Effective Date: July 1, 2009

Approval Date:

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

Preamble

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

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

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

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

State/Territory: ___________State of Washington____________________________ (Name of State/Territory)

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

________________________________________________________________________ (Signature of Governor, or designee, of State/Territory, Date Signed)

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

The following state officials are responsible for program administration and financial oversight (42 CFR 457.40(c)):

Name: Susan N. Dreyfus Position/Title: Secretary/Department of Social and Health Services Name: Doug Porter Position/Title: Assistant Secretary/Medicaid Purchasing Administration Name: Kevin Cornell Position/Title: Program Manager/Children’s Health Insurance Program According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0707. The time required to complete this information collection is estimated to average 160 hours (or minutes) per response, including the time to review instructions, search existing data resources, gather the data needed and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this Form, please write to: CMS, P.O. Box 26684, Baltimore, Maryland 21207 and to the Office of the Information and Regulatory Affairs, Office of Management and Budget, Washington, D.C. 20503.

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Table of Contents

Section 1. General Description and Purpose of the State Child Health Plans and State Child Health Plan Requirements (Section 2101) ................................................................ 5 1.1 The State will use funds provided under Title XXI primarily for (Check appropriate box) (42 CFR 457.70): .................................................................................................... 5 1.2 .................................................................................................................................. 6 1.3 .................................................................................................................................. 6 1.4 .................................................................................................................................. 6 Section 2. General Background and Description of State Approach to Child Health Coverage and Coordination (Section 2102 (a)(1)-(3)) and (Section 2105)(c)(7)(A)-(B)) .... 9 2.1. ................................................................................................................................. 9 2.2. ................................................................................................................................. 9 2.3. ............................................................................................................................... 12 Section 3. Methods of Delivery and Utilization Controls (Section 2102)(a)(4)) ......... 14 3.1. ............................................................................................................................... 14 3.2. ............................................................................................................................... 18 Section 4. Eligibility Standards and Methodology (Section 2102(b)) ............................. 20 4.1. ............................................................................................................................... 20 4.2. ............................................................................................................................... 23 4.3. ............................................................................................................................... 23 4.4. ............................................................................................................................... 25 Section 5. Outreach (Section 2102(c) ............................................................................ 30 Section 6. Coverage Requirements for Children’s Health Insurance (Section 2103) .... 32 6.1. ............................................................................................................................... 32 Indian Health Clinics ......................................................................................................... 6.2. ............................................................................................................................... 35 6.3 ................................................................................................................................ 37 6.4. ............................................................................................................................... 38

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Section 7. Quality and Appropriateness of Care ............................................................. 40 7.1. ............................................................................................................................... 40 7.2. ............................................................................................................................... 42 Availability of Practitioners ........................................................................................... 43 Section 8. Cost Sharing and Payment (Section 2103(e)) ............................................... 47 8.1. ............................................................................................................................... 47 8.2. ............................................................................................................................... 47 8.3. ............................................................................................................................... 48 8.4. ............................................................................................................................... 48 8.5. ............................................................................................................................... 49 8.6. ............................................................................................................................... 49 8.7. ............................................................................................................................... 49 8.8. ............................................................................................................................... 51 8.8.5. ............................................................................................................................ 51 Section 9. Strategic Objectives and Performance Goals and Plan Administration (Section 2107) ................................................................................................................................ 52 9.1. ............................................................................................................................... 52 9.2. ............................................................................................................................... 52 9.3. ............................................................................................................................... 52 9.4. ............................................................................................................................... 54 9.5. ............................................................................................................................... 54 9.6. ............................................................................................................................... 54 9.7. ............................................................................................................................... 54 9.8. ............................................................................................................................... 54 9.9. ............................................................................................................................... 54 9.10. ............................................................................................................................. 56 Section 10. Annual Reports and Evaluations (Section 2108) .......................................... 61 10.1. Annual Reports. ............................................................................................... 61 10.2. ............................................................................................................................. 61 10.3. ............................................................................................................................. 61

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Section 11. Program Integrity (Section 2101(a)) ............................................................. 62 11.1. ............................................................................................................................. 62 11.2. ............................................................................................................................. 62 Section 12. Applicant and Enrollee Protections (Sections 2101(a)) ................................ 63 12.1. Eligibility and Enrollment Matters ..................................................................... 63 12.2. Health Services Matters ................................................................................... 63 12.3. Premium Assistance Programs ....................................................................... 63

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Section 1. General Description and Purpose of the State Child Health Plans and State Child Health Plan Requirements (Section 2101)

1.1 The State will use funds provided under Title XXI primarily for

(Check appropriate box) (42 CFR 457.70):

1.1.1

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

1.1.2.

Providing expanded benefits under the State’s Medicaid plan (Title XIX); or

1.1.3.

A Combination of both of the above.

Washington’s CHIP offers comprehensive healthcare coverage to children through age 18, who reside in households with incomes up to 300% of the federal poverty level (FPL). Healthcare coverage for children in households with incomes up to 250% of FPL is a state mandated entitlement. Coverage for children in household with incomes above 250% of FPL is offered within available state funds appropriated by Washington’s legislature. Families are required to pay a modest premium for coverage. CHIP benefits are the same as the state’s Medicaid program for children. The program uses the state’s Medicaid managed care delivery system and employs Medicaid income eligibility criteria. However, the CHIP eligibility process is different due to restrictions about existing insurance. CHIP is administered by DSHS’s Medicaid Purchasing Administration (MPA) in coordination with other DSHS administrations and other state agencies including the Department of Health (DOH), the Governor’s Office, and the Health Care Authority (HCA).

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1.2

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

Washington State assures that expenditures for child health assistance will not be claimed prior to the time the State has legislative authority to operate the State plan or before the State plan amendment is approved by CMS.

1.3

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

Washington State assures that the state complies with all applicable civil rights requirements.

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

Amendment 1 - This amendment allowed the assignment of eligible children into managed care plans and created eligibility requirements similar to the Washington State Medicaid program. Submitted: February 8, 2001 Approved: May 7, 2001 Effective date: January 1, 2001 Amendment 2 - This amendment removed the co-pay requirement. Submitted: April 3, 2002 Approved: July 1, 2002 Effective date: January 1, 2002 Amendment 3 - This amendment updated the plan to specify the States compliance with the final CHIP regulation.

Submitted: October 3, 2002 Approved: December 19, 2002 Effective date: July 1, 2002

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Amendment 4 - This amendment allows CHIP coverage for unborn children of women up to 185% of the Federal poverty level who are not eligible for Medicaid. Submitted: June 25, 2003 Approved: September 22, 2003 Effective date: November 12, 2002 Amendment 5 - This amendment changed the eligibility review period from 12 months of continuous coverage to 6 months of non-continuous coverage. Submitted: January 22, 2004 Approved: June 16, 2004 Effective date: December 31, 2003 Amendment 6 - This amendment increased the premium amount from $10/mo. per child; $30/mo maximum per family to $15/mo per child; $45/mo maximum per family. The time allowed for non-payment of premiums was decreased from 4-months to 3- months; the waiting period after disenrollment for non-payment was decreased from 4-months to 3-months. Submitted: August 16, 2004 Approved: November 5, 2004 Effective date: July 1, 2004 Amendment 7 - This amendment restored the certification period back to 12 months continuous coverage; it also updated the State plan to reflect the name and organizational changes that occurred within the agency that administers CHIP. Submitted: May 2, 2006 Approved: August 1, 2006 Effective date: July 1, 2005 Amendment 8 - This amendment proposed a change in rates and payment methods and a requirement for a SSN for children. Submitted: November 27, 2006 Withdrawn: December 27, 2006 Amendment 9 - This amendment proposed funding for additional outreach activities. Submitted: January 23, 2007 Withdrawn: February 3, 2008

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Amendment 10 - This amendment increased funding from CHIP for additional outreach activities as a part of the passage of Cover All Kids legislation. Submitted: April 3, 2008 Approved: December 17, 2008 Effective date: July 1, 2007 Amendment 11 - This amendment proposes increasing the income limit to 300% FPL and creating a two-tiered premium structure for CHIP. The premium amount will also be increased. Good cause for dropping employer sponsored insurance is also amended from a cost of $50 to a cost of 2.5% household income. Submitted: April 14, 2008 Approved: April 3, 2009 Effective date: January 1, 2009 Amendment 12 - This amendment expanded the delivery of mental health services. Submitted: May 14, 2008 Approved: January 16, 2009 Effective date: July 1, 2008 Amendment 13 – This amendment is to provide federal funding for the Washington Poison Center (WAPC) under a health services initiative; expand CHIP coverage to lawfully residing alien children under age 19 ; require verification of citizenship; describe the CHIP dental coverage package; reference FQHC/RHC reimbursement methodology; and eliminate the 3 month sanction for failing to pay required premiums. Submitted date: June 29, 2010 Approved date: Effective date: July 1, 2009 for WAPC funding and Lawfully residing alien children.

October 1, 2009 for dental coverage and FQHC/RHC descriptions.

January 1, 2010 for citizenship verification requirement.

April 1, 2010 for elimination of 3 month sanction penalty.

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Approval Date: Section 2. General Background and Description of State Approach to Child Health Coverage and Coordination (Section 2102 (a)(1)-(3)) and (Section 2105)(c)(7)(A)-(B)) 2.1. Describe the extent to which, and manner in which, children in the state including targeted low-income children and other classes of children, by income level and other relevant factors, such as race and ethnicity and geographic location, currently have creditable health coverage (as defined in 42 CFR 457.10). To the extent feasible, make a distinction between creditable coverage under public health insurance programs and public-private partnerships (See Section 10 for annual report requirements). (42 CFR 457.80(a)) Based on the 2008 Washington State Population Survey (WSPS), 95.4% of all children in Washington had health care coverage in April/May 20081 2.2. Describe the current state efforts to provide or obtain creditable health coverage for uncovered children by addressing: (Section 2102)(a)(2) (42CFR 457.80(b)) . This represents a 2.4% increase in healthcare coverage since the year 2000. 95.3% of children between 200% and 300% of the federal poverty level (FPL) had healthcare coverage. Approximately 13,000 children in this income range remained without healthcare coverage and are the target population for outreach under Washington’s CHIP. 92.7% of children under 200% FPL had coverage at the time of the 2008 WSPS. Approximately 48,000 children in this income range were without healthcare coverage and are included in the target population for outreach as described in 42 CFR 457.90. 97.7% of children above 300% FPL had coverage at the time of the 2008 WSPS. Consistent with national trends, employer- based coverage was the principal source of coverage for higher income children. The rate of employer- sponsored coverage of children above 300% FPL was 85.1%, whereas the rate of employer- sponsored coverage of children below 200% FPL was only 18.8%.

1 Washington State used the biennial Washington State Population Survey (WSPS) to provide a profile of residents between decennial censuses. The WSPS replicates the Bureau of the Census’ Current Population Survey (CPS). However, the WSPS employs a greatly enhanced sample size, which allows for statistically reliable analysis for the state and regions within the state. The health status information reported is the household member’s status at the time of the interview (April and May 2008).

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Approval Date: 2.2.1. The steps the state is currently taking to identify and enroll all uncovered children who are eligible to participate in public health insurance programs (i.e., Medicaid and state-only child health insurance): Washington operates several programs to provide healthcare coverage to low- income children. The largest of these programs is Medicaid, which provides coverage to over 680,000 U.S. citizen and legal alien children annually, in households with incomes up to 200% FPL2 To facilitate the success of these programs, Washington has engaged in a number of enrollment and retention strategies to ensure a high penetration rate into Medicaid and CHIP eligible populations. Among our best practices are:

. Since 1988, Washington has operated the Basic Health Program (BHP) providing premium-subsidized health insurance to approximately 60,000 low- income adults and families (including children) with incomes up to 200% FPL. Washington’s CHIP program began in 2001 and currently provides coverage to nearly 20,000 children in households with incomes between 200% - 300% FPL. Washington’s CHIP coverage also provides coverage for over 9,000 low-income unborn children annually whose mothers do not qualify for Medicaid, but have household income below 185% FPL. In 2006, Washington reinstated its entirely state funded Children’s Health program for low- income children who do not qualify for Medicaid or CHIP based on their citizenship status. The Children’s Health program mirrors Medicaid and CHIP in its construction. As in the CHIP program, children in households with income between 200% and 300% FPL are required to pay a premium . • Continuous Eligibility – Once a child is found eligible for medical assistance, the child remains continuously eligible for a full twelve months, regardless of changes in the household income. • No asset test - There is no resource test applied to eligibility for children’s medical programs. • No interview requirement – Families do not need a face- to- face interview. Application can be made through the mail or by electronic submission.

2 Based on 2008 Medicaid Children Title XIX SEDS report.

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Approval Date: • Simplified Application – MPA has developed a one-page application for “Apple Health for Kids,” which is the State’s name for the program that combines all children’s medical programs. • Joint Application - Applications for medical assistance are automatically considered for Medicaid, CHIP, and state-funded programs. In addition, applicants for cash and food assistance benefits may request medical assistance on the same application used for cash and food assistance. • Extended Medical benefits – Children coming off TANF automatically receive Medicaid for one year after the end of their TANF assistance. • Application Agents – As funds are available the department contracts with local health jurisdictions and community based organizations to serve as application agents, directly assisting families with completion of a simplified one page Apple Health for Kids application. Application agents are paid a fee for successful enrollments. • Premium Payment Program – Parents may be reimbursed for the cost of employer- sponsored insurance to cover their Medicaid eligible child. • Renewal contacts – The department provides the renewal dates to three managed care organizations (MCO) who have volunteered to assist their enrollees with the renewal process. MCO staff contact the families by phone and assist them with completing the annual renewal form electronically.

2.2.2. The steps the state is currently taking to identify and enroll all uncovered children who are eligible to participate in health insurance programs that involve a public-private partnership: To assist in making health coverage affordable to low-income persons, the Health Care Authority’s (HCA) Basic Health Plan (BHP) has adopted a sponsorship program with public and private entities. These entities, including health care providers, but not health care plans, are allowed to pay all or a portion of the sponsored enrollee’s premium obligations, but not co-pays. About 27,000 BHP adults and children are receiving coverage through these sponsorship arrangements. Employers can also purchase group coverage for themselves and their employees through BHP. Employers must enroll at least 75% of all eligible employees within the classification

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Approval Date: of employees. BHP may charge a minimum financial contribution for each enrolled employee. Employers are required to offer their employees the complete choice of BHP plans available within the employer’s county of residence. About 1,000 adults and children are receiving BHP coverage through their employer. Although BHP’s financial sponsorship and employer coverage options are not specifically targeted to children, they provide affordable health coverage to families. Through the BHP Plus program, children in these families are able to receive full-scope Medicaid coverage without cost-sharing.3 MPA is coordinating its outreach efforts with BHP and private organizations. In Washington, nearly all children receiving free and reduced lunches are also eligible for Medicaid. In 2008, MPA expanded outreach efforts by coordinating with the Office of the Superintendent of Public Instruction (OSPI) to provide a list of potentially eligible children from the Free & Reduced Lunch program to the contracted outreach providers. These lists were used to conduct targeted outreach efforts. This effort continues today as funds are available. Most children are able to receive this coverage through the same health plan and provider network as their family members. Washington state continues to participate in the national Healthy Kids Now! (HKN!) toll-free 800#. This number provides information on Medicaid and CHIP eligibility for those clients who might qualify for services.

2.3. Describe the procedures the state uses to accomplish coordination of CHIP with other public and private health insurance programs, sources of health benefits coverage for children, and relevant child health programs, such as title V, that provide health care services for low-income children to increase

the number of children with creditable health coverage. (Previously 4.4.5.) (Section 2102)(a)(3) and 2102(c)(2) and 2102(b)(3)(E)) (42CFR 457.80(c))

Washington’s CHIP program uses the same application as its Medicaid program. Applications for medical assistance are submitted to the local Community Services Office (CSO) for review. Applications have a barcode label that creates an electronic assignment into the Document Management System (DMS) that notifies

3 This is part of the Health Care Authority’s subsidized healthcare program.

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Approval Date: local CSO staff that there is an application that needs processing. If the child is determined to be ineligible for Medicaid, the application is then electronically forwarded to Medical Eligibility Determination Services (MEDS) staff at MPA to determine the child’s eligibility for the CHIP program. In addition to this application process, Washington’s CHIP program coordinates with the BHP application process. Currently, Washington’s Medicaid program has an interagency agreement with the HCA’s BHP to cover children under 19 years of age with family incomes at or below 200% FPL. If a family checks a box on their application that states they would like to apply for BHP Plus for their children, HCA automatically forwards the application to MPA. This is permissible under the special rule provision of Title XXI, Section 2110(b)(3). MPA then processes the application, looking first at eligibility for Medicaid. If the children are not Medicaid eligible, then eligibility for CHIP is determined. For disabled children receiving services under the Title V Children with Special Health Care Needs (CSHCN) program, we identify clients through both self- identification and a data match with the Department of Health (DOH). We coordinate services for these children with representatives from DOH, regional CSHCN representatives, community-based groups and organizations, and CSHCN care coordinators. MPA representatives meet with these groups on a regular basis to discuss and clarify policies, care plans, relevant issues, and complaints. MPA also has a representative on the Medicaid Integration Team whose purpose is to share information and address issues regarding CSHCN that may come up at the regional level. We also use our outreach contractors to help identify potentially eligible-families, and assist them to apply for all types of benefits. Our statewide toll-free line helps families apply for all types of benefits and connects them with local resources. Our “Apple Health for Kids” application is available in a broad array of public and community locations, such as physician offices, schools, and community health departments.

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

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

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

Washington’s CHIP uses Washington’s Medicaid managed care delivery system. The managed care system contracts with managed care organizations (MCOs) for medical care coverage and a limited mental health benefit for enrollees that do not meet the criteria for primary mental health care services from the Regional Support Networks (RSN’s). Other Medicaid services are “carved out” of managed care and provided on a “wrap-around” fee-for-service (FFS) basis. These “wrap around” services include dental coverage, chemical dependency services, eyeglasses, hearing aid devices, pregnancy terminations, and non-emergent transportation. Children also receive services through MPA’s FFS program prior to enrollment in managed care. MPA contracts with MCOs registered with the state’s Office of the Insurance Commissioner (OIC) to provide full-scope medical coverage on a full-risk capitation basis. This program is called Healthy Options (HO). If MPA does not contract with at least two MCOs for coverage in a given service area, or if the contracting plan’s networks are not able to provide sufficient access throughout the county, enrollees will be allowed to receive coverage through FFS.

In service areas with a choice of at least two MCOs, CHIP enrollees will be required to enroll in an MCO and will receive the same schedule-of-benefits as Medicaid clients.

An CHIP household is not required to select a HO plan for their child as part of the application process. However, after approval of the application, if a client does not

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Approval Date: voluntarily choose a plan, the client will be assigned to a plan when there are two or more plans in their community. MPA contracts with Indian Health Services (IHS) and tribal operated health clinics to provide primary care case management (PCCM) coverage to American Indians/Alaska Natives as an alternative to managed care enrollment. Washington’s CHIP program reimburses Federally Qualified Health Centers (FQHC) and Rural Health Clinics (RHC) using the same alternative payment methodology (APM) as the State’s Medicaid program. There is no difference between the CHIP rates and the Medicaid rates for reimbursing Federally Qualified Health Centers (FQHC) and Rural Health Clinics (RHC). In the State of Washington, FQHCs/RHCs have the choice of reimbursement under the Prospective Payment System (PPS) as outlined in the Benefits Improvement and Protection Act of 2000 (BIPA) statutory language, or an Alternative Payment Methodology (APM). Prospective Payment System The facility-specific encounter rates were established in 2002, and they are considered the providers’ base encounter rates. The base rates were calculated using cost report data from 1999 and 2000, and in some cases, 2001. The corresponding enhancement rates were also established at this time. Pursuant to the requirements of the PPS, both the FFS encounter rates and managed care enhancement rates for each provider have been increased annually by the percentage change in the MEI. Alternative Payment Methodology The APM encounter rates were established by starting with each provider’s base PPS rate, and trending forward to 2009 using the APM index. The APM index is a Washington State specific health Care index developed by IHS Global Insight. Rates established under the APM will be inflated each year by the Washington State specific health care index. Annual reconciliation is a part of the APM. Rates determined under the APM will be periodically rebased.

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Approval Date: Supplemental Payments for Managed Care Clients For clients enrolled with a managed care contractor, the department will pay the FQHC/RHC a supplemental payment (called enhancement) in addition to the amount paid by the managed care contractor. These enhancements will pay monthly on a per-member-per-month basis. To ensure that the appropriate amounts are being paid to each FQHC/RHC, the department will perform an annual reconciliation and verify that the enhancement payments made in the previous year were in compliance with Section 1902(bb)(5)(A) of the Social Security Act.

An additional description of this methodology can be found on page 3 (RHC) and page 33 (FQHC) of Attachment 4.19-B of the Title XIX state plan, as approved by CMS on June 26, 2009. MPA’s Division of Behavioral Health and Recovery (DBHR) contracts with public Regional Support Networks (RSNs) to offer mental health services as prepaid inpatient health plans. To receive mental health care, all Medicaid and CHIP children are enrolled in the RSN providing coverage in their county of residence. Children enrolled in HO or in the FFS program receive their mental health care through their MCO or FFS provider if they do not meet the criteria for RSN services. In addition to psychiatrists, the following mental health professionals, when licensed by the Department of Health, may also provide mental health services beginning July 1, 2008: • Licensed Psychologists • Licensed Psychiatric Advanced Registered Nurse Practitioners • Licensed Independent Clinical Social Workers • Licensed Advanced Social Workers • Licensed Marriage and Family Therapists • Licensed Mental Health Counselors

MPA has developed procedures with DBHR to assure coordinated care. MPA sends a monthly tape to DBHR identifying Medicaid clients and their eligibility group and

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Approval Date: CHIP clients. DBHR provides services based on clinical need, not insurance coverage. DBHR-contracted and subcontracted outpatient treatment providers who have signed a Core Provider Agreement conduct assessments to determine the extent of the problem and the course of treatment.

Substance abuse treatment services are not included in the HO capitation rates and are paid outside the contracts. HO contracts require that licensed health carriers assure that care is coordinated with non-participating community health and social program providers, including substance abuse providers. In order for the alcohol and drug treatment to be paid through the medical assistance program, patients enrolled in HO must receive substance abuse treatment from state certified treatment agencies who have signed a Core Provider Agreement. One of the DBHR- contracted and subcontracted outpatient treatment providers who have signed a Core Provider Agreement conducts an assessment to determine the extent of the problem and the course of treatment.

Poison treatment advice and prevention through the Washington Poison Center (WAPC) is supported using CHIP funds available under the 10 percent federal administrative expenditures cap. The WAPC provides emergency telephone treatment advice, referral assistance, and information to manage exposure to poisonous and hazardous substances. The WAPC answers poisoning emergency calls from the general public 24 hours a day, 365 days each year at no charge. At all times, a Specialist in Poison Information (SPI) is available to manage cases and Certified Specialists in Poison Information (CSPI) are available to manage cases and direct Poison Information Providers. The service is provided via a toll-free phone number to all communities throughout Washington, including under-served, low- income, and indigent populations. Interpreters are available in over 150 languages and via telecommunications devices for the deaf and hearing impaired (TTY).

WAPC public education programs direct attention and resources to at-risk populations living in poverty, including minority and immigrant communities.

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Approval Date: Consumer-based educational materials have been developed that are culturally relevant, taking into consideration health literacy levels and clearly illustrating and describing WAPC services. In addition to English, materials are available in Spanish, Korean, Vietnamese, Laotian, Chinese, Russian, and Somali.

