individuals are considered to be residents of the state under the following conditions: Non-institutionalized individuals age 21 and over, or under age 21, capable of indicating intent and who are emancipated or married, if the individual is living in the state and: ■ Intends to reside in the state, including without a fixed address, or ■ Entered the state with a job commitment or seeking employment, whether or not currently employed. ■ Individuals age 21 and over, not living in an institution, who are not capable of indicating intent, are residents of the state in which they live. ■ Non-institutionalized individuals under 21 not described above and non IV-E beneficiary children: ■ Residing in the state, with or without a fixed address, or ■ The state of residency of the parent or caretaker, in accordance with 42 CFR 435.403(h)(1), with whom the individual resides. ■ Individuals living in institutions, as defined in 42 CFR 435.1010, including foster care homes, who became incapable of indicating intent before age 21 and individuals under age 21 who are not emancipated or married: ■ Regardless of which state the individual resides, if the parent or guardian applying for Medicaid on the individual's behalf resides in the state, or ■ Regardless of which state the individual resides, if the parent or guardian resides in the state at the time of the individual's placement, or ■ If the individual applying for Medicaid on the individual's behalf resides in the state and the parental rights of the institutionalized individual's parent(s) were terminated and no guardian has been appointed and the individual is institutionalized in the state. ■ Individuals living in institutions who became incapable of indicating intent at or after age 21, if physically present in the state, unless another state made the placement. ■ Individuals who have been placed in an out-of-state institution, including foster care homes, by an agency of the state. ■ Any other institutionalized individual age 21 or over when living in the state with the intent to reside there, and not placed in the institution by another state. ■ IV-E eligible children living in the state, or ■ TN No. 13-0012MM5 Vermont Approval Date: 02/27/2014 S88-1 Effective Date: 01/01/2014 OFFICIAL

Page 2 of 4 Medicaid Eligibility Otherwise meet the requirements of 42 CFR 435.403. ■ TN No. 13-0012MM5 Vermont Approval Date: 02/27/2014 S88-2 Effective Date: 01/01/2014 OFFICIAL

Page 3 of 4 Medicaid Eligibility Meet the criteria specified in an interstate agreement. Yes No The state has interstate agreements with the following selected states: ■ Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming The interstate agreement contains a procedure for providing Medicaid to individuals pending resolution of their residency status and criteria for resolving disputed residency of individuals who (select all that apply): ■ Are IV-E eligible Are in the state only for the purpose of attending school Are out of the state only for the purpose of attending school Retain addresses in both states Other type of individual The state has a policy related to individuals in the state only to attend school. Yes No Otherwise meet the criteria of resident, but who may be temporarily absent from the state. ■ The state has a definition of temporary absence, including treatment of individuals who attend school in another state. Yes No TN No. 13-0012MM5 Vermont Approval Date: 02/27/2014 S88-3 Effective Date: 01/01/2014 OFFICIAL

Page 4 of 4 Medicaid Eligibility Provide a description of the definition: An absence is temporary if the individual leaves the state with the intent to return when the purpose of the absence has been accomplished. Examples include, but are not limited to, absences for the purposes of: (1) Visiting; (2) Obtaining necessary medical care; (3) Obtaining education or training under a program of Vocational Rehabilitation, Work Incentive, or higher education program; or (4) Residence in a long-term care facility in another state, if arranged by an agent of the State of Vermont, unless the individual or their parents or legal guardian, as applicable, state intent to abandon Vermont residence and to reside outside Vermont upon discharge from long-term care.

For purposes of Medicaid eligibility, an absence is not temporary if another state verifies that the individual meets the residency standard of such other state.

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 40 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. TN No. 13-0012MM5 Vermont Approval Date: 02/27/2014 S88-4 Effective Date: 01/01/2014 OFFICIAL

_____________________________________ Table of Contents State/Territory Name: Vermont State Plan Amendment (SPA) #: 13-029 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages 

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

JFK Federal Building. Government Center

Room 2275

Boston, Massachusetts 02203

CMS

CENTERS FOR MEDICARE & MEDICAID SERVICES

Division of Medicaid and Children's Health Operations / Boston Regional Office

February 6, 2014

Douglas A. Racine, Secretary Agency of Human Services 208 Hurricane Lane, Suite 103 Williston, VT 05495

Dear Secretary Racine:

Enclosed for your records is an approved copy of Vermont's Alternative Benefit Plan (ABP) state plan amendment (SPA) VT 13-029. This SPA, which was submitted on December 19, 2013 meets all federal statutory and regulatory requirements for establishing an ABP. The SPA was approved on January 15, 2014 and is effective as of January 1, 2014 as requested by your Agency.

All requirements pertaining to ABPs must be met including, but not limited to: benefits, payment rates, reimbursement methodologies, cost-sharing state plan pages, and (if applicable) managed care service delivery systems (waivers and contracts). Amendments to the state’s approved

Medicaid program (SPAs, waivers, contracts) may require corresponding amendments to the ABP if the change to the benefit in the approved state plan will be mirrored in the ABP.

If you have any questions concerning this state plan amendment, please contact Lynn Wolfsfeld at 1-410-999-4004 or Lynn. Wolfsfeld(@cms.hhs.gov. Sincerely, /s/

Richard R. McGreal Associate Regional Administrator

Enclosure

met Mark Larson, Commissioner Ashley Berliner, DVHA Health Programs Administrator

/s/

se CCMS Alternative Benefit Plan

OMB Control Number: 0938-1148

OMB Expiration date: 10/31/2014 Alternative Benefit Plan Populations ABPI

Attachment 3.1-L- [|

Identify and define the population that will participate in the Alternative Benefit Plan.

Alternative Benefit Plan Population Name: New Adult Group

Identify eligibility groups that are included in the Alternative Benefit Plan's population, and which may contain individuals that meet any targeting criteria used to further define the population.

Eligibility Groups Included in the Alternative Benefit Plan Population:

Enrollment is Eligibility Group: mandatory or voluntary? + {Adult Group Mandatory xX Enrollment is available for all individuals in these eligibility group(s). es

Geographic Area

The Alternative Benefit Plan population will include individuals from the entire state/territory.

Any other information the state/territory wishes to provide about the population (optional)

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 5 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.20130724

Page | of 1 TN NO: VT 13-029 Approval Date: 1.15.14 Effective Date: 1.01.14 Supersedes TN: NEW

ABP1 Page 1 of 1

Alternative Benefit Plan

OMB Control Number: 0938-1148 Attachment 3.1-L- (a

OMB Expiration date: 10/31/2014 Voluntary Benefit Package Selection Assurances - Eligibility Group under Section 1902(a)(10)(A)

(D (VID of the Act ABP2a

The state/territory has fully aligned its benefits in the Alternative Benefit Plan using Essential Health Benefits and subject to 1937 requirements with its Alternative Benefit Plan that is the state’s approved Medicaid state plan that is not subject to 1937

requirements. Therefore the state/territory is deemed to have met the requirements for voluntary choice of benefit package for es individuals exempt from mandatory participation in a section 1937 Alternative Benefit Plan.

Explain how the state has fully aligned its benefits in the Alternative Benefit Plan using Essential Health Benefits and subject to 1937 requirements with its Alternative Benefit Plan that is the state’s approved Medicaid state plan that is not subject to 1937 requirements.

Vermont is an expansion state that will not have newly eligible groups under ACA. However, the state will recognize the New Adult group in the state plan and will use the Medicaid State Plan as the benefits plan for the New Adult Group. The Medicaid state plan is more comprehensive than the state's Benchmark plan selected for the Health Benefits Exchange, the BCBS 'Vermont Health Plan, LLC’ supplemented with the CHIP and FEDVIP plans. In Vermont the CHIP plan mirrors the Medicaid State Plan for Children.

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 5 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.20130807

Page | of 1

TN NO: VT 13-029 Approval Date: 1.15.14 Effective Date: 1.01.14 Supersedes TN: NEW

ABP2a Page 1 of 1

CET Om EOC A car REICH

CCHS Alternative Benefit Plan OFFICIAL

OMB Control Number: 0938-1148 OMB Expiration date: 10/31/2014 Selection of Benchmark Benefit Package or Benchmark-Equivalent Benefit Package ABP3.

Attachment 3.1 |

Select one of the following:

@ The state/territory is amending one existing benefit package for the population defined in Section 1.

C The state/territory is creating a single new benefit package for the population defined in Section 1.

Name of benefit package: |Medicaid State Plan

Selection of the Section 1937 Coverage Option

The state/territory selects as its Section 1937 Coverage option the following type of Benchmark Benefit Package or Benchmark- Equivalent Benefit Package under this Alternative Benefit Plan (check one):

@ Benchmark Benefit Package. C Benchmark-Equivalent Benefit Package.

The state/territory will provide the following Benchmark Benefit Package (check one that applies):

Cc The Standard Blue Cross/Blue Shield Preferred Provider Option offered through the Federal Employee Health Benefit Program (FEHBP).

C State employee coverage that is offered and generally available to state employees (State Employee Coverage):

Cc A commercial HMO with the largest insured commercial, non-Medicaid enrollment in the state/territory (Commercial HMO):

®

Secretary-Approved Coverage. @ The state/territory offers benefits based on the approved state plan.

The state/territory offers an array of benefits from the section 1937 coverage option and/or base benchmark plan benefit packages, or the approved state plan, or from a combination of these benefit packages.

@ The state/territory offers the benefits provided in the approved state plan.

C Benefits include all those provided in the approved state plan plus additional benefits.

C Benefits are the same as provided in the approved state plan but in a different amount, duration and/or scope. C The state/territory offers only a partial list of benefits provided in the approved state plan.

C. The state/territory offers a partial list of benefits provided in the approved state plan plus additional benefits.

Please briefly identify the benefits, the source of benefits and any limitations:

N/A

Selection of Base Benchmark Plan

Page 1 of 2 TN NO: VT 13-029 Approval Date: 1.15.14 Effective Date: 1.01.14 Supersedes TN: NEW ABP3 Page 1 of 2

Alternative Benefit Plan OFFICIAL

The state/territory must select a Base Benchmark Plan as the basis for providing Essential Health Benefits in its Benchmark or Benchmark-Equivalent Package.

The Base Benchmark Plan is the same as the Section 1937 Coverage option. |Yes

Other Information Related to Selection of the Section 1937 Coverage Option and the Base Benchmark Plan (optional)

1. The state assures that all services in the base benchmark have been accounted for throughout the benefit chart found in ABPS.

2. The state assures the accuracy of all information in ABPS depicting amount, duration and scope parameters of services authorized in the currently approved Medicaid state plan.

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 5 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.20130801

Page 2 of 2 TN NO: VT 13-029 Approval Date: 1.15.14 Effective Date: 1.01.14 Supersedes TN: NEW

ABP3 Page 2 of 2

Alternative Benefit Plan OFFICIAL

OMB Control Number: - seuss 0 ‘on| ra umber: 0938-1148 OMB Expiration date: 10/31/2014

ABP4

Alternative Benefit Plan Cost-Sharing

Any cost sharing described in Attachment 4.18-A applies to the Alternative Benefit Plan.

