us-vt/policy/cms/medicaid-state-plan/spa

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us-vt/policy/cms/medicaid-state-plan/spa — Axiom

(vt-11-008)(approval-document)(page-2)Page 2#

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 PAGE NUMBER OF THE SUPERSEDED PLAN SECTION : OR ATTACHMENT (if Applicable):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

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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

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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

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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

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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

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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

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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

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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

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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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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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.

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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

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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

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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

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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

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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

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ABP2a Page 1 of 1

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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

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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

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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

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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.

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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.

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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.

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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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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).

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

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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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.

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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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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.

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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.

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OFFICIAL

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OFFICIAL __ If you qualify for presumptive eligibility for Medicaid, what happens next?

= You will get a notice from the hospital saying you were approved.

= You can start using your presumptive eligibility for Medicaid coverage right away for Medicaid covered services such

as doctor visits, hospital care, and some prescription drugs. You can go to any health care provider who accepts Medicaid, starting the day you are approved.

e To start using your presumptive eligibility for Medicaid, the hospital will give you a notice saying you are

approved. Use the notice to get services until you get a card in the mail. If you lose the notice, you can call 1-855- 899-9600. If the notice says you qualify for presumptive eligibility for Medicaid because you are pregnant, you can get care at

outpatient clinics or other places in the community. Presumptive eligibility for Medicaid will not cover the cost if you are admitted to a hospital.

= If youdo not complete a Vermont Health Connect application to see if you qualify for regular Medicaid or other health

coverage, your presumptive eligibility for Medicaid coverage will end on the last day of the month after the month you are approved.

™» For example, if you qualified for presumptive eligibility for Medicaid in January, it will end on the last day of February.

= To see if you qualify for regular Medicaid or other health coverage, you can apply online, in person with

an assister, over the phone, or by mailing in an application. The hospital will provide you with an application.

If you do not qualify for presumptive eligibility for Medicaid, what happens next?

You will get a notice from the hospital saying you were not approved. You cannot appeal the hospital’s decision. BUT, you can still apply for regular Medicaid or other health coverage using the Vermont Health Connect application.

To apply for 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.

Questions? Ask your hospital representative or call usat 1-855-899-9600. ‘The call is free. (TTY: 1-888-834-7898). Or visit HealthConnect.Vermont.gov.

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Revision: HCFA-PM-91-4 (BPD) SUPPLEMENT 8a to ATTACHMENT 2.6-A October 1998 Page 3 OFFICIAL

OMB No.: 0938- STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State: VERMONT

MORE LIBERAL METHODS OF TREATING INCOME UNDER SECTION 1902(r)(2) OF THE ACT*

L] Section 1902 (f) XX] Non-Section 1902 (f) State

For medically needy individuals under 1902(a)(10)(C):

(1)

(2)

When determining the medically needy eligibility of a parent (including a step-parent and an adoptive parent), disregard the portion of the parent’s countable income deemed to a child under age 18, or to a child age 18, 19, or 20 who is living in the parent’s household unless the child makes a monthly or more frequent room or board payment to the parent and is either pregnant or a parent whose own child is living in the household. For example, for a parent with two children under the age of 18, one-third of the parent’s income would be allocated to each child and subtracted from the parent’s income.

When determining the medically needy eligibility of a parent/caretaker relative, pregnant woman, or child applicant whose spouse is a member of the applicant’s household, disregard the portion, based on family size, of the applicant’s countable income deemed to the applicant’s spouse. In turn, disregard the portion, based on family size, of the spouse’s countable income retained for the spouse’s own support and the support of other family members for whom the spouse is financially responsible. For example, for a married parent with two children under the age of 18, one quarter of the parent’s income would be allocated to the spouse and one quarter to each child, thereby subtracting three quarters of the parent’s income; in turn, three quarters of the spouse’s income would be retained by the spouse (one quarter for the spouse and one quarter for each of the two children) and the remaining one quarter of the spouse’s income would be added to the remaining one quarter of the parent’s income to determine the parent’s total income for purposes of medically needy eligibility.

TN No.

14-008 Effective Date: 04/01/14

Supersedes TN No. __02-06 Approval Date: 05/08/15

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Page 1 of 1 Medicaid Eligibility Transmittal Number: VT State Name: Vermont OMB Control Number: 0938‐1148 - 15 - 0002 Medicaid Eligibility Marriage Policy S12 1902(e)(14)(G) 1902(a)(17) With respect to individuals for whom the state must complete a determination of income either based on MAGI or for MAGI- excepted groups utilizing AFDC-related or SSI-related methodologies, the state: ■ Recognizes same-sex couples as spouses, if they are legally married under the laws of the state, territory, or foreign jurisdiction in which the marriage was celebrated. Does not recognize same-sex couples as spouses, even if they were legally married in a state, territory, or foreign jurisdiction that recognizes same-sex marriages. With respect to individuals whose eligibility for Medicaid is based on eligibility for another benefit program, and for whom the state does not complete a determination of income for Medicaid eligibility, the state will not make any determination concerning marital status. Medicaid eligibility will continue to be based on the determination of eligibility for the applicable benefits. ■ The option elected above, with respect to income determinations, also governs the state’s definition for post-eligibility issues, including spousal impoverishment, asset transfers and estate recovery rules, to the degree permitted by state law. ■ 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 1 hour 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.20141021 TN No: 15-0002 Supersedes TN No: NEW Approval Date: 3/26/15 S12 - 1 Effective Date: 1/1/15

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OFFICIAL

ATTACHMENT 3.1-A Page 13A

State: VERMONT

AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE CATEGORICALLY NEEDY

29. Integrated Care Models

Vermont Medicaid Shared Savings Program (VMSSP)

A. Providers

Accountable Care Organizations (ACOs) are organizations of healthcare and social service providers. ACOs must include primary care providers who provide primary care case management services under authority of $1905(t) of the Social Security Act, which includes location, coordination and monitoring of health care services. Pursuant to section 1905(t)(2)(A) - (B) of the Act, an ACO must be, employ, or contract with a physician, a physician group practice, or an entity employing or having other arrangements with physicians to provide such services. The ACO provides services in the following specialty areas: internal medicine, general medicine, geriatric medicine, family medicine, pediatrics, and naturopathic medicine.

B. Service Descriptions

ACOs are under contract to share savings gained on the total cost of care (TCOC) for defined services. Services included in the TCOC for year two include: inpatient hospital, outpatient hospital, physician (primary care and specialty), nurse practitioner, physical and occupational therapy, mental health facility and clinic, ambulatory surgery center, federally qualified health center, rural health center, chiropractor, podiatrist, psychologist, optometrist, optician, independent laboratory, home health, hospice, prosthetic/orthotics, medical supplies, durable medical equipment, emergency transportation, dialysis facility.

Performance year three may include an expanded TCOC. A full list of services will be posted on the Department of Vermont Health Access (DVHA) website in advance of the beginning of the

performance year, and can be found at: http://dvha.vermont.gov/administration/totalcostofcare.pdf

ACOs must be under contract with the State and have demonstrated through the procurement process that:

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OFFICIAL

ATTACHMENT 3.1-A Page 13B

State: VERMONT

AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE CATEGORICALLY NEEDY

29. Integrated Care Models (Continued)

1. They maintain full scope of primary care services, including locating, coordinating, and monitoring primary care and lab services, are provided by their ACO participants;

2. They will coordinate innovative approaches to sharing data and information, strengthening coordination at a local level, creating new partnerships, and disseminating evidence-based practices or clinical pathways;

3. They will establish partnerships with community-based organizations and public health resources;

4, They will establish a process to engage patients and their families meaningfully in the care they receive;

5. They will have the capacity to receive data from the State via secure electronic processes;

6. They will use data provided by the State to identify opportunities for recipient engagement and to stratify its population to determine the care model strategies needed to improve outcomes;

7. They will enhance coordination of care with other medical providers, which may include ACO participants or other independent or state entities, who are responsible for pertinent aspects of care; and,

8. They will participate in quality measurement activities as required by the State.

A. Outcomes

The overall goal of the program is to improve quality of care and contain the growth of healthcare costs. The payment of savings is contingent upon meeting quality of care thresholds. The measure set being used to assess quality for year two of the program contains ten payment measures and twenty reporting measures. This measure set includes process and outcome measures based on a combination of claims, clinical and survey data. The measures currently span ten domains. The measure set will be reviewed and updated annually. Changes in the measure set will be derived from recommendations generated as part of the Vermont Health Care Innovation Project. Please refer to the

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OFFICIAL

TITLE XIX Attachment 4.19-B State: Vermont Page 14 METHODS AND STANDARDS OF ESTABLISHING PAYMENT RATES - OTHER MEDICAL CARE (Continued)

A. Attribution Methodology Beneficiaries will be attributed to ACOs in the VMSSP through the following process:

1. Retrospective claims attribution using a methodology in which claims for eligible beneficiaries are identified for the presence of qualifying Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) codes billed in the previous twelve months by primary care providers enrolled with Medicaid.

For eligible beneficiaries not attributed by retrospective claims attribution, assign the beneficiary to his/her primary care provider that he/she selected or was auto-assigned upon enrollment.

Attribution is done at the rendering provider and billing provider TIN level that is affiliated with an ACO participant. Any ACO participant that includes at least one ACO rendering provider with attributed lives to him/her must have an exclusive participant relationship with only one ACO in the VMSSP. Those ACO participants who do not attribute lives can participate in multiple ACOs in the VMSSP.

D. Patient Freedom of Choice Beneficiaries will have freedom of choice with regard to their providers consistent with their benefit as described in 42 CFR 431.51.

E. Risk Score Risk adjustment is done using the most recently released CMS community version of the Hierarchical Condition Classification software.

F. Total Cost of Care

Participants in the VMSSP are responsible for the Total Cost of Care (TCOC) of their attributed population of beneficiaries in each performance year. The TCOC is comprised of a defined set of core services. Core services included in the TCOC for year two include: inpatient hospital, outpatient hospital, physician (primary care and specialty), nurse practitioner, physical and occupational therapy, mental health facility and clinic, ambulatory surgery center, federally qualified health center, rural health center, chiropractor, podiatrist, psychologist, optometrist, optician, independent laboratory, home health, hospice, prosthetic/orthotics, medical supplies, durable medical equipment, emergency transportation, dialysis facility. The TCOC is the sum of payments made for core services rendered in the given performance year. Expenditures for attributed beneficiaries are capped at the value of the 99" percentile of expenditures for the attributed lives within enrollment categories. ;

Core services are determined by the State annually. DVHA determines the core service applicable in each performance year prior to the start of the prograin year. Services not in the TCOC calculations are called

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OFFICIAL

TITLE XIX Attachment 4.19-B State: Vermont Page 15

METHODS AND STANDARDS OF ESTABLISHING PAYMENT RATES - OTHER MEDICAL CARE (Continued) non-core services. DVHA maintains the list of core and non-core services applicable to each performance year, which can be found at: http://dvha.vermont.gov/administration/totalcostofeare.pdf

G. Expected Total Cost of Care (TCOC)

The expected total cost of care calculation uses three historic benchmark years of claims data. In performance year two, calendar year 2015 (CY 2015), the three historic benchmark years are CY 2011, 2012 and 2013. The benchmark years will be updated on a rolling basis annually—that is, the oldest year of data used in the calculations of the benchmark in the previous performance year will be dropped and a more current year will be added to the benchmark reflecting data closer to the performance year.

The risk adjustment process described in section E and the truncation calculation described in section F are performed and a total ACO eligible population compound annual growth rate (CAGR) is calculated from re- priced data in the three benchmark years.

The expected TCOC is computed for each enrollment category separately.

The formula applied is:

(Truncated, risk adjusted PMPM from last year in the benchmark period) * (I1+CAGR) * (1+CAGR)

In some years, an additional adjustment may be made to the expected TCOC to account for rate changes made by DVHA between the benchmark years and the performance year that would not be reflected in the CAGR.

H. Actual Total Cost of Care

The actual TCOC calculation will be derived from claims for actual attributed population of each ACO during a performance year. Risk-adjustment and truncation are also performed as described in sections E and F.

I. Gain and Loss-Sharing

The maximum savings rate in the VMSSP is fifty percent. There are no loss-sharing and/or recoupment requirements under the program for the first three years.

J. Quality and Patient Experience Measures Requirements for Reporting Measures The VMSSP uses the Gate and Ladder methodology to calculate a Quality Score (QS) that is then used in

the calculation of the payment of shared savings as described in section A. The Gate and Ladder are defined as follows:

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OFFICIAL TITLE XIX Attachment 4.19-B State: Vermont Page 16

METHODS AND STANDARDS OF ESTABLISHING PAYMENT RATES - OTHER MEDICAL CARE (Continued) Gate -- The ACO must earn a minimum number of the eligible points as stated in its contract in order to receive a share of any generated savings. If the ACO is not able to meet the overall quality gate, then it will not be eligible for any shared savings.

Ladder -- In order to retain a greater portion of the savings for which the ACO is eligible, the ACO must achieve higher performance levels for the measures. There are six steps on the ladder, which reflect increased levels of performance.

For year two of the VMSSP pilot, the ACO’s performance on the payment measures will be compared to performance targets. The targets are based either on national Medicaid HEDIS benchmarks or ACO-specific prior year performance. When the targets are based on national Medicaid HEDIS benchmarks, 1, 2 or 3 points will be assigned based on whether the ACO performed at the national 25th, 50th or 75" percentile for the measure. When no national benchmarks are available, the ACO will receive 0 points for a statistically significant decline over prior year performance, 2 points for no statistically significant change over prior year performance, and 3 points for a Statistically significant improvement over prior year performance.