The WAPC promotes poison awareness through community forums. WAPC’s mascot “Mr. Yuk” is a familiar face at presentations in schools, community health fairs, and other local events and gatherings. The WAPC works closely with other community health programs such as Washington State’s Safe Kids Program and Safe Kids Coalition groups. The WAPC advertises their public toll-free number and toll-free TTY number in the white pages and consumer guides of all Washington state telephone directories, as well as on billboards across the state. Advertisements and billboards are in Spanish and English. The WAPC receives approximately 66,000 calls annually involving a poison or hazardous substance exposure. 63% of all calls received are regarding exposure of child under the age of 19. Over 35% of the total calls relate to exposure of a child in a family whose annual household income is no more than 300% FPL.4 WAPC intervention resulted in over 94% these exposures calls being handled in the home so that the child did not have to use an Emergency Department or need a 911 call and response. Each call to the WAPC significantly reduces costs in other medical spending. Cost savings in 1996 dollars were estimated at $175 per call.5 3.2. Describe the utilization controls under the child health assistance provided

4 The percentage of calls attributed to children in families with incomes no greater than 300% FPL is based on WAPC records for 2009. 66,083 total exposure calls were answered statewide. 41,827 exposure calls were for children ages 0 – 18. 2008 Washington State Population Survey (http://wa-state-ofm.us/SPSOnline/) estimates 55.5% of Washington children are living in households with incomes no more than 300%FPL. This represents 23,214 calls, or 35.1% of the total volume of calls. 5 Miller T.R. & Lestina, D.C. (1997). Costs of Poisoning in the United States and Savings from Poison Control Centers: A Benefit-Cost Analysis. Annuals of Emergency Medicine, 29(2), 239-45.

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

HO plans are required to manage service utilization according to standards in the state’s Quality Improvement Program Standards. Before being approved for participation in the program, health plans must have in place utilization review infrastructure and protocols for, but not limited to: • Determination of medical appropriateness and denial of services; • Referrals to specialty care; • Clinician participation and use of clinical practice guidelines; • Twenty-four hour availability of clinical consultation; • Availability and profiling of practitioners; • Identification of members with chronic/high-risk illnesses, hospital discharge planning, case management, and coordination of special needs; • Access and timeliness of services; and • Review of under or over utilization of care. Internal monitoring reviews will be routinely conducted to assure that medically necessary care is delivered in a cost-effective and efficient manner. External quality reviews, in accordance with federal law (Section 1902 (a) (30) (C) of the Social Security Act), will be conducted annually for selected services by all managed care organizations (MCOs) contracted with the program. Utilization controls for CHIP children on FFS coverage are consistent with all utilization review requirements of Title XIX. Examples of utilization controls include external review of hospital claims data, exception-to-policy procedures, data audits, pre-authorization for extended coverage utilization, and drug utilization review.

Refer to Section 7 – Quality and Appropriateness of Care – for more information on utilization control.

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Approval Date: Section 4. Eligibility Standards and Methodology (Section 2102(b))

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

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

4.1.1.

Geographic area served by the Plan: The entire state of Washington. 4.1.2.

Age: Children under the age of nineteen.

4.1.2.1

Age: Unborn, conception through birth. 4.1.3.

Income: Above 200% FPL up to and including 300% FPL for children under age 19. 4.1.3.1

Income: 0% of the FPL (and not eligible for Medicaid) through 185% of the FPL for unborn children. 4.1.3.2 Income: All wages paid by the Census Bureau for temporary employment related to decennial census activities are excluded. 4.1.4.

Resources (including any standards relating to spenddowns and disposition of resources): There is no resource test. 4.1.5.

Residency (so long as residency requirement is not based on length of time in state): A Washington resident who intends to continue living in the state, or who entered the state looking for a job or entered the state with a job commitment (WAC 388-468- 0005). 4.1.6.

Disability Status (so long as any standard relating to disability status does not restrict eligibility): There is no disability status requirement. 4.1.7.

Access to or coverage under other health coverage: CHIP coverage is not available to children who are otherwise eligible for Medicaid or who have “creditable coverage”.

28 Effective Date: July 1, 2001

Approval Date: 4.1.8.

Duration of eligibility: Twelve months of continuous coverage. Eligibility for CHIP may be retro-active up to three months prior to the month of application. In the case of an unborn child, retro-active coverage may begin up to three months prior to the month of application, but no sooner than the month of conception. 4.1.9.

Other standards (identify and describe):

4.1.9.1 Citizenship: Proof of U.S. citizenship or legal alien status is required for all new applicants. When proof of citizenship is not readily available a declaration will be accepted, and a reasonable opportunity to present satisfactory documentary evidence of citizenship will be given. The department will utilize available electronic data bases (e.g. Vital Records, EVVE, SVES) whenever possible to establish proof of citizenship on behalf of the applicant. The department will assist the family to obtain proof of citizenship, and when necessary authorize the purchase of a birth certificate from the child’s state of birth. In those instances where proof of citizenship status is not available at application it shall be required by the next redetermination.

4.1.10 Check if the State is electing the option under section 214 of the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA) to provide coverage to the following otherwise eligible children as specified below who are lawfully residing in the United States including the following:

A child shall be considered lawfully present if he or she is:

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

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

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

28 Effective Date: July 1, 2001

Approval Date: for prosecution, for deferred inspection or pending removal proceedings;

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

(i) Aliens currently in temporary resident status pursuant to section 210 or 245A of the INA (8 U.S.C. §§1160 or 1255a, respectively); (ii) Aliens currently under Temporary Protected Status (TPS) pursuant to section 244 of the INA (8 U.S.C. §1254a), and pending applicants for TPS who have been granted employment authorization; (iii) Aliens who have been granted employment authorization under 8 CFR 274a.12(c)(9), (10), (16), (18), (20), (22), or (24); (iv) Family Unity beneficiaries pursuant to section 301 of Pub. L. 101-649, as amended; (v) Aliens currently under Deferred Enforced Departure (DED) pursuant to a decision made by the President; (vi) Aliens currently in deferred action status; or (vii) Aliens whose visa petition has been approved and who have a pending application for adjustment of status;

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

(6) An alien who has been granted withholding of removal under the Convention Against Torture;

(7) A child who has a pending application for Special Immigrant Juvenile status as described in section 101(a)(27)(J) of the INA (8 U.S.C. § 1101(a)(27)(J));

(8) An alien who is lawfully present in the Commonwealth of the Northern Mariana Islands under 48 U.S.C. § 1806(e); or

(9) An alien who is lawfully present in American Samoa under the immigration laws of American Samoa.

The State elects the CHIPRA section 214 option for children up to age 19 The State elects the CHIPRA section 214 option for pregnant women through the 60-day postpartum period

4.1.10.1 The State provides assurance that for individuals whom it enrolls in

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Approval Date: CHIP under the CHIPRA section 214 option that it has verified, both at at the time of the individual’s initial eligibility determination and at the time of the eligibility redetermination, that the individual continues to be lawfully residing in the United States. The State must first attempt to verify this status using information provided at the time of initial application. If the State cannot do so from the information readily available, it must require the individual to provide documentation or further evidence to verify satisfactory immigration status in the same manner as it would for anyone else claiming satisfactory immigration status under section 1137(d) of the Act.

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

4.2.1.

These standards do not discriminate on the basis of diagnosis.

4.2.2.

Within a defined group of covered targeted low-income children, these standards do not cover children of higher income families without covering children with a lower family income. 4.2.3.

These standards do not deny eligibility based on a child having a pre-existing medical condition.

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

MPA uses two standardized application forms to make eligibility determinations. One form is used for clients applying for the Apple Health for Kids healthcare program (a one-page form). The other form is used for clients applying for cash benefits, food stamps, medical assistance and other benefits. Applicants for CHIP can apply for healthcare coverage by using either form.

Information from the application is entered into the state’s Automated Client Eligibility System (ACES), which automatically generates CHIP eligibility notices and reviews. ACES transfers eligibility information to the state’s Medical Management Information System (MMIS). MMIS information is used to enroll clients into managed care.

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Approval Date: The application asks the citizenship status and Social Security Number (SSN) of only those children for whom the family is seeking benefits. Since disclosure of the Social Security Number is optional, children are enrolled into CHIP without having a Social Security Number. Adults, and other children listed on the application for whom the family is not applying, are not required to declare their citizenship status or provide an SSN.

When the application is screened into the ACES system, data such as the SSN is transmitted to other available state and federal data exchanges. The information from these exchanges may then be used as electronic proof of eligibility requirements. One such system is the SVES data match with the Social Security Administration (SSA). SSN information is entered into the ACES system during the screening process, and transmitted to SSA in an overnight batch. Verification of citizenship and enumeration is federally verified and transmitted back to the ACES system where the clients’ record is automatically updated even before the application has completed the application process. Wherever possible, department staff utilize electronically available information rather than delaying the application approval process by requesting paper documents from the applicant.

For continuing enrollment, an eligibility review form is generated and mailed to the head of household approximately six weeks prior to the end of the client’s 12 month certification period. The eligibility review form must be completed and returned with current information such as household members, income, and health insurance status. The eligibility review form is reviewed first for Medicaid, and then reviewed for CHIP eligibility if the recipient is not Medicaid eligible. As an alternative to completing the eligibility review form, the client may call into a statewide 800# and complete the review over the phone with an eligibility specialist .

CHIP applicants have the same appeal rights as Medicaid applicants. Applicants who are denied eligibility are sent a letter with information on their rights for an Administrative Hearing. Clients may call the Office of Administrative Hearings (OAH)

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Approval Date: to set up a hearing. OAH notifies the client and the agency’s Administrative Hearing Coordinator. The Coordinator prepares the case and sets up a pre-hearing conference as a way to settle the dispute or collect information. Cases that are not resolved in the pre-hearing conference proceed to an Administrative Hearing. At the Administrative Hearing, an Administrative Law Judge gathers information from the client and agency staff. Hearings can be conducted via telephone or in person. The Judge’s decision is mailed to the client and the Administrative Hearings Coordinator. Either party may appeal the decision for additional review and if need be, to the courts.

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

Check here if this section does not apply to your State.

4.4. Describe the procedures that assure that:

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

At the time of application and redetermination, eligibility staff first determines whether an applicant or recipient is eligible for Medicaid. If the child is not Medicaid eligible, staff assesses eligibility for CHIP and enrolls them in CHIP, if appropriate. To assist in this process, eligibility staff uses ACES automated protocols. In addition, there is a series of required questions on the application and eligibility review form that ask about the child’s health insurance status. If these questions are not answered at the time of application or review, the applicant is sent an “Insurance Information Request” letter, which must be completed before eligibility can be determined.

The State’s MMIS system is also checked at the time of application and re- determination to see if there is any history of a third party insurance. In addition, the Coordination of Benefits section reviews a monthly report of currently eligible CHIP

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Approval Date: clients to see whether any clients have health insurance coverage.

At application or review a child applying for, or enrolled in, CHIP will not be eligible for the program if they are covered under a group health plan or health insurance coverage; has access to, or coverage under, a state health benefits plan; or are Medicaid eligible.

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

All applications are first reviewed for Medicaid eligibility. Applicants are enrolled in Medicaid if eligible. This process is automated through ACES automated protocols. Eligibility for CHIP is determined only after eligibility for Medicaid is reviewed and the child is found ineligible for Medicaid.

4.4.3. The State is taking steps to assist in the enrollment in CHIP of children determined ineligible for Medicaid. (Sections 2102(a)(1) and (2) and 2102(c)(2) (42CFR 431.636(b)(4))

The ACES eligibility system automatically checks for Medicaid eligibility prior to consideration of eligibility for CHIP. After Medicaid ineligibility is determined, ACES automatically checks for CHIP eligibility based on the applicant’s income level.

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

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

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

In several ways, the State ensures that substitution of coverage does not occur. First,

28 Effective Date: July 1, 2001

Approval Date: both the application and the eligibility review form ask a series of questions regarding health insurance status of the applicant’s children. If they respond affirmatively to any of these questions, we ask the applicant to list the name of the insurance company or employer providing the insurance. The following individuals are ineligible for CHIP: Anyone who at the time of application or redetermination is covered under a group health plan or health insurance coverage; has access to, or coverage under, a state health benefits plan; or who is Medicaid eligible. If the client does not respond to the questions, they are sent an “Insurance Information Request” letter that the applicant must respond to in order for CHIP eligibility to be determined. If the client has access to health insurance coverage, they are not enrolled in CHIP. Also, at the time of application and redetermination the MMIS is checked to see if there is any history showing of insurance coverage for the household. If a history shows, further inquiries can be made. To monitor substitution of coverage, the State tracks responses on the number of applications and eligibility reviews that show the applicant has insurance coverage. In addition, the State tracks the number of applications and eligibility reviews that are denied due to insurance coverage.

Additionally, the State tracks whether the applicant has disenrolled from employer sponsored coverage. If the applicant has lost employer sponsored insurance coverage within the past 4 months, the child must serve a four-month waiting period. However, prior to imposing a waiting period, we look at whether one of nine exceptions applies to the family’s situation. Exceptions to the four-month waiting period may be granted when: 1) Parent lost job that has medical coverage for children. 2) Parent with medical insurance died. 3) Child has a medical condition that, without medical care, would cause serious disability, loss of function or death. 4) Employer ended medical coverage for children.

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Approval Date: 5) Child’s medical coverage ended because the child reached the maximum lifetime coverage amount. 6) Coverage under a COBRA extension period ended. 7) Children could not get medical services locally (they have to travel to another city or state to get care for their children). 8) Domestic violence led to loss of coverage. 9) The family’s total out-of-pocket maximum for employer-sponsored dependent coverage is 2.5 percent per month or more of family countable income. If none of the exceptions apply, the child must serve a 4-month waiting period prior to enrollment in CHIP. Another way we monitor for substitution of coverage is through the review of a monthly report of currently eligible CHIP clients. MPA researches this report for health insurance coverage to ensure there was no substitution of coverage at the time of application or re-determination.

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

The same strategies that are used to prevent substitution of coverage as described in 4.4.4.2 will be utilized in establishing eligibility for children in the 250%-300%FPL group.

4.4.4.4. If the State provides coverage under a Premium Assistance Program, describe: The minimum period without coverage under a group health plan, including any allowable exceptions to the waiting period. The minimum employer contribution. The cost-effectiveness determination.

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

Targeted low-income children who are American Indian or Alaska Native (AI/AN) will

28 Effective Date: July 1, 2001

Approval Date: be subject to the same eligibility criteria as other low-income children. MPA has coordinated with and will continue to work with representatives of the Tribes in the state of Washington, urban Indian organizations, and Indian advocacy groups, including the Northwest Portland Area Indian Health Board, the American Indian Health Commission, and the DSHS Indian Policy Advisory Committee, to develop outreach programs and methods that specifically target AI/AN children. CHIP has been, and will continue to be, a regular agenda item at meetings with these groups.

CHIP policy will mirror MPA Medicaid enrollment policy for AI/AN children. AI/AN clients are not required to enroll in HO plans. Instead, AI/AN children may choose a managed care plan, an Indian clinic operating as a primary care case manager (PCCM), or fee-for-service.

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Approval Date: Section 5. Outreach (Section 2102(c)

Describe the procedures used by the State to accomplish:

Outreach to families of children likely to be eligible for child health assistance or other public or private health coverage to inform them of the availability of the programs, and to assist them in enrolling their children in such a program: (Section 2102(c)(1)) (42CFR 457.90) Washington’s Governor has outlined two major health goals for Washington’s children: • Improving the quality and efficiency of health care in Washington; and • Covering all children in Washington with health insurance by 2010. Washington’s legislature appropriated $4.4 million in state funds for state fiscal year (SFY) 2008 and 2009 for outreach activities to accomplish these goals. The following outreach activities have been conducted by Washington State under its “Apple Health for Kids” campaign: 1. Develop and implement a proactive statewide marketing campaign to inform low-income families about health care coverage. Included in this campaign are the contracting of a media consultant; the development of outreach and training materials; brochures; program advertising; and a rebranding of the program to “Apple Health for Kids”. 2. Hire staff to provide program oversight and facilitate local outreach efforts. 3. Contract with 32 local health jurisdictions and 6 community based organizations in all 39 counties in Washington State to conduct outreach with the goal of enrolling uninsured, low-income children as described in 42 CFR 457.90. 4. These contracts involved two elements: a. Infrastructure grants to assist contractors to build capacity to conduct local outreach activities to children who do not traditionally access government assistance programs. b. Technical Assistance Payments (TAP) of $75 per approved child as a result of a successful application. MPA has worked with other state agencies to develop lists of children who were likely to be eligible based on available data bases (such as WIC, Food Assistance, Division of Child

30 Effective Date: July 1, 2009

Approval Date: Support and Working Connections Child Care programs). Contractors use these lists to conduct outreach/application activities and receive the TAP payment for each child that is subsequently approved for coverage. 5. Implementation of a Media campaign including purchase of advertising in local target markets and a “School-bus” media campaign tour of the state to promote the “Apple Health for Kids” program. 6. Conducting 4 renewal pilots to test different retention strategies. 7. Contracting with the Division of Information services for the development and roll-out of the new “Apple Health for Kids” website. 8. Increase in contract payments beginning in October 1st, 2008 from $75/per approved child to $150/per approved child. This increase is based on a pilot of a performance based “Application Agent” model where payment is made based on specific application assistance. Applications are barcode labeled to identify and track the agent involved. The contractor will also be responsible for providing a health literacy component to their outreach efforts. The state will only seek federal match for $75/per approved child under this model. Ongoing Outreach activities: Washington State will continue the statewide contract to provide: 1. The external toll-free line. A dedicated toll-free line for CHIP outreach activities. 2. Child profile: This program targets potentially eligible children identified using Washington State’s health promotion and immunization registry system, 3. Washington Coalition of Medicaid Outreach (WCOMO): To facilitate a statewide stakeholder meeting, WCOMO disseminates pertinent eligibility information and outreach activities for stakeholders. 4. Application Agents – As funding is available the State will make payments to application agents for successful enrollments. When funding is not available the State will continue to provide data matches for community-based outreach organizations.

31 Effective Date: July 1, 2009

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

Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the State’s Medicaid Plan and continue on to Section 7.

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

6.1.1.

Benchmark coverage (Section 2103(a)(1) and 42 CFR 457.420)

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

6.1.2.

Benchmark-equivalent coverage (Section 2103(a)(2) and 42 CFR 457.430) Specify the coverage, including the amount, scope and duration of each service, as well as any exclusions or limitations. Please attach a signed actuarial report that meets the requirements specified in 42 CFR 457.431. See instructions. 6.1.3.

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

6.1.4.

Secretary-Approved Coverage (Section 2103(a)(4)) (42 CFR 457.450)

6.1.4.1. Coverage the same as Medicaid State Plan

Washington’s CHIP will provide the same scope of coverage as provided under its Medicaid program. The chart below lists the medically necessary services available

39 Effective Date: July 1, 2009

Approval Date: to children eligible for Categorically Needy (CN) Medicaid under Title XIX of the Social Security Act (SSA) and CHIP under Title XXI of the SSA.

6.1.4.2. Comprehensive coverage for children under a Medicaid Section 1115 Demonstration Project 6.1.4.3. Coverage that either includes the full EPSDT benefit or that the state has extended to the entire Medicaid population 6.1.4.4. Coverage that includes benchmark coverage plus additional coverage 6.1.4.5. Coverage that is the same as defined by existing comprehensive State-based coverage 6.1.4.6. Coverage under a Group Health Plan that is substantially equivalent to or greater than benchmark coverage through a benefit by benefit comparison. (Please provide a sample of how the comparison will be done.) 6.1.4.7. Other (Describe) SERVICE MEDICAID CN CHIP Advanced RN Practitioner Services Yes Yes Ambulance/Ground and Air Yes Yes Anesthesia Services Yes Yes Audiology Yes Yes Blood/Blood Administration Yes Yes Case Management – Maternity L L Chiropractic Care Yes Yes Clinic Services Yes Yes Community Mental Health Centers Yes Yes Dental Services Yes Yes Dentures Only Yes Yes Detox (3 days) Yes Yes Drugs and Pharmaceutical Supplies Yes Yes Elective Surgery Yes Yes Emergency Room Services Yes Yes Emergency Surgery Yes Yes Eyeglasses and Exams Yes Yes Family Planning Services Yes Yes

39 Effective Date: July 1, 2009

Approval Date: Healthy Kids (EPSDT) Yes Yes Hearing Aid Yes Yes Hospice Yes Yes Home Health Services Yes Yes Indian Health Clinics Yes Yes Inpatient Hospital Care Yes Yes Intermediate Care Facility/Services for MR Yes Yes Involuntary Commitment Yes Yes Maternity Support Services Yes Yes Medical Equipment, Durable (DME) Yes Yes Mental Health (Outpatient Services) Yes Yes Midwife Services Yes Yes Neuromuscular Centers Yes Yes Nursing Facility Services Yes Yes Nutrition Therapy Yes Yes Optometry Yes Yes Organ Transplants Yes Yes Out-of-State Care Yes Yes Outpatient Hospital Care Yes Yes Oxygen/Respiratory Therapy Yes Yes Pain Management (Chronic) Yes Yes Personal Care Services Yes Yes Physical/Occupational/Speech Therapy Yes Yes Physical Medicine and Rehabilitation Yes Yes Physician Yes Yes Podiatry Yes Yes Private Duty Nursing L L Prosthetic Devices/Mobility Aids Yes Yes Psychiatric Services Yes Yes Psychological Evaluation L L Rural Health Services & FQHC Yes Yes

39 Effective Date: July 1, 2009

Approval Date: Substance Abuse/Outpatient Yes Yes Surgical Appliances Yes Yes Total Enteral/Parenteral Nutrition Yes Yes Transportation Other than Ambulance Yes Yes X-Ray and Lab Services Yes Yes Key: Yes: Service is covered (may require prior approval or have other requirements) L: Limited coverage

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

6.2.1.

Inpatient Services (Section 2110(a)(1)) 6.2.2.

Outpatient Services (Section 2110(a)(2)) 6.2.3.

Physician Services (Section 2110(a)(3)) 6.2.4.

Surgical Services (Section 2110(a)(4)) 6.2.5.

Clinic services (including health center services) and other ambulatory health care services. (Section 2110(a)(5)) 6.2.6.

Prescription drugs (Section 2110(a)(6)) 6.2.7.

Over-the-counter medications (Section 2110(a)(7)) 6.2.8.

Laboratory and radiological services (Section 2110(a)(8)) 6.2.9.

Prenatal care and pre-pregnancy family services and supplies (Section 2110(a)(9)) 6.2.10.

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

These services are provided by contract through the Regional Support Services Networks (RSNs). 6.2.11.

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

6.2.11.1 RSN’s are the primary mental health care provider for children with substantial mental health needs. RSN’s do not have a limitation on the number of hours of treatment they provide.

39 Effective Date: July 1, 2009

Approval Date:

6.2.11.2 Children enrolled in Healthy Options or in the Fee For Service program receive their mental health care through their Healthy Options or FFS provider if they do not meet the criteria for RSN services. Children’s mental health outpatient services to include: outpatient psychotherapy; electroconvulsive therapy; and family psychotherapy - in any combination - one hour per day, per client, up to a total of twenty hours per calendar year if medically necessary. Psychiatric diagnostic interview examinations – one per calendar year unless an additional evaluation is medically necessary. Prior authorization is required for additional services that are medically necessary.

6.2.12.

Durable medical equipment and other medically related or remedial devices (such as prosthetic devices, implants, eyeglasses, hearing aids, dental devices, and adaptive devices) (Section 2110(a)(12)) 6.2.13.

Disposable medical supplies (Section 2110(a)(13)) 6.2.14.

Home and community-based health care services (See instructions) (Section 2110(a)(14)) 6.2.15.

Nursing care services (See instructions) (Section 2110(a)(15)) 6.2.16.