Attachment 4.18-A may be revised to include cost sharing for ABP services that are not otherwise described in the state plan. Any such cost sharing must comply with Section 1916 of the Social Security Act.

The Alternative Benefit Plan for individuals with income over 100% FPL includes cost-sharing other than that described in Attachment 4.18-A.

Other Information Related to Cost Sharing Requirements (optional):

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 5 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.20130807

Page | of 1

TN NO: VT 13-029 Approval Date: 1.15.14 Effective Date: 1.01.14 Supersedes TN: NEW

ABP4 Page 1 of 1

CaS cee ee yo | ST ST Ee Alternative Benefit Plan OFFICIAL

OMB Control Number: 0938-1148

Attachment 3.1.-L{ | OMB Expiration date: 10/31/2014 ABPS5

Benefits Description

The state/territory proposes a “Benchmark-Equivalent” benefit package. |No

Benefits Included in Alternative Benefit Plan

Enter the specific name of the base benchmark plan selected:

Blue Care, Vermont Health Plan, LLC, CDHP

Enter the specific name of the section 1937 coverage option selected, if other than Secretary-Approved. Otherwise, enter

“Secretary-Approved.”

Secretary-Approved

Page | of 43

TN NO: VT 13-029 Approval Date: 1.15.14 Effective Date: 1.01.14

Supersedes TN: NEW ABP5 Page 1 of 43

Alternative Benefit Plan

OFFICIAL

[m) Essential Health Benefit 1: Ambulatory patient services

Collapse All []

Benefit Provided:

Source:

Outpatient Hospital

State Plan 1905(a)

Remove

Authorization:

Provider Qualifications:

None

Medicaid State Plan

Amount Limit:

Duration Limit:

None

None

Scope Limit:

None

Other information regarding this benefit, including the specific name of the source plan if it is not the base

benchmark plan:

Benefit Provided:

Source:

Rural Health Clinic

State Plan 1905(a)

Authorization:

Provider Qualifications:

Authorization required in excess of limitation

Medicaid State Plan

Amount Limit:

Duration Limit:

5 visits per month; 1 visit per day

None

Scope Limit:

None

Other information regarding this benefit, including the specific name of the source plan if it is not the base

benchmark plan:

Benefit Provided:

Source:

Federally Qualified Health Center

State Plan 1905(a)

Authorization:

Provider Qualifications:

Authorization required in excess of limitation

Medicaid State Plan

Amount Limit:

Duration Limit:

5 visits per month; | visit per day None Scope Limit: None Page 2 of 43 TN NO: VT 13-029 Approval Date: 1.15.14 Effective Date: 1.01.14

Supersedes TN: NEW

ABP5 Page 2 of 43

Cccms

(COTO 0 MEDCANE CAND RHIC

Alternative Benefit Plan OFPFETCTIAL

Other information regarding this benefit, including the specific name of the source plan if it is not the base

benchmark plan:

Benefit Provided:

Source:

Physician Services in all settings

State Plan 1905(a)

Remove

[_Remove |

Authorization:

Provider Qualifications:

Authorization required in excess of limitation

Medicaid State Plan

Amount Limit:

Duration Limit:

See other information below

None

Scope Limit:

None

Other information regarding this benefit, including the specific name of the source plan if it is not the base

benchmark plan:

exceeded based on medical necessity.

Home & Office - 5 visits per month; Nursing Facility - up to | visit per week; Hospital - up to 1 admission visit per patient per diagnosis per month and up to one visit per day for acute care. Excludes solely cosmetic surgery; ineffective or unproven procedures; unnecessary testing; experimental; services provided without consent. Prior authorizations apply for certain circumstances and procedures. Limits may be

Benefit Provided:

Source:

Family Planning

State Plan 1905(a)

Remove

Authorization:

Provider Qualifications:

None

Medicaid State Plan

Amount Limit:

Duration Limit:

None

None

Scope Limit:

Reversal of sterilizations not covered

Other information regarding this benefit, including the specific name of the source plan if it is not the base

benchmark plan:

Benefit Provided:

Source:

Medical & Surgical furnished by Dentist

_|

State Plan 1905(a)

Authorization:

Provider Qualifications:

Prior Authorization

Medicaid State Plan

TN NO: VT 13-029 Supersedes TN: NEW

Approval Date: 1.15.14

Page 3 of 43 Effective Date: 1.01.14

ABP5 Page 3 of 43

SS Alternative Benefit Plan

OUTTA

Tt che hie hie Sad Sick Sill

Amount Limit: Duration Limit:

None None Remove

Scope Limit:

None

Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan:

Benefit Provided: Source: OLP: Chiropractic State Plan 1905(a) [ Remove | Authorization: Provider Qualifications: Authorization required in excess of limitation Medicaid State Plan Amount Limit: Duration Limit: 10 visits per year None

Scope Limit:

None

Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan:

Benefit Provided: Source: OLP: Podiatry State Plan 1905(a) [Remove | Authorization: Provider Qualifications: None Medicaid State Plan Amount Limit: Duration Limit: None None

Scope Limit:

Non-routine foot care only; Excludes flat foot; subluxations of foot not requiring surgery; corns, calluses, nail trimming preventative hygiene

Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan:

Benefit Provided: Source: Non-Emergency Transportation State Plan 1905(a) Page 4 of 43 TN NO: VT 13-029 Approval Date: 1.15.14 Effective Date: 1.01.14

Supersedes TN: NEW ABPS5 Page 4 of 43

Alternative Benefit Plan

OFFICIAL

Authorization: Provider Qualifications:

Prior Authorization Medicaid State Plan

Remove

Amount Limit: Duration Limit:

None None

Scope Limit:

None

Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan:

Benefit Provided: Source:

Remove

Hospice State Plan 1905(a)

Authorization: Provider Qualifications:

Other Medicaid State Plan

Amount Limit: Duration Limit:

None None

Scope Limit:

None

Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan:

6 months prior to end of life.

Benefit Provided: Source:

OLP: Pediatric or Family Nurse Practitioners

State Plan 1905(a)

Authorization:

Provider Qualifications:

Other

Medicaid State Plan

Amount Limit:

Duration Limit:

See other information below

None

Scope Limit:

None

Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan:

Home & Office - 5 visits per month; Nursing Facility - up to 1 visit per week; Hospital - up to 1 admission visit per patient per diagnosis per month and up to one visit per day for acute care. Excludes solely cosmetic surgery; ineffective or unproven procedures; unnecessary testing; experimental; services provided without consent. Prior authorizations apply for certain circumstances and procedures. Limits may be

Page 5 of 43 TN NO: VT 13-029 Effective Date: 1.01.14

Supersedes TN: NEW

Approval Date: 1.15.14

ABP5 Page 5 of 43

CCMS Alternative Benefit Plan

===>. OFFICIAL

[exceeded based on medical necessity. ]

Add

Page 6 of 43 TN NO: VT 13-029 Approval Date: 1.15.14 Effective Date: 1.01.14

Supersedes TN: NEW ABP5 Page 6 of 43

Alternative Benefit Plan

OFFICIAL

[®] Essential Health Benefit 2: Emergency services Collapse All [] Benefit Provided: Source: Outpatient Hospital: Emergency Care State Plan 1905(a) [ Remove | Authorization: Provider Qualifications: None Medicaid State Plan Amount Limit: Duration Limit: None None

Scope Limit:

None

Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan:

Benefit Provided: Source: Transportation: Ambulance State Plan 1905(a) Remove Authorization: Provider Qualifications: Other Medicaid State Plan Amount Limit: Duration Limit: None None

Scope Limit:

None

Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan:

For emergency services. Prior authorization is required for coverage of ambulance service to an out-of-state hospital. Transport to a border hospital does not require prior authorization.

Add

Page 7 of 43 TN NO: VT 13-029 Approval Date: 1.15.14 Effective Date: 1.01.14

Supersedes TN: NEW ABP5 Page 7 of 43

Alternative Benefit Plan OFFICIAL

[B] Essential Health Benefit 3: Hospitalization

Collapse All []

Benefit Provided:

Source:

Inpatient Hospital

State Plan 1905(a)

Remove

Authorization:

Provider Qualifications:

Concurrent Authorization

Medicaid State Plan

Amount Limit:

Duration Limit:

None

None

Scope Limit:

None

Other information regarding this benefit, including the specific name of the source plan if it is not the base

benchmark plan:

Substance Abuse Detox is performed in an inpatient hospital setting.

Benefit Provided:

Source:

Inpatient Psychiatric Hospital

State Plan 1905(a)

Remove

Authorization:

Provider Qualifications:

Concurrent Authorization

Medicaid State Plan

Amount Limit:

Duration Limit:

None

None

Scope Limit:

None

Other information regarding this benefit, including the specific name of the source plan if it is not the base

benchmark plan:

Not Institutions for Mental Disease (IMD).

Add

TN NO: VT 13-029 Supersedes TN: NEW

Approval Date: 1.15.14

Page 8 of 43 Effective Date: 1.01.14

ABPS5 Page 8 of 43

Alternative Benefit Plan OFFICIAL

{@] Essential Health Benefit 4: Maternity and newborn care

Collapse All []

Benefit Provided:

Source:

OLP: Licensed Lay Midwife

State Plan 1905(a)

Authorization:

Provider Qualifications:

None

Medicaid State Plan

Amount Limit:

Duration Limit:

None

None

Scope Limit:

None

Other information regarding this benefit, including the specific name of the source plan if it is not the base

benchmark plan:

Benefit Provided:

Source:

Nurse Midwife

State Plan 1905(a)

Remove

Authorization:

Provider Qualifications:

None

Medicaid State Plan

Amount Limit:

Duration Limit:

None

None

Scope Limit:

None

Other information regarding this benefit, including the specific name of the source plan if it is not the base

benchmark plan:

Benefit Provided:

Source:

Physician Services: Maternity Care

State Plan 1905(a)

Authorization:

Provider Qualifications:

None

Medicaid State Plan

Amount Limit:

Duration Limit:

None

None

Scope Limit:

None

TN NO: VT 13-029 Supersedes TN: NEW

Approval Date: 1.15.14

Page 9 of 43 Effective Date: 1.01.14

ABP5 Page 9 of 43

Alternative Benefit Plan

OPTICIAL

Other information regarding this benefit, including the specific name of the source plan if it is not the base

benchmark plan:

Benefit Provided:

Source:

Inpatient Hospital: Maternity Care

State Plan 1905(a) Remove

Authorization:

Provider Qualifications:

Concurrent Authorization

Medicaid State Plan

Amount Limit:

Duration Limit:

None

None

Scope Limit:

None

Other information regarding this benefit, including the specific name of the source plan if it is not the base

benchmark plan:

Current Authorization on the 13th day of stay.