In addition to earning points for attainment of quality relative to national benchmarks, ACOs can earn | additional point for every payment measure that is compared to a national benchmark for which they achieved statistically significant improvement relative to the prior program year. Improvement points will not be available for measures that already use ACO-specific improvement targets instead of national benchmarks.

The core measure set and Gate and Ladder threshold and scores are subject to change prior to the beginning of each performance year. Current measure sets, thresholds and scores can be found at the following web address:

http://dvha.vermont.gov/administration/performance-measures-and-shared-savings.pdf.

I. Monitoring and Reporting

The VMSSP includes a series of internal monitoring and reporting measures that are scheduled to be calculated and analyzed quarterly or at minimum, semi-annually.

As a condition of continuance beyond December 31, 2016, Vermont will evaluate the program to demonstrate improvement against past performance using cost and quality data to determine whether the payment methodology has achieved or needs revisions to achieve the goals of improving health, increasing quality and lowering the growth of health care costs. With regard to methodological changes and moving towards a more robust metric framework that is tied to payment, Vermont will reflect in its annual updates any changes to the measures being used to assess program performance and/or determine payment eligibility and distribution.

Vermont will: 1. Provide CMS, at least annually, with data and reports evaluating the success of the program against the goals of improving health, increasing quality and lowering the growth of health care costs; 2. Provide CMS, at least annually, with updates, as conducted, to the state’s metrics;

3. Review and renew the payment methodology as part of the evaluation; and,

4. Make all necessary modifications to the methodology, including those determined based on the evaluation and program success, through State Plan Amendment updates.

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TN# _ 14-017 Approval Date: 9/02/15

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Revision: HCFA-PM-91-4 (BPD) SUPPLEMENT 8b to ATTACHMENT 2.6-A

August 1991 Page 2 OFFICIAL OMB No.: 0938-

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: VERMONT MORE LIBERAL METHODS OF TREATING RESOURCES UNDER SECTION 1902(r)(2) OF THE ACT

* SSl-related Medicaid. (aged, blind and disabled individuals including individuals who are described at 1902(a)(10)(A)(ii), 1902(a)(10)(C)(i)CILI) and 1905(p) of the Social Security Act who are not receiving SSI/AABD cash assistance or deemed to be cash assistance recipients.

I. Non exempt real property which is up for sale is excluded as long as owners verify that they are making reasonable efforts to sell it.

Automobiles of any value are excluded. No limit is placed on the equity value of property used to produce goods for home consumption.

Life estates in real property are excluded when the owner does not retain the power to sell the real property.

MW & WwW wv

Separately identifiable burial funds designated for burial expenses, either singly or in combination, are exempt in an amount not to exceed $10,000. The burial funds must be designated by the title of the fund or by sworn

statement provided to the department. The burial funds in conjunction with the irrevocable burial trust referenced in Supplement 10 to Attachment 2.6-A, page 1, last paragraph, cannot exceed $10,000 in total.

6. Annuities, promissory notes, and similar resources that produce income are exempt resources if they would otherwise be countable by SSI as long as they meet the following criteria.

(i) Annuities are not a countable resource if they: have no beneficiary other than an individual requesting Medicaid or his or her spouse; and provide for payments to applicants or their spouses in equal intervals and equal amounts; and do not exceed the life expectancy of the applicants or their spouses, as determined by the department; and return to the beneficiary at least the amount used to establish the contract and any additional payments plus any earnings, as specified in the contract; and do not pay anyone other than the applicant, the applicant’s spouse, even if the applicant or spouse dies before the payment period ends. The department will also consider an annuity to meet the requirements above, if the owner of the annuity elects to designate Vermont Medicaid as the primary beneficiary up to the amount of long-term care payments it made, and names a contingent beneficiary other than the applicant or spouse to receive any surplus after Vermont Medicaid is paid.

(ii) Promissory notes and similar resources that produce income are not a countable resource if: (1) they meet the requirements in subsection (i) above, or (2) the individual owned a nonnegotiable or nonassignable promissory note executed before September 1, 2005 and the individual or spouse can expect to receive the full fair market value of the resource within the expected lifetime of the individual or spouse, as determined by the department.

7. Resources set aside in a separate bank account in the name of the Medicaid beneficiary are exempt in an amount not to exceed $30,000. The funds may only be spent on medical care, assistive technology devices or home modifications not covered by Medicare, private insurance or Medicaid. They must be found to be reasonable and necessary to assist an individual in achieving or maintaining independent living. Up to $500 per month of these resources may be spent for medical care and assistive technology devices. A one time expenditure of up to $7,500 of these resources may be spent for home modifications.

*For qualified children eligible (using AFDC income and asset requirements) under 1902(a)(10)(A)(i) CD) 1. Disregard all assets.

*BBA Work Incentive Eligibility Group (1902(a)(10)(A)(ii)(XILD): 1. Savings from excluded income are excluded. 2. An additional $8,000 in resources is disregarded for individuals; $12,000 for couples.

TN No. _ 16-0002 Effective Date: 1/1/18 Supersedes TN No. _08-06 Approval Date: 8/7/17

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DEPARTMENT OF I.ItsALTII & IJUMAN SERVICES Ccntcrs lor Mcdicare & Mcdictid Scrv¡ccs JFK Federâl Building, Cov(]rnmont Cenler Room 2275 Boston, Massachusetts 02203 CENTERS fOIì MIDICARE & MEDICAID SERVIC$ Division of Medicaid and Childrenrs Health Operations / Boston Regional Oflice ctums March29,2017 Al Gobeille, Secretary Vermont Agency of 0l{uman Services 280 State Drive - Center Building Waterbury, VT Dear Secretary Gobeille: This letter is being sent as a companion to Centers for Medicare & Medicaid Services (CMS) approval of State Plan Amendment (SPA) transmittal VT- No. 16-0017 . Our review of this submission included a review ofthe state's proposal to exempt cost sharing for sexual-assault related services as well as the Gl, G2a, G2b, G2c, G3 pages of this SPA. Regarding the process to track each household's aggregate incurred premiums and cost sharing, as required under 42 CFR $447.56(Ð, the state is cumently performing a calculation and produces a reporl within 90 days after the end ofeach quarter identifying ifany Medicaid beneficiaries have exceeded the aggregate limit of 5% ofthe household's income for cost sharing for that quarler. If the aggregated limit is exceeded, the state refunds the excess amount to the beneficiary. Per 42 CFR $447.56(Ð(3), in addition to implementing a process to track each household's incurred premiums and cost sharing, states must inform beneficiaries and providers when a beneficialy has incurred out-of-pocket premium and cost sharing expenses up to the aggregale household limit. When the limit has been reached, the individual is no longer subjected to cost sharing for the reminder ofthe household's cap period. Under the state's current process, due to its retrospective nature; the state is not notifying the beneficiary when the aggregafe household limit has been reached, nor is it notifying the provider and capping the cost-sharing before the beneficiary incurs more than the permissible 5% limit. CMS understa¡ds that the state is working towards an alternative process to track each household's incurred premiums and cost sharing that will address these concerns. As discussed during the July 26,2016letter and its enclosed documents regarding Vermont's mitigation plan for addressing def,rciencies in the Vetmont Health Connect eligibility and enrolhnent system, tlìe state is cunently evaluating a feasible timeline for full implementation of the MMIS intelface, which will include an alternative method for tracking premiums and cost- sharing amounts to the 5% aggregated limit per Medicaid household. We ur.rderstand that the state's current process to track premiums and cost-sharing amount is temporal and will be replaced with an alternative process once the MMIS interface is cornpleted. The alternative process will better address real time identifications ofindividuals who have reached their

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Page 1 of 2 Medicaid Premiums and Cost Sharing State Name: Vermont OMB Control Number: 0938‐1148 Transmittal Number: VT - 16 - 0017 Expiration date: 10/31/2014 Cost Sharing Requirements G1 1916 1916A 42 CFR 447.50 through 447.57 (excluding 447.55) The state charges cost sharing (deductibles, co-insurance or co-payments) to individuals covered under Medicaid. Yes The state assures that it administers cost sharing in accordance with sections 1916 and 1916A of the Social Security Act and 42 CFR 447.50 through 447.57. ✔ General Provisions The cost sharing amounts established by the state for services are always less than the amount the agency pays for the service. ✔ No provider may deny services to an eligible individual on account of the individual's inability to pay cost sharing, except as elected by the state in accordance with 42 CFR 447.52(e)(1). ■ The process used by the state to inform providers whether cost sharing for a specific item or service may be imposed on a beneficiary and whether the provider may require the beneficiary to pay the cost sharing charge, as a condition for receiving the item or service, is (check all that apply): ■ The state includes an indicator in the Medicaid Management Information System (MMIS) The state includes an indicator in the Eligibility and Enrollment System The state includes an indicator in the Eligibility Verification System The state includes an indicator on the Medicaid card, which the beneficiary presents to the provider Other process Description: Pursuant to Section 1916(e) of the ACT, the State permits the provider, in the absence of knowledge or indications to the contrary, to accept the Medicaid recipient's assertion that he or she is unable to pay. Contracts with managed care organizations (MCOs) provide that any cost-sharing charges the MCO imposes on Medicaid enrollees are in accordance with the cost sharing specified in the state plan and the requirements set forth in 42 CFR 447.50 through 447.57. ■ Cost Sharing for Non-Emergency Services Provided in a Hospital Emergency Department The state imposes cost sharing for non-emergency services provided in a hospital emergency department. No Cost Sharing for Drugs The state charges cost sharing for drugs. Yes The state has established differential cost sharing for preferred and non-preferred drugs. No TN#: VT-16-0017 Approval Date: 3/29/2017 Effective Date: 10/1/2016

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Page 1 of 5 Medicaid Premiums and Cost Sharing State Name: Vermont OMB Control Number: 0938‐1148 Transmittal Number: VT - 16 - 0017 Cost Sharing Limitations G3 42 CFR 447.56 1916 1916A The state administers cost sharing in accordance with the limitations described at 42 CFR 447.56, and 1916(a)(2) and (j) and 1916A(b) of the Social Security Act, as follows: ✔ Exemptions Groups of Individuals - Mandatory Exemptions The state may not impose cost sharing upon the following groups of individuals: Individuals ages 1 and older, and under age 18 eligible under the Infants and Children under Age 18 eligibility group (42 CFR 435.118). ■ Infants under age 1 eligible under the Infants and Children under Age 18 eligibility group (42 CFR 435.118), whose income does not exceed the higher of: ■ 133% FPL; and ■ If applicable, the percent FPL described in section 1902(l)(2)(A)(iv) of the Act, up to 185 percent. ■ Disabled or blind individuals under age 18 eligible for the following eligibility groups: ■ SSI Beneficiaries (42 CFR 435.120). ■ Blind and Disabled Individuals in 209(b) States (42 CFR 435.121). ■ Individuals Receiving Mandatory State Supplements (42 CFR 435.130). ■ Children for whom child welfare services are made available under Part B of title IV of the Act on the basis of being a child in foster care and individuals receiving benefits under Part E of that title, without regard to age. ■ Disabled children eligible for Medicaid under the Family Opportunity Act (1902(a)(10)(A)(ii)(XIX) and 1902(cc) of the Act). ■ Pregnant women, during pregnancy and through the postpartum period which begins on the last day of pregnancy and extends through the end of the month in which the 60-day period following termination of pregnancy ends, except for cost sharing for services specified in the state plan as not pregnancy-related. ■ Any individual whose medical assistance for services furnished in an institution is reduced by amounts reflecting available income other than required for personal needs. ■ An individual receiving hospice care, as defined in section 1905(o) of the Act. ■ Indians who are currently receiving or have ever received an item or service furnished by an Indian health care provider or through referral under contract health services. ■ Individuals who are receiving Medicaid because of the state's election to extend coverage to the Certain Individuals Needing Treatment for Breast or Cervical Cancer eligibility group (42 CFR 435.213). ■ TN#: VT-16-0017 Approval Date: 3/29/2017 Effective Date: 10/1/2016

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Page 2 of 5 Medicaid Premiums and Cost Sharing Groups of Individuals - Optional Exemptions The state may elect to exempt the following groups of individuals from cost sharing: The state elects to exempt individuals under age 19, 20 or 21, or any reasonable category of individuals 18 years of age or over. Yes Indicate below the age of the exemption: Under age 19 Under age 20 Under age 21 Other reasonable category The state elects to exempt individuals whose medical assistance for services furnished in a home and community-based setting is reduced by amounts reflecting available income other than required for personal needs. No Services - Mandatory Exemptions The state may not impose cost sharing for the following services: Emergency services as defined at section 1932(b)(2) of the Act and 42 CFR 438.114(a). ■ Family planning services and supplies described in section 1905(a)(4)(C) of the Act, including contraceptives and pharmaceuticals for which the state claims or could claim federal match at the enhanced rate under section 1903(a)(5) of the Act for family planning services and supplies. ■ Preventive services, at a minimum the services specified at 42 CFR 457.520, provided to children under 18 years of age regardless of family income, which reflect the well-baby and well child care and immunizations in the Bright Futures guidelines issued by the American Academy of Pediatrics. ■ Pregnancy-related services, including those defined at 42 CFR 440.210(a)(2) and 440.250(p), and counseling and drugs for cessation of tobacco use. All services provided to pregnant women will be considered pregnancy-related, except those services specificially identified in the state plan as not being related to pregnancy. ■ Provider-preventable services as defined in 42 CFR 447.26(b). ■ Enforceability of Exemptions The procedures for implementing and enforcing the exemptions from cost sharing contained in 42 CFR 447.56 are (check all that apply): To identify that American Indians/Alaskan Natives (AI/AN) are currently receiving or have ever received an item or service furnished by an Indian health care provider or through referral under contract health services in accordance with 42 CFR 447.56(a)(1)(x), the state uses the following procedures: ■ The state accepts self-attestation The state runs periodic claims reviews The state obtains an Active or Previous User Letter or other Indian Health Services (IHS) document The Eligibility and Enrollment and MMIS systems flag exempt recipients TN#: VT-16-0017 Approval Date: 3/29/2017 Effective Date: 10/1/2016