Abortion only if necessary to save the life of the mother or if the pregnancy is the result of an act of rape or incest (Section 2110(a)(16) 6.2.17.1 Dental services (Section 2110(a)(17)) State Specific Dental Benefit Package. The state adopted the Washington Medicaid dental benefit package for CHIP. This includes EPSDT coverage. The state assures dental services represented by the following categories of common dental terminology (CDT) codes are included in the dental benefit. A comprehensive description of covered services and schedules can be found at http://maa.dshs.wa.gov/Download/Billing_Instructions/Dental_Thr u_20/Dental_Program_Through_20_BI.pdf. 1. Diagnostic (i.e., clinical exams, x-rays)(CDT codes: D0100- D0999)(must follow periodicity schedule) 2. Preventative (i.e., dental prophylaxis, topical fluoride treatments)(CDT codes: D1000-D1999)(must follow periodicity schedule) 3. Restorative (i.e., fillings, crowns)(CDT codes: D2000-D2999) 4. Endontic (i.e., root canals)(CDT codes: D3000-D3999)

39 Effective Date: July 1, 2009

Approval Date: 5. Periodontic (treatment of gum disease)(CDT codes: D4000- 4999) 6. Prosthodontic (dentures)(CDT codes: D5000-D5899, D5900- D5999, and D6200-D6999) 7. Oral and Maxillofacial Surgery (i.e., extractions of teeth and other oral surgical procedures) (CDT codes: D7000-D7999) 8. Orthodontics (i.e., braces) (CDT codes D8000-D8999) 9. Emergency Dental Services 6.2.17.2 Dental Periodicity Schedule. The state has adopted the following periodicity schedule:

State-developed Medicaid-specific

American Academy of Pediatric Dentistry

Other Nationally recognized periodicity schedule: EPSDT

Other (description attached)6.2.18.

Inpatient substance abuse treatment services and residential substance abuse treatment services (Section 2110(a)(18)) 6.2.19.

Outpatient substance abuse treatment services (Section 2110(a)(19)) 6.2.20.

Case management services (Section 2110(a)(20)) 6.2.21.

Care coordination services (Section 2110(a)(21)) 6.2.22.

Physical therapy, occupational therapy, and services for individuals with speech, hearing, and language disorders (Section 2110(a)(22)) 6.2.23.

Hospice care (Section 2110(a)(23)) 6.2.24.

Any other medical, diagnostic, screening, preventive, restorative, remedial, therapeutic, or rehabilitative services. (See instructions) (Section 2110(a)(24)) 6.2.25.

Premiums for private health care insurance coverage (Section 2110(a)(25)) 6.2.26.

Medical transportation (Section 2110(a)(26)) 6.2.27.

Enabling services (such as transportation, translation, and outreach services (see instructions) (Section 2110(a)(27)) 6.2.28.

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

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

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

6.3.2.

The State contracts with a group health plan or group health

39 Effective Date: July 1, 2009

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

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

6.4.1.

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

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

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

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

6.4.2.

Purchase of Family Coverage. Describe the plan to purchase family coverage. Payment may be made to a state for the purpose of family coverage under a group health plan or health

39 Effective Date: July 1, 2009

Approval Date: insurance coverage that includes coverage of targeted low- income children, if it demonstrates the following: (Section 2105(c)(3)) (42CFR 457.1010) 6.4.2.1. Purchase of family coverage is cost-effective relative to the amounts that the state would have paid to obtain comparable coverage only of the targeted low-income children involved; and (Describe the associated costs for purchasing the family coverage relative to the coverage for the low income children.) (Section 2105(c)(3)(A)) (42CFR 457.1010(a)) 6.4.2.2. The State assures that the family coverage would not otherwise substitute for health insurance coverage that would be provided to such children but for the purchase of family coverage. (Section 2105(c)(3)(B)) (42CFR 457.1010(b)) 6.4.2.3. The State assures that the coverage for the family otherwise meets Title XXI requirements. (42CFR 457.1010(c))

40 Effective Date: July 1, 2009

Approval Date: Section 7. Quality and Appropriateness of Care

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

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

The quality and appropriateness of care, particularly with respect to well-baby care, well-child care, and age appropriate immunizations provided under the plan, are addressed for managed care coverage through contract requirements for participating Managed Care Organization (MCOs). Requirements and monitoring criteria are the same as those for the current HO and the fee-for-service (FFS) programs. The state contracts only with MCOs that are regulated by the Office of the Insurance Commissioner (OIC), which regulates and monitors financial solvency and other consumer protection safeguards. MPA monitors the quality and appropriateness of care through: • Monitoring and analysis of quality standards and performance measures for well-baby care, well-child care, and immunizations required through encounter data, chart review, HEDIS reporting, and a variety of other contract monitoring activities listed below; • Client interviews; • Biennial client satisfaction/health status surveys for managed care clients; • Complaint management system; • Exemption/disenrollment/fair hearing database; • Standards for health plan internal quality improvement programs; • Network adequacy standards; and • On-site contract compliance monitoring and technical assistance. Contract monitoring is performed through the following actions: • Requiring the same encounter data reporting (form, format, periodicity) as required under Medicaid HO; • Generating HEDIS reporting and the above mentioned quality measures with the same criteria as Medicaid HO and similar FFS review;

41 Effective Date: July 1, 2009

Approval Date: • Applying utilization controls for FFS coverage that are consistent with all current utilization review requirements under the state’s Medicaid plan. Examples of controls include external review of hospital claims data, exception-to-policy procedures, data audits, pre- authorization for extended coverage utilization, and drug utilization review; • Performing at minimum annual, on-site quality and operational reviews of the MCO contractors; • Reviewing of the MCOs by an External Quality Review Organization (EQRO), as required by federal law (Section 1902 (a) (30) (C) of the Social Security Act); • Requiring that MCOs maintain an internal program of quality assurance, as required by federal regulations (42 CFR 434.34); • Performing biennial client satisfaction surveys; • Monitoring of actions, grievances and appeals at both the health plan level and the Medicaid state agency level.

Will the State utilize any of the following tools to assure quality? (Check all that apply and describe the activities for any categories utilized.) 7.1.1.

Quality standards

In addition to the utilization controls described in Section 3.2, National Committee for Quality Assurance (NCQA) standards are the guidelines for contract requirements and monitoring. Generally, the NCQA standards address the following: • Quality Management and Improvement – program structure, program operations, health services contracting, availability of practitioners; • Accessibility of services, member satisfaction, health management systems, primary care provider role, scope and content of clinical quality improvement (QI) activities, clinical measurement activities, effectiveness of the QI program, and delegation of QI activity; • Utilization Management; • Credentialing and Re-credentialing; • Members’ Rights and Responsibilities; and • Preventative Health Services and Medical Records. Quality standards for FFS will be consistent with all quality utilization review requirements under the state’s Medicaid plan, and the additional quality activities listed in Section 7.1

46 Effective Date: July 1, 2009

Approval Date: 7.1.2.

Performance measurement

Health Plan Employer Data and Information Set (HEDIS) performance measures will be reported and preventive health services relevant to the program such as EPSDT and child immunizations will be evaluated with the same criteria as the current HO program and similar FFS review. See further performance criteria in Section 7.1.4.

7.1.3.

Information strategies

Encounter data, HEDIS measures, provider network adequacy standards, and health care experience data will be reported by health plans. The current complaint management system will be maintained at both the health plan level and the State level to assure timely resolution of client complaints and grievances. FFS information strategies will be consistent with all information requirements under the state’s Medicaid plan.

7.1.4.

Quality improvement strategies

The following strategies and activities have been implemented and are consistent with the HO and FFS programs: • Monitoring and analysis of quality standards and performance measures for well- baby care, well-child and adolescent care, and childhood immunizations required through encounter data, chart review, HEDIS reporting, and a variety of other contract monitoring activities listed below; • Client interviews; • Biennial client satisfaction/health status surveys for managed care clients; • Complaint management system; • Exemption/disenrollment/fair hearing database; • Standards for health plan internal quality improvement programs; • Network adequacy standards; and • On-site contract compliance monitoring and technical assistance.

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

7.2.1 Access to well-baby care, well-child care, well-adolescent care and

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Approval Date: childhood and adolescent immunizations. (Section 2102(a)(7)) (42CFR 457.495(a))

The methods used to assure access to covered services, including well-baby care, well-child care, well-adolescent care, and childhood and adolescent immunizations, are based on the Healthy Options program. The methods, including monitoring, will be the following: Availability of Practitioners MCOs must have a written access plan describing the mechanisms used to assure the availability of primary care providers (PCPs) and physician specialists, hospitals, and pharmacies. Standards for the number and geographic distribution of PCPs and specialty care practitioners are established in the procurement requirements. MCOs submit their provider networks to MPA. MCOs must collect and analyze data to measure performance against these standards and implement corrective action when necessary. As part of the procurement process, HO bidders are required to submit GeoNetwork analysis that describes how its network compares to MPA/HCA access guidelines for distribution (travel distance) and capacity of primary care providers (PCPs), obstetrical providers, hospitals and pharmacies. This information is compared to BHP and Public Employee Benefit Board (PEBB) networks to judge whether there is sufficient capacity. HO, BHP and PEBB plans are required to submit monthly updates of provider network changes.

Accessibility of Services • Covered services for managed care enrollees, such as types of practitioners and providers, location of practitioners and providers, and timeliness, must be made at least as accessible as for members enrolled under the MCO’s other state, federal, or private contracts. • Coverage for medical advice through a toll-free telephone number on a 24 hours per day, 7 days per week basis must be made available to members for the purpose of rendering medical advice concerning the emergency, urgent or routine nature of a medical condition, and authorizing care at other facilities when the use

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Approval Date: of participating facilities is not practical. This advice and authorization must be made by a licensed health care professional. • Mechanisms must be established to assure the accessibility of primary care services, urgent care services and member services. • Standards (which apply to HO, BHP, PEBB and CHIP) must be established that are no longer than the following: o Non-symptomatic (i.e., preventive care) office visit – within 30 calendar days; o Non-urgent, symptomatic (i.e., routine care) office visit – within 10 days; o Urgent, symptomatic (i.e., presentation of medical conditions requiring immediate attention, not life-threatening) office visit within 48 hours; and o Emergency medical care within 24 hours per day, 7 days per week.

• MCOs must collect and analyze data to measure their performance against the above standards. FFS quality standards and utilization controls are consistent with all quality and utilization review requirements under the state’s Medicaid plan. • Washington State Well-Child Exam Forms, developed collaboratively with the Washington Chapter of the American Academy of Pediatrics, the Department of Health, Head Start/ECEAP staff, health plan staff and many other stakeholder groups as part of a statewide focus on improving well-child care. Historical EPSDT chart review studies consistently demonstrated that providers using a structured charting or screening tool were significantly more likely to meet the minimum documentation requirements for a qualifying well-child visit. • These forms are free of charge to providers who deliver well-child care to Medicaid clients. The forms are unique to each age category and include the ages listed below: • Infancy – 2-4 weeks, 2 months, 4 months, 6 months, 9 months, 12 months, 18 months, and 2 years • Early childhood – 3 years, 4 years, 5 years, 6 years, 8 years, and 10 years • Late childhood – 12 years • Adolescence – 14 years, 16 years, 18 years

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Approval Date: • Each age-specific document is a two-page, NCR form. The first sheet is for the child’s medical record. On the back of the first page includes information about different components of the exam. The second page is given to the family after the exam. The back of the second page provides the family with both parent education and some information about the child’s growth and development between the current visit and the next anticipated visit. The forms are available in hard copy and can be ordered through MAA. The forms can also be downloaded at the DSHS website: http://www1.dshs.wa.gov/msa/forms/eforms.html (beginning at form # 13- 683). • Pay for Performance incentives for 2 year old immunizations and well-child care have been part of the Healthy Options/CHIP contract since 2004. DSHS set aside $1,000,000 each to be paid for improved performance on 2 year old immunizations and well-child care. Calculations are based on a point system that rewards health plans for both their current year performance relative to other plans and for their improvement from previous year to current year relative to other plans. The four highest performing plans share in the reward.

• EPSDT Rate Increase for Foster Care Children as a result of several studies that suggested that children in foster care were not receiving adequate health care services. MPA increased the rate of reimbursement for well-child care (for this population only) in late fall, 2001.

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

Please see response to Section 7.2.1 regarding access to covered services. The same criteria apply to all covered services.

For emergency services, the definition of emergency in the plan will be based on the current definition addressing need as defined by the “prudent layperson”. As noted above, standards assuring access and network adequacy must be written by MCOs

46 Effective Date: July 1, 2009

Approval Date: specifying how to access emergency medical care within 24 hours per day, 7 days per week. In addition, emergency care services for medical emergencies must be provided in non-participating facilities when a member: • Has a medical emergency meeting the contract definition and is not able to use a participating hospital (42 CFR 434.30), or • Presents at a non-participating hospital emergency department and the member’s condition is determined to be non-emergency. In such instances, the MCO must cover facility and professional services for medical screening examinations as defined in the contract.

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

The State’s contract with MCOs requires the MCO to provide all medically necessary specialty care for enrollees. If an enrollee needs specialty care from a specialist who is not available within the MCO’s provider network, the MCO must provide the necessary services with a qualified specialist outside of the MCO’s provider network.

7.2.4 Decisions related to the prior authorization of health services are completed in accordance with State law or, in accordance with the medical needs of the patient, within 14 days after the receipt of a request for services. (Section 2102(a)(7)) (42CFR 457.495(d)) Washington follows Washington Administrative Code 388-501-0165 related to the prior authorization of services.

47 Effective Date: July 1, 2009

Approval Date: Section 8. Cost Sharing and Payment (Section 2103(e))

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

8.1. Is cost-sharing imposed on any of the children covered under the plan? (42 CFR 457.505) 8.1.1.

YES, except for American Indians/Alaska Natives, who are exempt from this requirement. 8.1.2.

NO, skip to question 8.8. 8.2. Describe the amount of cost-sharing, any sliding scale based on income, the group or groups of enrollees that may be subject to the charge and the service for which the charge is imposed or time period for the charge, as appropriate. (Section 2103(e)(1)(A)) (42CFR 457.505(a), 457.510(b) &(c), 457.515(a)&(c))

8.2.1. Premiums: Households with income above 200% FPL, but not above 300% FPL, are required to pay a monthly premium for each enrolled child; up to a family maximum premium amount for two children. The premium amount will be based on the household’s income as indicated by the following Tiers:

Tier 1 (200%-250%FPL)

Tier 2 (251%-300%FPL) In January, 2009 these premiums will be:

Tier 1 - $20/mo. per child; up to a family maximum of $40/mo.

Tier 2 - $30/mo. per child; up to a family maximum of $60/mo. Payments can be made for periods greater than one month. Eligibility will end if premiums are not paid for three consecutive months.

Households with enrolled children will receive monthly billing statements. These monthly statements include the current amount as well as any overdue amount. The statement includes a note that informs the client that accounts over 90 days past due may result in loss of medical coverage. A phone number is provided with a notation

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Approval Date: to call if their income goes down, a family member moves in or out of their home, or a child under age 19 becomes pregnant or disabled, as their children may be eligible for a medical program with no premiums. There is also an additional warning on the statement of clients who are 30 or 60 days overdue.

If a child is terminated from CHIP for failure to pay premiums for three consecutive months, the household receives a letter outlining their rights and responsibilities. The letter says they will not be able to re-enroll until delinquent premiums are paid. There is no sanction period, however. If the delinquent premiums are paid, the child’s eligibility is restored back to the month of termination.

8.2.2. Deductibles: None. 8.2.3. Coinsurance or copayments: None. 8.2.4. Other: None.

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

State-published CHIP brochures and summary documents contain information about enrollee cost-sharing requirements. The CHIP application packet includes detailed information about cost-sharing requirements. CHIP enrollment and health plan enrollment documents also include all cost-sharing requirements.

If there is a change to cost-sharing requirements, the State sends each client a letter detailing the changes with a toll-free number to call if they have any questions about the changes. The information is relayed to the public through our outreach workers, advocates, and notification to providers.

8.4. The state assures that it has made the following findings with respect to the cost sharing in its plan: (Section 2103(e)) 8.4.1.

Cost-sharing does not favor children from higher income families over lower income families. (Section 2103(e)(1)(B)) (42CFR 457.530)

51 Effective Date: July 1, 2009

Approval Date: 8.4.2.

No cost-sharing applies to well-baby and well-child care, including age-appropriate immunizations. (Section 2103(e)(2)) (42CFR 457.520) 8.4.3.

No additional cost-sharing applies to the costs of emergency medical services delivered outside the network. (Section 2103(e)(1)(A)) (42CFR 457.515(f))

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

The only cost sharing requirement is the premium payment. For Tier 1 families, the monthly premium amount of $20 per child per month up to a maximum premium amount of $40 per month per family, will not exceed 1.4 percent of the family income. For Tier 2 families the monthly premium amount of $30 per child per month up to a maximum premium amount of $60 per month per family, will not exceed 1.5 percent of the family income.

8.6. Describe the procedures the State will use to ensure American Indian (as defined by the Indian Health Care Improvement Act of 1976) and Alaska Native children will be excluded from cost-sharing. (Section 2103(b)(3)(D)) (42CFR 457.535) American Indian and Alaska Native (AI/AN) children are self-identified at the time of application. This information is put into MMIS, which codes them appropriately so that no premium billing statement is sent to the household for those children.

If a child is not self-identified at the time of application, client materials, as well as the billing invoice, provide information on excluding AI/AN children from the cost-sharing requirement. If premiums were inadvertently paid for an AI or AN child, a refund is issued.

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

8.7.1 Please provide an assurance that the following disenrollment protections are being applied:

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Approval Date:

State has established a process that gives enrollees reasonable notice of and an opportunity to pay past due premiums, copayments, coinsurance, deductibles or similar fees prior to disenrollment. (42CFR 457.570(a)) The department has an established process that continues the child’s CHIP coverage even when premiums are not paid. Each month the client is notified in writing of the amount of their current premium, plus the balance of any delinquent premiums that have not been paid. Clients are not disenrolled for non-payment of premiums until they have missed three consecutive months of payment. Once the enrollee is three months in arrears, the enrollee is sent a letter advising them of disenrollment effective the end of the month unless the delinquent premium is paid in full. At any time prior to the end of the certification period the enrollee will be reinstated back to the month of disenrollment if the delinquent premium is paid. The letter gives them a toll-free number to call to make payment arrangements or to report a change in circumstances that may make them eligible for Medicaid. The letter also advises them of their right to an Administrative Hearing if they disagree with the decision to terminate benefits, and a right to continued benefits pending the outcome of the Administrative Hearing.

The disenrollment process affords the enrollee an opportunity to show that the enrollee’s family income has declined prior to disenrollment for non-payment of cost-sharing charges. (42CFR 457.570(b)) Prior to disenrollment, clients are notified in a letter that they can call a toll-free number to report any changes in income or household. This allows their eligibility to be determined for Medicaid or any programs for which they may be eligible.

In the instance mentioned above, that the state will facilitate enrolling the child in Medicaid or adjust the child’s cost-sharing category as appropriate. (42CFR 457.570(b))

Once the State’s eligibility section is notified of a change in income, they will automatically review eligibility for Medicaid.

The state provides the enrollee with an opportunity for an impartial review to address disenrollment from the program. (42CFR 457.570(c))

Enrollees are sent a letter informing them of disenrollment from CHIP. The letter

51 Effective Date: July 1, 2009

Approval Date: contains information on their rights for an Administrative Hearing. Clients can call the Office of Administrative Hearings (OAH) to set up a hearing, or they may contact MPA staff directly and request a hearing. OAH notifies the client and the agency’s Administrative Hearing Coordinator of the request. If the enrollee requests an Administrative Hearing prior to their disenrollment, the enrollee will receive continued benefits pending the outcome of the Administrative Hearing. The Coordinator prepares the case and sets up a pre-hearing conference as a way to settle the dispute or collect information. Cases that are not resolved in the pre-hearing conference proceed to an Administrative Hearing. The Administrative Law Judge conducts the hearing. The Judge’s decision is mailed to the client and the Administrative Hearing Coordinator. Either party may appeal the decision for additional review and to the courts, if need be.

8.8. The State assures that it has made the following findings with respect to the payment aspects of its plan: (Section 2103(e)) 8.8.1.

No Federal funds will be used toward State matching requirements. (Section 2105(c)(4)) (42CFR 457.220) 8.8.2.

No cost-sharing (including premiums, deductibles, copays, coinsurance and all other types) will be used toward state matching requirements. (Section 2105(c)(5) (42CFR 457.224) (Previously 8.4.5) 8.8.3.

No funds under this Title will be used for coverage if a private insurer would have been obligated to provide such assistance except for a provision limiting this obligation because the child is eligible under the this Title. (Section 2105(c)(6)(A)) (42CFR 457.626(a)(1)) 8.8.4.

Income and resource standards and methodologies for determining Medicaid eligibility are not more restrictive than those applied as of June 1, 1997. (Section 2105(d)(1) (42CFR 457.622(b)(5)) 8.8.5.

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

8.8.6.

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

52 Effective Date: July 1, 2009

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

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

Washington’s CHIP strategic objective is to increase the number of children in households between 200% and 300% of FPL who have health insurance coverage. In addition, CHIP will assist the Medicaid program to increase the number of low- income children in households below 200% of FPL who have health insurance coverage.

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

The following performance goals have been identified: 1. Increase the number of children between 200% and 300% of FPL who have health care coverage. 2. Reduce the percentage of uninsured children between 200% and 300% FPL. 3. Increase the number of children below 200% of FPL who have health coverage. 4. Reduce the percentage of uninsured children below 200% of FPL. 5. Track the satisfaction and health care of CHIP children compared to Medicaid children and non-Medicaid children.

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

MPA and the Governor’s Office of Financial Management (OFM) Forecast Section will analyze WSPS data to measure the number and percentage of children who are uninsured. The WSPS is a comprehensive survey conducted under contract with Washington State University’s Social and Economic Sciences Research Center. The survey is modeled after U.S. Bureau of the Census’s Current Population Survey

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Approval Date: (CPS). However, the survey is a statewide survey with a greatly enhanced sample size (6,950 households in 1998) to allow for statistically reliable analyses for the state and regions within the state. There are expanded samples of racial and ethnic minorities to be able to compare socio-economic characteristics of people of different racial and ethnic backgrounds. The WSPS is conducted biennially. Therefore, the CHIP uninsured performance measures will be reported every two years. The assessment of CHIP enrollees’ satisfaction with their health care and services is based on MPA’s work with the Consumer Assessment of Health Plans (CAHPS). These surveys are conducted every other year in accordance with CAHPS Consortium (A group of national survey experts associated with the Harvard Medical School, RAND, and the Research Triangle Institute protocols). The last survey was conducted in 2007, and 78% of respondents indicated there was no problem getting access to care. The survey included both HO enrollees and Medicaid FFS clients. MPA has been using HEDIS- and EPSDT related measures to assess the effectiveness of its HO contractors to provide medically appropriate services to Medicaid clients. MPA contracts with its external review organization to generate a set of similar, child appropriate measures for CHIP enrollees. Check the applicable suggested performance measurements listed below that the State plans to use: (Section 2107(a)(4)) 9.3.1.

The increase in the percentage of Medicaid-eligible children enrolled in Medicaid. 9.3.2.

The reduction in the percentage of uninsured children. 9.3.3.

The increase in the percentage of children with a usual source of care. 9.3.4.

The extent to which outcome measures show progress on one or more of the health problems identified by the state. 9.3.5.

HEDIS Measurement Set relevant to children and adolescents younger than 19. 9.3.6.

Other child appropriate measurement set. List or describe the set used. 9.3.7.

If not utilizing the entire HEDIS Measurement Set, specify which measures will be collected, such as: 9.3.7.1. Immunizations 9.3.7.2. Well childcare 9.3.7.3. Adolescent well visits 9.3.7.4. Satisfaction with care 9.3.7.5. Mental health 9.3.7.6. Dental care

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Approval Date: 9.3.7.7. Other, please list: MPA will track and compare CHIP dental access and usage with Medicaid children.

9.3.8.

Performance measures for special targeted populations.

9.4.

The State assures it will collect all data, maintain records and furnish reports to the Secretary at the times and in the standardized format that the Secretary requires. (Section 2107(b)(1)) (42CFR 457.720)

9.5.