Add

TN NO: VT 13-029 Supersedes TN: NEW

Approval Date: 1.15.14 Effective Date: 1.01.14

Page 10 of 43

ABP5 Page 10 of 43

4

Alternative Benefit Plan

IST NE Ar ODFTICIAL

@

Essential Health Benefit 5: Mental health and substance use disorder services including

behavioral health treatment

Collapse All []

Benefit Provided:

Source:

Clinic Services - Mental Health Clinic

State Plan 1905(a)

Remove

Authorization:

Provider Qualifications:

None

Medicaid State Plan

Amount Limit:

Duration Limit:

None

None

Scope Limit:

None

Other information regarding this benefit, including the specific name of the source plan if it is not the base

benchmark plan:

and chemotherapy.

Includes group therapy, individual psychotherapy, day hospital, diagnosis and evaluation, emergency care,

Benefit Provided:

Source:

OLP: Behavioral Health

State Plan 1905(a)

Authorization:

Provider Qualifications:

None

Medicaid State Plan

Amount Limit:

Duration Limit:

None

None

Scope Limit:

health clinic services.

Not covered if resident of inpatient hospital or mental health hospital, or concurrently receiving mental

Other information regarding this benefit, including the specific name of the source plan if it is not the base

benchmark plan:

Vermont has five designated hospitals that provided psychiatric services in the general hospital setting with wings of 8 beds or less and are not Institutions for Mental Disease (IMD).

Benefit Provided:

Source:

Rehab: Substance Abuse Services Residential Treat

State Plan 1905(a)

Authorization:

Provider Qualifications:

None

Medicaid State Plan

Amount Limit:

Duration Limit:

None

None

TN NO: VT 13-029 Supersedes TN: NEW

Approval Date: 1.15.14

Page 11 of 43

Effective Date: 1.01.14

ABP5 Page 11 of 43

Alternative Benefit Plan

WENT INT AT

at a a dd

Scope Limit:

None

Remove

Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan:

Not Institutions for Mental Disease (IMD).

Benefit Provided: Source:

Rehab: Substance Abuse Residential Detoxification

State Plan 1905(a)

Authorization: Provider Qualifications:

Authorization required in excess of limitation Medicaid State Plan

Amount Limit: Duration Limit:

7 days per acute episode None

Scope Limit:

None

Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan:

Not Institutions for Mental Disease (IMD).

Benefit Provided: Source:

Rehab: Substance Abuse Residential Post Detox Serv

State Plan 1905(a)

Authorization: Provider Qualifications:

Authorization required in excess of limitation Medicaid State Plan

Amount Limit: Duration Limit:

30 days per year None

Scope Limit:

None

Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan:

Not Institutions for Mental Disease (IMD).

Benefit Provided:

Source:

Rehab: Substance Abuse Resid. Extended Post Detox

State Plan 1905(a)

Authorization:

Provider Qualifications:

Prior Authorization

Medicaid State Plan

TN NO: VT 13-029 Supersedes TN: NEW

Approval Date: 1.15.14

Page 12 of 43 Effective Date: 1.01.14

ABP5 Page 12 of 43

Alternative Benefit Plan

STNENBTANT AT te ie I te id

Amount Limit:

Duration Limit:

183 days per year

None

Remove

Scope Limit:

None

Other information regarding this benefit, including the specific name of the source plan if it is not the base

benchmark plan:

Not Institutions for Mental Disease (IMD).

Benefit Provided:

Source:

Rehab:Substance Abuse Non-residential professional

State Plan 1905(a)

Remove

Authorization:

Provider Qualifications:

Authorization required in excess of limitation

Medicaid State Plan

Amount Limit:

Duration Limit:

90 hours counseling per episode

None

Scope Limit:

None

Other information regarding this benefit, including the specific name of the source plan if it is not the base

benchmark plan:

Add

TN NO: VT 13-029 Supersedes TN: NEW

Approval Date: 1.15.14

Effective Date: 1.01.14

Page 13 of 43

ABP5 Page 13 of 43

Ss Alternative Benefit Plan

C

{®) Essential Health Benefit 6: Prescription drugs

x O x x

Benefit Provided: Coverage is at least the greater of one drug in each U.S. Pharmacopeia (USP) category and class or the same number of prescription drugs in each category and class as the base benchmark.

Limit on days supply Limit on number of prescriptions Limit on brand drugs Other coverage limits

Preferred drug list

Prescription Drug Limits (Check all that apply.); Authorization:

Provider Qualifications:

Yes

State licensed

Coverage that exceeds the minimum requirements or other:

The State of Vermont's ABP prescription drug benefit plan is the same as under the approved Medicaid state plan for prescribed drugs.

TN NO: VT 13-029 Supersedes TN: NEW

Approval Date: 1.15.14

Page 14 of 43

Effective Date: 1.01.14

ABP5 Page 14 of 43

Alternative Benefit Plan

CPrriciAL

[| Essential Health Benefit 7: Rehabilitative and habilitative services and devices Collapse All [] Benefit Provided: Source: Outpatient Hospital - Rehabilitative therapies State Plan 1905(a) Remove | Authorization: Provider Qualifications: None Medicaid State Plan Amount Limit: Duration Limit: None None

Scope Limit: OT/PT/SLP

Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan:

Both rehabilitative and habilitative

Benefit Provided: Source: OT/PT/SLP (non-hospital based) State Plan 1905(a) [ Remove | Authorization: Provider Qualifications: Authorization required in excess of limitation Medicaid State Plan Amount Limit: Duration Limit: Under 21, 8 visits; over 21, 30 visits/year combin None

Scope Limit:

None

Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan:

Under 21, prior authorization after 8 visits; over 21, prior authorization for over 30 visits per year of any type. Both rehabilitative and habilitative.

Benefit Provided: Source:

Physical Therapies & Related Service: Hearing Aids State Plan 1905(a) Authorization: Provider Qualifications: Authorization required in excess of limitation Medicaid State Plan Amount Limit: Duration Limit:

Every three years None

Scope Limit:

Hearing loss has to meet certain conditions. Prior authorization is required for other degrees of hearing loss.

Page 15 of 43 TN NO: VT 13-029 Approval Date: 1.15.14 Effective Date: 1.01.14

Supersedes TN: NEW ABP5 Page 15 of 43

Alternative Benefit Plan

de! et

Other information regarding this benefit, including the specific name of the source plan if it is not the base

benchmark plan:

Benefit Provided:

Source:

Prosthetic Devices

State Plan 1905(a)

Remove

Authorization:

Provider Qualifications:

Other

Medicaid State Plan

Amount Limit:

Duration Limit:

None

None

Scope Limit:

None

Other information regarding this benefit, including the specific name of the source plan if it is not the base

benchmark plan:

Physician order is required for breast prostheses, trusses and socks ; all others require prior authorization.

Benefit Provided:

Source:

Nursing Facility 21 and older; rehab care

State Plan 1905(a)

Remove

Authorization:

Provider Qualifications:

Other

Medicaid State Plan

Amount Limit:

Duration Limit:

None

None

Scope Limit:

None

Other information regarding this benefit, including the specific name of the source plan if it is not the base

benchmark plan:

Requires a physician order; Out of state requires prior authorization.

Benefit Provided:

Source:

Home Health Intermittent Part Time Nursing

State Plan 1905(a)

Authorization:

Provider Qualifications:

Other

| [Medicaid State Plan

Amount Limit:

Duration Limit:

None

None

TN NO: VT 13-029 Supersedes TN: NEW

Approval Date: 1.15.14

Page 16 of 43 Effective Date: 1.01.14

ABP5 Page 16 of 43

CIAL

Alternative Benefit Plan

et de

Scope Limit:

None

Remove

Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan:

Requires physician order and plan of care.

Benefit Provided: Source:

Home Health Aide State Plan 1905(a)

Remove

Authorization: Provider Qualifications:

Other Medicaid State Plan

Amount Limit: Duration Limit:

None None

Scope Limit:

None

Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan:

Requires plan of care and supervision by OT/PT/SLP or nurse.

Benefit Provided: Source:

Home Health: Medical Supplies, Equip. and Appliance State Plan 1905(a)

Remove

Authorization: Provider Qualifications:

Other Medicaid State Plan

Amount Limit: Duration Limit:

None None

Scope Limit:

None

Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan:

Requires physician order.

Benefit Provided: Source:

Home Health PT/OT/SLP State Plan 1905(a)

Authorization: Provider Qualifications:

Authorization required in excess of limitation Medicaid State Plan

TN NO: VT 13-029 Supersedes TN: NEW

Approval Date: 1.15.14

Page 17 of 43

Effective Date: 1.01.14

ABP5 Page 17 of 43

Alternative Benefit Plan

OPFICIAL

Amount Limit: Duration Limit:

None four month limit Remove

Scope Limit:

None

Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan:

Benefit Provided: Source: Home Health: Private Duty Nursing State Plan 1905(a) | Remove | Authorization: Provider Qualifications: Prior Authorization Medicaid State Plan Amount Limit: Duration Limit: None None

Scope Limit:

None

Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan:

Add

Page 18 of 43 TN NO: VT 13-029 Approval Date: 1.15.14 Effective Date: 1.01.14

Supersedes TN: NEW ABP5 Page 18 of 43

CCMS Alternative Benefit Plan

TIENT ANT AW 4 E! GE Saks

[@] Essential Health Benefit 8: Laboratory services Collapse All [J Benefit Provided: Source: Other Laboratory and X-Ray Services State Plan 1905(a) [Remove | Authorization: Provider Qualifications: Other Medicaid State Plan Amount Limit: Duration Limit: Urine drug test limited to 8 per month None

Scope Limit:

None

Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan:

Exceptions to the urine drug test limitation must be prior approved. Diagnostic imaging requires prior authorization for high-tech (CT, CTA, MRI, MRA, PET, PET/CA) unless provided as part of ER or inpatient visit.

Add

Page 19 of 43 TN NO: VT 13-029 Approval Date: 1.15.14 Effective Date: 1.01.14 Supersedes TN: NEW ABP5 Page 19 of 43

Alternative Benefit Plan

OPT iCiAn

{@ Essential Health Benefit 9: Preventive and wellness services and chronic disease management Collapse All []

The state/territory must provide, at a minimum, a broad range of preventive services including: “A” and “B” services recommended by the United States Preventive Services Task Force; Advisory Committee for Immunization Practices (ACIP) recommended vaccines; preventive care and screening for infants, children and adults recommended by HRSA’s Bright Futures program/project; and additional preventive services for women recommended by the Institute of Medicine (IOM).