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Page 4 of 5 Medicaid Premiums and Cost Sharing Quarterly Monthly The state has a process to track each family's incurred premiums and cost sharing through a mechanism that does not rely on beneficiary documentation. Yes Describe the mechanism by which the state tracks each family's incurred premiums and cost sharing (check all that apply): ■ As claims are submitted for dates of services within the family's current monthly or quarterly cap period, the state applies the incurred cost sharing for that service to the family's aggregate limit. Once the family reaches the aggregate limit, based on incurred cost sharing and any applicable premiums, the state notifies the family and providers that the family has reached their aggregate limit for the current monthly or quarterly cap period, and are no longer subject to premiums or cost sharing. Managed care organization(s) track each family's incurred cost sharing, as follows: Other process: The Department of Vermont Health Access's (DVHA) fiscal agent tracks premiums and cost sharing in accordance with 42 CFR 447.56(f). Describe how the state informs beneficiaries and providers of the beneficiaries' aggregate family limit and notifies beneficiaries and providers when a beneficiary has incurred premiums and cost sharing up to the aggregate family limit and individual family members are no longer subject to premiums or cost sharing for the remainder of the family's current monthly or quarterly cap period: ■ See above. The state has a documented appeals process for families that believe they have incurred premiums or cost sharing over the aggregate limit for the current monthly or quarterly cap period. No Describe the process used to reimburse beneficiaries and/or providers if the family is identified as paying over the aggregate limit for the month/quarter: ■ DVHA reimburses beneficiaries in accordance with 42 CFR 447.56(f). Describe the process for beneficiaries to request a reassessment of their family aggregate limit if they have a change in circumstances or if they are being terminated for failure to pay a premium: ■ An individual may request a reassessment of their family aggregate limit if they have a change in circumstances or if they are being terminated for failure to pay a premium. TN#: VT-16-0017 Approval Date: 3/29/2017 Effective Date: 10/1/2016

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Page 1 of 1 Alternative Benefit Plan Attachment 3.1- OMB Control Number: 0938ဨ1148 OMB Expiration date: 10/31/2014 Voluntary Benefit Package Selection Assurances - Eligibility Group under Section 1902(a)(10)(A) (i)(VIII) 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 individuals exempt from mandatory participation in a section 1937 Alternative Benefit Plan. Yes 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 Supersedes: VT 15-0031 Transmittal Number: VT - 16-0025 Approval Date: October 19, 202 Effective Date: October 1, 2016 /

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Page 1 of 2 Alternative Benefit Plan Attachment 3.1- - OMB Control Number: 0938ဨ1148 OMB Expiration date: 10/31/2014 Selection of Benchmark Benefit Package or Benchmark-Equivalent Benefit Package ABP3 Select one of the following: The state/territory is amending one existing benefit package for the population defined in Section 1. 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. Benchmark-Equivalent Benefit Package. The state/territory will provide the following Benchmark Benefit Package (check one that applies): The Standard Blue Cross/Blue Shield Preferred Provider Option offered through the Federal Employee Health Benefit Program (FEHBP). State employee coverage that is offered and generally available to state employees (State Employee Coverage): 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. Benefits include all those provided in the approved state plan plus additional benefits. Benefits are the same as provided in the approved state plan but in a different amount, duration and/or scope. The state/territory offers only a partial list of benefits provided in the approved state plan. 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 Transmittal Number: VT - 16-0025 Supersedes: VT 15-0031 Approval Date: October 19, 2020 Effective Date: October 1, 2016 /

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Page 25 of 45 Alternative Benefit Plan Base Benchmark Benefits Not Covered due to Substitution or Duplication Collapse All Base Benchmark Benefit that was Substituted: Family Planning: Reversal of Sterilization Source: 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: 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. Remove Base Benchmark Benefit that was Substituted: Infertility Drugs with natural conception Source: 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 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. Remove Base Benchmark Benefit that was Substituted: Outpatient Hospital Fee Source: 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 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. Remove Base Benchmark Benefit that was Substituted: Outpatient Surgery Physician/Surgical Services Source: 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 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. Remove Base Benchmark Benefit that was Substituted: Urgent Care Centers or Facilities Source: Base Benchmark Transmittal Number: VT - 16-0025 Supersedes: VT 15-0031 Approval Date: October 19, 2020 Effective Date: October 1, 2016

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Page 26 of 45 Alternative Benefit Plan 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 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. Remove Base Benchmark Benefit that was Substituted: Primary Care Visit to Treat an Injury or Illness Source: 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 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. Remove Base Benchmark Benefit that was Substituted: Dental Services (not Routine) Source: 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 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. Remove Base Benchmark Benefit that was Substituted: Chiropractic Care Source: 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 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. Remove Base Benchmark Benefit that was Substituted: OLP: Routine Foot Care for diabetics only Source: Base Benchmark Transmittal Number: VT - 16-0025 Supersedes: VT 15-0031 Approval Date: October 19, 2020 Effective Date: October 1, 2016

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Page 27 of 45 Alternative Benefit Plan 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 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. Remove Base Benchmark Benefit that was Substituted: Emergency Room Services Source: 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 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. Remove Base Benchmark Benefit that was Substituted: Emergency Transportation/ Ambulance Source: 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 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. Remove Base Benchmark Benefit that was Substituted: Inpatient Hospital Services Source: 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 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. Remove Base Benchmark Benefit that was Substituted: Inpatient Physician and Surgical Services Source: 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 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. Remove Transmittal Number: VT - 16-0025 Supersedes: VT 15-0031 Approval Date: October 19, 2020 Effective Date: October 1, 2016

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Page 28 of 45 Alternative Benefit Plan Base Benchmark Benefit that was Substituted: Substance Abuse Disorder Inpatient Services Source: 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 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. Remove Base Benchmark Benefit that was Substituted: Cosmetic Surgery if reconstructive Source: 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 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. Remove Base Benchmark Benefit that was Substituted: Bariatric Surgery Source: 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 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. Remove Base Benchmark Benefit that was Substituted: Transplant-deceased donor Source: 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 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. Remove Transmittal Number: VT - 16-0025 Supersedes: VT 15-0031 Approval Date: October 19, 2020 Effective Date: October 1, 2016

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Page 29 of 45 Alternative Benefit Plan Base Benchmark Benefit that was Substituted: Transplant live donor Source: 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 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. Remove Base Benchmark Benefit that was Substituted: Mental/Behavioral Health Inpatient Services Source: 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 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. Remove Base Benchmark Benefit that was Substituted: Other Practitioner Office Visit (Nurse, Physician Source: 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 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. Remove Base Benchmark Benefit that was Substituted: Prenatal and Postnatal Care Source: 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 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. Remove Transmittal Number: VT - 16-0025 Supersedes: VT 15-0031 Approval Date: October 19, 2020 Effective Date: October 1, 2016

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Page 30 of 45 Alternative Benefit Plan Base Benchmark Benefit that was Substituted: Delivery and All Inpatient Services for Maternity Source: 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 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. Remove Base Benchmark Benefit that was Substituted: Diagnostic Test (Lab Work) Source: 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 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. Remove Base Benchmark Benefit that was Substituted: Diagnostic Tests and Imaging Source: 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 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. Remove Base Benchmark Benefit that was Substituted: Preventive Care Source: 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 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. Remove Base Benchmark Benefit that was Substituted: Nutritional Counseling Source: 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 Naturopathic Physician and Physician Services were used in order to Transmittal Number: VT - 16-0025 Supersedes: VT 15-0031 Approval Date: October 19, 2020 Effective Date: October 1, 2016

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Page 31 of 45 Alternative Benefit Plan 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. Remove Base Benchmark Benefit that was Substituted: Generic Drugs Source: 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 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. Remove Base Benchmark Benefit that was Substituted: Preferred brand, non-pref. brand, & specialty drug Source: 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 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. Remove Base Benchmark Benefit that was Substituted: Nutritional Formulae Source: 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 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. Remove Base Benchmark Benefit that was Substituted: Mental/Behavioral Health Outpatient Services Source: 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 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- Transmittal Number: VT - 16-0025 Supersedes: VT 15-0031 Approval Date: October 19, 2020 Effective Date: October 1, 2016

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Page 32 of 45 Alternative Benefit Plan shock therapy; and intensive outpatient mental health 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 mental health services, prior approval is required beginning with the 11th visit. Remove Base Benchmark Benefit that was Substituted: Neuropsychological Testing Source: 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 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. Remove Base Benchmark Benefit that was Substituted: Substance Abuse Disorder Outpatient Services Source: 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 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. Remove Base Benchmark Benefit that was Substituted: Outpatient Rehabilitation Services Source: 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 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. Remove Base Benchmark Benefit that was Substituted: Outpatient physical, speech and occupational thera Source: Base Benchmark Transmittal Number: VT - 16-0025 Supersedes: VT 15-0031 Approval Date: October 19, 2020 Effective Date: October 1, 2016

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Page 33 of 45 Alternative Benefit Plan 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. Remove Base Benchmark Benefit that was Substituted: Durable Medical Equipment Source: 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 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. Remove Base Benchmark Benefit that was Substituted: Skilled Nursing Facility Source: 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 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. Remove Base Benchmark Benefit that was Substituted: Home Health Care Services Source: 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 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. Remove Transmittal Number: VT - 16-0025 Supersedes: VT 15-0031 Approval Date: October 19, 2020 Effective Date: October 1, 2016

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Page 34 of 45 Alternative Benefit Plan Base Benchmark Benefit that was Substituted: Private-Duty Nursing Source: 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. Remove Base Benchmark Benefit that was Substituted: Hospice Services Source: 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 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. Remove Base Benchmark Benefit that was Substituted: Home Health Aide Source: 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 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. Remove Base Benchmark Benefit that was Substituted: Habilitation Autism Source: 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 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. Transmittal Number: VT - 16-0025 Supersedes: VT 15-0031 Approval Date: October 19, 2020 Effective Date: October 1, 2016

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Page 35 of 45 Alternative Benefit Plan This benefit maps to EHB 10: Pediatric services including oral and vision care. Remove Base Benchmark Benefit that was Substituted: Preventive Care/ Screening/ Immunization Source: 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 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. Remove Base Benchmark Benefit that was Substituted: Eye Glasses for Children Source: 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 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. Remove Base Benchmark Benefit that was Substituted: Dental Check-Up for Children Source: 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 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. Remove Base Benchmark Benefit that was Substituted: Family Planning: All Other Services Source: 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 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. Remove Add Transmittal Number: VT - 16-0025 Supersedes: VT 15-0031 Approval Date: October 19, 2020 Effective Date: October 1, 2016

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Page 41 of 45 Alternative Benefit Plan Authorization: Other Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: Excludes residents of nursing home or enhanced residential care facilities. Should not exceed seven days per week, 12 hours per day. Other: Adult Day Health Services is a comprehensive, non-residential program designed to address the health, safety, and psychological needs of adults through individual plans of care that may include a provision of medication administration, health monitoring and oversight, personal care, maintenance therapies, and care coordination. No prior authorization required. This benefit has the same effective date as SPA 15-007. Remove Other 1937 Benefit Provided: Targeted Case Management (4 targeted groups) Source: Section 1937 Coverage Option Benchmark Benefit Package Authorization: Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: 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) Individuals and families who have a history of child abuse or neglect, trauma, behavioral challenges, family dysfunction, and/or family violence who are in need of assistance to identify, obtain and monitor needed medical (including mental health and substance abuse), social, educational, and other services; (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; (4) Individuals who receive special education and related medically necessary Medicaid covered services pursuant to an Individualized Education Plan (IEP). Remove Other 1937 Benefit Provided: Respiratory Care Services Source: Section 1937 Coverage Option Benchmark Benefit Package Authorization: Provider Qualifications: Medicaid State Plan Transmittal Number: VT - 16-0025 Supersedes: VT 15-0031 Approval Date: October 19, 2020 Effective Date: October 1, 2016

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Page 1 of Alternative Benefit Plan Attachment 3.1- OMB Control Number: 0938ဨ1148 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. Yes 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. 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 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. ✔ Transmittal Number: VT - 16-0025 Supersedes: VT 15-0031 Approval Date: October 19, 2020 Effective Date: October 1, 2016 /

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Page 2 of 2 Alternative Benefit Plan 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 Transmittal Number: VT - 16-0025 Supersedes: VT 15-0031 Approval Date: October 19, 2020 Effective Date: October 1, 2016

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Page 1 of 2 Alternative Benefit Plan Attachment 3.1- - OMB Control Number: 0938ဨ1148 OMB Expiration date: 10/31/2014 Service Delivery Systems ABP8 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: Managed care. Fee-for-service. 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 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 #11-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. Transmittal Number: VT - 16-0025 Supersedes: VT 15-0031 Approval Date: October 19, 2020 Effective Date: October 1, 2016 /