The State assures it will comply with the annual assessment and evaluation required under Section 10. Briefly describe the state’s plan for these annual assessments and reports. (Section 2107(b)(2)) (42CFR 457.750)

Washington State will report on the number of CHIP enrolled children on an annual basis. The number and percentage of uninsured children between 200% and 300% FPL will be reported on a biennial basis using WSPS data.

9.6.

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

9.7.

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

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

9.8.1.

Section 1902(a)(4)(C) (relating to conflict of interest standards) 9.8.2.

Paragraphs (2), (16) and (17) of Section 1903(i) (relating to limitations on payment) 9.8.3.

Section 1903(w) (relating to limitations on provider donations and taxes) 9.8.4.

Section 1132 (relating to periods within which claims must be filed)

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

Over the past decade of expanding services to children, Washington State has relied

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Approval Date: on several strategies to assure high levels of community involvement: • The public had an opportunity to testify on the Governor’s proposed CHIP during both the 1998 and 1999 legislative sessions. The public also had an opportunity to comment on an alternative CHIP program that was being offered by House Republicans. Stakeholders and advocacy groups met throughout the 1999 session to comment on and ask legislators to pass the Governor’s proposal, which was enacted on a bipartisan basis during the 1999 session. • MPA also worked with the Seattle Campaign for Kids 2001 and a potential CHIP demonstration project prior to the 1999 session. Input in that project was reflected in the Governor’s proposal and MPA’s CHIP operational design. • During the development of the CHIP state plan, MPA involved representatives of various stakeholder groups including the state medical association, the state hospital association, provider groups, representatives of the Legislature, health care plans, client rights organizations and client advocacy groups. The public meetings held to review the plan submittal were jointly sponsored by MPA and the Children’s Alliance – a statewide children’s advocacy group. • MPA sponsored fourteen local community groups to provide feedback on the Healthy Options program. The Healthy Options Committees were asked to provide input, as well as feedback throughout implementation. • MPA consulted with the American Indian Health Commission of Washington State and the Northwest Portland Area Indian Health Board on the design of CHIP. CHIP had been an item of discussion for over a year with these groups. • MPA also provided an opportunity for all interested parties to review and com- ment on the original State Plan application through MPA’s CHIP website. • Public testimony during the 2007 session in which the state legislature passed SSSB 5093 “Cover All Kids” with bipartisan support, approving an increase in the CHIP program to 300%FPL.

59 Effective Date: July 1, 2009

Approval Date: The combination of statewide and local input provided a robust mechanism for assuring broad input into the planning, implementation, and ongoing development of CHIP. 9.9.1 Describe the process used by the state to ensure interaction with Indian Tribes and organizations in the state on the development and implementation of the procedures required in 42 CFR 457.125.

(Section 2107(c)) (42CFR 457.120(c)) MPA consulted with the American Indian Health commission of Washington State and the Northwest Portland Area Indian Health Board on the design of CHIP. MPA has coordinated with and will continue to work with representatives of the Tribes in the state of Washington, urban Indian organizations, and Indian advocacy groups, including the Northwest Portland Area Indian Health Board, the American Indian Health Commission, and the DSHS Indian Policy Advisory Committee. Although the total number of Indian children served by CHIP continues to be small (less than 500), the ongoing commitment by the State to Indian health issues is viewed by the Tribes as an important move.

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

The CHIP expansion to 300% of FPL was authorized by Second Substitute Senate Bill (2SSB 5093) which was signed into law by the Governor on March 13, 2007, and which became effective July 22, 2007. The legislation has been codified under Section 74.09.470 of the Revised Code of Washington (RCW). The expansion provisions are found in RCW.74.09.470(1). 2SSB 5093 was subject to public comment in the House Health Care & Wellness Committee, House Appropriations Committee, Senate Health & Long-Term Care Committee and Senate Ways & Means Committee. The bill was also subject to debate and vote by the House and Senate.

9.10. Provide a 1- year projected budget. A suggested financial form for the budget is attached. The budget must describe: (Section 2107(d)) (42CFR 457.140)

59 Effective Date: July 1, 2009

Approval Date: • Planned use of funds, including: o Projected amount to be spent on health services; o Projected amount to be spent on administrative costs, such as

outreach, child health initiatives, and evaluation; and o Assumptions on which the budget is based, including cost per

child and expected enrollment. • Projected sources of non-Federal plan expenditures, including any

requirements for cost-sharing by enrollees.

Washington State SCHIP Budget Plan Federal Fiscal Year Costs Federal Fiscal Year Costs Enhanced FMAP rate 65.08% 65.00% Benefit Costs FFY 2010 FFY 2011 Insurance Payments - - Managed Care – Children (200-300%FPL) PM/PM $106 $119 • 17,293 FFY10 eligibles; 19,188 FFY11 eligibles $22,015,372 $27,508,684 • 179 FFY10 eligibles; 181 FFY11 eligibles [Section 214, Title XXI] (1) $227,881 $259,489 • 3,876 FFY10 eligibles; 4,564 FFY11 eligibles [Section 214, Title XIX](1) (2) $4,934,458 $6,543,133 Fee for Service - Children (200-300%FPL) PM/PM $155 $156 • 3,023 FFY10 eligibles; 3,349 FFY11 eligibles $5,622,054 $6,282,188 • 31 FFY10 eligibles; 32 FFY11 eligibles [Section 214, Title XXI](1) • 677 FFY10 eligibles; 797 FFY11 eligibles [Section 214, Title XIX] (1) (2)

$57,653

$1,259,058

$60,027

$1,495,044 Fee for Service - Unborn Child (185%FPL) PM/PM $188 $190 • 7,377 FFY10 eligibles; 7,378 FFY11 eligibles $16,601,616 $16,814,763 133% Medicaid Children (FMAP to EFMAP Federal Only)(3) $10,450,000 $24,575,000 Total Benefit Costs $61,168,093 $83,540,205 (Total offsetting beneficiary cost sharing payments) ($3,811,611) ($4,297,723) Net Benefit Costs $57,356,482 $79,242,482 Administration Costs(4)

59 Effective Date: July 1, 2009

Approval Date: Personnel $427,219 $448,580 General Administration $313,982 $329,681 Contractors/Brokers (e.g., Within Reach) $162,194 $170,304 Claims Processing $47,403 $49,773 Outreach/Marketing Costs(5) $1,215,000 0 Health Services Initiative – Washington Poison Center(6) $921,210 $945,714 Total Administration Costs $3,087,008 $1,944,052

10% Administrative Cost Ceiling $6,372,942 $8,804,720 Federal Share (multiplied by enhanced-FMAP rate) $32,535,763 $36,797,497 133% Medicaid Children (FMAP to EFMAP Federal Only) $10,450,000 $24,575,000 State Share $17,457,727 $19,814,037 TOTAL PROGRAM COSTS* $60,443,490 $81,186,534 *No new sources of state funds are being used to fund the measures in this budget. The source of state matching funds remains appropriations by the state legislature.

(1)Section 214 eligibility expansion (1) Upon approval of this SPA Washington estimates that 32,456 children will be eligible for FFP under its CHIP State Plan in FFY2010, including an additional 4,763 children as a result of CHIPRA, Section 214 eligibility expansion in CHIP and Medicaid. Washington estimates that 35,490 children will be eligible for FFP under its CHIP State Plan in FFY11, including an additional 5,574 children as a result of CHIPRA, Section 214 eligibility expansion in both CHIP and Medicaid. The total projected costs for CHIPRA, Section 214 eligibility expansion is estimated at $6.48 million dollars in FY10, the federal share is estimated at $4.22 million dollars in FY10. The total projected costs for CHIPRA, Section 214 eligibility expansion is estimated at $8.36 million dollars in FY11, the federal share is estimated at $5.43 million dollars in FY11. (2) Section 214 Medicaid Children Children added to Medicaid as a result of CHIPRA, Section 214 eligibility expansion are exempt from cost-sharing premiums. (3) 133% Medicaid Children (FMAP to EFMAP Federal Only) Washington is a qualified state under §2105(g) to claim an "uncapped" portion of

59 Effective Date: July 1, 2009

Approval Date: expenditures for Medicaid children at or above 133%FPL. The amount of the claim for these expenditures is based on the difference between the EFMAP for CHIP and the current FMAP rate for Medicaid. In FFY 2010 the federal share is estimated at $10.45 million dollars; in FFY 2011 the federal share is estimated at $24.58 million dollars.

(4)Calculation of Unused Administration Funding FFY2010 FFY2011 Current Program Costs $57,356,482 $79,242,482 10% Administrative Cap $6,372,942 $8,804,720 Federal Share $4,147,511 $5,723,068 Administrative Costs - Current Plan $3,087,008 $1,944,052 Federal Share $2,009,025 $1,263,634 Unused Administration Funding Available $3,285,934 $6,860,668 Federal Share $2,138,486 $4,459,434

(5)Calculation of Children's Outreach Funding FFY2010 FFY2011 Statewide Application Agent Program $500,000 $0 Media Campaign & Other Outreach Contracts $715,000 $0 Total Benefit Costs $1,215,000 $0 Federal Share $790,722 $0 State Share $424,278 $0 Outreach costs including Application Agent fees, media campaigns, publications, and other outreach efforts are suspended in 2011 because of state budget constraints. As funding becomes available, these services will be restored. If state appropriations are restored for outreach, Washington assures that administrative expenditures will not exceed the 10% cap.

(6) WAPC Health Services Initiative Funding FFY2010 FFY2011 State Appropriation $321,687 $331,000 Federal Title XXI Share $599,523 $614,714 Total Federal/State Share $921,210 $945,714 The WAPC’s total operating budget is calculated at just over $2.6 million in FY2010, and just over $2.9 million in FY2011. Based on call demographics the cost to the WAPC

59 Effective Date: July 1, 2009

Approval Date: operating budget attributed to providing services for low-income children was $921,210 dollars in FY2010 and just over $1 million dollars in FY 2011. The legislature appropriated $331,000 dollars in state funding from the State General Fund for FY 2010 and $331,000 dollars in state funding from the State General Fund for FY 2011. This appropriations are intended to match federal dollars under Title XXI to support an HSI to fund the WAPC as provided under Section 2105(a)(1)(D)(ii). In FY 2010 the actual state expenditure was $321,687 dollars. In FY 2011 the total state and federal match is estimated at no more than $945,714 based on the limit of appropriated state funds.

Summary of projected costs for SPA 13 In FFY2010 the total projected costs for this SPA will increase the budget by $7,400,259 dollars. The increased federal share in FFY2010 is calculated at $4,816,089 dollars. In FFY 2011 the total projected costs for this SPA will increase the budget by $9,303,407 dollars. The increased federal share in FFY2011 is calculated at $6,047,215 dollars. Expenditure FFY2010 FFY2011 Sec. 214 children in Title XXI State share $99,708 $111,831 Federal share $185,826 $207,685 subtotal $285,534 $319,516 Sec. 214 children in Title XIX State share $2,162,776 $2,813,362 Federal share $4,030,740 $5,224,815 subtotal $6,193,516 $8,038,177 Washington Poison Center State share $321,687 $331,000 Federal share $599,523 $614,714 Subtotal $921,210 $945,714 Expenditure total $7,400,259 $9,303,407 Federal share total $4,816,089 $6,047,215

60 Effective Date: July 1, 2009

Approval Date: Section 10. Annual Reports and Evaluations (Section 2108)

10.1. Annual Reports. The State assures that it will assess the operation of the State Plan under this Title in each Fiscal Year, including: (Section 2108(a)(1),(2)) (42CFR 457.750)

10.1.1.

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

10.2.

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

10.3.

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

10.3.1

The State agrees to submit yearly the approved dental benefit package and to submit quarterly the required information on dental providers in the State to the Health Resources and Services Administration for posting on the Insure Kids Now! Website.

61 Effective Date: July 1, 2009

Approval Date: Section 11. Program Integrity (Section 2101(a))

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

11.1.

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

11.2. The State assures, to the extent they apply, that the following provisions of the Social Security Act will apply under Title XXI, to the same extent they apply to a State under Title XIX. (Section 2107(e)) (42CFR 457.935(b))

The items below were moved from section 9.8. (Previously items 9.8.6-9.8.9) 11.2.1.

42 CFR Part 455 Subpart B (relating to disclosure of information by providers and fiscal agents) 11.2.2.

Section 1124 (relating to disclosure of ownership and related information) 11.2.3.

Section 1126 (relating to disclosure of information about certain convicted individuals) 11.2.4.

Section 1128A (relating to civil monetary penalties) 11.2.5.

Section 1128B (relating to criminal penalties for certain additional charges) 11.2.6.

Section 1128E (relating to the national health care fraud and abuse data collection program)

62 Effective Date: July 1, 2009

Approval Date: Section 12. Applicant and Enrollee Protections (Sections 2101(a))

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

12.1. Eligibility and Enrollment Matters Please describe the review process for eligibility and enrollment matters that complies with 42 CFR 457.1120. All CHIP clients have an opportunity for review of eligibility and enrollment matters. Clients may contact MPA’s Medical Eligibility Determination Services (MEDS) section or the Office of Administrative Hearings (OAH) to begin the review process. The MPA AdministrativeHearing Coordinator is notified of the request for review. The Coordinator prepares the case and sets up a pre-hearing conference as a way to settle the dispute or collect information. Cases that are not resolved through a pre- hearing conference proceed to an Administrative Hearing. At the Administrative Hearing, an Administrative Law Judge gathers information from the client and agency staff. Hearings can be conducted via telephone or in person. The Judge’s decision is mailed to the client and the Administrative Hearing Coordinator. Either party may appeal the decision for additional review and to the courts if need be.

12.2. Health Services Matters Please describe the review process for health services matters that comply with 42 CFR 457.1120. All CHIP clients also have an opportunity for review of health services matters. The process as described in section 12.1 is the same process used for review of health services matters. 12.3. Premium Assistance Programs If providing coverage through a group health plan that does not meet the requirements of 42 CFR 457.1120, please describe how the State will assure that applicants and enrollees have the option to obtain health benefits coverage other than through the Group Health Plan at initial enrollment and at each redetermination of eligibility. Not applicable to Washington State’s CHIP.

1 WASHINGTON TITLE XXI STATE PROGRAM FACT SHEET

Name of Plan:

Washington CHIP

Date Plan Submitted:

June 30, 1999 Date Plan Approved:

September 8, 1999 Effective Date:

January 1, 2000

Date Amendment #1 Submitted:

February 8, 2001 Date Amendment #1 Approved:

May 7, 2001 Date Amendment #1 Effective:

January 1, 2001

Date Amendment #2 Submitted:

April 3, 2002 Date Amendment #2 Approved:

July 1, 2002 Date Amendment #2 Effective:

January 1, 2002

Date Amendment #3 Submitted:

October 3, 2002 Date Amendment #3 Approved:

December 19, 2002 Date Amendment #3 Effective:

July 1, 2002

Date Amendment #4 Submitted:

June 25, 2003 Date Amendment #4 Approved:

September 22, 2003 Date Amendment #4 Effective:

November 12, 2002

Date Amendment #5 Submitted:

January 22, 2004 Date Amendment #5 Approved:

June 16, 2004 Date Amendment #5 Effective:

December 31, 2003

Date Amendment #6 Submitted:

August 16, 2004 Date Amendment #6 Approved:

November 5, 2004 Date Amendment #6 Effective:

July 1, 2004

Date Amendment #7 Submitted:

May 2, 2006 Date Amendment #7 Approved:

August 1, 2006 Date Amendment #7 Effective:

July 1, 2006

Date Amendment #8 Submitted:

November 27, 2006 Date Amendment #8 Withdrawn:

December 27, 2006

Date Amendment #9 Submitted:

January 25, 2007 Date Amendment #9 Withdrawn:

February 5, 2008

Date Amendment #10 Submitted:

April 3, 2008 Date Amendment #10 Approved:

December 17, 2008 Date Amendment #10 Effective:

July 1, 2007

2 Date Amendment #11 Submitted:

April 21, 2008 Date Amendment #11 Approved:

April 3, 2009 Date Amendment #11 Effective:

January 1, 2009

Date Amendment #12 Submitted:

May 22, 2008 Date Amendment #12 Approved:

January 16, 2009 Date Amendment #12 Effective:

July 1, 2008

Date Amendment #13 Submitted:

June 28, 2010 Date Amendment #13 Approved:

December 06, 2010 Date Amendment #13 Effective:

July 1, 2009, for the HSI October 1, 2009, for Dental Coverage and the Application of Medicaid FQHC/RHC Payment Requirements to CHIP January 1, 2010, for the Social Security data match April 1, 2010, for the elimination of the 3- month sanction

• On September 8, 1999, Washington submitted a Title XXI State Plan to implement a new State Children’s Health Insurance Program (CHIP). The program provided comprehensive health care coverage to uninsured children under age 19 with family incomes above 200 percent up to and including 250 percent of the Federal poverty level (FPL).

Amendments

• The State submitted its first State Plan Amendment on May 7, 2001, which modified the assignment process and eliminated the requirement for families to select a plan as part of the application process. The amendment also eliminated the requirement for families to sign a written agreement to pay premiums as a condition of eligibility.

• A second amendment was submitted by the State on April 3, 2002. This amendment eliminated co-payment charges for children enrolled in CHIP.

• Washington submitted its third amendment on October 3, 2002, to update its State Plan to indicate compliance with the final CHIP regulations.

• Washington submitted its fourth amendment to its Title XXI State Plan to add coverage for unborn children with family incomes up to and including 185 percent of the FPL and not eligible for Medicaid. Coverage will include prenatal care and associated health services for children from conception through birth.

• On January 22, 2004, Washington submitted its fifth amendment to its Title XXI State Plan to change the duration of eligibility from 12 months to 6 months. This change will affect CHIP clients enrolled on and after July 2003, with a 6-month review date on and after December 31, 2003.

• On August 16, 2004, Washington submitted its sixth amendment to its Title XXI State plan to increase monthly premiums from $10 to $15 per child per month for families with

3 income above 200 through 250 percent of the Federal poverty level (FPL) and to raise the family maximum for premiums from $30 to $45 per month. This amendment also reduces the number of consecutive months a client can be in arrears on paying premiums from 4 months to 3 months and reduces the waiting period for reinstating benefits after termination from 4 months to 3 months.

• On May 2, 2006, Washington submitted its seventh amendment to its Title XXI State Plan to extend the State Children’s Health Insurance Program (CHIP) continuous eligibility period from 6 months to 12 months, and to update the State plan to reflect the name change and organizational changes that occurred within the agency that administers CHIP.

• On November 27, 2006, Washington submitted its eighth amendment to its Title XXI State Plan. This amendment was withdrawn by the State on December 27, 2006.

• On January 25, 2007, Washington submitted its ninth amendment to its Title XXI State plan. This amendment was withdrawn by the State on February 5, 2008.

• On April 3, 2008, Washington submitted its tenth amendment to its Title XXI State plan. This SPA permits Washington to institute a pilot Application Agent program to assist families applying for CHIP and other child health programs in the state. Application Agents will receive a $75 fee for each application that results in new coverage. Washington is also seeking funding to finance a media campaign for its Apple Health for Kids program.

• On April 21, 2008, Washington submitted its eleventh amendment to its Title XXI State plan. This amendment seeks to increase the financial eligibility standard for its separate CHIP from the current family net income eligibility level at or below 250 percent of the FPL to family net income at or below 300 percent of the FPL. The SPA also proposes a two-child maximum premium limit. Cost sharing for children above 200 percent of the FPL up to and including 250 percent of the FPL will decrease in total from $15 per child per month, with a maximum of $45 per family to $20 per child per month, with a maximum of $40 per family. And cost sharing for children from 251 percent of the FPL up to and including 300 percent of the FPL is proposed to be $30 per month per child; up to a family maximum of $60 per month.

• On May 22, 2008, Washington submitted its twelfth amendment to its Title XXI State plan. This SPA permits Washington to increase children’s mental health outpatient services from up to 12 hours per calendar year to up to 20 hours per calendar year for those children receiving mental health benefits through managed care or the fee-for-service (FFS) system.

• On June 28, 2010, Washington submitted its thirteenth amendment to its Title XXI State plan. This SPA permits Washington to obtain Federal matching funds to implement a new health service initiative (HIS) to fund the Washington Poison Control System and to expand eligibility to uninsured non-citizen optional targeted low-income children, who have gross family incomes up to and including 300 percent of the Federal poverty level, and who are lawfully residing in the United States, as permitted by section 214 of the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA). This amendment also eliminates the 3 month sanction for families that have not paid their premium and acknowledges existing practices in Washington’s title XXI State Plan that are in compliance with CHIPRA sections 211 (Citizenship Documentation Requirement), 501 (Dental

4 Coverage), and 503 (Prospective Payments for Federally Qualified Health Centers (FQHCs) and Rural Health Centers (RHCs).

Children Covered Under Program

• The state reported that 35,894 children were ever enrolled in the program as of September 30, 2010

Health Care Delivery System

• The Department’s Medicaid Purchasing Administration (MPA) in coordination with the Department of Social and Health Services and other state agencies, including the Department of Health, the Governor’s Office, and the Health Care Authority, administers Washington CHIP.

• The program utilizes the State's Medicaid managed care delivery system and employs the Medicaid income eligibility criteria. The managed care system consists of contracts with health carriers for medical care coverage, contracts with Regional Support Networks (RSN) for mental health care, and fee for service (FFS) for primary care case management (PCCM) clinics.

• Families are not required to select a managed care plan for their child at the time of application. An automatic assignment will be made when a family does not make a selection at the time of application and there are two or more plans in that community.

Benefit Package

• Washington provides the same coverage to CHIP children that are provided to enrollees covered under the Medicaid State Plan.

Cost Sharing

• Washington charges a premium of $20 per month per child enrolled in CHIP with a family maximum of $40 per month for children above 200 percent of the FPL up to and including 250 percent of the FPL. For children from 251 percent of the FPL up to and including 300 percent of the FPL, premiums are $30 per month per child with a family maximum of $60 per month.

Crowd-Out Strategy

• In order to avoid crowd out, eligible children must be uninsured for 4 months prior to application in cases where the applicant had employer-sponsored dependent coverage. The State allows for certain exceptions to the 4-month waiting period.

• The CHIP application requests information regarding other insurance coverage for each

5 child.

Outreach Activities

• In combination with the media campaign, Washington is creating a pilot Application Agent program to assist families applying for CHIP and other child health programs in the state. Application Agents will receive a $75 fee for each application that results in a new child being enrolled.

• In July 2007, Washington’s legislature appropriated state funds to cover all children in Washington with health insurance by 2010. The legislation combined three existing children’s health programs (Medicaid, CHIP, and Children’s Health Program (state funded)) into a new consolidated program, referred to as Apple Health for Kids. As part of this initiative, Washington is also conducting a media campaign, which began on July 1, 2007.

Coordination Between CHIP and Medicaid

• Washington uses two standardized application forms to make eligibility determinations. One form is used for clients applying for the Medicaid Children’s Medical Program (a one- page form). The other form is used for clients applying for cash benefits, food stamps, medical coverage and other benefits. Potential CHIP eligibles can apply for medical coverage by using either form. Information from the application is entered into the State’s Automated Client Eligibility System (ACES), which automatically generates CHIP eligibility notices and yearly reviews.