Benefit Provided: Source: Clinic Services State Plan 1905(a) Remove Authorization: Provider Qualifications: None Medicaid State Plan Amount Limit: Duration Limit: None None Scope Limit: None

Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan:

Benefit Provided: Source: OLP: Naturopathic Physician State Plan 1905(a) [ Remove | Authorization: Provider Qualifications: None Medicaid State Plan Amount Limit: Duration Limit: None None

Scope Limit:

None

Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan:

Benefit Provided: Source: Other diagnostic, screening, preventative and reha State Plan 1905(a) |

Authorization: Provider Qualifications:

None | |Medicaid State Plan |

Amount Limit: Duration Limit:

None None

Page 20 of 43 TN NO: VT 13-029 Approval Date: 1.15.14 Effective Date: 1.01.14

Supersedes TN: NEW ABP5 Page 20 of 43

aaa ee DD RST RES] Alternative Benefit Plan

Scope Limit:

None Remove |

Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan:

Add

Page 21 of 43 TN NO: VT 13-029 Approval Date: 1.15.14 Effective Date: 1.01.14 Supersedes TN: NEW ABP5 Page 21 of 43

Alternative Benefit Plan

OFFICIAL

{m) Essential Health Benefit 10: Pediatric services including oral and vision care

Collapse All []

Benefit Provided: Medicaid State Plan EPSDT Benefits

Authorization:

Source:

State Plan 1905(a)

Remove

Provider Qualifications:

Other

Medicaid State Plan

Amount Limit:

Duration Limit:

None

None

Scope Limit:

None

benchmark plan:

Other information regarding this benefit, including the specific name of the source plan if it is not the base

All federally required services in accordance CFR and Statute.

Benefit Provided: Medicaid State Plan EPSDT Benefits

Authorization:

Source:

State Plan 1905(a)

Provider Qualifications:

None

Medicaid State Plan

Amount Limit:

Duration Limit:

None

None

Scope Limit:

None

benchmark plan:

Other information regarding this benefit, including the specific name of the source plan if it is not the base

Nursing facility under 21. Rehabilitation Center services provided in nursing facilities located outside of Vermont for the severely disabled such as head injured or ventilator dependent people require authorization prior to admission from the Medicaid Director or a designee. Coverage of this care is limited to one year

Add

TN NO: VT 13-029 Supersedes TN: NEW

Approval Date: 1.15.14

ABI

Page 22 of 43

Effective Date: 1.01.14

P5 Page 22 of 43

CCMS Alternative Benefit Plan

WHICTA Tv clin le te = snd (J Other Covered Benefits from Base Benchmark Collapse All [7] Page 23 of 43 TN NO: VT 13-029 Approval Date: 1.15.14 Effective Date: 1.01.14

Supersedes TN: NEW ABP5 Page 23 of 43

Alternative Benefit Plan

Geo y

Pe oe op eee |

>

Base Benchmark Benefits Not Covered due to Substitution or Duplication Collapse All [] Base Benchmark Benefit that was Substituted: Source: ~ 7 cians Base Benchmark Family Planning: Reversal of Sterilization

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:

Substitution - Non-Emergency Transportation was substituted in the ambulatory care EHB category. The Medicaid State Plan does not cover reversal of sterilization and the state seeks an identical benefit plan for this former 1115 expansion, now state plan, group in the Medicaid program.

Base benchmark benefit limitation(s): One attempt at reversal of sterilization covered.

Base Benchmark Benefit that was Substituted: Source: a age 2 ; Base Benchmark Infertility Drugs with natural conception

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:

Duplication - The Medicaid State Plan Generic and Brand Name Drug benefit services includes Hormone treatments and were used in order to ensure identical benefits for all beneficiaries in the Medicaid program.

Base benchmark benefit limitation(s): Infertility Drugs up to 4 months per year for natural conception.

This benefit maps to EHB 6: Prescription Drugs.

Base Benchmark Benefit that was Substituted: Source: Base Benchmark

Outpatient Hospital Fee

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:

Duplication - The Medicaid State Plan Outpatient Hospital service was used in order to ensure identical benefits for all beneficiaries in the Medicaid program.

This benefit maps to EHB 1: Ambulatory Patient Services.

Base Benchmark Benefit that was Substituted: Source:

Base Benchmark Outpatient Surgery Physician/Surgical Services ene

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:

Duplication - The Medicaid State Plan Outpatient Hospital service was used in order to ensure identical benefits for all beneficiaries in the Medicaid program.

This benefit maps to EHB 1: Ambulatory Patient Services.

Base Benchmark Benefit that was Substituted: Source: Base Benchmark

Urgent Care Centers or Facilities

Page 24 of 43 TN NO: VT 13-029 Approval Date: 1.15.14 Effective Date: 1.01.14 Supersedes TN: NEW ABP5 Page 24 of 43

Alternative Benefit Plan

—sr tak

oe ee er |

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate

section 1937 benchmark benefit(s) included above under Essential Health Benefits: Ronove

Duplication - The Medicaid State Plan Other Ambulatory Services - Rural Health Clinic and FQHC’s and Physician Services In all settings service was used in order to ensure identical benefits for all beneficiaries in the Medicaid program. Certain clinics provide urgent care, however Vermont does not have stand alone urgent care center providers who are not affiliated with a health clinic or hospital.

This benefit maps to EHB 1: Ambulatory Patient Services.

Base Benchmark Benefit that was Substituted: Source:

- ~ i Base Benchmark Primary Care Visit to Treat an Injury or Illness

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:

Duplication - The Medicaid State Plan Physician Services In all settings service was used in order to ensure identical benefits for all beneficiaries in the Medicaid program.

This benefit maps to EHB 1: Ambulatory Patient Services.

Base Benchmark Benefit that was Substituted: Source:

5 : Base Benchmark Dental Services (not Routine)

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:

Duplication - The Medicaid State Plan Medical & Surgical furnished by dentist service was used in order to ensure identical benefits for all beneficiaries in the Medicaid program.

Base benchmark benefit limitation(s): Prior approval required.

This benefit maps to EHB 1: Ambulatory Patient Services.

Base Benchmark Benefit that was Substituted: Source:

~ , Base Benchmark Chiropractic Care

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:

Duplication - The Medicaid State Plan Chiropractic service was used in order to ensure identical benefits for all beneficiaries in the Medicaid program.

Base benchmark benefit limitation(s): Prior Approval is required after the 12th visit.

This benefit maps to EHB 1: Ambulatory Patient Services.

Base Benchmark Benefit that was Substituted: Source: Base Benchmark

OLP: Routine Foot Care for diabetics only

Page 25 of 43 TN NO: VT 13-029 Approval Date: 1.15.14 Effective Date: 1.01.14 Supersedes TN: NEW ABP5 Page 25 of 43

Alternative Benefit Plan

are ae oe

ae! A eS

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: [ Remove | — Remove

Duplication - The Medicaid State Plan Podiatry service was used in order to ensure identical benefits for all beneficiaries in the Medicaid program.

Base benchmark benefit limitation(s): Covered for Diabetics only; excluded for all other members.

This benefit maps to EHB 1: Ambulatory Patient Services.

Base Benchmark Benefit that was Substituted: Source:

7 Base Benchmark Emergency Room Services

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:

Duplication - The Medicaid State Plan Outpatient Hospital Emergency Care service was used in order to ensure identical benefits for all beneficiaries in the Medicaid program.

This benefit maps to EHB 2: Emergency Services.

Base Benchmark Benefit that was Substituted: Source: = Base Benchmark Emergency Transportation/ Ambulance

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:

Duplication - The Medicaid State Plan Transportation: Ambulance service was used in order to ensure identical benefits for all beneficiaries in the Medicaid program.

This benefit maps to EHB 2: Emergency Services.

Base Benchmark Benefit that was Substituted: Source: - F 7 Base Benchmark Inpatient Hospital Services

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:

Duplication - The Medicaid State Plan Inpatient Hospital, Physician Services In all settings was used in order to ensure identical benefits for all beneficiaries in the Medicaid program.

This benefit maps to EHB 3: Hospitalization.

Base Benchmark Benefit that was Substituted: Source: , = i A Base Benchmark Inpatient Physician and Surgical Services Remove

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:

Duplication - The Medicaid State Plan Inpatient Hospital, Physician Services In all settings was used in order to ensure identical benefits for all beneficiaries in the Medicaid program.

This benefit maps to EHB 3: Hospitalization and EHB 1: Ambulatory Care.

Page 26 of 43 TN NO: VT 13-029 Approval Date: 1.15.14 Effective Date: 1.01.14

Supersedes TN: NEW ABP5 Page 26 of 43

Ph SEIS ERNE a a PE Se RE IOS FNS MIO IE AY MEARE SEDGE MSNT R Alternative Benefit Plan OFFICIAL

Base Benchmark Benefit that was Substituted: Source: . 7 7 Be se ey Substance Abuse Disorder Inpatient Services ase Benchmarks

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:

Duplication - The Medicaid State Plan Inpatient Hospital, Physician Services In all settings was used in order to ensure identical benefits for all beneficiaries in the Medicaid program.

This benefit maps to EHB 3: Hospitalization and EHB 1: Ambulatory Care.

Base benchmark benefit limitation(s): Excludes services provided by non-participating providers or facilities, treatment without concurrent review, non-traditional or alternative therapies, services that focus on education or socialization or delinquency, custodial care that is not medically necessary and biofeedback, pain management, stress reduction classes or pastoral counseling.

Prior Approval is required for all non-Emergency Inpatient or partial-Inpatient substance abuse services.

Base Benchmark Benefit that was Substituted: Source: z ~ " Base Benchmark Cosmetic Surgery if reconstructive

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:

Duplication - The Medicaid State Plan Inpatient Hospital, Physician Services In all settings was used in order to ensure identical benefits for all beneficiaries in the Medicaid program.

This benefit maps to EHB 3: Hospitalization and EHB 1: Ambulatory Care.

Base Benchmark Benefit that was Substituted: Source: Raa Base Benchmark Bariatric Surgery

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:

Duplication - The Medicaid State Plan Inpatient Hospital, Physician Services In all settings was used in order to ensure identical benefits for all beneficiaries in the Medicaid program.

This benefit maps to EHB 3: Hospitalization and EHB 1: Ambulatory Care.

Base Benchmark Benefit that was Substituted: Source: Base Benchmark Transplant-deceased donor

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:

Duplication - The Medicaid State Plan Inpatient Hospital, Physician Services In all settings was used in order to ensure identical benefits for all beneficiaries in the Medicaid program.

This benefit maps to EHB 3: Hospitalization and EHB 1: Ambulatory Care.

Page 27 of 43 TN NO: VT 13-029 Approval Date: 1.15.14 Effective Date: 1.01.14

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Alternative Benefit Plan

OFFICIAL

Base Benchmark Benefit that was Substituted: Source:

5 Base Benchmark Transplant live donor Remove

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:

Duplication - The Medicaid State Plan Inpatient Hospital, Physician Services In all settings was used in order to ensure identical benefits for all beneficiaries in the Medicaid program.

This benefit maps to EHB 3: Hospitalization and EHB 1: Ambulatory Care.

Base Benchmark Benefit that was Substituted: Source: A 5 5 Base Benchmark Mental/Behavioral Health Inpatient Services ase mene

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:

Duplication - The Medicaid State Plan Inpatient psychiatric Hospital service was used in order to ensure identical benefits for all beneficiaries in the Medicaid program.

This benefit maps to EHB 3: Hospitalization.

Base benchmark benefit limitation(s): Excludes services provided by non-participating providers or facilities, treatment without concurrent review, non-traditional or alternative therapies, services that focus ‘on education or socialization or delinquency, custodial care that is not medically necessary and biofeedback, pain management, stress reduction classes or pastoral counseling.