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Page 1 of 1 Alternative Benefit Plan Attachment 3.1- - OMB Control Number: 0938ဨ1148 OMB Expiration date: 10/31/2014 Employer Sponsored Insurance and Payment of Premiums ABP9 The state/territory provides the Alternative Benefit Plan through the payment of employer sponsored insurance for participants with such coverage, with additional benefits and services provided through a Benchmark or Benchmark-Equivalent Benefit Package. Yes Provide a description of employer sponsored insurance, including the population covered, the amount of premium assistance by population, employer sponsored insurance activities including required contribution, cost-effectiveness test requirements, and benefit information: The state assures that ESI coverage is established in sections 3.2 and 4.22(h) of the state’s approved Medicaid state plan. The beneficiary will receive a benefit package that includes a wrap of benefits around the employer sponsored insurance plan that equals the benefit package to which the beneficiary is entitled. The beneficiary will not be responsible for payment of premiums or other cost sharing that exceeds nominal levels as established at 42 CFR part 447 subpart A. The state/territory otherwise provides for payment of premiums. No Other Information Regarding Employer Sponsored Insurance or Payment of Premiums: 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. Transmittal Number: VT - 16-0025 Supersedes: VT 15-0031 Approval Date: October 19, 2020 Effective Date: October 1, 2016 /

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Page 1 of 1 Alternative Benefit Plan Attachment 3.1- - OMB Control Number: 0938ဨ1148 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. V.20130807 Transmittal Number: VT - 16-0025 Supersedes: VT 15-0031 Approval Date: October 19, 2020 Effective Date: October 1, 2016 /

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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 in November 2019 amends the “VT 2016 Supplemental Drug Rebate Agreement” authorized by CMS effective July 30, 2015. 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 November 2019 supplemental rebate agreement and the approved SSDC Addendum apply to drugs dispensed beginning November 15, 2019.  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 supplemental 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. OFFICIAL __________________________________________________________________________________________ TN No. 19-0005

Effective Date: 11/15/2019 Supersedes TN No. 13-003

Approval Date: 12/13/2019

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DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 601 E. 12th St., Room 355 Kansas City, Missouri 64106 Medicaid and CHIP Operations Group June 26, 2020 VIA E-MAIL Mike Smith, Secretary Vermont Agency of Human Services 280 State Drive - Center Building Waterbury, VT 05671 Dear Secretary Smith: This letter is being sent with the Centers for Medicare and Medicaid Services’ (CMS) approval of Vermont’s State Plan Amendment (SPA) #20-0011, consistent with the State Medicaid Director letter (SMD) #10-020 published on October 1, 2010 (relating to SPA review process), to address concerns that the state has not implemented a tracking system that complies with federal statute and regulations. Vermont’s SPA #20-0011 proposes to eliminate cost sharing on preventive dental services and this policy has been approved. During review of SPA #20-0011, CMS identified a cost sharing policy that is not consistent with federal requirements. Sections 1916A(a)(2)(B), (b)(1)(B)(ii) and (b)(2)(A) of the Social Security Act (the Act), implemented at 42 CFR §447.56(f), set an aggregate cap on the total premiums and cost sharing charged to a given beneficiary (or, in the case of a family with multiple beneficiaries, all beneficiaries in the household) to five percent of the beneficiary’s family income. This five percent aggregate cap may be applied, at state option, on either a monthly or quarterly basis (“aggregate cap period”). As discussed on multiple phone calls with the state, the state has not yet implemented a system to track beneficiaries’ premiums and cost sharing payments prior to beneficiaries reaching their household aggregate cap. As part of a SPA approved in 2016, the state had agreed to integrate tracking functionality into its eligibility and claims systems and review claims history after the quarter ended to reimburse any beneficiary who exceeded his/her aggregate cap in the prior quarter as a temporary mitigation. However, three years later, the state has still not integrated tracking functionality into its information systems due to project delays. CMS believes three years exceed a temporary mitigation. CMS has supplied some options for the state to consider as it re-examines its compliance with the tracking requirements. During a phone call on June 25, 2020 CMS reiterated the need for the state to track cost sharing and premiums consistent with statutory and regulatory requirements. Tracking cost sharing and premiums is not integral to the purpose of SPA #20-0011. In accordance with SMD #10-020, CMS

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DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-26-12 Baltimore, Maryland 21244-1850 May 2 2020 Cory Gustafson, Commissioner Department of Vermont Health Access 280 State Drive Waterbury, VT 05671 Re: Vermont State Plan Amendment (SPA) 20-0015 Dear Commissioner Gustafson: We have reviewed the proposed amendment to add section 7.4 Medicaid Disaster Relief for the COVID-19 National Emergency to your Medicaid state plan, as submitted under transmittal number (TN) 20-0015. This amendment proposes to implement temporary policies, which are different from those policies and procedures otherwise applied under your Medicaid state plan, during the period of the Presidential and Secretarial emergency declarations related to the COVID-19 outbreak (or any renewals thereof). On March 13, 2020, the President of the United States issued a proclamation that the COVID-19 outbreak in the United States constitutes a national emergency by the authorities vested in him by the Constitution and the laws of the United States, including sections 201 and 301 of the National Emergencies Act (50 U.S.C. 1601 et seq.), and consistent with section 1135 of the Social Security Act (Act). On March 13, 2020, pursuant to section 1135(b) of the Act, the Secretary of the United States Department of Health and Human Services invoked his authority to waive or modify certain requirements of titles XVIII, XIX, and XXI of the Act as a result of the consequences of the COVID-19 pandemic, to the extent necessary, as determined by the Centers for Medicare & Medicaid Services (CMS), to ensure that sufficient health care items and services are available to meet the needs of individuals enrolled in the respective programs and to ensure that health care providers that furnish such items and services in good faith, but are unable to comply with one or more of such requirements as a result of the COVID-19 pandemic, may be reimbursed for such items and services and exempted from sanctions for such noncompliance, absent any determination of fraud or abuse. This authority took effect as of 6PM Eastern Standard Time on March 15, 2020, with a retroactive effective date of March 1, 2020. The emergency period will terminate, and this state plan provision will no longer be in effect, upon termination of the public health emergency, including any extensions. Pursuant to section 1135(b)(5) of the Act, for the period of the public health emergency, CMS is modifying the requirement at 42 C.F.R. 430.20 that the state submit SPAs related to the COVID- 19 public health emergency by the final day of the quarter, to obtain a SPA effective date during the quarter, enabling SPAs submitted after the last day of the quarter to have an effective date in a previous quarter, but no earlier than the effective date of the public health emergency.

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The State of Vermont also requested a waiver of public notice requirements applicable to the SPA submission process. Pursuant to section 1135(b)(1)(C) of the Act, CMS is also waiving public notice requirements applicable to the SPA submission process. Public notice for SPAs is required under 42 C.F.R. §447.205 for changes in statewide methods and standards for setting Medicaid payment rates, 42 C.F.R. §447.57 for changes to premiums and cost sharing, and 42 C.F.R. §440.386 for changes to Alternative Benefit Plans (ABPs). Pursuant to section 1135(b)(1)(C) of the Act, CMS is approving the state’s request to waive these notice requirements otherwise applicable to SPA submissions. These waivers of the requirements related to SPA submission timelines and public notice apply only with respect to SPAs that meet the following criteria: (1) the SPA provides or increases beneficiary access to items and services related to COVID-19 (such as by waiving or eliminating cost sharing, increasing payment rates or amending ABPs to add services or providers); (2) the SPA does not restrict or limit payment or services or otherwise burden beneficiaries and providers; and (3) the SPA is temporary, with a specified sunset date that is not later than the last day of the declared COVID-19 public health emergency (or any extension thereof). We nonetheless encourage states to make all relevant information about the SPA available to the public so they are aware of the changes. We conducted our review of your submittal according to the statutory requirements at section 1902(a) of the Act and implementing regulations. This letter is to inform you that Vermont’s Medicaid SPA Transmittal Number 20-0015 is approved effective March 1, 2020. Enclosed is a copy of the CMS-179 summary form and the approved state plan pages. Please contact Gilson DaSilva at (617) 565-1227 or by email at gilson.dasilva@cms.hhs.gov if you have any questions about this approval. We appreciate the efforts of you and your staff in responding to the needs of the residents of the State of Vermont and the health care community. Sincerely, Anne Marie Costello Deputy Director Center for Medicaid & CHIP Services Enclosures Anne M. Costello -S Digitally signed by Anne M. Costello -S Date: 2020.05.29 09:55:12 -04'00'

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ϴϵĂ TN: _20-0015_ Supersedes TN: _None_ Section 7 – General Provisions 7.4. Medicaid Disaster Relief for the COVID-19 National Emergency On March 13, 2020, the President of the United States issued a proclamation that the COVID-19 outbreak in the United States constitutes a national emergency by the authorities vested in him by the Constitution and the laws of the United States, including sections 201 and 301 of the National Emergencies Act (50 U.S.C. 1601 et seq.), and consistent with section 1135 of the Social Security Act (Act). On March 13, 2020, pursuant to section 1135(b) of the Act, the Secretary of the United States Department of Health and Human Services invoked his authority to waive or modify certain requirements of titles XVIII, XIX, and XXI of the Act as a result of the consequences COVID-19 pandemic, to the extent necessary, as determined by the Centers for Medicare & Medicaid Services (CMS), to ensure that sufficient health care items and services are available to meet the needs of individuals enrolled in the respective programs and to ensure that health care providers that furnish such items and services in good faith, but are unable to comply with one or more of such requirements as a result of the COVID-19 pandemic, may be reimbursed for such items and services and exempted from sanctions for such noncompliance, absent any determination of fraud or abuse. This authority took effect as of 6PM Eastern Standard Time on March 15, 2020, with a retroactive effective date of March 1, 2020. The emergency period will terminate, and waivers will no longer be available, upon termination of the public health emergency, including any extensions. The State Medicaid agency (agency) seeks to implement the policies and procedures described below, which are different than the policies and procedures otherwise applied under the Medicaid state plan, during the period of the Presidential and Secretarial emergency declarations related to the COVID-19 outbreak (or any renewals thereof), or for any shorter period described below: Describe shorter period here. NOTE: States may not elect a period longer than the Presidential or Secretarial emergency declaration (or any renewal thereof). States may not propose changes on this template that restrict or limit payment, services, or eligibility, or otherwise burden beneficiaries and providers. Request for Waivers under Section 1135 _X__ The agency seeks the following under section 1135(b)(1)(C) and/or section 1135(b)(5) of the Act: Ă͘ X_ SPA submission requirements – the agency requests modification of the requirement to submit the SPA by March 31, 2020, to obtain a SPA effective date during the first calendar quarter of 2020, pursuant to 42 CFR 430.20. ď͘ _X_ Public notice requirements – the agency requests waiver of public notice requirements that would otherwise be applicable to this SPA submission. These requirements may include those specified in 42 CFR 440.386 (Alternative Benefit Plans), 42 CFR 447.57(c) (premiums and cost sharing), and 42 CFR 447.205 (public notice of changes in statewide methods and standards for setting payment rates). OFFICIAL Effective Date: 3/1/2020 Approval Date: ϱͬϮϵͬϮϬϮϬ State/Territory: Vermont

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ϴϵĐ TN: _20-0015_ Effective Date: 3/1/2020 ƉƉƌŽǀĂů ĂƚĞ͗ ϱͬϮϵͬϮϬϮϬ Supersedes TN: _None_ 4. _____ The agency considers individuals who are evacuated from the state, who leave the state for medical reasons related to the disaster or public health emergency, or who are otherwise absent from the state due to the disaster or public health emergency and who intend to return to the state, to continue to be residents of the state under 42 CFR 435.403(j)(3). 5. _____ The agency provides Medicaid coverage to the following individuals living in the state, who are non-residents: 6. _____ The agency provides for an extension of the reasonable opportunity period for non- citizens declaring to be in a satisfactory immigration status, if the non-citizen is making a good faith effort to resolve any inconsistences or obtain any necessary documentation, or the agency is unable to complete the verification process within the 90-day reasonable opportunity period due to the disaster or public health emergency. Section B – Enrollment 1. _____ The agency elects to allow hospitals to make presumptive eligibility determinations for the following additional state plan populations, or for populations in an approved section 1115 demonstration, in accordance with section 1902(a)(47)(B) of the Act and 42 CFR 435.1110, provided that the agency has determined that the hospital is capable of making such determinations. Please describe the applicable eligibility groups/populations and any changes to reasonable limitations, performance standards or other factors. 2. _____ The agency designates itself as a qualified entity for purposes of making presumptive eligibility determinations described below in accordance with sections 1920, 1920A, 1920B, and 1920C of the Act and 42 CFR Part 435 Subpart L. Please describe any limitations related to the populations included or the number of allowable PE periods. 3. ____ The agency designates the following entities as qualified entities for purposes of making presumptive eligibility determinations or adds additional populations as described below in accordance with sections 1920, 1920A, 1920B, and 1920C of the Act and 42 CFR Part 435 OFFICIAL State/Territory: Vermont

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ϴϵĚ TN: _20-0015_ Effective Date: 3/1/2020 ƉƉƌŽǀĂů ĂƚĞ͗ ϱͬϮϵͬϮϬϮϬ Supersedes TN: _None_ Subpart L. Indicate if any designated entities are permitted to make presumptive eligibility determinations only for specified populations. Please describe the designated entities or additional populations and any limitations related to the specified populations or number of allowable PE periods. 4. _____ The agency adopts a total of _____ months (not to exceed 12 months) continuous eligibility for children under age enter age _____ (not to exceed age 19) regardless of changes in circumstances in accordance with section 1902(e)(12) of the Act and 42 CFR 435.926. 5. _____ The agency conducts redeterminations of eligibility for individuals excepted from MAGI- based financial methodologies under 42 CFR 435.603(j) once every _____ months (not to exceed 12 months) in accordance with 42 CFR 435.916(b). 6. _____ The agency uses the following simplified application(s) to support enrollment in affected areas or for affected individuals (a copy of the simplified application(s) has been submitted to CMS). a. _____ The agency uses a simplified paper application. b. _____ The agency uses a simplified online application. c. _____ The simplified paper or online application is made available for use in call-centers or other telephone applications in affected areas. Section C – Premiums and Cost Sharing 1. __X__ The agency suspends deductibles, copayments, coinsurance, and other cost sharing charges as follows: Please describe whether the state suspends all cost sharing or suspends only specified deductibles, copayments, coinsurance, or other cost sharing charges for specified items and services or for specified eligibility groups consistent with 42 CFR 447.52(d) or for specified income levels consistent with 42 CFR 447.52(g). - There will be no copayments for outpatient hospital visits. - There will be no copayments for medications used to treat the symptoms of COVID-19. Ϯ͘ ____ The agency suspends enrollment fees, premiums and similar charges for: Ă͘ _____ All beneficiaries ď͘ ____ The following eligibility groups or categorical populations: Please list the applicable eligibility groups or populations. OFFICIAL State/Territory: Vermont