Financial Information

Total FFY ’11 CHIP Allotment -- $79,883,308 FFY ’11 Enhanced Federal Matching Rate – 66.06%

Date Last Updated: CMCS, CAHPG, DCHIP, 05/05/11

_____________________________________________________________________________ Table of Contents State/Territory Name: Washington State Plan Amendment (SPA) #: WA-14-0002 This file contains the following documents in the order listed: 1) Approval Letter 2) SPA Summary Form 3) Approved SPA Pages The complete title XXI state plan for Washington consists of the most recent state plan posted on Medicaid.gov under CHIP and State Plan Amendments. The link is provided below. The following approved templates are in addition to, or replace sections of the state’s posted current state plan. The attached approval letter(s) explain how these templates fit into that state plan. Link to state title XXI state plans and amendments: http://medicaid.gov/Medicaid-CHIP-Program-Information/By- Topics/Childrens-Health-Insurance-Program-CHIP/CHIP-State-Program-Information.html

DEPARTMENT OF HEALTH & HUMAN SERVICES

Centers for Medicare & Medicaid Services ~C yt Ge 7500 Security Boulevard, Mail Stop: $2-26-12 ‘

Children and Adults Health Programs Group

JUL 17 2014

Manning J. Pellanda, Director Eligibility Policy & Service Delivery Washington State Health Care Authority 805 Plum Street, NE., MS 45534 Olympia, WA 98504-5534

Dear Mr. Pellanda:

I am pleased to inform you that the Centers for Medicare & Medicaid Services has approved your title XXI Children’s Health Insurance Program (CHIP) state plan amendment (SPA) number WA 14-0002 submitted on May 21, 2014. This SPA relates to Modified Adjusted Gross Income (MAGI) Eligibility and has an effective date of January 1, 2014.

The SPA number WA 14-0002 describes the state’s plan to provide coverage in its separate CHIP, for children subject to Section 2101(f) of the Affordable Care Act, as specified in the state’s submission of CS14: Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards. A copy of the approved CS14 is attached, and should be incorporated within a separate subsection under Section 4.1 of Washington’s approved CHIP state plan.

Your title XXI project officer is Ms. Victoria Collins. She is available to answer questions concerning this amendment and other CHIP-related issues. Ms. Collins’ contact information is as follows:

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

7500 Security Boulevard

Baltimore, MD 21244-1850

Telephone: (410) 786-2176

Facsimile: (410) 786-5882

E-mail: Victoria.Collins@cems.hhs.gov

Official communications regarding program matters should be sent simultaneously to Ms. Collins and to Ms. Carol Peverly, Associate Regional Administrator (ARA) in our Seattle Regional Office. Ms. Peverly’s address is:

Page 2 - Mr. Manning Pellanda Centers for Medicare & Medicaid Services Division of Medicaid and Children's Health Operations 2201 6 th Avenue, Mail Stop RX-43 Seattle, WA 98121 Congratulations on the approval. We look forward to continuing to work with you and your staff toward the approval of your remaining MAGI Eligibility SP As. If you have additional questions, please contact Ms. Kelly Whitener, Director, Division of State Coverage Programs at ( 410) 786- 0719. Enclosure cc: Sincerely, Eliot Fishman Director Carol Peverly, ARA, CMS Region X, Seattle

Children's Health Insurance Program Eligibility

Control P I on a : or ae Children's Health Insurance Program Eligibility: General Summary Page

Information

State/Territory Washington File Management name: Transmittal Number: SSSR TATE Please enter the Transmittal Number (TN) in the format ST- Tribal Input ¥YY-0000 where ST= the state abbreviation, YY = the last two

digits of the submission year, and OOOO = a four digit number

with leading zeros. The dashes must also be entered. |WA 14-0002

Summary

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

Proposed Effective Date

(nm/a/ yyy)

Federal Statute/ Regulation Citation

|42 CFR 457.310(d)

Federal Budget Impact

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

State Funds: $

Federal Funds: $ Please attach a revised CHIP budget.

Document

Please provide a short description of this support

document:

Character Count:30 out of 2000 WA State CHIP Budget 2014-2015

Uploaded Document Name:

Date Uploaded: WA State CHIP Budget Plan FFY14-FF¥15 6-30-14 xlsx

Download

Subject of Amendment

Please provide a brief summary of SPA changes.

Character Count: 23 out of 2000 Establish 2101({£) Group

Signature of State Agency Official

Submitted By: Ann Myers

Last Revision Jul 1, 2014 Date:

Submit Date: May 21, 2014

coms. CHIP Eligibility

OMB Control Number: 0938-1148

Section 2101(f) of the ACA and 42 CFR 457.3 10(d)

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

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

The state assures that separate CHIP coverage will be provided for children ineligible for Medicaid due to the elimination of income disregards in accordance with 42 CFR 457.3 L0(d). Coverage for this population will cease when the last child protected

* from loss of Medicaid coverage as a result of the elimination of income disregards has been afforded 12 months of coverage ina separate CHIP (expected to be no later than April 1, 2016 ).

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

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

The state will enroll all children in a separate CHIP who lose Medicaid eligibility because of an increase in family income at their first renewal applying MAGI methods. The state will enroll children in a separate CHIP whose family income falls above the converted MAGI Medicaid FPL but at or below the following percentage of FPL. The state has demonstrated and CMS has agreed that all or almost all the children who

“ would have maintained Medicaid eligibility if former disregards were applied will be within this income range and therefore covered in the separate CHIP.

% FPL.

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

C Other.

Describe the benefits provided to this population:

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

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

Describe premiums and cost sharing required of this population:

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

SPA# WA 14-0002 Approval Date: JUL i 7 2014 Effective Date: January 1, 2014

Page 1 of 2

Cems CHIP Eligibility

(@ Premiums and cost sharing are the same as for targeted low-income children in the state's separate CHIP. C No premiums, copayments, deductibles, coinsurance or other cost sharing is required.

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

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

SPA# WA 14-0002 Approval Date: JUL j 7d 2014 Effective Date: January 1, 2014 Page 2 of 2

_____________________________________________________________________________ Table of Contents State/Territory Name: Washington State Plan Amendment (SPA) #: WA-14-0003 This file contains the following documents in the order listed: 1) Approval Letter 2) SPA Summary Form 3) Approved SPA Pages The complete title XXI state plan for Washington consists of the most recent state plan posted on Medicaid.gov under CHIP and State Plan Amendments. The link is provided below. The following approved templates are in addition to, or replace sections of the state’s posted current state plan. The attached approval letter(s) explain how these templates fit into that state plan. Link to state title XXI state plans and amendments: http://medicaid.gov/Medicaid-CHIP-Program-Information/By- Topics/Childrens-Health-Insurance-Program-CHIP/CHIP-State-Program-Information.html

DEPARTMENT OF HEALTH & HUMAN SERVICES - Centers for Medicare & Medicaid Services Cc M Ss 7500 Security Boulevard, Mail Stop: S2-26-12

(CENTERS FOR MEDICARE & MEDICAID SERVICES

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

Children and Adults Health Programs Group

MAR 1 8 205 Ms. Mary Wood

CHIP Director

Eligibility Policy & Service Delivery Washington State Health Care Authority 626 8" Avenue SE

Olympia, WA 98504-5534

Dear Ms. Wood:

I am pleased to inform you that the Centers for Medicare & Medicaid Services has approved your title XX!I Children’s Health Insurance Program (CHIP) state plan amendment (SPA) number WA-14- 0003 submitted on May 21, 2014. This SPA relates to Modified Adjusted Gross Income (MAGI) Eligibility and has an effective date of January 1, 2014.

The SPA number WA-14-0003 is approved to clarify the state’s non-financial eligibility policies on residency, citizenship, social security numbers, substitution of coverage, non-payment of premiums, and continuous eligibility. Copies of the approved state plan pages are attached and these approved pages supersede sections of Washington’s current state plan as detailed below:

New State Plan Page Impact on Current State Plan Section

CS17: Non-Financial Eligibility— Residency | Section 4.1.5

CS18: Non-Financial Eligibility — Citizenship | Section 4.1.0; 4.1-LR; 4.1.1-LR

CS19: Non-Financial Eligibility — Social Section 4.1.9.1 Security Number C820: Non-Financial Eligibility — Section 4.4.4

Substitution of Coverage

C821: Non-Financial Eligibility — Non- Section 8.7 Payment of Premiums

CS23: Non-Financial Eligibility - Other Section 4.1.9 Eligibility Standards

Page 2 - Ms. Mary Wood Your title XXI project officer, Ms. Victoria Collins, is available to answer questions concerning this amendment and other CHIP-related issues. Ms. Collins' contact information is as follows: Centers for Medicare & Medicaid Services Center for Medicaid and CHIP Services Mail Stop: S2-01-16 7500 Security Blvd. Baltimore, MD 21244-1850 Telephone: (410) 786-2176 Facsimile: ( 410) 786-5882 E-mail: Victoria.Collins@cms.hhs.gov Official communications regarding program matters should be sent simultaneously to Ms. Collins and to Ms. Carol Peverly, Associate Regional Administrator (ARA), in our Seattle Office. Ms. Peverly' s address is: Office of the Regional Administrator 701 Fifth A venue, Suite 1600 Seattle, WA 98104 If you have additional questions, please contact Ms. Kelly Whitener, Director, Division of State Coverage Programs at (410) 786-0719. We look forward to continuing to work with you and your staff toward the approval of your remaining MAGI Eligibility SP As. Sincerely,
..  Enclosures cc: Ms. Carol Peverly, ARA, CMS Seattle Region Eliot Fishman Director

DEPARTMENT OF HEALTH & HUMAN SERVICES ~ Centers for Medicare & Medicaid Services Cc M Ss 7500 Security Boulevard, Mail Stop: S2-26-12

(CENTERS FOR MEDICARE & MEDICAID SERVICES:

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

Children and Adults Health Programs Group

MAR 1 8 2015 Mary Wood

CHIP Director

Eligibility Policy & Service Delivery Washington State Health Care Authority 626 8" Avenue SE

Olympia, WA 98504-5534

Dear Ms. Wood:

The Centers for Medicare & Medicaid Services (CMS) has recently completed the review and approval of Washington CHIP state plan amendment (SPA) WA-14-0003 related to non- financial eligibility matters, including the state’s policies related to non-payment of premiums. In the course of our review of SPA WA-14-0003, however, we determined that state systems are not yet in compliance with one aspect of the federal CHIP rules regarding premium lock-out periods. This letter documents the agreed upon timing and mitigation strategies associated with the state coming into full compliance with our regulations regarding premium lock-out periods.

Consistent with final rulemaking published in the Federal Register on July 15, 2013, states may not require the collection of past due premiums as a condition of eligibility for enrollment once the lock-out period has ended, and may not have a premium lock-out period that exceeds 90 days as specified at 42 CFR 457.570. Washington informed us during the SPA review process that current system functionality is incapable of reinstating coverage to children at the end of the state’s 90 day lock-out period regardless of premium payment status. The state will implement a system change to correct this lack of functionality no later than July 1, 2015. After the system change is implemented, the state will be able to enroll children still eligible for CHIP, once the 90 day lock-out period has elapsed.

In the interim, the state has been approved to implement a mitigation strategy to enroll eligible children whose 90 day premium lock-out period has already elapsed. Washington will identify children who were dis-enrolled from CHIP due to non-payment of premiums and have been without CHIP coverage for at least 90 days. Children in families earning above 210 percent up to and including 312 percent of the Federal poverty level terminated for non-payment of premiums that have exceeded the 90 day lock-out period will be sent a letter with a paper application and return envelope. The letter will instruct parents who would like reconsideration for CHIP to complete and return the enclosed application. Applications will be directed to a

Page 2 - Ms. Mary Wood specialty unit for processing to determine if the family continues to meet all of the eligibility requirements for CHIP. Families who return the application and continue to have CHIP-eligible children will have CHIP restored back to the first month following the 90 day lock-out period. Before the state requests additional information, Washington has assured us that eligibility staff will make every effort to reconcile inconsistencies using available electronic data sources, and attempt to call the applicant to resolve any inconsistencies. A reasonable opportunity will be provided to reconcile any discrepancies. We are available to provide technical assistance during this time. If you have any questions or wish to discuss this issue further, your staff may contact Vickie Collins at (410) 786-2176. She will provide or arrange for any technical assistance that you may require. Thank you for your cooperation. Sincerely, Kelly Whitener Director, Division of State Coverage Programs cc: Kevin Cornell, CHIP Program Manager Ms. Carol Peverly, ARA, CMS Seattle Region

Children's Health Insurance Program Eligibility

Control Panel

Children's Health Insurance Program Eligibility: Summary Page

General

Information

#esteeuet seen sent seme ste ste State/Territory Washington

File Management name: Transmittal Number:

enon ac nnn Ny po ENN Please enter the Transmittal Number (TN) in the format ST-

Tribal Input YY-0000 where ST= the state abbreviation, YY = the last two

co setenneesniteeni digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered.

Summary

[WA 14-0003

Type of SPA: MAGI Eligibility & Methods XXI Medicaid Expansion Establish 2101(f) Group Eligibility Processing ¥ Non-Financial Eligibility Proposed Effective Date

(mm/dd/yy)

Federal Statute/ Regulation Citation

[42 CFR 457.310, 320, 342, 570 and 42 CFR 435.926

Federal Budget Impact

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

State Funds: $

Federal Funds: $ Please attach a revised CHIP budget.

Document

Please provide a short description of this support

document:

Character Count:25 out of 2000 WA State CHIP Budget Plan

Uploaded Document Name: Date Uploaded: WA State CHIP Budget Plan FFY14-FFY15 6-30-14 xlsx

Download

Subject of Amendment

Please provide a brief summary of SPA changes.

Character Count:25 out of 2000 Non-Financial eligibility

Signature of State Agency Official

Submitted By: Ann Myers

Last Revision Jan 7, 2015 Date:

Submit Date: May 21, 2014

CHIP Eligibility

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

42 CFR 457.320

Residency

4)

The CHIP Agency provides CHIP to otherwise eligible residents of the state, including residents who are absent from the state under certain conditions.

A child is considered to be a resident of the state under the following conditions:

A non-institutionalized child, if capable of indicating intent and who is emancipated or married, if the child is living in the state and:

a 1, Intends to reside in the state, including without a fixed address, or 2. Has entered the state with a job commitment or seeking employment, whether or not currently employed. [fl A non-institutionalized child not described above and a child who is not a ward of the state:

1. Residing in the state, with or without a fixed address, or

2. The state of residency of the parent or caretaker, in accordance with 42 CFR.435.403(h)(1), with whom the individual resides.

ry An institutionalized child, who is not a ward of the state, if the state is the state of residence of the child's custodial parent or caretaker at the time of placement, or

[Ml A child who is a ward of the state regardless of where the child lives, or

A child physically located in the state when there is a dispute with one or more states as to the child's actual state of residence.

If the state covers pregnant women, a pregnant woman is considered to be a resident under the following conditions: [A non-institutionalized pregnant woman who is living in the state and: 1. Intends to reside in the state, including without a fixed address, or if incapable of indicating intent, is living in the state, or

2. Entered with a job commitment or seeking employment, whether or not currently employed.

An institutionalized pregnant woman placed in an out-of-state-institution, as defined in 42 CFR 435.1010, including foster care homes, by an agency of the state, or

Cy

im An institutionalized pregnant woman residing in an in-staté-instituti on, as defined in 42 CFR 435.1010, whether or not the individual established residency in the state prior to entering the institution, or

A pregnant woman physically located in the state when there is a dispute with one or more states as to the pregnant woman's actual state of residence.

im

The state has in place related to the residency of children and pregnant women (if covered by the state):

SPA# WA 14-0003 Approval Date: f f A R { 8 70 5 Effective Date: January 1, 2014

Page 1 of 2

CcCMs. CHIP Eligibility

One or more interstate agreement(s). No

A policy related to individuals in the state only for educational purposes. Yes

Provide a description of the policy:

Individuals who are living in the state solely for the purposes of attending an educational institution are not considered residents of the state.

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

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

MAR 1 8 2015

SPA# WA 14-0003 Approval Date:, Effective Date: January 1, 2014 Page 2 of 2

Cems. CHIP Eligibility

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

Sections 2105(c)(9) and 2107(e)(1)(J) of the SSA and 42 CFR 457.320(b)(6), (c) and (d)

Citizenship

The CHIP Agency provides CHIP eligibility to otherwise eligible citizens and nationals of the United States and certain non-citizens, [7] including the time period during which they are provided with reasonable opportunity to submit verification of their citizenship, national status or satisfactory immigration status.

[M The CHIP Agency provides eligibility under the Plan to otherwise eligible individuals:

Who are citizens or nationals of the United States; or

Who are qualified non-citizens as defined in section 431 of the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) (8 U.S.C. §1641), or whose eligibility is required by section 402(b) of PRWORA (8 U.S.C. §1612(b)) and is not prohibited by section 403 of PRWORA (8 U.S.C. §1613); or

Who have declared themselves to be citizens or nationals of the United States, or an individual having satisfactory immigration status, during a reasonable opportunity period pending verification of their citizenship, nationality, or satisfactory immigration status consistent with requirem ents of 1903(x), 1137(d), and 1902(ee) of the Act, and 42 CFR 435.406, 407, 956 and 457.380.

The reasonable opportunity period begins on and extends 90 days from the date the notice of reasonable opportunity is received by the individual.

The agency provides for an extension of the reasonable opportunity period if the individual is making a good faith effort to resolve any inconsistencies or obtain any necessary documentation, or the agency needs more time to complete the Yes verification process.

The agency begins to furnish benefits to otherwise eligible individuals during the reasonable opportunity period on a date

earlier than the date the notice is received by the individual. Yes

The date benefits are furnished is: @ The date of application containing the declaration of citizenship or immigration status. C The date the reasonable opportunity notice is sent.

© Other date, as described:

The CHIP Agency elects the option to provide CHIP coverage to otherwise eligible children up to age 19, lawfully residing

in the United States, as provided in Section 2107(e)(1)(J) of the SSA (Section 214 of CHIPRA 2009, P.L. 111-3). Yes

Otherwise eligible children means children meeting the eligibility requirements of targeted low-income children with the exception of non-citizen status.

The CHIP Agency provides assurance that lawfully residing children are also covered under the state's Medicaid program.

SPA# WA 14-0003 Approval Date: MAR 4 8 2045 Effective Date: January 1, 2014

Page 1 of 3

cEmMs CHIP Eligibility

The CHIP Agency elects the option to provide CHIP coverage to otherwise eligible pregnant women, lawfully residing in the United States, as provided in Section 214 of CHIPRA 2009, P.L. 111-3. The state may not select this option unless the state also elects to cover lawfully residing children. A state may not select this option unless the state also covers Targeted Low- Income Pregnant Women.

No

i An individual is considered to be lawfully residing in the United States if he or she is lawfully present and meets state residency requirements.

[lM An individual is considered to be lawfully present in the United States if he or she is: 1. A qualified non-citizen as defined in 8 U.S.C. 1641(b) and (c);

2. A non-citizen in a valid nonimmigrant status, as defined in 8 U.S.C. 1101(a)(15) or otherwise under the immigration laws (as defined in 8 U.S.C. 1101(a)(17));

3. A non-citizen who has been paroled into the United States in accordance with 8 U.S.C.1182(d)(5) for less than 1 year, except for an individual paroled for prosecution, for deferred inspection or pending removal proceedings;

4. A non-citizen who belongs to one of the following classes: (i) Granted tem porary resident status in accordance with 8 U.S.C.1160 or 1255a, respectively;

(ii) Granted Temporary Protected Status (T PS) in accordance with 8 U.S.C. §1254a, and individuals with pending applications for TPS who have been granted employment authorization;

(iii) Granted employment authorization under 8 CFR 274a.12(c);

(iv) Family Unity beneficiaries in accordance with section 301 of Pub. L. 101-649, as amended;

(v) Under Deferred Enforced Departure (DED) in accordance with a decision made by the President; (vi) Granted Deferred Action status;

(vii) Granted an administrative stay of removal under 8 CFR 241;

(viii) Beneficiary of approved visa petition who has a pending application for adjustment of status;

5. Is an individual with a pending application for asylum under 8 U.S.C. 1158, or for withholding of removal under 8 U.S.C.1231,or under the Convention Against Torture, who:

(i) Has been granted employment authorization; or

(ii) Is under the age of 14 and has had an application pending for at least 180 days; 6. Has been granted withholding of removal under the Convention Against Torture; 7. 1s a child who has a pending application for Special Immigrant Juvenile status as described in 8 U.S.C.1101(a)(27)(J); 8. Is lawfully present in American Samoa under the immigration laws of American Samoa; or

9. Is a victim of severe trafficking in persons, in accordance with the Victims of Trafficking and Violence Protection Act of 2000, Pub. L. 106-386, as amended (22 U.S.C. 7105(b)).

MAR 1 8 2045

SPA# WA 14-0003 Approval Date:. Effective Date: January 1, 2014 Page 2 of 3

CHIP Eligibility

10. Exception: An individual with deferred action under the Department of Homeland Security's deferred action for the childhood arrivals process, as described in the Secretary of Homeland Security's June 15, 2012 memorandum, shall not be considered to be lawfully present with respect to any of the above categories in paragraphs (1) through (9) of this definition.

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

MAR 1 8 2015

SPA# WA 14-0003 Approval Date: Effective Date: January 1, 2014 Page 3 of 3

CHIP Eligibility

OMB Control Number: 0938-1148

42 CFR 457.340(b)

Social Security Number

As a condition of eligibility, the CHIP Agency must require individuals who have a social security number or are eligible for one as determined by the Social Security Administration, to furnish their social security number, or numbers if they have more than one number.

The state may request non-applicant household members to voluntarily provide their SSN, if the state meets the requirements below.

The CHIP Agency requires individuals, as a condition of eligibility, to furnish their social security number(s), with the following exceptions:

Individuals refusing to obtain a social security number (SSN) because of well established religious objections, or Individuals who are not eligible for an SSN, or

Individuals who are issued an SSN only for a valid non-work purpose.

The CHIP Agency assists individuals, who are required to provide their SSN, to apply for or obtain an SSN from the Social Security Administration if the individual does not have or forgot their SSN.

The CHIP Agency informs individuals required to provide their SSN: By what statutory authority the number is solicited; and

How the state will use the SSN.

The CHIP Agency provides assurance that it will verify each SSN furnished by an applicant or beneficiary with the Social Security Administration, not deny or delay services to an otherwise eligible applicant pending issuance or verification of the individual's SSN by the Social Security Administration and that the state's utilization of the SSNs is consistent with sections 205 and 1137 of the Social Security Act and the Privacy Act of 1974.

The state requests non-applicant household members to voluntarily provide their Ves SSN.

(Z] When requesting an SSN for non-applicant household members, the state assures that:

im At the time such SSN is requested, the state informs the non-applicant that this information is voluntary and provides information regarding how the SSN will be used; and

im The state only uses the SSN for determination of eligibility for CHIP or other insurance affordability programs, or for a purpose directly connected with the administration of the state plan.

PRA Disclosure Statement

MAR 1 8 205

SPA# WA 14-0003 Approval Date: Effective Date: January 1, 2014

Page 1 of 2

CHIP Eligibility

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

MAR 1 8 2085

SPA# WA 14-0003 Approval Date: Effective Date: January 1, 2014 Page 2 of 2

CcCMsS. CHIP Eligibility

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

457.310(b)(2) and (b)(3), 457.320(a)(9) and 2110(b)(1)(C) of the SSA

Substitution of Coverage

The CHIP Agency provides assurance that it has methods and policies in place to prevent the substitution of group health coverage or other commercial health insurance with public funded coverage. These policies include:

[MH Substitution of coverage prevention strategy:

Name of policy Description

Tracking of the number of applicants _| Each applicant will be asked if they have dropped

who drop group health insurance group health insurance coverage in the 4 months preceding their application. Ifthe incidence of dropped coverage exceeds 5% of approved applications, the Agency will conduct a survey to see if one of nine "good cause" reasons apply. The outcome of the survey will determine if substitution of coverage is a substantial enough issue to require implementation of a waiting period not to exceed the statutory maximum.

A waiting period during which an individual is ineligible due to having dropped group health coverage. No |

If the state covers pregnant women, the waiting period does not apply to pregnant women.

If the state elects to offer dental only supplemental coverage, the following assurances apply:

Oo The other coverage exclusion does not apply to children who are otherwise eligible for dental only supplemental coverage as provided in section 2110(b)(5) of the SSA.

(CJ The waiting period does not apply to children eligible for dental only supplemental coverage.