Prior Approval is required for all non-Emergency Inpatient or partial-Inpatient Mental Health services.

Base Benchmark Benefit that was Substituted: Source: - 7 oe - Base Benchmark Other Practitioner Office Visit (Nurse, Physician

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:

Duplication - The Medicaid State Plan Pediatric or Family Nurse Practitioners’ Services was used in order to ensure identical benefits for all beneficiaries in the Medicaid program.

This benefit maps to EHB 1: Ambulatory Patient Services.

Base Benchmark Benefit that was Substituted: Source: Base Benchmark Prenatal and Postnatal Care

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:

Duplication - The Medicaid State Plan Licensed Lay Midwife, Physician Services: Maternity Care services were used in order to ensure identical benefits for all beneficiaries in the Medicaid program.

This benefit maps to EHB 4: Maternity and Newborn Care.

Page 28 of 43 TN NO: VT 13-029 Approval Date: 1.15.14 Effective Date: 1.01.14

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Ss Alternative Benefit Plan

pao waver

Base Benchmark Benefit that was Substituted: Source:

Delivery and All Inpatient Services for Maternity ave Benchmark Remove

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:

Duplication - The Medicaid State Plan Nurse Mid Wife, Physician Services: Maternity Care, Inpatient Hospital: Maternity Care was used in order to ensure identical benefits for all beneficiaries in the Medicaid program.

This benefit maps to EHB 4: Maternity and Newborn Care.

Base Benchmark Benefit that was Substituted: Source:

i Base Benchmark Diagnostic Test (Lab Work) ase Benchmar: E

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:

Duplication - The Medicaid State Plan Other Laboratory and X-Ray Services was used in order to ensure identical benefits for all beneficiaries in the Medicaid program.

This benefit maps to EHB 8: Laboratory Services.

Base Benchmark Benefit that was Substituted: Source: 2 q 3 Base Benchmark Diagnostic Tests and Imaging

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:

Duplication - The Medicaid State Plan Other Laboratory and X-Ray Services was used in order to ensure identical benefits for all beneficiaries in the Medicaid program.

This benefit maps to EHB 8: Laboratory Services.

Base Benchmark Benefit that was Substituted: Source: 5 Base Benchmark Preventive Care Remove

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:

Duplication - The Medicaid State Plan Physician Services In all settings, Clinic Services, and Other diagnostic, screening, preventative and rehab services were used in order to ensure identical benefits for all beneficiaries in the Medicaid program.

This benefit maps to EHB 9: Preventive and Wellness Services and Chronic Disease Management and EHB 1: Ambulatory Care.

Base Benchmark Benefit that was Substituted: Source: Base Benchmark

Nutritional Counseling

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:

Duplication - The Medicaid State Plan Naturopathic Physician and Physician Services were used in order to

OFFICIAL

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Alternative Benefit Plan

OFFICIAL

ensure identical benefits for all beneficiaries in the Medicaid program. This benefit maps to EHB 9: Preventive and Wellness Services and Chronic Disease Management and EHB 1: Ambulatory Care. Base Benchmark Benefit that was Substituted: Source: 5 Base Benchmark Generic Drugs

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:

Duplication - The Medicaid State Plan Generic drug benefit was used in order to ensure identical benefits for all beneficiaries in the Medicaid program.

This benefit maps to EHB 6: Prescription Drugs.

Base Benchmark Benefit that was Substituted: Source: Base Benchmark Preferred brand, non-pref. brand, & specialty drug ase enema

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:

Duplication - The Medicaid State Brand Name drug benefit was used in order to ensure identical benefits for all beneficiaries in the Medicaid program.

This benefit maps to EHB 6: Prescription Drugs.

Base Benchmark Benefit that was Substituted: Source:

a Base Benchmark Nutritional Formulae

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:

Duplication - The Medicaid State Plan Generic, Brand Name and OTC drug benefit was used in order to ensure identical benefits for all beneficiaries in the Medicaid program.

This benefit maps to EHB 6: Prescription Drugs.

Base Benchmark Benefit that was Substituted: Source: Base Benchmark

Mental/Behavioral Health Outpatient Services

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:

Duplication - The Medicaid State Plan Clinic Services - Mental Health Clinic (group therapy; individual psychotherapy; day hospital; diagnosis and evaluation; emergency care; chemotherapy) and OLP: Behavioral Health services were used in order to ensure identical benefits for all beneficiaries in the Medicaid program.

This benefit maps to EHB 5: Mental Health and Substance Use Disorder Services Including Behavioral Health Treatment.

Base benchmark benefit limitation(s): Prior authorization is required for psychological testing, electro-

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Alternative Benefit Plan

shock therapy; and intensive outpatient mental health services. For all other outpatient services, there 1s a 10 visit limit per plan year without prior approval. If more than 10 visits are required for outpatient mental health services, prior approval is required beginning with the 11th visit. Remove

Base Benchmark Benefit that was Substituted: Source: Neuropsychological Testing ase Benchmark

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:

Duplication - The Medicaid State Plan Clinic Services - Mental Health Clinic (group therapy; individual psychotherapy; day hospital; diagnosis and evaluation; emergency care; chemotherapy) service was used in order to ensure identical benefits for all beneficiaries in the Medicaid program.

This benefit maps to EHB 5: Mental Health and Substance Use Disorder Services Including Behavioral Health Treatment.

Base Benchmark Benefit that was Substituted: Source: 5 , R Base Benchmark Substance Abuse Disorder Outpatient Services

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:

Duplication - The Medicaid State Plan Substance Abuse Services Residential Treatment .

Substance Abuse Services Residential Detoxification, Substance Abuse Services Residential Post Detox Services, Substance Abuse Services Residential Extended post detox, and

Substance Abuse Services Non-residential professional services were used in order to ensure identical benefits for all beneficiaries in the Medicaid program.

This benefit maps to EHB 5: Mental Health and Substance Use Disorder Services Including Behavioral Health Treatment.

Base benchmark benefit limitation(s): Prior authorization is required for psychological testing, electro- shock therapy; and intensive outpatient substance abuse services. For all other outpatient services, there is a 10 visit limit per plan year without prior approval. If more than 10 visits are required for outpatient substance abuse services, prior approval is required beginning with the 11th visit.

Base Benchmark Benefit that was Substituted: Source: A pee 7 Base Benchmark Outpatient Rehabilitation Services

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:

Duplication - The Medicaid State Plan Outpatient Hospital - Rehabilitative therapies (OT/PT/SLP) service was used in order to ensure identical benefits for all beneficiaries in the Medicaid program.

This benefit maps to EHB 7: Rehabilitative and Habilitative Services and Devices.

Base Benchmark Benefit that was Substituted: Source: Base Benchmark

Outpatient physical, speech and occupational thera

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Alternative Benefit Plan

OFFICIAL Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate

section 1937 benchmark benefit(s) included above under Essential Health Benefits:

Duplication - The Medicaid State Plan OT/PT/SLP (non-hospital based)service was used in order to ensure identical benefits for all beneficiaries in the Medicaid program.

Base benchmark benefit limitation(s): Covered up to 30 visits combined per plan year.

This benefit maps to EHB 7: Rehabilitative and Habilitative Services and Devices.

Base Benchmark Benefit that was Substituted: Source: 7 ~ Base Benchmark Durable Medical Equipment ne Remove

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:

Duplication - The Medicaid State Plan Communication Devices, Wheelchair, Physical Therapies & Related Services: Hearing Aids, Prosthetic Devices, Home Health: Medical Supplies, Equipment and Appliances were used in order to ensure identical benefits for all beneficiaries in the Medicaid program.

Base benchmark benefit limitation(s): Some durable medical equipment and supplies require prior approval. Includes supplies and equipment necessary for administration, orthotics (if approved), prosthetics, and devices. Threshold applies.

This benefit maps to EHB 7: Rehabilitative and Habilitative Services and Devices.

Base Benchmark Benefit that was Substituted: Source: . , a: Base Benchmark Skilled Nursing Facility Remove

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:

Duplication - The Medicaid State Plan Nursing Facility 21 and older was used in order to ensure identical benefits for all beneficiaries in the Medicaid program.

Base benchmark benefit limitation(s): Covered by participating facility only for Acute Care.

This benefit maps to EHB 7: Rehabilitative and Habilitative Services and Devices.

Base Benchmark Benefit that was Substituted: Source: P Base Benchmark Home Health Care Services

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:

Duplication - The Medicaid State Plan Home Health Aide and Home Health PT/OT and SLP Services were used in order to ensure identical benefits for all beneficiaries in the Medicaid program.7a. Home Health Intermittent part time nursing.

This benefit maps to EHB 7: Rehabilitative and Habilitative Services and Devices.

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Alternative Benefit Plan

OFFICIAL

Base Benchmark Benefit that was Substituted: Source:

Private-Duty Nursing Base Benchmark

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:

Duplication - The Medicaid State Plan Home Health: Private Duty Nursing service was used in order to ensure identical benefits for all beneficiaries in the Medicaid program.

Base benchmark benefit limitation(s): Covered up to $2,000 per plan year; Requires prior approval and recertification of treatment plan every 60 days.

This benefit maps to EHB 7: Rehabilitative and Habilitative Services and Devices.

Base Benchmark Benefit that was Substituted: Source:

= Base Benchmark Hospice Services °

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:

Duplication - The Medicaid State Plan Hospice service was used in order to ensure identical benefits for all beneficiaries in the Medicaid program.

Base benchmark benefit limitation(s): 100 hours per month.

This benefit maps to EHB 1: Ambulatory Services.

Base Benchmark Benefit that was Substituted: Source: Base Benchmark

Home Health Aide

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:

Duplication - The Medicaid State Plan Home Health Aide was used in order to ensure identical benefits for all beneficiaries in the Medicaid program.

Base benchmark benefit limitation(s): 100 hours per month.

This benefit maps to EHB 7: Rehabilitative and Habilitative Services and Devices.

Base Benchmark Benefit that was Substituted: Source: Base Benchmark

Habilitation Autism

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:

Duplication - The Medicaid State Plan EPSDT service was used in order to ensure identical benefits for all beneficiaries in the Medicaid program.

VT requires private insurers to cover services to children up to the age of 21 who have an ASD regardless of whether they are gaining a new skill or recovering a lost skill. This is the same coverage that EPSDT provides e.g. to ameliorate, or prevent from worsening or promote healthy development.

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Ss Alternative Benefit Plan

NOUR FO ONCE A AME NCRNO IETY

This benefit maps to EHB 10: Pediatric services including oral and vision care.

Base Benchmark Benefit that was Substituted: Source: A _ = Base Benchmark Preventive Care/ Screening/ Immunization se enenman Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplication - The Medicaid State Plan EPSDT and Physician Services in All Settings was used in order to ensure identical benefits for all beneficiaries in the Medicaid program. This benefit maps to EHB 1: Ambulatory Patient Services and EHB 10: Pediatric Services including Oral and Vision Care. Base Benchmark Benefit that was Substituted: Source: Base Benchmark Eye Glasses for Children

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:

Duplication - The Medicaid State Plan EPSDT service was used in order to ensure identical benefits for all beneficiaries in the Medicaid program.