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ϴ9ŝ TN: _20-0015_ Effective Date: 3/1/2020 ƉƉƌŽǀĂů ĂƚĞ͗ ϱͬϮϵͬϮϬϮϬ Supersedes TN: _None_ a. _____ The individual’s total income b. _____ 300 percent of the SSI federal benefit rate c. _____ Other reasonable amount: _________________ 2. _____ The state elects a new variance to the basic personal needs allowance. (Note: Election of this option is not dependent on a state electing the option described the option in F.1. above.) The state protects amounts exceeding the basic personal needs allowance for individuals who have the following greater personal needs: Please describe the group or groups of individuals with greater needs and the amount(s) protected for each group or groups. Section G – Other Policies and Procedures Differing from Approved Medicaid State Plan /Additional Information Vermont does not need to include temporary payment changes in this disaster SPA due to its 1115 Global Commitment waiver authority at Special Term and Condition 29, and the 1135 waiver of public notice in this SPA is still applicable. 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 (Expires 03/31/2021). The time required to complete this information collection is estimated to average 1 to 2 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. Your response is required to receive a waiver under Section 1135 of the Social Security Act. All responses are public and will be made available on the CMS web site. 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. ***CMS Disclosure*** Please do not send applications, claims, payments, medical records or any documents containing sensitive information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information collection burden approved under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please contact the Centers for Medicaid & CHIP Services at 410-786-3870. OFFICIAL State/Territory: Vermont

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Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | VT2022MS0004O | VT-22-0002 Package Header Package ID VT2022MS0004O Submission Type Official Approval Date 12/20/2022 Superseded SPA ID N/A SPA ID VT-22-0002 Initial Submission Date 9/30/2022 Effective Date N/A SPA ID and Effective Date SPA ID VT-22-0002 Reviewable Unit Proposed Effective Date Superseded SPA ID Eligibility Determinations of Individuals Age 65 or Older or Who Have Blindness or a Disability 7/1/2022 VT-21-0002 Medically Needy Income Level 7/1/2022 VT-91-12; VT-02-06 Handling of Excess Income (Spenddown) 7/1/2022 VT-91-12 Medically Needy Resource Level 7/1/2022 VT-91-12; VT-10-0004 Mandatory Eligibility Groups 7/1/2022 VT-21-0002 SSI Beneficiaries 7/1/2022 VT-92-10; VT-93-9 Closed Eligibility Groups 7/1/2022 VT-91-12 Individuals Deemed To Be Receiving SSI 7/1/2022 VT-92-1; VT-91-12 Working Individuals under 1619(b) 7/1/2022 VT-91-12 Qualified Medicare Beneficiaries 7/1/2022 VT-91-12 Qualified Disabled and Working Individuals 7/1/2022 VT-10-004 Specified Low Income Medicare Beneficiaries 7/1/2022 VT-91-12 Qualifying Individuals 7/1/2022 VT-91-12 Optional Eligibility Groups 7/1/2022 VT-21-0002 Individuals Eligible for but Not Receiving Cash Assistance 7/1/2022 VT-91-12 Individuals Eligible for Cash Except for Institutionalization 7/1/2022 VT-91-12 Individuals Receiving Home and Community- Based Waiver Services under Institutional Rules 7/1/2022 N/A removed from package Individuals in Institutions Eligible under a Special Income Level 7/1/2022 VT-91-12 Individuals Receiving Hospice 7/1/2022 VT-91-12 Work Incentives 7/1/2022 VT-91-12 Protected Medically Needy Individuals Who Were Eligible in 1973 7/1/2022 VT-91-12 Medically Needy Populations Based on Age, Blindness or Disability 7/1/2022 VT-91-12 Page Number of the Superseded Plan Section or Attachment (If Applicable): Vermont has a long list of superseded SPA IDs as well as fully and partially superseded pages for each Reviewable Unit that exceeds the character limit for these text boxes. Please see attached excel file for full crosswalk to superseded SPA IDs.

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Qualified Medicare Beneficiaries MEDICAID | Medicaid State Plan | Eligibility | VT2022MS0004O | VT-22-0002 Package Header Package ID VT2022MS0004O Submission Type Official Approval Date 12/20/2022 Superseded SPA ID VT-91-12 User-Entered SPA ID VT-22-0002 Initial Submission Date 9/30/2022 Effective Date 7/1/2022 B. Financial Methodologies 1. SSI methodologies are used in calculating household income. Please refer as necessary to Non-MAGI Methodologies, completed by the state. 2. Less restrictive methodologies are used in calculating countable income. The less restrictive income methodologies are: Name of disregard: Description: COLA Forecast From January 1 until April 1, the Department will disregard the difference between its estimated Federal Poverty Levels (FPLs) and the currently approved FPLs as published in the Federal Register. Effective April 1, the Department will issue a second increase if the actual FPLs exceed its estimate. If the department's estimated FPLs issued January 1 are higher than the actual FPLs, the department will continue to disregard the difference between its estimated FPLs and the ones published in the Federal Register. Description of disregard: Wages paid by the Census Bureau for temporary employment related to census activities are excluded as income for this eligibility group. Name of methodology: Description: Lump Sum Receipt of Earnings Lump sum receipt of earnings such as sale of crops or livestock are averaged over the six-month accounting period. Name of income type: Description: Income of an ineligible spouse Countable income of an ineligible spouse is added to the countable income of an eligible individual and compared, after deductions, to the Medically Needy Income Level for two. Yes No General income disregard: Census Bureau wages are disregarded. A less restrictive methodology is used with respect to lump sum income: Specified methodology for the treatment of lump sums as income: A specified type of income is disregarded:

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Specified Low Income Medicare Beneficiaries MEDICAID | Medicaid State Plan | Eligibility | VT2022MS0004O | VT-22-0002 Package Header Package ID VT2022MS0004O Submission Type Official Approval Date 12/20/2022 Superseded SPA ID VT-91-12 User-Entered SPA ID VT-22-0002 Initial Submission Date 9/30/2022 Effective Date 7/1/2022 B. Financial Methodologies 1. SSI methodologies are used in calculating household income. Please refer as necessary to Non-MAGI Methodologies, completed by the state. 2. Less restrictive methodologies are used in calculating countable income. The less restrictive income methodologies are: Name of disregard: Description: COLA Forecast From January 1 until April 1, the Department will disregard the difference between its estimated Federal Poverty Levels (FPLs) and the currently approved FPLs as published in the Federal Register. Effective April 1, the Department will issue a second increase if the actual FPLs exceed its estimate. If the department's estimated FPLs issued January 1 are higher than the actual FPLs, the department will continue to disregard the difference between its estimated FPLs and the ones published in the Federal Register. Description of disregard: Wages paid by the Census Bureau for temporary employment related to census activities are excluded as income for this eligibility group. Name of methodology: Description: Lump Sum Receipt of Earnings Lump sum receipt of earnings such as sale of crops or livestock are averaged over the six-month accounting period. Name of income type: Description: Income of an ineligible spouse Countable income of an ineligible spouse is added to the countable income of an eligible individual and compared, after deductions, to the Medically Needy Income Level for two. Yes No General income disregard: Census Bureau wages are disregarded. A less restrictive methodology is used with respect to lump sum income: Specified methodology for the treatment of lump sums as income: A specified type of income is disregarded:

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Qualifying Individuals MEDICAID | Medicaid State Plan | Eligibility | VT2022MS0004O | VT-22-0002 Package Header Package ID VT2022MS0004O Submission Type Official Approval Date 12/20/2022 Superseded SPA ID VT-91-12 User-Entered SPA ID VT-22-0002 Initial Submission Date 9/30/2022 Effective Date 7/1/2022 B. Financial Methodologies 1. SSI methodologies are used in calculating household income. Please refer as necessary to Non-MAGI Methodologies, completed by the state. 2. Less restrictive methodologies are used in calculating countable income. The less restrictive income methodologies are: Name of disregard: Description: COLA Forecast From January 1 until April 1, the Department will disregard the difference between its estimated Federal Poverty Levels (FPLs) and the currently approved FPLs as published in the Federal Register. Effective April 1, the Department will issue a second increase if the actual FPLs exceed its estimate. If the department's estimated FPLs issued January 1 are higher than the actual FPLs, the department will continue to disregard the difference between its estimated FPLs and the ones published in the Federal Register. Description of disregard: Wages paid by the Census Bureau for temporary employment related to census activities are excluded as income for this eligibility group. Name of methodology: Description: Lump Sum Receipt of Earnings Lump sum receipt of earnings such as sale of crops or livestock are averaged over the six-month accounting period. Name of income type: Description: Income of an ineligible spouse Countable income of an ineligible spouse is added to the countable income of an eligible individual and compared, after deductions, to the Medically Needy Income Level for two. Yes No General income disregard: Census Bureau wages are disregarded. A less restrictive methodology is used with respect to lump sum income: Specified methodology for the treatment of lump sums as income: A specified type of income is disregarded:

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Individuals Eligible for but Not Receiving Cash Assistance MEDICAID | Medicaid State Plan | Eligibility | VT2022MS0004O | VT-22-0002 Package Header Package ID VT2022MS0004O Submission Type Official Approval Date 12/20/2022 Superseded SPA ID VT-91-12 User-Entered SPA ID VT-22-0002 Initial Submission Date 9/30/2022 Effective Date 7/1/2022 C. Financial Methodologies 1. In calculating household income and resources for individuals who are seeking eligibility on the basis of being age 65 or older or having blindness or disability, SSI methodologies are used. Please refer as necessary to Non-MAGI Methodologies, completed by the state. 3. Less restrictive methodologies are used in calculating countable income. The less restrictive income methodologies are: Name of disregard: Description: COLA Forecast From January 1 until April 1, the Department will disregard the difference between its estimated Federal Poverty Levels (FPLs) and the currently approved FPLs as published in the Federal Register. Effective April 1, the Department will issue a second increase if the actual FPLs exceed its estimate. If the department's estimated FPLs issued January 1 are higher than the actual FPLs, the department will continue to disregard the difference between its estimated FPLs and the ones published in the Federal Register. Description of disregard: Wages paid by the Census Bureau for temporary employment related to census activities are excluded as income for this eligibility group. Name of methodology: Description: Lump Sum Receipt of Earnings Lump sum receipt of earnings such as sale of crops or livestock are averaged over the six-month accounting period. Name of income type: Description: Income of an ineligible spouse Countable income of an ineligible spouse is added to the countable income of an eligible individual and compared, after deductions, to the Yes No General income disregard: Census Bureau wages are disregarded. A less restrictive methodology is used with respect to lump sum income: Specified methodology for the treatment of lump sums as income: A specified type of income is disregarded:

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Name of income type: Description: Medically Needy Income Level for two. Cash Contributions or Gifts Infrequent or irregular voluntary cash contributions or gifts are excluded. Vermont Tax Credit Any refundable credit against taxes made pursuant to Vermont's child tax credit (32 V.S.A. § 5830f) or pursuant to a similar tax credit enacted by the State and directed by state law to not be considered as countable income for benefit programs. Workforce Recruitment & Retention Program Any wages that are made pursuant to Vermont's Premium Pay for Workforce Recruitment and Retention Program enacted in Act 83 of 2021 or a similar workforce recruitment and retention program enacted in Vermont and directed by state law to not be considered as countable income in determining eligibility for benefit programs. 4. Less restrictive methodologies are used in calculating countable resources. The less restrictive resource methodologies are: Name of methodology: Description: Burial Funds Separately identifiable burial funds designated for burial expenses, either singly or in combination, are exempt in an amount not to exceed $10,000. The burial funds must be designated by the title of the fund or by sworn statement provided to the department. The burial funds in conjunction with the irrevocable burial trust referenced in Supplement 10 to Attachment 2.6-A, page 1, last paragraph, cannot exceed $10,000 in total. Name of resource type: Description: Real Property Real property is excluded if the income it produces is significant to meeting living expenses and consistent with its fair market value. Savings from Excluded Income Savings from excluded income are excluded. Real Property for Sale Non exempt real property which is up for sale is excluded as long as Yes No The state uses a less restrictive methodology with respect to resources set aside for burial. Specified methodology for the treatment of resources set aside for burial: A specified type of resource is disregarded:

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Name of resource type: Description: owners verify that they are making reasonable efforts to sell it. Automobiles Automobiles of any value are excluded. Equity value of Property No limit is placed on the equity value of property used to produce goods for home consumption. Life Estates Life estates in real property are excluded when the owner does not retain the power to sell the real property. Annuities, promissory notes, and similar resources Annuities, promissory notes, and similar resources that produce income are exempt resources if they would otherwise be countable by SSI as long as they meet the following criteria: (1) Annuities are not a countable resource if they: have no beneficiary other than an individual requesting Medicaid or his/her spouse; and provide for payments to applicants or their spouses, in equal intervals and equal amounts; and do not exceed the life expectancy of the applicants or their spouses, as determined by the department; and return to the beneficiary at least the amount used to establish the contract and any additional payments plus any earnings, as specified in the contract; and do not pay anyone other than the applicant, the applicant's spouse, even if the applicant or spouse dies before the payment period ends. The department will also consider an annuity to meet the requirements above, if the owner of the annuity elects to designate Vermont Medicaid as the primary beneficiary up to the amount of long-term care payments it made, and names a contingent beneficiary other than the applicant or spouse to receive any surplus after Vermont Medicaid is paid. (2) Promissory notes and similar resources that produce income are not a countable resource if: (a) they meet the requirements in subsection (1) above, or (b) the individual owned a nonnegotiable or nonassignable promissory note executed before September 1, 2005 and the individual or spouse can expect to receive the full fair market value of the resource within the expected lifetime of the individual or spouse, as determined by the department. State Tax Credit Any refundable credit against taxes made pursuant to Vermont's child tax credit (32 V.S.A. § 5830f) or pursuant to a similar tax credit enacted by the State and directed by state law to not be considered

(vt-22-0002)(approval-document)(page-74)Page 76#

Individuals Eligible for Cash Except for Institutionalization MEDICAID | Medicaid State Plan | Eligibility | VT2022MS0004O | VT-22-0002 Package Header Package ID VT2022MS0004O Submission Type Official Approval Date 12/20/2022 Superseded SPA ID VT-91-12 User-Entered SPA ID VT-22-0002 Initial Submission Date 9/30/2022 Effective Date 7/1/2022 C. Financial Methodologies 1. In calculating household income and resources for individuals who are seeking eligibility on the basis of being age 65 or older or having blindness or disability, SSI methodologies are used. Please refer as necessary to Non-MAGI Methodologies, completed by the state. 2. In calculating household income and resources for populations for which AFDC is the most closely related program, the following methodology(ies) are used: 3. Less restrictive methodologies are used in calculating countable income. The less restrictive income methodologies are: Name of disregard: Description: COLA Forecast From January 1 until April 1, the Department will disregard the difference between its estimated Federal Poverty Levels (FPLs) and the currently approved FPLs as published in the Federal Register. Effective April 1, the Department will issue a second increase if the actual FPLs exceed its estimate. If the department's estimated FPLs issued January 1 are higher than the actual FPLs, the department will continue to disregard the difference between its estimated FPLs and the ones published in the Federal Register. Description of disregard: Wages paid by the Census Bureau for temporary employment related to census activities are excluded as income for this eligibility group. Name of methodology: Description: Lump Sum Receipt of Earnings Lump sum receipt of earnings such as sale of crops or livestock are averaged over the six-month accounting period. a. MAGI-like methodologies. Please refer as necessary to Non-MAGI Methodologies, completed by the state. b. AFDC methodologies. Please refer as necessary to Non-MAGI Methodologies, completed by the state. Yes No General income disregard: Census Bureau wages are disregarded. A less restrictive methodology is used with respect to lump sum income: Specified methodology for the treatment of lump sums as income: A specified type of income is disregarded:

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Name of income type: Description: Income of an ineligible spouse Countable income of an ineligible spouse is added to the countable income of an eligible individual and compared, after deductions, to the Medically Needy Income Level for two. Cash Contributions or Gifts Infrequent or irregular voluntary cash contributions or gifts are excluded. Vermont Tax Credit Any refundable credit against taxes made pursuant to Vermont's child tax credit (32 V.S.A. § 5830f) or pursuant to a similar tax credit enacted by the State and directed by state law to not be considered as countable income for benefit programs. Workforce Recruitment & Retention Program Any wages that are made pursuant to Vermont's Premium Pay for Workforce Recruitment and Retention Program enacted in Act 83 of 2021 or a similar workforce recruitment and retention program enacted in Vermont and directed by state law to not be considered as countable income in determining eligibility for benefit programs. 4. Less restrictive methodologies are used in calculating countable resources. The less restrictive resource methodologies are: Name of methodology: Description: Burial Funds Separately identifiable burial funds designated for burial expenses, either singly or in combination, are exempt in an amount not to exceed $10,000. The burial funds must be designated by the title of the fund or by sworn statement provided to the department. The burial funds in conjunction with the irrevocable burial trust referenced in Supplement 10 to Attachment 2.6-A, page 1, last paragraph, cannot exceed $10,000 in total. Name of resource type: Description: Real Property Real property is excluded if the income it produces is significant to meeting living expenses and consistent with its fair market value. Yes No The state uses a less restrictive methodology with respect to resources set aside for burial. Specified methodology for the treatment of resources set aside for burial: A specified type of resource is disregarded:

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Name of resource type: Description: Savings from Excluded Income Savings from excluded income are excluded. Real Property for Sale Non exempt real property which is up for sale is excluded as long as owners verify that they are making reasonable efforts to sell it. Automobiles Automobiles of any value are excluded. Equity value of Property No limit is placed on the equity value of property used to produce goods for home consumption. Life Estates Life estates in real property are excluded when the owner does not retain the power to sell the real property. Annuities, promissory notes, and similar resources Annuities, promissory notes, and similar resources that produce income are exempt resources if they would otherwise be countable by SSI as long as they meet the following criteria: (1) Annuities are not a countable resource if they: have no beneficiary other than an individual requesting Medicaid or his/her spouse; and provide for payments to applicants or their spouses, in equal intervals and equal amounts; and do not exceed the life expectancy of the applicants or their spouses, as determined by the department; and return to the beneficiary at least the amount used to establish the contract and any additional payments plus any earnings, as specified in the contract; and do not pay anyone other than the applicant, the applicant's spouse, even if the applicant or spouse dies before the payment period ends. The department will also consider an annuity to meet the requirements above, if the owner of the annuity elects to designate Vermont Medicaid as the primary beneficiary up to the amount of long-term care payments it made, and names a contingent beneficiary other than the applicant or spouse to receive any surplus after Vermont Medicaid is paid. (2) Promissory notes and similar resources that produce income are not a countable resource if: (a) they meet the requirements in subsection (1) above, or (b) the individual owned a nonnegotiable or nonassignable promissory note executed before September 1, 2005 and the individual or spouse can expect to receive the full fair market value of the resource within the expected lifetime of the individual or spouse, as determined by the department.

(vt-22-0002)(approval-document)(page-77)Page 79#

Name of resource type: Description: State Tax Credit Any refundable credit against taxes made pursuant to Vermont's child tax credit (32 V.S.A. § 5830f) or pursuant to a similar tax credit enacted by the State and directed by state law to not be considered as countable resources for benefit programs. Workforce Recruitment & Retention Program Any wages that are made pursuant to Vermont's Premium Pay for Workforce Recruitment and Retention Program enacted in Act 83 of 2021 or a similar workforce recruitment and retention program enacted in Vermont and directed by state law to not be considered as countable resources in determining eligibility for benefit programs. Name of methodology: Description: Resource spend-down Resources may be spent-down to the applicable Resource Maximum if used for medical or maintenance expenses. Resources at any time during the month Vermont does not use the first moment of the first day of the month in counting resources. If the applicant(s) is under resources at any time during the month, Medicaid is granted for the entire month if all other eligibility criteria are met. Resources of Couple Resources of couple, where one member has been admitted to a long-term care facility are combined for 6 months if this is to the advantage of the couple. Resources in account up to $30,000 Resources set aside in a separate bank account in the name of the Medicaid beneficiary are exempt in an amount not to exceed $30,000. The funds may only be spent on medical care, assistive technology devices or home modifications not covered by Medicare, private insurance or Medicaid. They must be found to be reasonable and necessary to assist an individual in achieving or maintaining independent living. Up to $500 per month of these resources may be spent for medical care and assistive technology devices. A one time expenditure of up to $7,500 of these resources may be spent for home modifications. The following less restrictive methodologies are used:

(vt-22-0002)(approval-document)(page-82)Page 84#

Individuals in Institutions Eligible under a Special Income Level MEDICAID | Medicaid State Plan | Eligibility | VT2022MS0004O | VT-22-0002 Package Header Package ID VT2022MS0004O Submission Type Official Approval Date 12/20/2022 Superseded SPA ID VT-91-12 User-Entered SPA ID VT-22-0002 Initial Submission Date 9/30/2022 Effective Date 7/1/2022 C. Financial Methodologies 1. In calculating household income, the methodologies of the most closely related cash assistance program are used, except that disregards are not applied. 2. In calculating household resources, the methodologies of the most closely related cash assistance program are used Please refer as necessary to Non-MAGI Methodologies, completed by the state. 3. Less restrictive methodologies are used in calculating countable resources. The less restrictive resource methodologies are: Name of methodology: Description: Burial Funds Separately identifiable burial funds designated for burial expenses, either singly or in combination, are exempt in an amount not to exceed $10,000. The burial funds must be designated by the title of the fund or by sworn statement provided to the department. The burial funds in conjunction with the irrevocable burial trust referenced in Supplement 10 to Attachment 2.6-A, page 1, last paragraph, cannot exceed $10,000 in total. Name of resource type: Description: Annuities, promissory notes, and similar resources Annuities, promissory notes, and similar resources that produce income are exempt resources if they would otherwise be countable by SSI as long as they meet the following criteria: (1) Annuities are not a countable resource if they: have no beneficiary other than an individual requesting Medicaid or his/her spouse; and provide for payments to applicants or their spouses, in equal intervals and equal amounts; and do not exceed the life expectancy of the applicants or their spouses, as determined by the department; and return to the beneficiary at least the amount used to establish the contract and any additional payments plus any earnings, as specified in the contract; and do not pay anyone other than the applicant, the applicant's spouse, even if the Yes No The state uses a less restrictive methodology with respect to resources set aside for burial. Specified methodology for the treatment of resources set aside for burial: A specified type of resource is disregarded:

(vt-22-0002)(approval-document)(page-83)Page 85#

Name of resource type: Description: applicant or spouse dies before the payment period ends. The department will also consider an annuity to meet the requirements above, if the owner of the annuity elects to designate Vermont Medicaid as the primary beneficiary up to the amount of long-term care payments it made, and names a contingent beneficiary other than the applicant or spouse to receive any surplus after Vermont Medicaid is paid. (2) Promissory notes and similar resources that produce income are not a countable resource if: (a) they meet the requirements in subsection (1) above, or (b) the individual owned a nonnegotiable or nonassignable promissory note executed before September 1, 2005 and the individual or spouse can expect to receive the full fair market value of the resource within the expected lifetime of the individual or spouse, as determined by the department. State Tax Credit Any refundable credit against taxes made pursuant to Vermont's child tax credit (32 V.S.A. § 5830f) or pursuant to a similar tax credit enacted by the State and directed by state law to not be considered as countable resources for benefit programs. Workforce Recruitment & Retention Program Any wages that are made pursuant to Vermont's Premium Pay for Workforce Recruitment and Retention Program enacted in Act 83 of 2021 or a similar workforce recruitment and retention program enacted in Vermont and directed by state law to not be considered as countable resources in determining eligibility for benefit programs. Real Property Real property is excluded if the income it produces is significant to meeting living expenses and consistent with its fair market value. Savings from Excluded Income Savings from excluded income are excluded. Real Property for Sale Non exempt real property which is up for sale is excluded as long as owners verify that they are making reasonable efforts to sell it. Automobiles Automobiles of any value are excluded. Equity value of Property No limit is placed on the equity value of property used to produce goods for home consumption. Life Estates Life estates in real property are excluded when the owner does not

(vt-22-0002)(approval-document)(page-96)Page 98#

Work Incentives MEDICAID | Medicaid State Plan | Eligibility | VT2022MS0004O | VT-22-0002 Package Header Package ID VT2022MS0004O Submission Type Official Approval Date 12/20/2022 Superseded SPA ID VT-91-12 User-Entered SPA ID VT-22-0002 Initial Submission Date 9/30/2022 Effective Date 7/1/2022 C. Step Two Financial Methodologies and Income/Resource Test 1. Financial methodologies a. SSI methodologies are used in calculating income and resources, except that earned income is not counted. Please refer as necessary to Non-MAGI Methodologies, completed by the state. b. Less restrictive methodologies are used in calculating countable income. The less restrictive income methodologies are: Name of disregard: Description: COLA Forecast From January 1 until April 1, the Department will disregard the difference between its estimated Federal Poverty Levels (FPLs) and the currently approved FPLs as published in the Federal Register. Effective April 1, the Department will issue a second increase if the actual FPLs exceed its estimate. If the department's estimated FPLs issued January 1 are higher than the actual FPLs, the department will continue to disregard the difference between its estimated FPLs and the ones published in the Federal Register. Description of disregard: Wages paid by the Census Bureau for temporary employment related to census activities are excluded as income for this eligibility group. Name of methodology: Description: Lump Sum Receipt of Earnings Lump sum receipt of earnings such as sale of crops or livestock are averaged over the six-month accounting period. Name of income type: Description: Income of an ineligible spouse Countable income of an ineligible spouse is added to the countable income of an eligible individual and compared, after deductions, to the Yes No General income disregard: Census Bureau wages are disregarded. A less restrictive methodology is used with respect to lump sum income: Specified methodology for the treatment of lump sums as income: A specified type of income is disregarded:

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Name of resource type: Description: Real Property Real property is excluded if the income it produces is significant to meeting living expenses and consistent with its fair market value. Savings from Excluded Income Savings from excluded income are excluded. Real Property for Sale Non exempt real property which is up for sale is excluded as long as owners verify that they are making reasonable efforts to sell it. Automobiles Automobiles of any value are excluded. Equity value of Property No limit is placed on the equity value of property used to produce goods for home consumption. Life Estates Life estates in real property are excluded when the owner does not retain the power to sell the real property. Annuities, promissory notes, and similar resources Annuities, promissory notes, and similar resources that produce income are exempt resources if they would otherwise be countable by SSI as long as they meet the following criteria: (1) Annuities are not a countable resource if they: have no beneficiary other than an individual requesting Medicaid or his/her spouse; and provide for payments to applicants or their spouses, in equal intervals and equal amounts; and do not exceed the life expectancy of the applicants or their spouses, as determined by the department; and return to the beneficiary at least the amount used to establish the contract and any additional payments plus any earnings, as specified in the contract; and do not pay anyone other than the applicant, the applicant's spouse, even if the applicant or spouse dies before the payment period ends. The department will also consider an annuity to meet the requirements above, if the owner of the annuity elects to designate Vermont Medicaid as the primary beneficiary up to the amount of long-term care payments it made, and names a contingent beneficiary other than the applicant or spouse to receive any surplus after Vermont Medicaid is paid. (2) Promissory notes and similar resources that produce income are not a countable resource if: (a) they meet the requirements in subsection (1) above, or (b) the individual owned a nonnegotiable or nonassignable promissory note executed before September 1, 2005 and the individual or spouse can expect to receive the full fair

(vt-22-0002)(approval-document)(page-99)Page 101#

Name of resource type: Description: market value of the resource within the expected lifetime of the individual or spouse, as determined by the department. State Tax Credit Any refundable credit against taxes made pursuant to Vermont's child tax credit (32 V.S.A. § 5830f) or pursuant to a similar tax credit enacted by the State and directed by state law to not be considered as countable resources for benefit programs. Workforce Recruitment & Retention Program Any wages that are made pursuant to Vermont's Premium Pay for Workforce Recruitment and Retention Program enacted in Act 83 of 2021 or a similar workforce recruitment and retention program enacted in Vermont and directed by state law to not be considered as countable resources in determining eligibility for benefit programs. Name of methodology: Description: Resource spend-down Resources may be spent-down to the applicable Resource Maximum if used for medical or maintenance expenses. Resources at any time during the month Vermont does not use the first moment of the first day of the month in counting resources. If the applicant(s) is under resources at any time during the month, Medicaid is granted for the entire month if all other eligibility criteria are met. Resources of Couple Resources of couple, where one member has been admitted to a long-term care facility are combined for 6 months if this is to the advantage of the couple. Resources in account up to $30,000 Resources set aside in a separate bank account in the name of the Medicaid beneficiary are exempt in an amount not to exceed $30,000. The funds may only be spent on medical care, assistive technology devices or home modifications not covered by Medicare, private insurance or Medicaid. They must be found to be reasonable and necessary to assist an individual in achieving or maintaining independent living. Up to $500 per month of these resources may be spent for medical care and assistive technology devices. A one time expenditure of up to $7,500 of these resources may be spent for home modifications. 2. Income Test The following less restrictive methodologies are used:

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Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | VT2022MS0005O | VT-23-0002 Package Header Package ID VT2022MS0005O Submission Type Official Approval Date 5/3/2023 Superseded SPA ID N/A SPA ID VT-23-0002 Initial Submission Date 3/8/2023 Effective Date N/A Governor's Office Review PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state’s program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. 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- 1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), 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. This view was generated on 5/4/2023 1:33 PM EDT No comment Comments received No response within 45 days Other 0 0 0 0

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MAGI Based Methodologies MEDICAID | Medicaid State Plan | Eligibility | VT2022MS0005O | VT-23-0002 Package Header Package ID VT2022MS0005O Submission Type Official Approval Date 5/3/2023 Superseded SPA ID VT 13-010 System-Derived SPA ID VT-23-0002 Initial Submission Date 3/8/2023 Effective Date 1/1/2023 B. Household Income Financial eligibility is determined consistent with the following provisions: 1. When determining eligibility for new applicants, financial eligibility is based on current monthly income and family size. 2. When determining eligibility for current beneficiaries, financial eligibility is based on: 3. In determining current monthly or projected annual household income, the state considers reasonably predictable changes in income: 4. MAGI-based income is calculated using the financial methodologies defined in section 36B(d)(2)(B) of the Internal Revenue Code, except as described at 42 CFR 435.603(e), and without regard to whether an individual expects to file taxes. 5. 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. 6. In determining the eligibility of an individual using MAGI-based income, the state must subtract an amount equivalent to 5 percentage points of the federal poverty level for the applicable family size only to determine the eligibility of an individual for medical assistance under the eligibility group with the highest income standard using MAGI-based methodologies in the applicable Title of the Act, but not to determine eligibility for a particular eligibility group. 7. 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. a. Current monthly household income and family size b. Projected annual household income and family size for the remaining months of the current calendar year. Yes No Yes No 0 0 0 0 0 0

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MAGI Based Methodologies MEDICAID | Medicaid State Plan | Eligibility | VT2022MS0005O | VT-23-0002 Package Header Package ID VT2022MS0005O Submission Type Official Approval Date 5/3/2023 Superseded SPA ID VT 13-010 System-Derived SPA ID VT-23-0002 Initial Submission Date 3/8/2023 Effective Date 1/1/2023 C. Resource Test There is no resource test applied to eligibility groups that use MAGI-based methodologies. D. Additional Information (optional) PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state’s program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. 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- 1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), 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. This view was generated on 5/4/2023 1:34 PM EDT

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AFDC Income Standards MEDICAID | Medicaid State Plan | Eligibility | VT2022MS0005O | VT-23-0002 Package Header Package ID VT2022MS0005O Submission Type Official Approval Date 5/3/2023 Superseded SPA ID VT 13-002 System-Derived SPA ID VT-23-0002 Initial Submission Date 3/8/2023 Effective Date 1/1/2023 I. Additional Information (optional) PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state’s program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. 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- 1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), 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. This view was generated on 5/4/2023 1:36 PM EDT

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Mandatory Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | VT2022MS0005O | VT-23-0002 Package Header Package ID VT2022MS0005O Submission Type Official Approval Date 5/3/2023 Superseded SPA ID VT-22-0002 System-Derived SPA ID VT-23-0002 Initial Submission Date 3/8/2023 Effective Date 1/1/2023 B. The state elects the Adult Group, described at 42 CFR 435.119. Families and Adults Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Adult Group APPROVED C. Additional Information (optional) Eligibility Groups Deselected from Coverage The following eligibility groups were previously covered in the source approved version of the state plan and deselected from coverage as part of this submission package: N/A PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state’s program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. 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- 1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), 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. This view was generated on 5/4/2023 1:38 PM EDT Yes No

0 0 □ 0

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Children with Title IV-E Adoption Assistance, Foster Care or Guardianship Care MEDICAID | Medicaid State Plan | Eligibility | VT2022MS0005O | VT-23-0002 Package Header Package ID VT2022MS0005O Submission Type Official Approval Date 5/3/2023 Superseded SPA ID VT-91-12 User-Entered SPA ID VT-23-0002 Initial Submission Date 3/8/2023 Effective Date 1/1/2023 B. Additional Information (optional) PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state’s program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. 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- 1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), 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. This view was generated on 5/4/2023 1:39 PM EDT

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Records / Submission Packages - View All VT - Submission Package - VT2022MS0005O - (VT-23-0002) - Eligibility Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter Transaction Logs News Related Actions Medicaid State Plan Eligibility Eligibility Groups - Mandatory Coverage Former Foster Care Children MEDICAID | Medicaid State Plan | Eligibility | VT2022MS0005O | VT-23-0002 Individuals under the age of 26, who were in foster care and on Medicaid when they turned age 18 or aged out of foster care. CMS-10434 OMB 0938-1188 Package Header Package ID VT2022MS0005O Submission Type Official Approval Date 5/3/2023 Superseded SPA ID VT-13-002 User-Entered SPA ID VT-23-0002 Initial Submission Date 3/8/2023 Effective Date 1/1/2023 The state covers the mandatory former foster care children group in accordance with the following provisions: A. Characteristics Individuals qualifying under this eligibility group must meet the following criteria: 1. Are under age 26 2. Were in foster care upon attaining age 18 or a higher age at which the state's or Tribe's foster care assistance ends under title IV-E of the Act (up to age 21). 3. Are described under either Section B. or C. B. Individuals Covered For individuals who turn 18 before January 1, 2023: 1. The state covers individuals who: a. Upon attaining age 18 or a higher age at which the state's or Tribe's foster care assistance ends under title IV-E of the Act (up to age 21) were: i. In foster care under the responsibility of the state or a Tribe within the state (including children who were cared for through a grant to the state under the unaccompanied refugee minor program); and ii. Enrolled in Medicaid under the state's Medicaid state plan or 1115 demonstration; and b. 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. 2. In addition to B.1., the state elects to cover individuals who were in foster care under the responsibility of the state or a Tribe within the state (including children who were cared for through a grant to the state under the unaccompanied refugee minor program) when they turned 18 or a higher age at which the state's or Tribe's foster care assistance ends under title IV-E of the Act, and meet the following criteria: C. Individuals Covered For individuals who turn 18 on or after January 1, 2023: 1. The state covers individuals who: a. Upon attaining age 18 or a higher age at which the state's or Tribe's foster care assistance ends under title IV-E of the Act (up to age 21) were: i. In foster care under the responsibility of any state or a Tribe within any state (including children who were cared for through a grant to the state under the unaccompanied refugee minor program); and ii. Enrolled in Medicaid under a state's Medicaid state plan or 1115 demonstration; and b. Are not enrolled in mandatory coverage under the state plan, except that eligibility under this group takes precedence over eligibility under the Adult Group. 2. In addition to C.1., the state elects to cover individuals who were in foster care under the responsibility of any state or a Tribe within any state (including children who were cared for through a grant to a state under the unaccompanied refugee minor program) when they turned 18 or a higher age at which that state's or Tribe's foster care assistance ends under title IV-E of the Act, and meet the following criteria: a. They were enrolled in Medicaid under the state's Medicaid state plan or 1115 demonstration at any time during the foster care period in which they turned 18 or a higher age at which the state's or Tribe's foster care assistance ends. b. They were placed by the state or Tribe in another state and were enrolled in Medicaid under the other state’s Medicaid state plan or 1115 demonstration project when they turned 18 or a higher age at which the state's or Tribe's foster care assistance ends. c. They were placed by the state or Tribe in another state and were enrolled in Medicaid under the other state’s Medicaid state plan or 1115 demonstration project at any time during the foster care period in which they turned 18 or a higher age at which the state's or Tribe's foster care assistance ends. □ □ □ -

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Former Foster Care Children MEDICAID | Medicaid State Plan | Eligibility | VT2022MS0005O | VT-23-0002 Package Header Package ID VT2022MS0005O Submission Type Official Approval Date 5/3/2023 Superseded SPA ID VT-13-002 User-Entered SPA ID VT-23-0002 Initial Submission Date 3/8/2023 Effective Date 1/1/2023 D. Additional Information (optional) PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state’s program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. 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- 1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), 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. This view was generated on 5/4/2023 1:43 PM EDT

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Optional Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | VT2022MS0005O | VT-23-0002 Package Header Package ID VT2022MS0005O Submission Type Official Approval Date 5/3/2023 Superseded SPA ID VT-22-0002 System-Derived SPA ID VT-23-0002 Initial Submission Date 3/8/2023 Effective Date 1/1/2023 C. Additional Information (optional) Eligibility Groups Deselected from Coverage The following eligibility groups were previously covered in the source approved version of the state plan and deselected from coverage as part of this submission package: N/A PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state’s program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. 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- 1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), 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. This view was generated on 5/4/2023 1:46 PM EDT

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Children with Non IV-E Adoption Assistance MEDICAID | Medicaid State Plan | Eligibility | VT2022MS0005O | VT-23-0002 Package Header Package ID VT2022MS0005O Submission Type Official Approval Date 5/3/2023 Superseded SPA ID VT 13-002 System-Derived SPA ID VT-23-0002 Initial Submission Date 3/8/2023 Effective Date 1/1/2023 F. Additional Information (optional) PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state’s program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. 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- 1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), 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. This view was generated on 5/4/2023 1:48 PM EDT

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Page 1 of 2 Medicaid Premiums and Cost Sharing State Name: Vermont OMB Control Number: 09381148 Transmittal Number: VT - 23 - 0029 Cost Sharing Amounts - Targeting G2c 1916 1916A 42 CFR 447.52 through 54 The state targets cost sharing to a specific group or groups of individuals. Yes Population Name (optional): All individuals except those in the 12-month extended postpartum period Eligibility Group(s) Included: All individuals other than individuals in any eligibility group who are eligible for 12-month extended postpartum coverage under section 1902(e)(16) of the SSA Incomes Greater than TO Incomes Less than or Equal to Add Service Amount Dollars or Percentage Unit Explanation Remove Add Pharmacy 1.00 $ Prescription $1.00 for prescription drugs costing less than $30.00. *Cost refers to the amount of reimbursement Remove Add Pharmacy 2.00 $ Prescription $2.00 for prescription drugs costing $30.00 or more but less than $50.00. *Cost refers to the amount of reimbursement Remove Add Pharmacy 3.00 $ Prescription $3.00 for prescription drugs costing $50.00 or more. *cost refers to the amount of reimbursement Remove Add Outpatient 3.00 $ Day $3.00 per day per hospital. Sexual assault related services are exempt from cost sharing. Remove Add Dental 3.00 $ Visit $3.00 per provider per date of service. Preventive dental services are exempt from cost sharing. Remove The state permits providers to require individuals to pay cost sharing as a condition for receiving items or services, subject to the conditions specified at 42 CFR 447.52(e)(1). This is only permitted for non-exempt individuals with family income above 100% FPL. No Cost Sharing for Non-preferred Drugs Charged to Otherwise Exempt Individuals If the state targets cost sharing for non-preferred drugs to specific groups of individuals (entered above), answer the following question: The state charges cost sharing for non-preferred drugs to otherwise exempt individuals. No OFFICIAL VT 23-0029 Approval date: 0/2023 Effective Date: 04/01/2023 □ □