PRA Disclosure Statement

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

V.20130718

MAR 1 8 2015

SPA# WA 14-0003 Approval Date: Effective Date: January 1, 2014 Page 1 of 1

Cems. CHIP Eligibility

State Name:| Washington | OMB Control Number: 0938-1148

Transmittal Number: WA - 14 - 0005 Expiration date: 10/31/2014

42 CFR 457.570

Non-Payment of Premiums

Does the state impose premiums or enrollment fees? Yes Can non-payment of premiums or enrollment fees result in loss of CHIP eligibility? =~ Yes Does the state have a premium lock out period? Yes

Please describe the lock-out period:

When a family fails to pay the required premium for 3 consecutive months, coverage is suspended for CHIP for a period not to exceed 90 days. The family may resolve this suspension at any time by paying the delinquent prem ium or reporting a change in their circumstances resulting in eligibility for Medicaid. If the family pays the delinquent premium at any time during the initial certification period, eligibility will be restored to the first day of the lock-out period and no new application will be necessary. If the family does not pay the delinquent premium, they will need to reapply at the end of the 90 days and will have their eligibility for CHIP redeterm ined.

What is the length of the time premium lock-out period? Select a length of time: C One month

C. Two months @ 90 days

C Other (not to exceed 90 days)

Are there exceptions to the required lock-out period? Yes

[71 Individual's income decreased to a level where no premium is required or within Medicaid standards (1 Other financial hardship Other

Describe

The debt is written off after twelve months

The family pays the delinquent premium during the lock-out period

The state assures that:

It does not require the collection of past due premiums or enrollment fees as a condition of eligibility for enrollment once the lock-out period has expired; and a 9 Ont TO cut SPA# WA 14-0003 Approval Date: Effective Date: January 1, 2014

Page 1 of 2

CHIP Eligibility

It provides enrollees with an opportunity for an impartial review to address disenrollment from the program in accordance with section 457.1130(a)(3); and

The child will be reenrolled in CHIP during the lock-out period upon payment of past due premiums or enrollment fees.

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

V.20140415

MAR 1 8 2015

SPA# WA 14-0003 Approval Date: Effective Date: January 1, 2014 Page 2 of 2

CccmMs CHIP Eligibility

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

2105(a)(4)(A) of the SSA and 42 CFR 457.342 and 435.926

The CHIP Agency may provide that children who have been determined eligible under the state plan shall remain eligible, regardless of any changes in the family’s circumstances, during a continuous eligibility period up to 12 months, or until the time the child reaches an age specified by the state (not to exceed age 19), whichever is earlier.

The CHIP Agency elects to provide continuous eligibility to children under this provision. | Yes

@ For children up to age 19

C For children up to age

The continuous eligibility period begins on the effective date of the child's most recent determination or redetermination of eligibility, and ends:

[MH Atthe end ofthe |12 months continuous eligibility period.

Exceptions to the continuous eligibility period: [Ml The child attains the age specified by the state Agency or age 19. [Hl The child or child's representative requests voluntary disenrollment. [i The child is no longer a resident of the state.

ml The Agency determines that eligibility was erroneously granted at the most recent determination or renewal of eligibility because of Agency error or fraud, abuse, or perjury attributed to child or child's representative.

[ll The child dies. {M] There is a failure to pay required premiums or enrollment fees on behalf of a child, as provided for in the state plan.

| Other

Describe

a child who becomes an inmate of a public institution, as defined in WAC 388-500-0005. If the child is released during the certification period, eligibility is restored from the date of release through the continuous eligibility period.

PRA Disclosure Statement

MAR 1 8 2015

SPA# WA 14-0003 Approval Date:. Effective Date: January 1, 2014 Page 1 of 2

ccms CHIP Eligibility

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

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

V.20130717

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SPA# WA 14-0003 Approval Date: Effective Date: January 1, 2014 Page 2 of 2

_____________________________________________________________________________

Table of Contents

State/Territory Name: Washington

State Plan Amendment (SPA) #: WA-14-0004-MC4

This file contains the following documents in the order listed:

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

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

DEPARTMENT OF HEALTH & HUMAN SERVICES

Centers for Medicare & Medicaid Services i“ CM See

7500 Security Boulevard, Mail Stop: S2-26-12

a

Children and Adults Health Programs Group

AUG 15 2014

Mr. Manning J. Pellanda

Director

Eligibility Policy & Service Delivery Washington State Health Care Authority 626 8"" Ave SE

Olympia, WA 98504-5534

Dear Mr. Pellanda:

I am pleased to inform you that the Centers for Medicare & Medicaid Services (CMS) has approved Washington’s Children’s Health Insurance Program (CHIP) state plan amendment (SPA), WA-14-0004-MC4 submitted on May 21, 2014. This SPA incorporates the Modified Adjusted Gross Income (MAGI)-based eligibility process requirements in accordance with the Affordable Care Act. The effective date of this SPA is October 1, 2013.

The state is using an interim alternative single streamlined paper application and an interim alternative single streamlined online application. By December 31, 2014, the state will implement revised alternative single streamlined paper and online applications that address CMS concerns outlined in the companion letter issued with this SPA approval.

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

e Template CS24 — Separate Child Health Insurance Program

e Attachment 1 — Statement of use with respect to the alternative single, streamlined paper application

e Attachment 2 — Statement of use with respect to the alternative single, streamlined online application

This approval and the enclosures supercede the following sections of the current CHIP state plan:

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

The CMS appreciates the significant amount of work your staff dedicated to preparing this State Plan Amendment. Your title XXI project officer is Ms. Victoria Collins. She is available to answer questions concerning this amendment and other CHIP-related issues.

Page 2 — Mr. Manning J. Pellanda

Ms. Collin’s contact information is as follows:

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

7500 Security Blvd.

Baltimore, MD 21244-1850

Telephone: (410) 786-2176

Facsimile: (410) 786-5882

E-mail: Victoria.Collins@cms.hhs.gov

Official communications regarding program matters should be sent simultaneously to Ms. Collins and Ms. Carol Peverly, Associate Regional Administrator, in our Seattle Regional Office. Ms. Peverly’s address is:

Ms. Carol Peverly

Office of the Regional Administrator 701 Fifth Ave., Ste. 1600

Seattle, WA 98104

If you have additional questions, please contact Ms. Kelly Whitener, Director, Division of State Coverage Programs at 410-786-0719.

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

Eliot Fishman Director

Enclosure

ce: Ms. Carol Pevely, ARA, CMS Region X

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

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

Children and Adults Health Programs Group

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

AUG 15 2014

Mr. Manning J. Pellanda

Director

Eligibility Policy & Service Delivery Washington State Health Care Authority 626 8" Ave SE

Olympia, WA 98504-5534

RE: CS24 - Eligibility Process State Plan Amendment (SPA), WA-14-0004-MC4

Dear Mr. Pellanda:

This letter is being sent as a companion to the Centers for Medicare & Medicaid Services (CMS) approval of Children’s Health Insurance Program (CHIP) state plan amendment (SPA) transmittal WA-14-0004-MC4, which was submitted to CMS on May 21, 2014. Our review of this submission included a review of the alternative single streamlined paper and online

applications developed by the state.

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

Necessary changes to paper application Date by which changes will be completed:

Non-applicants will be given the option to December 31, 2014

provide their Social Security numbers for purposes of income verification.

Applicants will not be asked about previous year | December 31, 2014

tax filing status.

Applicants will be asked about anticipated December 31, 2014

changes to income or projected annual income.

Page 2 — Mr. Manning J. Pellanda

Necessary changes to paper application

Date by which changes will be completed:

American Indians and Alaska Natives applicants will have the opportunity to identify themselves as recipients of Indian Health Services for purposes of cost-sharing protections, and identify American Indian and Alaska Native income not countable for Medicaid and CHIP income determinations.

December 31, 2014

State will revisit the inclusion of a question on former foster care program participation.

December 31, 2014

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

Necessary changes to online application

Date by which changes will be completed:

Questions regarding residency will not be directed to household members not seeking any benefits, and will be designated for applicants only.

December 31, 2014

Questions regarding incarceration will not be directed to household members not seeking any benefits, and will be designated for applicants only.

December 31, 2014

All questions regarding citizenship and immigration status will not be directed to household members not seeking any benefits, and will be designated for applicants only.

December 31, 2014

The non-MAGI screening questions related to disability and long term care will not be directed to household members not seeking any benefits, and will be designated for applicants only.

December 31, 2014

Questions regarding tobacco use will be asked only of applicants above the income limit for Medicaid and CHIP.

December 31, 2014

Page 3 — Mr. Manning J. Pellanda

Necessary changes to online application

Date by which changes will be completed:

Applicants will be asked about anticipated changes to income, or projected annual income.

December 31, 2014

American Indians and Alaska Natives applicants will have the opportunity to identify themselves as recipients of Indian Health Services for purposes of cost-sharing protections, and identify American Indian and Alaska Native income not countable for Medicaid and CHIP income determinations.

Deceinber 31, 2014

Questions regarding access to employer- sponsored coverage, beyond what is needed for Medicaid and CHIP, will be asked only of applicants above the income limit for Medicaid and CHIP.

December 31, 2014

Applicants will not be asked about previous year tax filing status.

December 31, 2014

Applicants will be asked about income of household members of all ages (with exception allowed for tax dependents not required to file taxes as noted in the paper application or state could ask for all taxable income and make that calculation on the back-end.

December 31, 2014

State will revisit the inclusion of a question on former foster care program participation.

December 31, 2014

Page 4 — Mr. Manning J. Pellanda

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

Director Division of State Coverage Programs

ce: Ms. Carol Peverly, AR A, CMS Region X

logged in as TONIABROWN(CMS CO Staff) read only mode application rev p01 Children's Health Insurance Program Eligibility WA.1021.R00.00 - Jan 01, 2014 Home Logout Finder Save Validate Print Help Control Panel General Information File Management Tribal Input Summary State/Territory name: Washington State Funds: $ 6208255.00 Federal Funds: $ 11529616.00 Submitted By: Ann Myers Children's Health Insurance Program Eligibility: Summary Page Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. WA 14-0004 Type of SPA: MAGI Eligibility & Methods XXI Medicaid Expansion Establish 2101(f) Group Eligibility Processing Non-Financial Eligibility Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation 42 CFR 570, subpart C Federal Budget Impact This SPA has a budget impact. Total budget impact: Please attach a revised CHIP budget. Document Subject of Amendment Please provide a brief summary of SPA changes. Character Count:22 out of 2000 Eligibility Processing Signature of State Agency Official Page 1 of 2 Children's Health Insurance Program Eligibility: CMS 179 11/02/2014 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01/pages/chp_179.jsp

Last Revision Date: Oct 15, 2014 Submit Date: May 21, 2014 FAQs | Site Map | Contact | Medicaid.gov | CMS.gov Page 2 of 2 Children's Health Insurance Program Eligibility: CMS 179 11/02/2014 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01/pages/chp_179.jsp

Cems. CHIP Eligibility

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

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

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

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:

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

An alternative single, streamlined application developed by the state and approved by the Secretary in accordance with section 1413(b)(1)(B) of the Affordable Care Act.

An alternative application used to apply for multiple human service programs approved by the Secretary, provided that the (7) agency makes readily available the single or alternative application used only for insurance affordability programs to individuals seeking assistance only through such programs.

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

The agency accepts applications in the following other electronic means.

Other electronic means:

Name of method Description

FAX The applicant may fax a copy of their paper application to a published fax number.

Screen and Enroll Process

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

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

Procedures include:

AUG 15 2014

SPA# WA-14-0004-MC4 Approval Date: Effective Date: October 1, 2013 Page | of 3

cemMs. CHIP Eligibility

ry] Screening of application to identify all individuals eligible or potentially eligible for CHIP or other insurance affordability programs; and \ rT Income eligibility test, with calculation of household income consistent with 42 CFR 457.315 for individuals identified as potentially eligible for Medicaid or other insurance affordability programs based on household income; and

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

The CHIP agency has entered into an arrangement with the Exchange to make eligibility determinations for advanced Yes premium tax credits in accordance with section 1943(b)(2) of the SSA.

Redetermination Processing

wi 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 457.343:

[Mf] Once every 12 months.

mm 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 [ll information to complete the redetermination, it provides the individual with a pre-populated renewal form containing the information already available.

Screening by Other Insurance Affordability Programs

The CHIP Agency provides assurance that it has adopted procedures to accept and process electronic accounts of individuals screened as potentially eligible for CHIP by other insurance affordability programs in accordance with the requirements of 42

0 CFR 457.348(b) and to determine eligibility in accordance with 42 CFR 457.340 in the same manner as if the application had been submitted directly to, and processed by the state.

The CHIP Agency elects the option to accept CHIP eligibility decisions made by the Exchange or other agencies administering x insurance affordability programs as provided in 42 CFR 457.348 and to furnish CHIP in accordance with requirem ents of 42 " CFR 457.340 to the same extent and in the same manner as if the applicant had been determined by the state to be eligible for CHIP. Check all types of agencies that apply: The Exchange EK) Medicaid

Other agency administering insurance affordability programs

Name of Agency

Department of Social and Health Services staff assisting an applicant or | a recipient of Medicaid with an online application through the Washington Healthplanfinder.

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

SPA# WA-14-0004-MC4 Approval Date: AUG { 5 2014 Effective Date: October 1, 2013 Page 2 of 3

CccmMsS CHIP Eligibility

PRA Disclosure Statement

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

V.20130709

SPA# WA-14-0004-MC4 Approval Date: AUG j 5 2044 Effective Date: October 1, 2013

Page 3 of 3

USE OF THE ALTERNATIVE SINGLE STREAMLINED APPLICATION

O Paper Application

[X] Online Application

TRANSMITTAL NUMBER:

WA-14-0004-MC4

STATE:

Washington

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

into the state plan.

USE OF THE ALTERNATIVE SINGLE STREAMLINED APPLICATION

[xIPaper Application OOnline Application TRANSMITTAL NUMBER: STATE: WA-14-0004-MC4 Washington

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

into the state plan.

_____________________________________________________________________________ Table of Contents State/Territory Name: State Plan Amendment (SPA) #: This file contains the following documents in the order listed: 1) Approval Letter 2) State Plan Pages Washington WA-18-0001

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-01-16 Baltimore, MD 21244-1850

Children and Adults Health Programs Group

March 18, 2021

MaryAnne Lindeblad Medicaid Director Health Care Authority 626 8th Avenue SE Post Office Box 45502 Olympia, WA 98504-5502

Dear Ms. Lindeblad:

This letter is to inform you that your title XXI Children's Health Insurance Program (CHIP) state plan amendment (SPA), WA-18-0001, submitted on June 28, 2018, has been approved. This SPA has an effective date of October 2, 2017. WA-18-0001 implements mental health parity regulations at 42 CFR 457.496 to ensure that treatment limitations and financial requirements applied to mental health (MH) and substance use disorder (SUD) benefits are no more restrictive than those applied to medical/surgical benefits. Through this SPA, Washington conducted a full parity analysis for the unborn population and requested deemed compliance for children birth to age 19.

Unborn Population Section 2103(c)(7)(A) of the Social Security Act (the Act), as implemented through regulations at 42 CFR 457.496(d)(3)-(5), require states to ensure that financial requirements and treatment limitations applied to MH/SUD benefits covered under the state child health plan are consistent with the mental health parity requirements of 2705(a) of the Public Health Service Act, in the same manner in which such requirements apply to a group health plan. To the extent that a state provides both M/S and MH/SUD benefits, it must demonstrate that financial requirements and treatment limitations applied to MH/SUD benefits covered under the state child health plan comply with these requirements. Washington demonstrated compliance by providing the necessary assurances and supporting documentation that the state's application of non- quantitative treatment limitations to MH/SUD benefits are consistent with section 2103(c)(7)(A) of the Act.

Apple Health for Kids Section 2103(c)(7)(B) of the Act, as implemented through regulations at 42 CFR 457.496(b), provides that if CHIP coverage includes Early, Periodic Screening, Diagnostic and Treatment (EPSDT) as defined in section 1905(r) of the Act and provided in accordance with section 1902(a)(43) of the Act, the state plan will be deemed to satisfy parity requirements. Washington has provided the necessary assurances and supporting documentation that EPSDT is covered under Washington’s CHIP program and provided in accordance with sections 1905(r) and 1902(a)(43) of the Act.

Page 2 — Ms. MaryAnne Lindeblad

This approval relates only to the benefits provided under the CHIP state plan; Medicaid benefits will be analyzed separately.

Your title XXI project officer is Ms. Janice Adams. She is available to answer questions concerning this amendment and other CHIP-related issues. Her contact information is as follows:

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

701 Fifth Avenue, Suite 1600, Mail Stop: RX-200 Seattle, WA 98104

Telephone: (206) 615-2541

E-mail: Janice. Adams@cms.hhs.gov

If you have additional questions, please contact Meg Barry, Director, Division of State Coverage Programs at (410) 786-1536. We look forward to continuing to work with you and your staff.

Sincerely, /Signed Amy Lutzky/

Amy Lutzky Deputy Director

1 Effective Date: October 2, 2017

Approval Date:

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

Preamble

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

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

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

2 Effective Date: October 2, 2017

Approval Date:

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

State/Territory:

Washington

As a condition for receipt of Federal funds under Title XXI of the Social Security Act, (42 CFR, 457.40 (b)) ___________________________________________________________________________________ (Signature of Governor, or designee, of State/Territory, Date Signed) submits the following Child Health Plan for the Children’s Health Insurance Program and hereby agrees to administer the program in accordance with the provisions of the approved Child Health Plan, the requirements of Title XXI and XIX of the Act (as appropriate) and all applicable Federal regulations and other official issuances of the Department. The following State officials are responsible for program administration and financial oversight (42 CFR 457.40(c)):

Name: Sue Birch

Position/Title: Director, Health Care Authority Name: MaryAnne Lindeblad Position/Title: Medicaid and CHIP Director, Health Care Authority

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0707. The time required to complete this information collection is estimated to average 160 hours (or minutes) per response, including the time to review instructions, search existing data resources, gather the data needed and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this Form, please write to: CMS, P.O. Box 26684, Baltimore, Maryland 21207 and to the Office of the Information and Regulatory Affairs, Office of Management and Budget, Washington, D.C. 20503.

3 Effective Date: October 2, 2017

Approval Date:

Introduction: Section 4901 of the Balanced Budget Act of 1997 (BBA), public law 1005-33 amended the Social Security Act (the Act) by adding a new title XXI, the Children’s Health Insurance Program (CHIP). In February 2009, the Children’s Health Insurance Program Reauthorization Act (CHIPRA) renewed the program. The Patient Protection and Affordable Care Act, as amended by the Health Care and Education Reconciliation Act of 2010, further modified the program. The HEALTHY KIDS Act and The Bipartisan Budget Act of 2018 together resulted in an extension of funding for CHIP through federal fiscal year 2027.

This template outlines the information that must be included in the state plans and the State plan amendments (SPAs). It reflects the regulatory requirements at 42 CFR Part 457 as well as the previously approved SPA templates that accompanied guidance issued to States through State Health Official (SHO) letters. Where applicable, we indicate the SHO number and the date it was issued for your reference. The CHIP SPA template includes the following changes: • Combined the instruction document with the CHIP SPA template to have a single document. Any modifications to previous instructions are for clarification only and do not reflect new policy guidance. • Incorporated the previously issued guidance and templates (see the Key following the template for information on the newly added templates), including: • Prenatal care and associated health care services (SHO #02-004, issued November 12, 2002) • Coverage of pregnant women (CHIPRA #2, SHO # 09-006, issued May 11, 2009) • Tribal consultation requirements (ARRA #2, CHIPRA #3, issued May 28, 2009) • Dental and supplemental dental benefits (CHIPRA # 7, SHO # #09-012, issued October 7, 2009) • Premium assistance (CHIPRA # 13, SHO # 10-002, issued February 2, 2010) • Express lane eligibility (CHIPRA # 14, SHO # 10-003, issued February 4, 2010) • Lawfully Residing requirements (CHIPRA # 17, SHO # 10-006, issued July 1, 2010) • Moved sections 2.2 and 2.3 into section 5 to eliminate redundancies between sections 2 and 5. • Removed crowd-out language that had been added by the August 17 letter that later was repealed. • Added new provisions related to delivery methods, including managed care, to section 3 (81 FR 27498, issued May 6, 2016) States are not required to resubmit existing State plans using this current updated template. However, States must use this updated template when submitting a new State Plan Amendment. Federal Requirements for Submission and Review of a Proposed SPA. (42 CFR Part 457 Subpart A) In order to be eligible for payment under this statute, each State must submit a Title XXI plan for approval by the Secretary that details how the State intends to use the funds and fulfill other requirements under the law and regulations at 42 CFR Part 457. A SPA is approved in 90 days unless the Secretary notifies the State in writing that the plan is disapproved or that specified additional information is needed. Unlike Medicaid SPAs, there is only one 90 day review period, or clock for CHIP SPAs that may be stopped by a request for additional information and restarted after a complete response is received. More information on the SPA review process is found at 42 CFR 457 Subpart A.

When submitting a State plan amendment, states should redline the changes that are being made to the existing State plan and provide a “clean” copy including changes that are being made to the existing state plan.

4 Effective Date: October 2, 2017

Approval Date:

The template includes the following sections: 1. General Description and Purpose of the Children’s Health Insurance Plans and the Requirements- This section should describe how the State has designed their program. It also is the place in the template that a State updates to insert a short description and the proposed effective date of the SPA, and the proposed implementation date(s) if different from the effective date. (Section 2101); (42 CFR, 457.70) 2. General Background and Description of State Approach to Child Health Coverage and Coordination- This section should provide general information related to the special characteristics of each state’s program. The information should include the extent and manner to which children in the State currently have creditable health coverage, current State efforts to provide or obtain creditable health coverage for uninsured children and how the plan is designed to be coordinated with current health insurance, public health efforts, or other enrollment initiatives. This information provides a health insurance baseline in terms of the status of the children in a given State and the State programs currently in place. (Section 2103); (42 CFR 457.410(A)) 3. Methods of Delivery and Utilization Controls- This section requires the State to specify its proposed method of delivery. If the State proposes to use managed care, the State must describe and attest to certain requirements of a managed care delivery system, including contracting standards; enrollee enrollment processes; enrollee notification and grievance processes; and plans for enrolling providers, among others. (Section 2103); (42 CFR Part 457. Subpart L) 4. Eligibility Standards and Methodology- The plan must include a description of the standards used to determine the eligibility of targeted low-income children for child health assistance under the plan. This section includes a list of potential eligibility standards the State can check off and provide a short description of how those standards will be applied. All eligibility standards must be consistent with the provisions of Title XXI and may not discriminate on the basis of diagnosis. In addition, if the standards vary within the state, the State should describe how they will be applied and under what circumstances they will be applied. In addition, this section provides information on income eligibility for Medicaid expansion programs (which are exempt from Section 4 of the State plan template) if applicable. (Section 2102(b)); (42 CFR 457.305 and 457.320) 5. Outreach- This section is designed for the State to fully explain its outreach activities. Outreach is defined in law as outreach to families of children likely to be eligible for child health assistance under the plan or under other public or private health coverage programs. The purpose is to inform these families of the availability of, and to assist them in enrolling their children in, such a program. (Section 2102(c)(1)); (42 CFR 457.90) 6. Coverage Requirements for Children’s Health Insurance- Regarding the required scope of health insurance coverage in a State plan, the child health assistance provided must consist of any of the four types of coverage outlined in Section 2103(a) (specifically, benchmark coverage; benchmark-equivalent coverage; existing comprehensive state-based coverage; and/or Secretary-approved coverage). In this section States identify the scope of coverage and benefits offered under the plan including the categories under which that coverage is offered. The amount, scope, and duration of each offered service should be fully explained, as well as any corresponding limitations or exclusions. (Section 2103); (42 CFR 457.410(A)) 7. Quality and Appropriateness of Care- This section includes a description of the methods (including monitoring) to be used to assure the quality and appropriateness of care and to assure access to covered services. A variety of methods are available for State’s use in monitoring and evaluating the quality and appropriateness of care in its child health assistance program. The

5 Effective Date: October 2, 2017

Approval Date:

section lists some of the methods which states may consider using. In addition to methods, there are a variety of tools available for State adaptation and use with this program. The section lists some of these tools. States also have the option to choose who will conduct these activities. As an alternative to using staff of the State agency administering the program, states have the option to contract out with other organizations for this quality of care function. (Section 2107); (42 CFR 457.495) 8. Cost Sharing and Payment- This section addresses the requirement of a State child health plan to include a description of its proposed cost sharing for enrollees. Cost sharing is the amount (if any) of premiums, deductibles, coinsurance and other cost sharing imposed. The cost-sharing requirements provide protection for lower income children, ban cost sharing for preventive services, address the limitations on premiums and cost-sharing and address the treatment of pre- existing medical conditions. (Section 2103(e)); (42 CFR 457, Subpart E) 9. Strategic Objectives and Performance Goals and Plan Administration- The section addresses the strategic objectives, the performance goals, and the performance measures the State has established for providing child health assistance to targeted low income children under the plan for maximizing health benefits coverage for other low income children and children generally in the state. (Section 2107); (42 CFR 457.710) 10. Annual Reports and Evaluations- Section 2108(a) requires the State to assess the operation of the Children’s Health Insurance Program plan and submit to the Secretary an annual report which includes the progress made in reducing the number of uninsured low income children. The report is due by January 1, following the end of the Federal fiscal year and should cover that Federal Fiscal Year. In this section, states are asked to assure that they will comply with these requirements, indicated by checking the box. (Section 2108); (42 CFR 457.750) 11. Program Integrity- In this section, the State assures that services are provided in an effective and efficient manner through free and open competition or through basing rates on other public and private rates that are actuarially sound. (Sections 2101(a) and 2107(e); (42 CFR 457, subpart I) 12. Applicant and Enrollee Protections- This section addresses the review process for eligibility and enrollment matters, health services matters (i.e., grievances), and for states that use premium assistance a description of how it will assure that applicants and enrollees are given the opportunity at initial enrollment and at each redetermination of eligibility to obtain health benefits coverage other than through that group health plan. (Section 2101(a)); (42 CFR 457.1120) Program Options. As mentioned above, the law allows States to expand coverage for children through a separate child health insurance program, through a Medicaid expansion program, or through a combination of these programs. These options are described further below: • Option to Create a Separate Program- States may elect to establish a separate child health program that are in compliance with title XXI and applicable rules. These states must establish enrollment systems that are coordinated with Medicaid and other sources of health coverage for children and also must screen children during the application process to determine if they are eligible for Medicaid and, if they are, enroll these children promptly in Medicaid. • Option to Expand Medicaid- States may elect to expand coverage through Medicaid. This option for states would be available for children who do not qualify for Medicaid under State rules in effect as of March 31, 1997. Under this option, current Medicaid rules would apply.