This benefit maps to EHB 10: Pediatric Services Including Oral and Vision Care.

Base Benchmark Benefit that was Substituted: Source:

= Z Base Benchmark Dental Check-Up for Children

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:

Duplication - The Medicaid State Plan EPSDT service was used in order to ensure identical benefits for all beneficiaries in the Medicaid program.

This benefit maps to EHB 10: Pediatric Services Including Oral and Vision Care.

Base Benchmark Benefit that was Substituted: Source: Base Benchmark

Family Planning: All Other Services

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:

Duplication - The Medicaid State Plan Family Planning service was used in order to ensure identical benefits for all beneficiaries in the Medicaid program.

This benefit maps to EHB 1: Ambulatory Patient Services.

Add

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AB 8 nC SEEVICTS

Ss Alternative Benefit Plan

OFFICIAL

Other Base Benchmark Benefits Not Covered

Collapse All []

Base Benchmark Benefit not Included in the Alternative Source:

Benefit Plan:

Base Benchmark

Routine Eye Exam (Adult)

Explain why the state/territory chose not to include this benefit:

beneficiaries in the Medicaid program.

Routine adult eye exams are not considered an EHB.

The Medicaid State Plan Optometry service was used in order to ensure identical benefits for all

Base benchmark benefit limitation(s): 1 routine eye exam per calendar year; Does not cover the evaluation and fitting of contact lenses or other supplemental tests, routine eye care, eye exercises or visual training.

TN NO: VT 13-029 Supersedes TN: NEW

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Alternative Benefit Plan

COTE IO MOAN A CAO EEVICTY

TIT ATAT

Other 1937 Covered Benefits that are not Essential Health Benefits Collapse All [J Other 1937 Benefit Provided: Source: Denul Proohvlnde Section 1937 Coverage Option Benchmark Benefit ental- Prophylaxis Package Authorization: Provider Qualifications: Authorization required in excess of limitation Medicaid State Plan Amount Limit: Duration Limit: 1 visit every 6 months; $510 per year None

Scope Limit:

Excludes cosmetic; elective; TMJ treatment except TMJ splint fabrication.

Other: Other 1937 Benefit Provided: Source: Section 1937 Coverage Option Benchmark Benefit ICF/ID Paceiga Authorization: Provider Qualifications: Prior Authorization Medicaid State Plan Amount Limit: Duration Limit: None None Scope Limit: None Other: Other 1937 Benefit Provided: Source:

= - Section 1937 Coverage Option Benchmark Benefit OLP: High Tech Nursing Package

Authorization: Provider Qualifications:

Prior Authorization Medicaid State Plan

Amount Limit: Duration Limit:

None None

Scope Limit:

None Other:

Page 36 of 43

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Alternative Benefit Plan FEICIAL

Remove

Other 1937 Benefit Provided:

Extended Services (home visits) for Pregnant Women

Authorization:

Source: Section 1937 Coverage Option Benchmark Benefit Package

Provider Qualifications:

Prior Authorization Medicaid State Plan

Amount Limit: Duration Limit:

None None

Scope Limit:

None

Other: Other 1937 Benefit Provided: Source:

- Opticians Section 1937 Coverage Option Benchmark Benefit OLP: Opticians Package

Authorization: Provider Qualifications:

Medicaid State Plan

Amount Limit: Duration Limit:

None None

Scope Limit:

Limited to eye glass dispensing only.

Other:

No authorization requirement. Other 1937 Benefit Provided: Source:

_ Section 1937 Coverage Option Benchmark Benefit

Face-to-Face Tobacco cessation for pregnant women Package

Authorization:

Provider Qualifications:

Medicaid State Plan

Amount Limit:

Duration Limit:

None

None

Scope Limit:

16 visits per calendar year.

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Alternative Benefit Plan

FASNE SALT AT

Other:

No authorization requirement.

Remove

Other 1937 Benefit Provided:

Case Management for TB related services

Authorization:

Source: Section 1937 Coverage Option Benchmark Benefit Package

Provider Qualifications:

Remove

Medicaid State Plan

Amount Limit:

Duration Limit:

None

None

Scope Limit:

None

Other:

No authorization requirement.

Other 1937 Benefit Provided:

Outpatient Hospital - Partial Hospitalization

Authorization:

Source: Section 1937 Coverage Option Benchmark Benefit Package

Provider Qualifications:

Medicaid State Plan

Amount Limit:

Duration Limit:

None

None

Scope Limit:

None

Other:

No authorization requirement.

Other 1937 Benefit Provided:

Therapeutic Substance Abuse Services (PNMI)

Authorization:

Source: Section 1937 Coverage Option Benchmark Benefit Package

Provider Qualifications:

Medicaid State Plan

Amount Limit:

Duration Limit:

None

None

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CCMS Alternative Benefit Plan

CTTIClA a dS a Ls

Scope Limit:

None Remove

Other:

No authorization requirement.

Other 1937 Benefit Provided: Source: Section 1937 Coverage Option Benchmark Benefit Community Mental Health Center Services HoaNs, a oH em om Package Authorization: Provider Qualifications:

Medicaid State Plan

Amount Limit: Duration Limit:

None None

Scope Limit:

None

Other:

No authorization requirement.

Diagnosis and evaluation; emergency care; psychotherapy; chemotherapy; group therapy; specialized rehabilitation services provided by Mental Health Designated Providers authorized by DMH and required by state law. The benefit category in Vermont's State plan is "Other Diagnostic, Screening, Preventive and Rehabilitative Services."

Other 1937 Benefit Provided: Source: A F : Section 1937 Coverage Option Benchmark Benefit Assertive Community Care Services (PNMI) Package ackage Authorization: Provider Qualifications:

Medicaid State Plan

Amount Limit: Duration Limit:

None None

Scope Limit:

Persons with functional impairments and/or cognitive disabilities.

Other:

No authorization requirement.

Other 1937 Benefit Provided: Source: =. Section 1937 Coverage Option Benchmark Benefit Day Health Rehabilitation - Center based Packs Package Page 39 of 43 TN NO: VT 13-029 Approval Date: 1.15.14 Effective Date: 1.01.14

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Alternative Benefit Plan

yt i WN cok

Authorization: Provider Qualifications:

Prior Authorization Medicaid State Plan Remove Amount Limit: Duration Limit:

None None

Scope Limit:

Excludes residents of nursing home or enhanced residential care facilities.

Other: Other 1937 Benefit Provided: Source: Section 1937 Coverage Option Benchmark Benefit Targeted Case Management (3 targeted groups) Package Authorization: Provider Qualifications: Medicaid State Plan Amount Limit: Duration Limit: None None

Scope Limit:

None

Other:

No authorization requirement.

Three target groups for persons over 18 years old: (1) Persons with developmental disabilities who are unable to access needed medical, social, educational and other services because of adaptive deficits due to their level of disability, or who lack the active assistance of a family member or other interested person to assist them in accessing needed services; (2) Families whose children are abused or neglected or suspected of being at imminent risk thereof and Families of children receiving post adoption assistance; (3) Pregnant and postpartum women and infants through twelve months of age enrolled in the Vermont Department for Children and Families, Healthy Babies, Kids, and Families Program.

Other 1937 Benefit Provided: Source: _ Section 1937 Coverage Option Benchmark Benefit Respiratory Care Services Package Authorization: Provider Qualifications:

Medicaid State Plan

Amount Limit: Duration Limit: None None Scope Limit: None Page 40 of 43 TN NO: VT 13-029 Approval Date: 1.15.14 Effective Date: 1.01.14

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CCMS Alternative Benefit Plan

OFFICIAL

Other:

No authorization requirement.

Other 1937 Benefit Provided:

Personal Care Services

Authorization:

Source: Section 1937 Coverage Option Benchmark Benefit Package

Provider Qualifications:

Prior Authorization

Medicaid State Plan

Amount Limit:

Duration Limit:

Nursing Facility 21 and older; custodial care

Authorization:

None None Scope Limit: None Other: Other 1937 Benefit Provided: Source:

Section 1937 Coverage Option Benchmark Benefit Package

Provider Qualifications:

Other

Medicaid State Plan

Amount Limit:

Duration Limit:

None

None

Scope Limit:

None

Other:

Requires a physician order; Out of state requires prior authorization,

Remove

Other 1937 Benefit Provided:

OLP: Optometry

Authorization:

Source: Section 1937 Coverage Option Benchmark Benefit Package

Provider Qualifications:

Other

Medicaid State Plan

Amount Limit:

Duration Limit:

Routine exam 1/2 years; diagnostic exam 1/2 years

None

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CCMS Alternative Benefit Plan YEICIAL

Scope Limit:

None Remove Other: Contact Lens prior authorization; Aids to vision approved when legally blind and will improve at least one ADL or IADL. Other 1937 Benefit Provided: Source: P ae Section 1937 Coverage Option Benchmark Benefit Inpatient Psych. Services for Individuals Under 22 Package BEN Authorization: Provider Qualifications: Medicaid State Plan Amount Limit: Duration Limit: None None

Scope Limit:

None

Other:

No authorization requirement.

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CCMS Alternative Benefit Plan

oe Ae

a it bb

o Additional Covered Benefits (This category of benefits is not applicable to the adult group under Collapse All [] section 1902(a)(10)(A)(i)(VIID of the Act.)

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 5 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.20130814

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Alternative Benefit Plan

FFICIAL

OMB Control Number: 0938-1148

Attachment 3.1L [_] OMB Expiration date: 10/31/2014 Benefits Assurances ABP7 EPSDT Assurances

If the target population includes persons under 21, please complete the following assurances regarding EPSDT. Otherwise, skip to the Prescription Drug Coverage Assurances below.

The alternative benefit plan includes beneficiaries under 21 years of age.

The state/territory assures that the notice to an individual includes a description of the method for ensuring access to EPSDT services (42 CFR 440.345).

The state/territory assures EPSDT services will be provided to individuals under 21 years of age who are covered under the state/ territory plan under section 1902(a)(10)(A) of the Act.

Indicate whether EPSDT services will be provided only through an Alternative Benefit Plan or whether the state/territory will provide additional benefits to ensure EPSDT services:

@ Through an Alternative Benefit Plan.

C_ Through an Alternative Benefit Plan with additional benefits to ensure EPSDT services as defined in 1905(r).

Other Information regarding how ESPDT benefits will be provided to participants under 21 years of age (optional):

Prescription Drug Coverage Assurances

The state/territory assures that it meets the minimum requirements for prescription drug coverage in section 1937 of the Act and implementing regulations at 42 CFR 440.347. Coverage is at least the greater of one drug in each United States Pharmacopeia (USP) category and class or the same number of prescription drugs in each category and class as the base benchmark.

The state/territory assures that procedures are in place to allow a beneficiary to request and gain access to clinically appropriate prescription drugs when not covered.