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(vt-24-0004)(approval-document)(page-6)Page 6#

Submission - Summary MEDICAID I Medicaid State Plan I Eligibility I VT2023MS0004O I VT-24-0004 Package Header Package ID VT2023MS0004O Submission Type Official Approval Date 05/03/2024 Superseded SPA ID N/A Governor's Office Review 0 No comment 0 Comments received 0 No response within 45 days QOther SPA ID VT-24-0004 Initial Submission Date 3/27/2024 Effective Date NIA PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children's Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state's program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children's Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid 0MB control number. The valid 0MB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), 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. This view was generated on 517/2024 1 :41 PM EDT

(vt-24-0004)(approval-document)(page-10)Page 10#

l Optional Eligibility Groups MEDICAID I Medicaid State Plan I Eligibility I VT2023MS0004O I VT-24-0004 Package Header Package ID VT2023MS0004O Submission Type Official Approval Date 05/03/2024 Superseded SPA ID VT-23-0002 System-Derived C. Additional Information (optional) Eligibility Groups Deselected from Coverage SPA ID VT-24-0004 Initial Submission Date 3/27/2024 Effective Date 1 /1 /2024 The following eligibility groups were previously covered in the source approved version of the state plan and deselected from coverage as part of this submission package: • N/A PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children's Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state's program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children's Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid 0MB control number. The valid 0MB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), 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. This view was generated on 517/2024 1 :42 PM EDT

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Optional State Supplement Beneficiaries MEDICAID I Medicaid State Plan I Eligibility I VT2023MS0004O I VT-24-0004 Package Header Package ID VT2023MS0004O Submission Type Official Approval Date 05/03/2024 Superseded SPA ID VT-21-0002 System-Derived E. Additional Information (optional) SPA ID VT-24-0004 Initial Submission Date 3/27/2024 Effective Date 1 /1 /2024 The income standards for the classifications above are a product of the supplemental security income (S5I) federal benefit rate added to the maximum payment level for each classification. A state plan amendment will be submitted should the maximum payment levels, identified below, change for any of the classifications. For the "Independent Living" classification, the maximum payment levels for a single individual and couple are, respectively, $55.68 and $105.80 (thus, in 2024, with the S5I FBR being $943 and $1,415 for a single individual and couple, respectively, the income standards are $998.68 and $1,520.80). For the Licensed Residential Care Level Ill Limited Nursing Care classification, the maximum payment levels for a single individual and couple are, respectively, $267.13 and $603.69. For the Licensed Residential Care Level I11-Assistive Community Care classification, the maximum payment levels for a single individual and couple are, respectively, $51 .77 and $103.54. For the Licensed Residential Care Level IV classification, the maximum payment levels for a single individual and couple are, respectively, $239.62 and $601 .40. For the classification of Individuals Living in Household of Another, the maximum payment levels for a single individual and couple are, respectively, $42.05 and $51.69 (which are added to the SSI FBR payable to individuals living in the household of another). For the Custodial Care Family Home classification, the maximum payment levels for a single individual and couple are, respectively, $105.60 and $356.12. For the Long-Term Care (Medicaid Personal Needs Allowance) classification, the maximum payment standards for a single individual and couple are, respectively, $49.93 and $99.85 (which are added to the maximum SSI FBRs payable to institutionalized individuals and couples who otherwise have $0 in other countable income).

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Medicaid Premiums and Cost Sharing State Name:Ĉlv_ enn __ o_nt _ _ _ _ _ _ _ _ _ _ _ _ _ _ ĉ 0MB Control Number: 09381148 Transmittal Number: VT - 24 - 0008 Cost Sharing Amounts - Targeting G2c 1916 1916A 42 CFR 447.52 through 54 The state targets cost sharing to a specific group or groups of individuals. Ċ Population Name (optional): !All individuals except those in the 12-month extended postpartum period I Eligibility Group(s) Included: !All individuals other than individuals in any eligibility group who are eligible for 12-month extended I postpartum coverage under section 1902( e )( 16) of the SSA Incomes Greater than I I TO Incomes Less than or Equal to I I Dollars or Add Service Amount Percentage Unit Explanation Remove Pharmacy 1.00 $1. 00 for prescription drugs costing less than $30.00. Add $ Prescription *Cost refers to the amount of Remove reimbursement *Pharmacy cost sharing is suspended for dates of service 2/21/24 - 3/18/24. Pharmacy 2.00 $2.00 for prescription drugs costing $30.00 or more but less than $50.00. Add $ Prescription *Cost refers to the amount of Remove reimbursement *Pharmacy cost sharing is suspended for dates of service 2/21/24 - 3/18/24. Pharmacy 3.00 $3.00 for prescription drugs costing $50.00 or more. Add $ Prescription *Cost refers to the amount of Remove reimbursement *Pharmacy cost sharing is suspended for dates of service 2/21/24 - 3/18/24. Outpatient 3.00 $3.00 per day per hospital. Add $ Day Sexual assault related services are Remove exempt from cost sharing. Dental 3.00 $3.00 per provider per date of Add $ Visit service. Remove Preventive dental services are exempt from cost sharing. The state permits providers to require individuals to pay cost sharing as a condition for receiving items or services, subject to G the conditions specified at 42 CTR 447.52( e )(I). This is only permitted for non-exempt individuals with family income above No 100%FPL. TN: 24-0008 Supersedes TN: New Approval Date: 06/28/2024 Effective Date: 02/21/2024 Page I of2 I - D □ □

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Qualified Medicare Beneficiaries MEDICAID I Medicaid State Plan I Eligibility I VT2024MS0004O I VT-24-0010 Package Header Package ID VT2024MS0004O Submission Type Official Approval Date 03/14/2025 Superseded SPA ID VT-22-0002 System-Derived B. Financial Methodologies SPA ID VT-24-0010 Initial Submission Date 6/28/2024 Effective Date 4/1/2024 1. 551 methodologies are used in calculating household income. Please refer as necessary to Non-MAGI Methodologies, completed by the state. 2. Less restrictive methodologies are used in calculating countable income. 0Yes QNo The less restrictive income methodologies are: Å General income disregard: l!.I Census Bureau wages are disregarded. Å Dividends are disregarded. l!.IA less restrictive methodology is used with respect to lump sum income: Name of disregard: COLA Forecast Description: From January 1 until April 1, the Department will disregard the difference between its estimated Federal Poverty Levels (FPLs) and the currently approved FPLs as published in the Federal Register. Effective April 1, the Department will issue a second increase if the actual FPLs exceed its estimate. If the department's estimated FPLs issued January 1 are higher than the actual FPLs, the department will continue to disregard the difference between its estimated FPLs and the ones published in the Federal Register. Description of disregard: Wages paid by the Census Bureau for temporary employment related to census activities are excluded as income for this eligibility group. Description of disregard: Interest and dividend income Å Specified methodology for the treatment of lump sums as income: Name of methodology: Lump Sum Receipt of Earnings ÅA specified type of income is disregarded: Name of income type: Income of an ineligible spouse Cash Contributions or Gifts Vermont Tax Credit Description: Lump sum receipt of earnings such as sale of crops or livestock are averaged over the six-month accounting period. Description: Countable income of an ineligible spouse is added to the countable income of an eligible individual and compared, after deductions, to the Medically Needy Income Level for two. Infrequent or irregular voluntary cash contributions or gifts are excluded. Any refundable credit against taxes made pursuant to Vermont's child tax credit (32 V.S.A. § 5830f) or pursuant to a similar tax credit enacted by the State and directed by state law to not be considered as countable income for benefit programs.

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Qualified Medicare Beneficiaries MEDICAID I Medicaid State Plan I Eligibility I VT2024MS0004O I VT-24-0010 Package Header Package ID VT2024MS0004O Submission Type Official Approval Date 03/14/2025 Superseded SPA ID VT-22-0002 System-Derived F. Additional Information (optional) SPA ID VT-24-0010 Initial Submission Date 6/28/2024 Effective Date 4/1/2024 PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children's Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state's program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children's Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid 0MB control number. The valid 0MB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), 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. This view was generated on 4/9/2025 3:01 PM EDT

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Specified Low Income Medicare Beneficiaries MEDICAID I Medicaid State Plan I Eligibility I VT2024MS0004O I VT-24-0010 Package Header Package ID VT2024MS0004O Submission Type Official Approval Date 03/14/2025 Superseded SPA ID VT-22-0002 System-Derived B. Financial Methodologies SPA ID VT-24-0010 Initial Submission Date 6/28/2024 Effective Date 4/1/2024 1. 551 methodologies are used in calculating household income. Please refer as necessary to Non-MAGI Methodologies, completed by the state. 2. Less restrictive methodologies are used in calculating countable income. 0Yes QNo The less restrictive income methodologies are: Å General income disregard: l!.I Census Bureau wages are disregarded. Å Dividends are disregarded. l!.IA less restrictive methodology is used with respect to lump sum income: Name of disregard: COLA Forecast Description: From January 1 until April 1, the Department will disregard the difference between its estimated Federal Poverty Levels (FPLs) and the currently approved FPLs as published in the Federal Register. Effective April 1, the Department will issue a second increase if the actual FPLs exceed its estimate. If the department's estimated FPLs issued January 1 are higher than the actual FPLs, the department will continue to disregard the difference between its estimated FPLs and the ones published in the Federal Register. Description of disregard: Wages paid by the Census Bureau for temporary employment related to census activities are excluded as income for this eligibility group. Description of disregard: Interest and dividend income Å Specified methodology for the treatment of lump sums as income: Name of methodology: Lump Sum Receipt of Earnings ÅA specified type of income is disregarded: Name of income type: Income of an ineligible spouse Cash Contributions or Gifts Vermont Tax Credit Description: Lump sum receipt of earnings such as sale of crops or livestock are averaged over the six-month accounting period. Description: Countable income of an ineligible spouse is added to the countable income of an eligible individual and compared, after deductions, to the Medically Needy Income Level for two. Infrequent or irregular voluntary cash contributions or gifts are excluded. Any refundable credit against taxes made pursuant to Vermont's child tax credit (32 V.S.A. § 5830f) or pursuant to a similar tax credit enacted by the State and directed by state law to not be considered as countable income for benefit programs.

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Qualifying Individuals MEDICAID I Medicaid State Plan I Eligibility I VT2024MS0004O I VT-24-0010 Package Header Package ID VT2024MS0004O Submission Type Official Approval Date 03/14/2025 Superseded SPA ID VT-22-0002 System-Derived B. Financial Methodologies SPA ID VT-24-0010 Initial Submission Date 6/28/2024 Effective Date 4/1/2024 1. 551 methodologies are used in calculating household income. Please refer as necessary to Non-MAGI Methodologies, completed by the state. 2. Less restrictive methodologies are used in calculating countable income. 0Yes QNo The less restrictive income methodologies are: Å General income disregard: l!.I Census Bureau wages are disregarded. Å Dividends are disregarded. l!.IA less restrictive methodology is used with respect to lump sum income: Name of disregard: COLA Forecast Description: From January 1 until April 1, the Department will disregard the difference between its estimated Federal Poverty Levels (FPLs) and the currently approved FPLs as published in the Federal Register. Effective April 1, the Department will issue a second increase if the actual FPLs exceed its estimate. If the department's estimated FPLs issued January 1 are higher than the actual FPLs, the department will continue to disregard the difference between its estimated FPLs and the ones published in the Federal Register. Description of disregard: Wages paid by the Census Bureau for temporary employment related to census activities are excluded as income for this eligibility group. Description of disregard: Interest and dividend income Å Specified methodology for the treatment of lump sums as income: Name of methodology: Lump Sum Receipt of Earnings ÅA specified type of income is disregarded: Name of income type: Income of an ineligible spouse Cash Contributions or Gifts Vermont Tax Credit Description: Lump sum receipt of earnings such as sale of crops or livestock are averaged over the six-month accounting period. Description: Countable income of an ineligible spouse is added to the countable income of an eligible individual and compared, after deductions, to the Medically Needy Income Level for two. Infrequent or irregular voluntary cash contributions or gifts are excluded. Any refundable credit against taxes made pursuant to Vermont's child tax credit (32 V.S.A. § 5830f) or pursuant to a similar tax credit enacted by the State and directed by state law to not be considered as countable income for benefit programs.

(vt-11-008)(approval-document)Vermont Medicaid SPA VT-11-008: Approval Document (approved December 21, 2011, effective July 1, 2011)#

(vt-11-008)(approval-document)Vermont Medicaid SPA VT-11-008: Approval Document (approved December 21, 2011, effective July 1, 2011)#

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(vt-11-023b)(approval-document)Vermont Medicaid SPA VT-11-023B: Approval Document (approved April 26, 2012, effective July 1, 2011)#

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(vt-11-033)(approval-document)Vermont Medicaid SPA VT-11-033: Approval Document (approved March 2, 2012, effective January 1, 2012)#

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(vt-11-035)(approval-document)Vermont Medicaid SPA VT-11-035: Approval Document (approved March 23, 2012, effective October 1, 2012)#

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(vt-12-005)(approval-document)Vermont Medicaid SPA VT-12-005: Approval Document (approved April 26, 2012, effective March 31, 2012)#

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(vt-13-0002-mm1)(approval-document)Vermont Medicaid SPA VT-13-0002-MM1: Approval Document (approved December 13, 2013, effective January 1, 2014)#

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(vt-13-0006-mm2)(approval-document)Vermont Medicaid SPA VT-13-0006-MM2: Approval Document (approved February 27, 2014, effective October 1, 2013)#

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