6 Effective Date: October 2, 2017

Approval Date:

Medicaid Expansion- CHIP SPA Requirements In order to expedite the SPA process, states choosing to expand coverage only through an expansion of Medicaid eligibility would be required to complete sections: • 1 (General Description) • 2 (General Background) They will also be required to complete the appropriate program sections, including: • 4 (Eligibility Standards and Methodology) • 5 (Outreach) • 9 (Strategic Objectives and Performance Goals and Plan Administration including the budget) • 10 (Annual Reports and Evaluations). Medicaid Expansion- Medicaid SPA Requirements States expanding through Medicaid-only will also be required to submit a Medicaid State plan amendment to modify their Title XIX State plans. These states may complete the first check-off and indicate that the description of the requirements for these sections are incorporated by reference through their State Medicaid plans for sections: • 3 (Methods of Delivery and Utilization Controls) • 4 (Eligibility Standards and Methodology) • 6 (Coverage Requirements for Children’s Health Insurance) • 7 (Quality and Appropriateness of Care) • 8 (Cost Sharing and Payment) • 11 (Program Integrity) • 12 (Applicant and Enrollee Protections) • Combination of Options- CHIP allows states to elect to use a combination of the Medicaid program and a separate child health program to increase health coverage for children. For example, a State may cover optional targeted-low income children in families with incomes of up to 133 percent of poverty through Medicaid and a targeted group of children above that level through a separate child health program. For the children the State chooses to cover under an expansion of Medicaid, the description provided under “Option to Expand Medicaid” would apply. Similarly, for children the State chooses to cover under a separate program, the provisions outlined above in “Option to Create a Separate Program” would apply. States wishing to use a combination of approaches will be required to complete the Title XXI State plan and the necessary State plan amendment under Title XIX. Where the state’s assurance is requested in this document for compliance with a particular requirement of 42 CFR 457 et seq., the state shall place a check mark to affirm that it will be in compliance no later than the applicable compliance date.

Proposed State plan amendments should be submitted electronically and one signed hard copy to the Centers for Medicare & Medicaid Services at the following address: Name of Project Officer Centers for Medicare & Medicaid Services 7500 Security Blvd Baltimore, Maryland 21244 Attn: Children and Adults Health Programs Group Center for Medicaid and CHIP Services Mail Stop - S2-01-16

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TABLE OF CONTENTS Section 1. General Description and Purpose of the State Child Health Plans and State Child Health Plan Requirements (Section 2101). 1.1 The State will use funds provided under Title XXI primarily for (42 CFR 457.70)...1 1 1.2 ……………………………………………………………………………………………….11 1.3 ………………………………………………………………………………………………..11 1.4 …………………………………………………………………………………………..11 Section 2. General Background and Description of State Approach to Child Health Coverage and Coordination (Section 2102 (a)(1)-(3)) and (Section 2105)(c)(7)(A)-)).....17 2.1. ..................................................................................................................................17 2.2. ..................................................................................................................................18 2.3. ..................................................................................................................................20 Section 3. Methods of Delivery and Utilization Controls (Section 2102)(a)(4))….......21 3.1. ..................................................................................................................................21 3.2. ..................................................................................................................................30 3.3 ……………………………………………………………………………………………….31 3.4. ……………………………………………………………………………………………….33 3.5. ……………………………………………………………………………………………….38 3.6. ……………………………………………………………………………………………….45 3.7. ……………………………………………………………………………………………….52 3.8. ……………………………………………………………………………………………….55 3.9. ……………………………………………………………………………………………….56 3.10. ……………………………………………………………………………………………….63 3.11. ……………………………………………………………………………………………….69 3.12. ……………………………………………………………………………………………….70 Section 4. Eligibility Standards and Methodology (Section 2102(b))..……………………..84 4.1. ...................................................................................................................................84 4.2. ...................................................................................................................................89 4.3. ...................................................................................................................................90 4.4. ...................................................................................................................................95 Section 5. Outreach (Section 2102(c)…………………………………………………………97

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Section 6. Coverage Requirements for Children’s Health Insurance (Section 2103)…100 6.1. ...............................................................................................................................100 6.2. ...............................................................................................................................107 6.3 ................................................................................................................................125 6.4. ...............................................................................................................................125 Section 7. Quality and Appropriateness of Care……………………………………………132 7.1. ...............................................................................................................................133 7.2. ...............................................................................................................................136 Section 8. Cost Sharing and Payment (Section 2103(e)).………………………………..140 8.1. ................................................................................................................................140 8.2. ................................................................................................................................141 8.3. ................................................................................................................................142 8.4. ................................................................................................................................143 8.5. ................................................................................................................................146 8.6. ................................................................................................................................146 8.7. ................................................................................................................................146 8.8. ................................................................................................................................148 Section 9. Strategic Objectives, Performance Goals and Plan Administration (Section 2107) 9.1. ................................................................................................................................149 9.2. ................................................................................................................................149 9.3. ................................................................................................................................150 9.4. .................................................................................................................................152 9.5. ................................................................................................................................152 9.6. ................................................................................................................................152 9.7. ................................................................................................................................152 9.8. ................................................................................................................................153 9.9. ................................................................................................................................153 9.10. ..............................................................................................................................156 Section 10. Annual Reports and Evaluations (Section 2108)……………………………...158 10.1. Annual Reports………………………………………………………………………..158 10.2. ............................................................................................................................158

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10.3. ............................................................................................................................158 Section 11. Program Integrity (Section 2101(a))……………………………………………..159 11.1. .............................................................................................................................159 11.2. .............................................................................................................................159 Section 12. Applicant and Enrollee Protections (Sections 2101(a))………………………..160 12.1. Eligibility and Enrollment Matters………………………………………………….160 12.2. Health Services Matters……………………………………………………………160 12.3. Premium Assistance Programs……………………………………………………161

Key and Glossary....………………………………………………………………………………..164 Appendix 1: Superseding SPA templates: WA-14-0001 (CS7, CS15, CS9)……………………………………………………………..166 WA-14-0002 (CS14)………………………………………………………………………….173 WA-14-0004 (CS24)………………………………………………………………………….175 WA-14-0003 (CS17, CS18, CS19, CS20)…………………………………………………..181 WA-14-0005 (CS21, CS27)…………………………………………………………………189 Appendix 2: Hospital Presumptive Eligibility SPA WA-15-0001 (CS28, CS30) ............................................................................................................. 193

Appendix 3: Children of Public Employees (CS10) ……………………………………………. 196

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Section 1. General Description and Purpose of the Children’s Health Insurance Plans and the Requirements 1.1 The state will use funds provided under Title XXI primarily for (Check appropriate box) (Section 2101)(a)(1)); (42 CFR 457.70): Guidance: Check below if child health assistance shall be provided primarily through the development of a separate program that meets the requirements of Section 2101, which details coverage requirements and the other applicable requirements of Title XXI.

1.1.1. Obtaining coverage that meets the requirements for a separate child health program (Sections 2101(a)(1) and 2103); OR

Guidance: Check below if child health assistance shall be provided primarily through providing expanded eligibility under the State’s Medicaid program (Title XIX). Note that if this is selected the State must also submit a corresponding Medicaid SPA to CMS for review and approval.

1.1.2. Providing expanded benefits under the State’s Medicaid plan (Title XIX) (Section 2101(a)(2)); OR

Guidance: Check below if child health assistance shall be provided through a combination of both 1.1.1. and 1.1.2. (Coverage that meets the requirements of Title XXI, in conjunction with an expansion in the State’s Medicaid program). Note that if this is selected the state must also submit a corresponding Medicaid state plan amendment to CMS for review and approval. 1.1.3. A combination of both of the above. (Section 2101(a)(2))

Washington’s CHIP offers comprehensive healthcare coverage to children through age 18, who reside in households with incomes up to 312% of the federal poverty level (FPL). Healthcare coverage for children in households with incomes up to 250% of FPL is a state mandated entitlement. Coverage for children in households with incomes above 250% of FPL is offered within available state funds appropriated by Washington’s legislature. Families are required to pay a modest premium for coverage. CHIP benefits are the same as the state’s Medicaid program for children. The program uses the state’s Medicaid managed care delivery system and employs Medicaid income eligibility criteria.

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1.1-DS

The State will provide dental-only supplemental coverage. Only States operating a separate CHIP program are eligible for this option. States choosing this option must also complete sections 4.1-DS, 4.2-DS, 6.2-DS, 8.2-DS, and 9.10 of this SPA template. (Section 2110(b)(5))

1.2.

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

1.3.

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

Guidance: The effective date as specified below is defined as the date on which the State begins to incur costs to implement its State plan or amendment. (42 CFR 457.65) The implementation date is defined as the date the State begins to provide services; or, the date on which the State puts into practice the new policy described in the State plan or amendment. For example, in a State that has increased eligibility, this is the date on which the State begins to provide coverage to enrollees (and not the date the State begins outreach or accepting applications).

1.4. Provide the effective (date costs begin to be incurred) and implementation (date services begin to be provided) dates for this SPA (42 CFR 457.65). A SPA may only have one effective date, but provisions within the SPA may have different implementation dates that must be after the effective date.

Original Plan Effective Date: January 1, 2000 Implementation Date: January 1, 2000

Amendment 1 - This amendment allowed the assignment of eligible children into

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managed care plans and created eligibility requirements similar to the Washington State Medicaid program. Submitted: February 8, 2001 Approved: May 7, 2001 Effective date: January 1, 2001

Amendment 2 - This amendment removed the co-pay requirement. Submitted: April 3, 2002 Approved: July 1, 2002 Effective date: January 1, 2002

Amendment 3 - This amendment updated the plan to specify the States compliance with the final CHIP regulation. Submitted: October 3, 2002 Approved: December 19, 2002 Effective date: July 1, 2002

Amendment 4 - This amendment allows CHIP coverage for unborn children of women up to 185% of the Federal poverty level who are not eligible for Medicaid. Submitted: June 25, 2003 Approved: September 22, 2003 Effective date: November 12, 2002

Amendment 5 - This amendment changed the eligibility review period from 12 months of continuous coverage to 6 months of non-continuous coverage. Submitted: January 22, 2004 Approved: June 1, 2004 Effective date: December 31, 2003

Amendment 6 - This amendment increased the premium amount from $10/mo. per

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child; $30/mo. maximum per family to $15/mo. per child; $45/mo. maximum per family. The time allowed for non-payment of premiums was decreased from 4-months to 3- months; the waiting period after disenrollment for non-payment was decreased from 4- months to 3-months. Submitted: August 16, 2004 Approved: November 5, 2004 Effective date: July 1, 2004

Amendment 7 - This amendment restored the certification period back to 12 months continuous coverage; it also updated the State plan to reflect the name and organizational changes that occurred within the agency that administers CHIP. Submitted: May 2, 2006 Approved: August 1, 2006 Effective date: July 1, 2005

Amendment 8 - This amendment proposed a change in rates and payment methods and a requirement for a SSN for children. Submitted: November 27, 2006 Withdrawn: December 27, 2006

Amendment 9 - This amendment proposed funding for additional outreach activities. Submitted: January 23, 2007 Withdrawn: February 3, 2008

Amendment 10 - This amendment increased funding from CHIP for additional outreach activities as a part of the passage of Cover All Kids legislation. Submitted: April 3, 2008 Approved: December 17, 2008 Effective date: July 1, 2007

Amendment 11 - This amendment proposes increasing the income limit to 300% FPL and creating a two-tiered premium structure for CHIP. The premium amount will also

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be increased. Good cause for dropping employer sponsored insurance is also amended from a cost of $50 to a cost of 2.5% household income. Submitted: April 14, 2008 Approved: April 3, 2009 Effective date: January 1, 2009

Amendment 12 - This amendment expanded the delivery of mental health services. Submitted: May 14, 2008 Approved: January 16, 2009 Effective date: July 1, 2008

Amendment 13 – This amendment is to provide federal funding for the Washington Poison Center (WAPC) under a health services initiative; expand CHIP coverage to lawfully residing alien children under age 19; require verification of citizenship; describe the CHIP dental coverage package; reference FQHC/RHC reimbursement methodology; and eliminate the 3 month sanction for failing to pay required premiums.

Submitted date: June 29, 2010 Approved date: December 9, 2010 Effective date: July 1, 2009 for WAPC funding and lawfully residing alien children. October 1, 2009 for dental coverage and FQHC/RHC descriptions. January 1, 2010 for citizenship verification requirement. April 1, 2010 for elimination of 3 month sanction penalty.

Amendment 14-0001, 14-0002, 14-0003, 14-0004: See Appendix 1 & Table below

Amendment 15-001: Hospital Presumptive Eligibility: See Appendix 2 & Table below

Amendment 16-0001: This amendment is to comply with federal regulation in the implementation of the Affordable Care Act (ACA) including conversion of the current

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CHIP effective income limit to a MAGI equivalent and technical corrections to reflect approved CHIP SPA templates referenced in the table below. Submitted date: April 18, 2016 Approved date: June 1, 2016 Effective date: July 1, 2015.

Amendment 18-0001: This amendment documents compliance of Washington’s child health plan with the Mental Health Parity and Addiction Equity Act (MHPAEA) Submitted date: June 28, 2019 Approved date: Approval Pending Effective date: October 2, 2017

Amendment 19-0001: Record compliance with Managed Care final rule provisions within the CHIP state plan. Submitted date: June 4, 2019 Approved date: June 18, 2019 Effective date: July 1, 2018

Amendment 20-0001: CHIP Disaster Relief State Plan Amendment To implement provisions for temporary adjustments to enrollment and redetermination policies, cost sharing, premium requirements for children in families, changes in circumstances, reasonable opportunity period, waiting periods, and dental services during the Federal COVID-19 public health emergency. Submitted date: April 29, 2020 Approved date: July 15, 2020 Effective date: March 1, 2020 Implementation Dates: • March 18, 2020 for all flexibilities except waiving premiums • May 1, 2020, for waiving premiums Amendment 20-0002: CHIP Public Employees State Plan Amendment To expand CHIP coverage to include eligible children of public employees as allowed

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under Section 10203(b)(2)(D) of the Affordable Care Act. Public employees are enrolled in Public Employees Benefits (PEB) and School Employees Benefits (SEB). See Appendix 3 Submitted date: June 24, 2020 Approved Date: August 28, 2020 Effective Date: January 1, 2020

1.4- TC Tribal Consultation (Section 2107(e)(1)(C)) Describe the consultation process that occurred specifically for the development and submission of this State Plan Amendment, when it occurred and who was involved. Washington’s tribes were notified via email, with hard copy letters to the Tribal Chairpersons, on April 20, 2020. Washington has a standard tribal mailing list of email and physical mailing addresses.

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Section 2. General Background and Description of Approach to Children’s Health Insurance Coverage and Coordination

Guidance: The demographic information requested in 2.1. can be used for State planning and will be used strictly for informational purposes. THESE NUMBERS WILL NOT BE USED AS A BASIS FOR THE ALLOTMENT. Factors that the State may consider in the provision of this information are age breakouts, income brackets, definitions of insurability, and geographic location, as well as race and ethnicity. The State should describe its information sources and the assumptions it uses for the development of Superseding Pages of MAGI CHIP State Plan Material State: Washington Transmittal Number SPA Group PDF # Description Superseded Plan Section(s) WA-14-0001 Effective/ Implementation Date: January 1, 2014 MAGI Eligibility & Methods CS7 CS9 CS15 Eligibility – Targeted Low Income Children Eligibility – Coverage from Conception to Birth MAGI-Based Income Methodologies Supersedes the current sections Geographic Area 4.1.1; Age 4.1.2; and Income 4.1.3 Supersedes the current section Age 4.1.2.1 Incorporate within a separate subsection WA-14-0002 Effective/ Implementation Date: January 1, Establish 2101(f) Group CS14 Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards Incorporate within a separate subsection under section 4.1 WA-14-0004 Effective/ Implementation Date: October 1, Eligibility Processing CS24 Eligibility Process Supersedes the current sections 4.3 and 4.4 WA-14-0003 Effective/ Implementation Date: January 1, 2014 Non- Financial Eligibility CS17 CS18 CS19 CS20 CS21 CS27 Non-Financial Eligibility – Residency Non- Financial – Citizenship Non-Financial – Social Security Number Substitution of Coverage Non-Payment of Premiums Continuous Eligibility Supersedes the current section 4.1.5 Supersedes the current sections 4.1.9.1 Supersedes the current section 4.1.9.2 Supersedes the current section 4.4.4 Supersedes the current section 8.7.1 Supersedes the current section 4.1.8 WA-15 - 0001 CS28 Hospital presumptive eligibility See Appendix 2

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its description. • Population • Number of uninsured • Race demographics • Age Demographics • Info per region/Geographic information

2.1. Describe the extent to which, and manner in which, children in the State (including targeted low-income children and other groups of children specified) identified , by income level and other relevant factors, such as race, ethnicity and geographic location, currently have creditable health coverage (as defined in 42 CFR 457.10). To the extent feasible, distinguish between creditable coverage under public health insurance programs and public-private partnerships (See Section 10 for annual report requirements). (Section 2102(a)(1)); (42 CFR 457.80(a)) Based on the 2008 Washington State Population Survey (WSPS), 95.4% of all children in Washington had health care coverage in April/May 2008. This represents a 2.4% increase in healthcare coverage since the year 2000. 95.3% of children between 200% and 300% of the federal poverty level (FPL) had healthcare coverage. Approximately 13,000 children in this income range remained without healthcare coverage and are the target population for outreach under Washington’s CHIP. 92.7% of children under 200% FPL had coverage at the time of the 2008 WSPS. Approximately 48,000 children in this income range were without healthcare coverage and are included in the target population for outreach as described in 42 CFR 457.90. 97.7% of children above 300% FPL had coverage at the time of the 2008 WSPS. Consistent with national trends, employer- based coverage was the principal source of coverage for higher income children. The rate of employer- sponsored coverage of children above 300% FPL was 85.1%, whereas the rate of employer- sponsored coverage of children below 200% FPL was only 18.8%.

Guidance: Section 2.2 allows states to request to use the funds available under the 10 percent limit on administrative expenditures in order to fund services not otherwise allowable. The health services

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initiatives must meet the requirements of 42 CFR 457.10.

2.2. Health Services Initiatives- Describe if the State will use the health services initiative option as allowed at 42 CFR 457.10. If so, describe what services or programs the State is proposing to cover with administrative funds, including the cost of each program, and how it is currently funded (if applicable), also update the budget accordingly. (Section 2105(a)(1)(D)(ii)); (42 CFR 457.10) HCA funds poison treatment advice and prevention for children in Washington State under a health services initiative option as described in 42 CFR 457.10 through a contract with the Washington Poison Center (WAPC). The WAPC provides emergency telephone treatment advice, referral assistance, and information to manage exposure to poisonous and hazardous substances. The WAPC answers poisoning emergency calls from the general public 24 hours a day, 365 days each year at no charge. At all times, a Specialist in Poison Information (SPI) is available to manage cases and Certified Specialists in Poison Information (CSPI) are available to manage cases and direct Poison Information Providers. The service is provided via a toll-free phone number to all communities throughout Washington, including under- served, low-income, and indigent populations. Interpreters are available in over 150 languages and via telecommunications devices for the deaf and hearing impaired TTY). WAPC public education programs direct attention and resources to at-risk populations living in poverty, including minority and immigrant communities. Consumer-based educational materials have been developed that are culturally relevant, taking into consideration health literacy levels and clearly illustrating and describing WAPC services. In addition to English, materials are available in Spanish, Korean, Vietnamese, Laotian, Chinese, Russian, and Somali. The WAPC promotes poison awareness through community forums. WAPC’s mascot “Mr. Yuk” is a familiar face at presentations in schools, community health fairs, and other local events and gatherings. The WAPC works closely with other community health programs such as Washington State’s Safe Kids Program and Safe Kids Coalition groups. The WAPC advertises their public toll-free number and toll-free TTY number in the

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white pages and consumer guides of all Washington state telephone directories, as well as on billboards across the state. Advertisements and billboards are in Spanish and English. The WAPC receives approximately 66,000 calls annually involving a poison or hazardous substance exposure. 63% of all calls received are regarding exposure of child under the age of 19. Over 35% of the total calls relate to exposure of a child in a family whose annual household income is no more than 300% FPL.1 WAPC intervention resulted in over 94% these exposures calls being handled in the home so that the child did not have to use an Emergency Department or need a 911 call and response. Each call to the WAPC significantly reduces costs in other medical spending. Cost savings in 1996 dollars were estimated at $175 per call.2 The current annual contract is approximately $1.8 million dollars and is based on the WAPC’s annual operating budget multiplied by the percentage of phone calls received on behalf of children. The expenditure is within the 10% administrative cap for the CHIP program.

1 The percentage of calls attributed to children in families with incomes no greater than 300% FPL is based on WAPC records for 2009. 66,083 total exposure calls were answered statewide. 41,827 exposure calls were for children ages 0 – 18. 2008 Washington State Population Survey (http://wa-state-ofm.us/SPSOnline/) estimates 55.5% of Washington children are living in households with incomes no more than 300%FPL. This represents 23,214 calls, or 35.1% of the total volume of calls.