The state/territory assures that when it pays for outpatient prescription drugs covered under an Alternative Benefit Plan, it meets the requirements of section 1927 of the Act and implementing regulations at 42 CFR 440.345, except for those requirements that are directly contrary to amount, duration and scope of coverage permitted under section 1937 of the Act.

The state/territory assures that when conducting prior authorization of prescription drugs under an Alternative Benefit Plan, it complies with prior authorization program requirements in section 1927(d)(5) of the Act.

Other Benefit Assurances

The state/territory assures that substituted benefits are actuarially equivalent to the benefits they replaced from the base benchmark y rep! plan, and that the state/territory has actuarial certification for substituted benefits available for CMS inspection if requested by CMS.

The state/territory assures that individuals will have access to services in Rural Health Clinics (RHC) and Federally Qualified Health Centers (FQHC) as defined in subparagraphs (B) and (C) of section 1905(a)(2) of the Social Security Act.

The state/territory assures that payment for RHC and FQHC services is made in accordance with the requirements of section 1902(bb) of the Social Security Act.

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CCMS Alternative Benefit Plan

ee ora a

ie i DN

The state/territory assures that it will comply with the requirement of section 1937(b)(5) of the Act by providing, effective January 1, 2014, to all Alternative Benefit Plan participants at least Essential Health Benefits as described in section 1302(b) of the Patient Protection and Affordable Care Act.

The state/territory assures that it will comply with the mental health and substance use disorder parity requirements of section 1937(b)(6) of the Act by ensuring that the financial requirements and treatment limitations applicable to mental health or substance use disorder benefits comply with the requirements of section 2705(a) of the Public Health Service Act in the same manner as such requirements apply to a group health plan.

The state/territory assures that it will comply with section 1937(b)(7) of the Act by ensuring that benefits provided to Alternative Benefit Plan participants include, for any individual described in section 1905(a)(4)(C), medical assistance for family planning services and supplies in accordance with such section.

The state/territory assures transportation (emergency and non-emergency) for individuals enrolled in an Alternative Benefit Plan in accordance with 42 CFR 431.53.

The state/territory assures, in accordance with 45 CFR 156.115(a)(4) and 45 CFR 147.130, that it will provide as Essential Health Benefits a broad range of preventive services including: “A” and “B” services recommended by the United States Preventive Services Task Force; Advisory Committee for Immunization Practices (ACIP) recommended vaccines; preventive care and screening for infants, children and adults recommended by HRSA's Bright Futures program/project; and additional preventive services for women recommended by the Institute of Medicine (IOM).

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 5 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.20130807

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CCMS Alternative Benefit Plan

TINT ANT AY a a)

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

Service Delivery Systems ABP8

Attachment 3.1-L- [|

Provide detail on the type of delivery system(s) the state/territory will use for the Alternative Benefit Plan's benchmark benefit package or benchmark-equivalent benefit package, including any variation by the participants' geographic area.

Type of service delivery system(s) the state/territory will use for this Alternative Benefit Plan(s). Select one or more service delivery systems:

(J Managed care.

Fee-for-service.

{X] Other service delivery system.

Fee-For-Service Options

Indicate whether the state/territory offers traditional fee-for-service and/or services managed under an administrative services organization:

@ Traditional state-managed fee-for-service C Services managed under an administrative services organization (ASO) arrangement

Please describe this fee-for-service delivery system, including any bundled payment arrangements, pay for performance, fee-for- service care management models/non-risk, contractual incentives as well as the population served via this delivery system.

Choices for Care 1115 Long Term Care (Control #11-W-00191/6) and CHIP beneficiaries receive all state plan services using all state plan approved payment methodologies including a variety of bundled rate options.

Additional Information: Fee-For-Service (Optional)

Provide any additional details regarding this service delivery system (optional):

Other Service Delivery Model

Name of service delivery system:

Global Commitment to Health (MCO) model (Control # 11-W-001941) and Choices for Care 1115 (Control #11-W-00191/6) Demonstration Waivers

Provide a narrative description of the model:

The state operates its Medicaid Program under two 1115 Demonstration waivers. One for long term care (Control #1 1-W-00191/6) and one using a managed care model and adhering to the MCO regulatory structure and 42 CFR 438 as per the STC's (Control # 11- W-001941/1). The new adult is moving from an ‘expansion population’ in the Global Commitment to Health (MCO) waiver to a state plan group under the same waiver. For Global Commitment populations, Medicaid eligibility is considered synonymous with MCO enrollment under the model. Current beneficiaries will be converted from ‘expansion population to 'state plan as part of the state's CMS approved transition plan. Other members will move seamlessly into their new ACA group during annual recertification reviews. As of January 1, 2014 new members will be enrolled directly into the new adult group upon eligibility determination for the Medicaid program. Members who qualify for Long Term Care Medicaid will receive all state plan and any approved demonstration services under the state's long term care waiver Choices for Care. Former 1915 Home and Community Based Waivers and former 1115 (b) Demonstrations are incorporated into the 1115 Demonstration for individuals with a Developmental Disability, Traumatic Brain Injury, Severe and Persistent Mental Illness and Children with a severe emotional disturbance and their families. The state has a several networks of designated specialty providers for the behavioral health and disability related carve outs under the current 1115 Demonstration. All former 1915 services for the elderly have been incorporated into the 1115 Choices for Care, Long Term Care waiver.

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CCMsS Alternative Benefit Plan

TTI MI Ar

The state/territory assures that it will comply with the requirement of section 1937(b)(5) of the Act by providing, effective January 1,

2014, to all Alternative Benefit Plan participants at least Essential Health Benefits as described in section 1302(b) of the Patient Protection and Affordable Care Act.

The state/territory assures that it will comply with the mental health and substance use disorder parity requirements of section 1937(b)(6) of the Act by ensuring that the financial requirements and treatment limitations applicable to mental health or substance use disorder benefits comply with the requirements of section 2705(a) of the Public Health Service Act in the same manner as such requirements apply to a group health plan.

The state/territory assures that it will comply with section 1937(b)(7) of the Act by ensuring that benefits provided to Alternative Benefit Plan participants include, for any individual described in section 1905(a)(4)(C), medical assistance for family planning services and supplies in accordance with such section.

The state/territory assures transportation (emergency and non-emergency) for individuals enrolled in an Alternative Benefit Plan in accordance with 42 CFR 431.53.

The state/territory assures, in accordance with 45 CFR 156.115(a)(4) and 45 CFR 147.130, that it will provide as Essential Health Benefits a broad range of preventive services including: “A” and “B” services recommended by the United States Preventive Services Task Force; Advisory Committee for Immunization Practices (ACIP) recommended vaccines; preventive care and screening for infants, children and adults recommended by HRSA's Bright Futures program/project; and additional preventive services for women recommended by the Institute of Medicine (IOM).

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 5 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.20130807

ABP 8 Page 2 of 2

TN NO: VT 13-029 Approval Date: 1.15.14 Effective Date: 1.01.14 Supersedes TN: NEW

Alternative Benefit Plan

aE Py) .s OMB Control Number: 0938-1148 Attachment 3.1-L- [| OMB Expiration date: 10/31/2014

General Assurances ABP10

Economy and Efficiency of Plans

The state/territory assures that Alternative Benefit Plan coverage is provided in accordance with Federal upper payment limit requirements and other economy and efficiency principles that would otherwise be applicable to the services or delivery system through which the coverage and benefits are obtained.

Economy and efficiency will be achieved using the same approach as used for Medicaid state plan services. Yes

Compliance with the Law

The state/territory will continue to comply with all other provisions of the Social Security Act in the administration of the state/ territory plan under this title.

The state/territory assures that Alternative Benefit Plan benefits designs shall conform to the non-discrimination requirements at 42 CFR 430.2 and 42 CFR 440.347(e).

The state/territory assures that all providers of Alternative Benefit Plan benefits shall meet the provider qualification requirements of the Base Benchmark Plan and/or the Medicaid state plan.

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 5 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.

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C s Alternative Benefit Plan FEICIAL OMB Control Number: 0938-1148

Attachment 3.1-L- [] OMB Expiration date: 10/31/2014 Payment Methodology ABP1I1

Alternative Benefit Plans - Payment Methodologies

The state/territory provides assurance that, for each benefit provided under an Alternative Benefit Plan that is not provided through managed care, it will use the payment methodology in its approved state plan or hereby submits state plan amendment Attachment 4.19a, 4.19b or 4.19d, as appropriate, describing the payment methodology for the benefit.

An attachment is submitted.

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 5 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.

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Page 1 of 1

TN NO: VT 13-029 Approval Date: 1.15.14 Effective Date: 1.01.14 Supersedes TN: NEW

ABP11 Page 1 of 1

Table of Contents

State/Territory Name: Vermont

State Plan Amendment (SPA) #: 14-0006MM7

This file contains the following documents in the order listed:

1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages 4) Additional Attachments that are part of the state plan

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

JFK Federal Building. Government Center

Room 2275

Boston, Massachusetts 02203

CMS

CENTERS FOR MEDICARE & MEDICAID SERVICES

Division of Medicaid and Children's Health Operations / Boston Regional Office

July 17, 2014

Douglas A. Racine, Secretary Agency of Human Services 208 Hurricane Lane, Suite 103 Williston, VT 05495

Dear Secretary Racine:

We are pleased to enclose a copy of approved State plan amendment (SPA) No. 14-0006MM7. This SPA was approved on June 18, 2014 with an effective date of January 1, 2014, as requested by your Agency.

This SPA transmits a proposed amendment to your approved Title XIX State plan to indicate that hospitals in the State determine eligibility presumptively under the option at 42 CFR 435.1110, and that the State provides Medicaid coverage for individuals determined presumptively eligible

under this provision.

If there are questions, please contact Lynn Wolfsfeld at (410) 999-4004.

Sincerely, /s/

Richard R. McGreal Associate Regional Administrator

Enclosure

ce: Mark Larson, Commissioner Lindsay Parker, Health Program Administrator, Policy Unit

Medicaid State Plan Eligibility: Summary Page (CMS 179)

State/Territory 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.

VT 14-006

Vermont

Proposed Effective Date 01/01/2014 (mm/dd/y

Federal Statute/Regulation Citation 24 CFR 435.1110

Federal Budget Impact

Federal Fiscal Year Amount

First Year 2014 $0.00

Second Year 2015 $0.00

Subject of Amendment

This amendment seeks to modify the state plan to allow qualified hospitals in the State to determine presumptive eligibility for Vermont Medicaid coverage for certain groups of individuals deemed presumptively eligible under 24 CFR 435.1110. The proposed amendment is effective January 1, 2014.

Governor's Office Review Governor's office reported no comment

Comments of Governor's office received Describe:

No reply received within 45 days of submittal

Other, as specified Describe: Signature of Secretary of Administration

Signature of State Agency Official Submitted By: Lindsay Parker Last Revision Date: Jun 16, 2014

Submit Date: Mar 28, 2014

Plan Approved - One Copy Attached Date Approved: 6/18/14 Signature of Regional Official

Date Received: 3/28/14 Effective Date of Approved Material: 1/1/14

Typed Name: Richard R. McGreal

Division of Medicaid and Children's Health Operations, Boston Regional Office

Medicaid Eligibility OFFICIAL

OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Presumptive Eligibility by Hospitals $21

42 CFR 435.1110

One or more qualified hospitals are determining presumptive eligibility under 42 CFR 435.1110, and the state is providing Medicaid coverage for individuals determined presumptively eligible under this provision.

@ Yes (No

The state attests that presumptive eligibility by hospitals is administered in accordance with the following provisions: [@] A qualified hospital is a hospital that: Participates as a provider under the Medicaid state plan or a Medicaid 1115 Demonstration, notifies the Medicaid agency of

[Bi] its election to make presumptive eligibility determinations and agrees to make presumptive elig lity determinations consistent with state policies and procedures.

Has not been disqualified by the Medicaid agency for failure to make presumptive eligibility determinations in accordance

[@) with applicable state policies and procedures or for failure to meet any standards that may have been established by the Medicaid agency.

Assists individuals in completing and submitting the full application and understanding any documentation requirements.

@ Yes C No

{@] The eligibility groups or populations for which hospitals determine eligibility presumptively are:

(®) Pregnant Women

{) Infants and Children under Age 19

[B) Parents and Other Caretaker Relatives

[B®] Adult Group, if covered by the state

[HJ Individuals above 133% FPL under Age 65, if covered by the state

{W) Individuals Eligible for Family Planning Services, if covered by the state

[B] Former Foster Care Children

[B) Certain Individuals Needing Treatment for Breast or Cervical Cancer, if covered by the state

(J Other Family/Adult groups:

L Eligibility groups for individuals age 65 and over

(5 Eligibility groups for individuals who are blind

( Eligibility groups for individuals with disabilities

(F Other Medicaid state plan eligibility groups

LD Demonstration populations covered under section 1115

The state establishes standards for qualified hospitals making presumptive eligibility determinations.

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TN No. VT 14-O006MM7 Effective Date: 1/1/14 Supecedes: NEW Approval Date 6/18/14

Medicaid -Eligibility

@ Yes (No

Select one or both:

The state has standards that relate to the proportion of individuals determined presumptively eligible who submit a regular application, as described at 42 CFR 435.907, before the end of the presumptive eligibility period.

The state will establish performance standards in this area after establishing baseline data for a

Description of standards:| . analy aner P . period of 12 months. See complete list of performance areas below.

The state has standards that relate to the proportion of individuals who are determined eligible for Medicaid based on the submission of an application before the end of the presumptive eligibility period.

For the first 12 months, the state will establish baseline data, and will require 100% compliance with data reporting, after which performance standards will be set in the following areas:

1) The number of PE applications submitted

2) The proportion of those individuals approved for PE that complete and submit an application for full ongoing coverage

Description of standards: |3) The proportion of those individuals approved for PE and that complete and submit an application for full ongoing coverage who are determined eligible for full ongoing benefits

4) The accuracy of Hospitals’ determination that applicants do not have coverage

5) The accuracy of Hospitals’ determination that applicants do not have a prior period of PE in the preceding twelve month period

[B) The presumptive period begins on the date the determination is made. [B] The end date of the presumptive period is the earlier of:

The date the eligibility determination for regular Medicaid is made, if an application for Medicaid is filed by the last day of the month following the month in which the determination of presumptive eligibility is made; or

The last day of the month following the month in which the determination of presumptive eligibility is made, if no application for Medicaid is filed by that date.

[B) Periods of presumptive eligibility are limited as follows: @ No more than one period within a calendar year. C No more than one period within two calendar years.

No more than one period within a twelve-month period, starting with the effective date of the initial presumptive eligibility period.

C Other reasonable limitation: The state requires that a written application be signed by the applicant, parent or representative, as appropriate. @ Yes (© No

C The state uses a single application form for Medicaid and presumptive eligibility, approved by CMS.

3 The state uses a separate application form for presumptive eligibility, approved by CMS. A copy of the application form is included.

Page 2 of 3

TN No. VT 14-O006MM7 Effective Date: 1/1/14 Supecedes: NEW Approval Date 6/18/14

Medicaid Eligibility °°"

An attachment is submitted.

[B] The presumptive eligibility determination is based on the following factors:

The individual’s categorical or non-financial eligibility for the group for which the individual’s presumptive eligibility is [] being determined (e.g., based on age, pregnancy status, status as a parent/caretaker relative, disability, or other requirements specified in the Medicaid state plan or a Medicaid 1115 demonstration for that group)

a Houschold income must not exceed the applicable income standard for the group for which the individual's presumptive eligibility is being determined, if an income standard is applicable for this group.

State residency [X] Citizenship, status as a national, or satisfactory immigration status

The state assures that it has communicated the requirements for qualified hospitals, and has provided adequate training to the hospitals. A copy of the training materials has been included.

An attachment is submitted.

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 40 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.

Page 3 of 3

TN No. VT 14-0006MM7 Effective Date: 1/1/14 Supecedes: NEW Approval Date 6/18/14

y HEALTH CONNECT

Find the plan that's right for you.

Application for Presumptive Eligibility for Medicaid

OFFICIAL You can use this form to apply if you are a patient of the hospital, a patient’s family member, or a community member.

Use this form to find out quickly if you qualify for presumptive eligibility for Medicaid. Presumptive eligibility offers you and your family immediate access to health care while you apply for regular Medicaid or other health coverage.

To find out if you qualify for regular Medicaid or other health coverage, you must complete the Vermont Health Connect Application. While you wait to learn if you qualify for regular Medicaid or other health coverage, you can get your health services through presumptive eligibility for Medicaid.

To apply for regular Medicaid you can apply online at HealthConnect.Vermont.gov, in person with an assistor, over the phone at 1-855-899-9600, or by mailing in an application.

Who can qualify You can qualify for presumptive eligibility for Medicaid if you meet all of these rules:

for presumptive eligibility for ‘i

= Your income is below the monthly limit = You area U.S. citizen, U.S. national, or eligible immigrant You do not already have Medicaid

Medicaid? = You have not had presumptive eligibility for Medicaid in the past calendar year. Or, if you are pregnant, you have not had presumptive eligibility for Medicaid during this pregnancy. = You are in one of the groups that qualifies for presumptive eligibility for Medicaid:

Children under age 19

Parents and caretaker relatives

Pregnant women

Other adults age 19-64

People under age 26 who were in foster care at age 18 (no income limit) Individuals in treatment for breast and cervical cancer]

Get help with this : : application Ask your hospital representative for assistance If you need (Arabic) 1-855-899-9600 p+ al 28, 8 G6 pad 2G Las) a Ako su Vam potrebne usluge tumacenja, pozovite 1-855-899-9600. (Bosnian) interpretation s : ! . pum;jyef Oefaqmifr_vkyfief;udktvdktSdygu 1-855-899-9600 odk«zkef;qufac:yg? (Burmese) services... Si vous avez besoin de services d’interprétation, appelez le 1-855-899-9600. (French) Mugihe woba ushaka impfashanyo yo gusigurirwa, hamagara uyu murongo 1-855-899-9600. (Kirundi) Fe TISeS STN AaTH SA TVA, 1-855-899-9600 At Het AeFeHA| (Nepali) Haddii aad u baahan tahay adeegyo turjumaan, wac 1-855-899-9600. (Somali) Si usted necesita servicios de interpretacion, llame al 1-855-899-9600. (Spanish) Ikiwa unahitaji huduma za ukalimani, piga simu 1-855-899-9600. (Swahili) Néu quy vi can dich vu théng ng6n, hay goi 1-855-899-9600. (Vietnamese) Questions? Ask your hospital representative or call usat 1-855-899-9600. The call is free. 1

X (TTY: 1-888-834-7898). Or visit HealthConnect.Vermont.gov.

Tell us about yourself OFFICIAL

We ask for this information so that we can contact you about this application.

Name (first, middle, last)

Home address (leave blank if you don’t have one)

City State ZIP code

Mailing address (if different from home address)

Phone number (if you have one) Email address (if you have one)

Tell us about your family

List yourself and the members of your immediate family who live with you. Include your spouse and your children under age 19, or ifa full time student under age 21. Do not list other relatives or friends even if they live with you.

Name Date of Relationship | Applying for Already has State policy: U.S. Citizen, State policy: (first, middle, last) birth to you presumptive Medicaid? U.S. National, or eligible Resident of State? (XX/XX/ eligibility for (Yes or No) immigrant? (Yes or No) XXXX) Medicaid? - ee (YesorNo) -! (Yes or No) Answer for family members who are applying. If a person is not applying, you do not have to answer these questions for that person. (Same as above) (Self) ee a — _ —

Questions? Ask your hospital representative or call usat 1-855-899-9600. The call is free. 2 (TTY: 1-888-834-7898). Or visit HealthConnect.Vermont.gov.

OFFICIAL

Other questions

Answer these questions for yourself and your family members listed in Section 2. Your answers will make it easier to find out if you and any family members qualify.

Is anyone pregnant, even if she is not applying for presumptive eligibility for Medicaid]? Clyves [] No

Tf YOS, WHO? creecsssnessnetntinenennensse .. How many babies does she expect?...

Isanyone who is applying for presumptive eligibility for Medicaid receiving Medicare?] Dyes [] No

If yes, who?

Is anyone who is applying for presumptive eligibility for Medicaid a parent or caretaker relative? Clyves [] No For example, a grandparent who is the main person taking care of a child.

If yes, who?

Was anyone who is applying for presumptive eligibility for Medicaid in foster care at age 18?

Dyes FL) No If YES, WHO? cesssssesetatesntnnintintntisinnatntissinnansnsstnnstsnenntineinietntnnsnstinsiinisisintusustininininrniseinieiinieieeinnvinnieneeintieansnenusiniuiistiinsissnseessse Isanyone who is applying for presumptive eligibility for Medicaid being treated for Oyves [No breast or cervical cancer? IP YES, WHO? wsisnutnnininninnniinninininiininininntninnninintineinnitinintniiniiinniutiinininiiiteiininiiesissiniinsusnitnstnsnttneats Tell us about your family’s income Write the total income before taxes are taken out for all family members listed in Section 2. w Job income For example, wages, salaries, and self-employment income. AMOUNE S...csccscnentnmeneieineneueitnnanaeneaieie How often? (check one) [_] Weekly (Biweekly [] Monthly [J Yearly ~ Other income Forexample, unemployment checks, alimony, or disability payments from the Social Security Administration (“SSDI”). Do not include Supplemental Security Income (“SSI payments”) or any child support you receive. AROUNE S sinccncenncncaneccanausemacmasmnees How often? (check one) [_] Weekly CI Biweekly [Monthly [] Yearly canemi cats nee ears pc AE UE 2 Ae oo oe ae sR Sign this form here By signing, you are swearing that everything you wrote on this form is true as far as you know. We will keep your information secure and private. Your signature: Date: Questions? Ask your hospital representative or call usat 1-855-899-9600. The call is free. 3

(TTY: 1-888-834-7898). Or visit HealthConnect.Vermont.gov.