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2.3-TC Tribal Consultation Requirements- (Sections 1902(a)(73) and 2107(e)(1)(C)); (ARRA #2, CHIPRA #3, issued May 28, 2009) Section 1902(a)(73) of the Social Security Act (the Act) requires a State in which one or more Indian Health Programs or Urban Indian Organizations furnish health care services to establish a process for the State Medicaid agency to seek advice on a regular, ongoing basis from designees of Indian health programs, whether operated by the Indian Health Service (IHS), Tribes or Tribal organizations under the Indian Self-Determination and Education Assistance Act (ISDEAA), or Urban Indian Organizations under the Indian Health Care Improvement Act (IHCIA). Section 2107(e)(1)(C) of the Act was also amended to apply these requirements to the Children’s Health Insurance Program (CHIP). Consultation is required concerning Medicaid and CHIP matters having a direct impact on Indian health programs and Urban Indian organizations.

Describe the process the State uses to seek advice on a regular, ongoing basis from federally-recognized tribes, Indian Health Programs and Urban Indian Organizations on matters related to Medicaid and CHIP programs and for consultation on State Plan Amendments, waiver proposals, waiver extensions, waiver amendments, waiver renewals and proposals for demonstration projects prior to submission to CMS. Include information about the frequency, inclusiveness and process for seeking such advice.

The Health Care Authority (HCA) has an extensive tribal consultation and communication policy that promotes a collaborative process between HCA, federally recognized Tribal governments, the Indian Health Service, Urban Indian Health Programs (UIHP), and the American Indian Health Commission for Washington State (AIHC). This process is set forth in Wa sh ing to n ’s Med icaid S ta te Plan se ction 1 .4 with additional information available on the Tribal Affairs home page at https://www.hca.wa.gov/about-hca/tribal- affairs.

Section 3. Methods of Delivery and Utilization Controls

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Check here if the State elects to use funds provided under Title XXI only to provide expanded eligibility under the State’s Medicaid plan, and continue on to Section 4 (Eligibility Standards and Methodology).

Guidance: In Section 3.1, describe all delivery methods the State will use to provide services to enrollees, including: (1) contracts with managed care organizations (MCO), prepaid inpatient health plans (PIHP), prepaid ambulatory health plans (PAHP), primary care case management entities (PCCM entities), and primary care case managers (PCCM); (2) contracts with indemnity health insurance plans; (3) fee-for-service (FFS) paid by the State to health care providers; and (4) any other arrangements for health care delivery. The State should describe any variations based upon geography and by population (including the conception to birth population). States must submit the managed care contract(s) to CMS’ Regional Office for review.

3.1. Delivery Systems (Section 2102(a)(4)) (42 CFR 457.490; Part 457, Subpart L)

Washington’s CHIP program reimburses Federally Qualified Health Centers (FQHC) and Rural Health Clinics (RHC) using the same alternative payment methodology (APM) as the State’s Medicaid program. There is no difference between the CHIP rates and the Medicaid rates for reimbursing FQHCs and RHCs.

FQHCs/RHCs have a choice of reimbursement under the Prospective Payment System (PPS) as outlined in the Benefits Improvement and Protection Act of 2000 (BIPA) statutory language, or an Alternative Payment Methodology (APM).

Prospective Payment System

The facility-specific encounter rates were established in 2002, and they are considered the providers’ base encounter rates. The base rates were calculated using cost report data from 1999 and 2000, and in some cases, 2001. The corresponding enhancement rates were also established at that this time. Pursuant to the requirements of the PPS, both FFS encounter rates and managed care enhancement rates for each provider have been increased annually by the percentage change in the MEI.

Alternative Payment Methodology

The APM encounter rates were established by starting with each provider’s base PPS

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rate, and trending forward to 2009 using the APM index. The APM index is a Washington specific health care index developed by IHS Global Insight. Rates established under the APM will be inflated each year by the Washington State specific health care index. Annual reconciliation is a part of the APM. Rates determined under the APM will be periodically rebased.

Supplemental Payments for Managed Care Clients

For clients enrolled with a managed care contractor, the Agency will pay the FQHC/RHC a supplemental payment (called enhancement) in addition to the amount paid by the managed care contractor. These enhancements will pay monthly on a per-member-per- month basis. To ensure that the appropriate amounts are being paid to each FQHC/RHC, the Agency will perform an annual reconciliation and verify that the enhancement payments made in the previous year were in compliance with Section 1902(bb)(5)(A) of the Social Security Act.

An additional description of this methodology can be found on page 3 (RHC) and page 33(FQHC) of Attachment 4.19-B of the Title XIX state plan, as approved by CMS on June 26th, 2009.

3.1.1 Choice of Delivery System 3.1.1.1 Does the State use a managed care delivery system for its CHIP populations? Managed care entities include MCOs, PIHPs, PAHPs, PCCM entities and PCCMs as defined in 42 CFR 457.10. Please check the box and answer the questions below that apply to your State. No, the State does not use a managed care delivery system for any CHIP populations. Yes, the State uses a managed care delivery system for all CHIP populations.

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Yes, the State uses a managed care delivery system; however, only some of the CHIP population is included in the managed care delivery system and some of the CHIP population is included in a fee-for-service system. If the State uses a managed care delivery system for only some of its CHIP populations and a fee-for- service system for some of its CHIP populations, please describe which populations are, and which are not, included in the State’s managed care delivery system for CHIP. States will be asked to specify which managed care entities are used by the State in its managed care delivery system below in Section 3.1.2. Children birth through eighteen are enrolled in the managed care delivery system. Children who are AI/AN may opt into managed care, PCCM, or remain fee for service. Unborn children are only covered under the fee-for-service network at this time. Guidance: Utilization control systems are those administrative mechanisms that are designed to ensure that enrollees receiving health care services under the State plan receive only appropriate and medically necessary health care consistent with the benefit package. Examples of utilization control systems include, but are not limited to: requirements for referrals to specialty care; requirements that clinicians use clinical practice guidelines; or demand management systems (e.g., use of an 800 number for after-hours and urgent care). In addition, the State should describe its plans for review, coordination, and implementation of utilization controls, addressing both procedures and State developed standards for review, in order to assure that necessary care is delivered in a cost-effective and efficient manner. (42 CFR 457.490(b)) If the State does not use a managed care delivery system for any or some of its CHIP populations, describe the methods of delivery of the child health assistance using Title XXI funds to targeted low-income children. Include a description of:

• The methods for assuring delivery of the insurance products and delivery of health care services covered by such products to the enrollees, including any variations. (Section 2102(a)(4); 42 CFR 457.490(a)) • The utilization control systems designed to ensure that enrollees receiving health care services under the State plan receive only appropriate and medically necessary health care consistent with the benefit package described in the approved State plan. (Section 2102(a)(4); 42 CFR 457.490(b))

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Washington provides comprehensive healthcare coverage for the unborn population through our fee-for-service network for medical services. Behavioral health services, including substance use disorder treatment is provided through managed care organizations under a behavioral health services only (BHSO) contract; or through regionally based Behavioral Health Organizations (BHOs). BHOs will be phased out by Jan. 1, 2020.

Guidance: Only States that use a managed care delivery system for all or some CHIP populations need to answer the remaining questions under Section 3 (starting with 3.1.1.2). If the State uses a managed care delivery system for only some of its CHIP population, the State’s responses to the following questions will only apply to those populations. 3.1.1.2 Do any of your CHIP populations that receive services through a managed care delivery system receive any services outside of a managed care delivery system? No Yes If yes, please describe which services are carved out of your managed care delivery system and how the State provides these services to an enrollee, such as through fee- for-service. Examples of carved out services may include transportation and dental, among others. The following Covered Services are provided by the state and are NOT included in the MC delivery system:  School-based Health Care Services for Children in Special Education with an Individualized Education Plan or Individualized Family Service Plan who have a disability, developmental delay or are diagnosed with a physical or mental condition;  Eyeglass frames, lenses, and fabrication services covered under HCA’s selective contract for these services for children under age twenty-one (21), and associated fitting and dispensing services. The Contractor is encouraged to inform eye practitioners of the availability of Airway Heights

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Correctional Center to access glasses for adult clients age twenty-one (21) and over if not offered by the Contractor as a value added benefit;  Voluntary Termination of Pregnancy;  Court-ordered transportation services, including ambulance services;  Transportation Services other than ambulance, including but not limited to: taxi, cabulance, voluntary transportation, public transportation, and common carriers;  Ambulance services, including air and ground ambulance transportation services with dates of service after December 31, 2017;  Services provided by dentists and oral surgeons for dental diagnoses; anesthesia for dental care; prescriptions written by a dentist or oral surgeon for a dental diagnosis.  Orthodontics;  Maternity Support Services (MSS), consistent with the Marketing and Information, Subcontracts, and Care Coordination provisions of this Contract;  Sterilizations for Enrollees under age twenty-one (21), or those that do not meet other federal requirements (42 C.F.R. § 441 Subpart F);  Services provided by a health department when a Enrollee self-refers for care if the health department is not contracted with the Contractor;  HIV Case Management;  Prenatal Genetic Counseling;  Hemophiliac Products – Blood factors VII, VIII, and IX, anti-inhibitor, and all FDA approved products labeled with an indication for use in treatment of hemophilia and von Willebrand disease when distributed for administration in the Enrollee’s home or other outpatient setting;  Immune modulators and anti-viral medications to treat Hepatitis C. This exclusion does not apply to any other contracted service related to the diagnosis or treatment of Hepatitis C;  The following drugs • axicabtagene ciloleucel, as marketed under the brand name

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Yescarta®; • burosumab-twza, as marketed under the brand name Crysvita®; • cerliponase alfa, as marketed under the brand name BrineuraTM; • edaravone, as marketed under the brand name RadicavaTM; • eteplirsen, as marketed under the brand name Exondys 51TM; • nusinersen, as marketed under the brand name Spinraza®; • pegvaliase-pqpz, as marketed under the brand name Palynziq TM; • tisagenlecleucel-t, as marketed under the brand name KymriahTM; and • voretigene neparvovec-rzyl, as marketed under the brand name LuxturnaTM.  Sexual reassignment surgery as described in WAC 182-531-1675(6)(d) and (e) as well as hospitalizations, physician, and Ancillary Services required to treat postoperative complications of these procedures; and  Chemical-Using Pregnant (CUP) Women program as described in WAC 182-533-0730 when provided by an HCA-approved CUP provider.  Inpatient psychiatric services, including psychiatric consultations when the inpatient admission is approved by a BHO;  Substance use treatment services covered through the HCA, Division of Behavioral Health and Recovery. Drugs prescribed as Medication Assisted Treatment or maintenance therapy for substance use disorders are a separate course of treatment, not ancillary to other treatment services and are a contracted service under the Pharmaceutical Products provisions of this Contract; The following services are covered by other state agencies and are not Contracted Services. The Contractor is responsible for coordinating and referring Enrollees to these services through all means possible, e.g., Adverse Benefit Determination notifications, call center communication or Contractor publications.  Long-term private duty nursing for Enrollees ages 18 and over. These services are covered by DSHS, Aging and Long-Term Support Administration (ALTSA);

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 Community-based services (e.g., COPES, CFC and Personal Care Services) covered through the ALTSA;  Nursing facility stays that do not meet rehabilitative or skilled criteria are covered through the ALTSA;  Mental health services separately purchased for all Medicaid clients by the HCA;  Health care services covered through the DSHS, Developmental Disabilities Administration (DDA) for institutionalized clients;  Infant formula for oral feeding provided by the Women, Infants and Children (WIC) program in the Department of Health; and  Any service provided to an Enrollee while incarcerated with the Washington State Department of Corrections (DOC).

3.1.2 Use of a Managed Care Delivery System for All or Some of the State’s CHIP Populations 3.1.2.1 Check each of the types of entities below that the State will contract with under its managed care delivery system, and select and/or explain the method(s) of payment that the State will use:

Managed care organization (MCO) (42 CFR 457.10)

Capitation payment

Describe population served: Children birth through eighteen who do not have third party liability coverage.

Prepaid inpatient health plan (PIHP) (42 CFR 457.10)

Capitation payment

Other (please explain)

Describe population served: All CHIP enrollees. Guidance: If the State uses prepaid ambulatory health plan(s) (PAHP) to exclusively provide non-emergency medical transportation (a NEMT PAHP), the State should not check the following box for that plan. Instead, complete section 3.1.3 for the NEMT PAHP.

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Prepaid ambulatory health plan (PAHP) (42 CFR 457.10) Capitation payment Other (please explain)

Describe population served:

Primary care case manager (PCCM) (individual practitioners) (42 CFR 457.10)

Case management fee

Other (please explain)

Primary care case management entity (PCCM Entity) (42 CFR 457.10)

Case management fee

Shared savings, incentive payments, and/or other financial rewards for improved quality outcomes (see 42 CFR 457.1240(f))

Other (please explain)

If PCCM entity is selected, please indicate which of the following function(s) the entity will provide (as described in 42 CFR 457.10), in addition to PCCM services: Provision of intensive telephonic case management Provision of face-to-face case management Operation of a nurse triage advice line Development of enrollee care plans Execution of contracts with fee-for-service (FFS) providers in the FFS program Oversight responsibilities for the activities of FFS providers in the FFS program Provision of payments to FFS providers on behalf of the State Provision of enrollee outreach and education activities

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Operation of a customer service call center Review of provider claims, utilization and/or practice patterns to conduct provider profiling and/or practice improvement Implementation of quality improvement activities including administering enrollee satisfaction surveys or collecting data necessary for performance measurement of providers Coordination with behavioral health systems/providers Other (please describe)

3.1.2.2

The State assures that if its contract with an MCO, PAHP, or PIHP allows the entity to use a physician incentive plan, the contract stipulates that the entity must comply with the requirements set forth in 42 CFR 422.208 and 422.210. (42 CFR 457.1201(h), cross- referencing to 42 CFR 438.3(i)) 3.1.3 Nonemergency Medical Transportation PAHPs Guidance: Only complete Section 3.1.3 if the State uses a PAHP to exclusively provide non- emergency medical transportation (a NEMT PAHP). If a NEMT PAHP is the only managed care entity for CHIP in the State, please continue to Section 4 after checking the assurance below. If the State uses a PAHP that does not exclusively provide NEMT and/or uses other managed care entities beyond a NEMT PAHP, the State will need to complete the remaining sections within Section 3.

The State assures that it complies with all requirements applicable to NEMT PAHPs, and through its contracts with such entities, requires NEMT PAHPs to comply with all applicable requirements, including the following (from 42 CFR 457.1206(b)):

• All contract provisions in 42 CFR 457.1201 except those set forth in 42 CFR 457.1201(h) (related to physician incentive plans) and 42 CFR 457.1201(l) (related to mental health parity). • The information requirements in 42 CFR 457.1207 (see Section 3.5

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below for more details). • The provision against provider discrimination in 42 CFR 457.1208. • The State responsibility provisions in 42 CFR 457.1212 (about disenrollment), 42 CFR 457.1214 (about conflict of interest safeguards), and 42 CFR 438.62(a), as cross-referenced in 42 CFR 457.1216 (about continued services to enrollees). • The provisions on enrollee rights and protections in 42 CFR 457.1220, 457.1222, 457.1224, and 457.1226. • The PAHP standards in 42 CFR 438.206(b)(1), as cross-referenced by 42 CFR 457.1230(a) (about availability of services), 42 CFR 457.1230(d) (about coverage and authorization of services), and 42 CFR 457.1233(a), (b) and (d) (about structure and operation standards). • An enrollee's right to a State review under subpart K of 42 CFR 457. • Prohibitions against affiliations with individuals debarred or excluded by Federal agencies in 42 CFR 438.610, as cross referenced by 42 CFR 457.1285. • Requirements relating to contracts involving Indians, Indian Health Care Providers, and Indian managed care entities in 42 CFR 457.1209.

3.2. General Managed Care Contract Provisions

3.2.1

The State assures that it provides for free and open competition, to the maximum extent practical, in the bidding of all procurement contracts for coverage or other services, including external quality review organizations, in accordance with the procurement requirements of 45 CFR part 75, as applicable. (42 CFR 457.940(b); 42 CFR 457.1250(a), cross referencing to 42 CFR 438.356(e)) 3.2.2

The State assures that it will include provisions in all managed care contracts that define a sound and complete procurement contract, as required by 45 CFR part 75, as applicable. (42 CFR 457.940(c))

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3.2.3

The State assures that each MCO, PIHP, PAHP, PCCM, and PCCM entity complies with any applicable Federal and State laws that pertain to enrollee rights, and ensures that its employees and contract providers observe and protect those rights (42 CFR 457.1220, cross-referencing to 42 CFR 438.100). These Federal and State laws include: Title VI of the Civil Rights Act of 1964 (45 CFR part 80), Age Discrimination Act of 1975 (45 CFR part 91), Rehabilitation Act of 1973, Title IX of the Education Amendments of 1972, Titles II and III of the Americans with Disabilities Act, and section 1557 of the Patient Protection and Affordable Care Act. 3.2.4

The State assures that it operates a Web site that provides the MCO, PIHP, PAHP, and PCCM entity contracts. (42 CFR 457.1207, cross-referencing to 42 CFR 438.10(c)(3)) MCO contracts are posted. PCCM contracts are currently under revision and are not posted at this time. 3.3 Rate Development Standards and Medical Loss Ratio 3.3.1 The State assures that its payment rates are: Based on public or private payment rates for comparable services for comparable populations; and Consistent with actuarially sound principles as defined in 42 CFR 457.10. (42 CFR 457.1203(a))

Guidance: States that checked both boxes under 3.3.1 above do not need to make the next assurance. If the state is unable to check both boxes under 3.1.1 above, the state must check the next assurance. If the State is unable to meet the requirements under 42 CFR 457.1203(a), the State attests that it must establish higher rates because such rates are necessary to ensure sufficient provider participation or provider access or to enroll providers who demonstrate exceptional efficiency or quality in the provision of services. (42 CFR 457.1203(b))

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3.3.2

The State assures that its rates are designed to reasonably achieve a medical loss ratio standard equal to at least 85 percent for the rate year and provide for reasonable administrative costs. (42 CFR 457.1203(c)) 3.3.3

The State assures that it will provide to CMS, if requested by CMS, a description of the manner in which rates were developed in accordance with the requirements of 42 CFR 457.1203(a) through (c). (42 CFR 457.1203(d)) 3.3.4

The State assures that it annually submits to CMS a summary description of the reports pertaining to the medical loss ratio received from the MCOs, PIHPs, and PAHPs. (42 CFR 457.1203(e), cross referencing to 42 CFR 438.74(a)) 3.3.5 Does the State require an MCO, PIHP, or PAHP to pay remittances through the contract for not meeting the minimum MLR required by the State? (42 CFR 457.1203(e), cross referencing to 42 CFR 438.74(b)(1)) No, the State does not require any MCO, PIHP, or PAHP to pay remittances. Yes, the State requires all MCOs, PIHPs, and PAHPs to pay remittances. Yes, the State requires some, but not all, MCOs, PIHPs, and PAHPs to pay remittances. If the State requests some, but not all, MCOs, PIHPs, and PAHPs to pay remittances through the contract for not meeting the minimum MLR required by the State, please describe which types of managed care entities are and are not required to pay remittances. For example, if a state requires a medical MCO to pay a remittances but not a dental PAHP, please include this information. The state requires all contracted medical MCOs to pay a remittance if they fail to meet the minimum MLR required by the state. NEMT PAHPs are not required to pay remittances. If the answer to the assurance above is yes for any or all managed care entities, please answer the next assurance:

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The State assures that it if a remittance is owed by an MCO, PIHP, or PAHP to the State, the State: • Reimburses CMS for an amount equal to the Federal share of the remittance, taking into account applicable differences in the Federal matching rate; and • Submits a separate report describing the methodology used to determine the State and Federal share of the remittance with the annual report provided to CMS that summarizes the reports received from the MCOs, PIHPs, and PAHPs. (42 CFR 457.1203(e), cross referencing to 42 CFR 438.74(b))

3.3.6

The State assures that each MCO, PIHP, and PAHP calculates and reports the medical loss ratio in accordance with 42 CFR 438.8. (42 CFR 457.1203(f)) 3.4 Enrollment

The State assures that its contracts with MCOs, PIHPs, PAHPs, PCCMs, and PCCM entities provide that the MCO, PIHP, PAHP, PCCM or PCCM entity: • Accepts individuals eligible for enrollment in the order in which they apply without restriction (unless authorized by CMS), up to the limits set under the contract (42 CFR 457.1201(d), cross-referencing to 42 CFR 438.3(d)(1)); • Will not, on the basis of health status or need for health care services, discriminate against individuals eligible to enroll (42 CFR 457.1201(d), cross- referencing to 42 CFR 438.3(d)(3)); and • Will not discriminate against individuals eligible to enroll on the basis of race, color, national origin, sex, sexual orientation, gender identity, or disability and will not use any policy or practice that has the effect of discriminating on the basis of race, color, national origin, sex, sexual orientation, gender identity or disability. (42 CFR 457.1201(d), cross-referencing to 438.3(d)(4)) 3.4.1 Enrollment Process

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3.4.1.1

The State assures that it provides informational notices to potential enrollees in an MCO, PIHP, PAHP, PCCM, or PCCM entity that includes the available managed care entities, explains how to select an entity, explains the implications of making or not making an active choice of an entity, explains the length of the enrollment period as well as the disenrollment policies, and complies with the information requirements in 42 CFR 457.1207 and accessibility standards established under 42 CFR 457.340. (42 CFR 457.1210(c)) 3.4.1.2

The State assures that its enrollment system gives beneficiaries already enrolled in an MCO, PIHP, PAHP, PCCM, or PCCM entity priority to continue that enrollment if the MCO, PIHP, PAHP, PCCM, or PCCM entity does not have the capacity to accept all those seeking enrollment under the program. (42 CFR 457.1210(b)) 3.4.1.3 Does the State use a default enrollment process to assign beneficiaries to an MCO, PIHP, PAHP, PCCM, or PCCM entity? (42 CFR 457.1210(a)) Yes No

NOTE: While Washington does have a default process for enrollment in an MCO, enrollees are also given the option of selecting a plan at the time they are approved for CHIP coverage. If the State uses a default enrollment process, please make the following assurances: The State assigns beneficiaries only to qualified MCOs, PIHPs, PAHPs, PCCMs, and PCCM entities that are not subject to the intermediate sanction of having suspension of all new enrollment (including default enrollment) under 42 CFR 438.702 and have capacity to enroll beneficiaries. (42 CFR 457.1210(a)(1)(i))

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The State maximizes continuation of existing provider- beneficiary relationships under 42 CFR 457.1210(a)(1)(ii) or if that is not possible, distributes the beneficiaries equitably and does not arbitrarily exclude any MCO, PIHP, PAHP, PCCM or PCCM entity from being considered. (42 CFR 457.1210(a)(1)(ii), 42 CFR 457.1210(a)(1)(iii))

3.4.2 Disenrollment 3.4.2.1

The State assures that the State will notify enrollees of their right to disenroll consistent with the requirements of 42 CFR 438.56 at least annually. (42 CFR 457.1207, cross-referencing to 42 CFR 438.10(f)(2)) 3.4.2.2

The State assures that the effective date of an approved disenrollment, regardless of the procedure followed to request the disenrollment, will be no later than the first day of the second month following the month in which the enrollee requests disenrollment or the MCO, PIHP, PAHP, PCCM or PCCM entity refers the request to the State. (42 CFR 457.1212, cross-referencing to 438.56(e)(1)) 3.4.2.3

If a beneficiary disenrolls from an MCO, PIHP, PAHP, PCCM, or PCCM entity, the State assures that the beneficiary is provided the option to enroll in another plan or receive benefits from an alternative delivery system. (Section 2103(f)(3) of the Social Security Act, incorporating section 1932(a)(4); 42 CFR 457.1212, cross referencing to 42 CFR 438.56; State Health Official Letter #09-008) 3.4.2.4 MCO, PIHP, PAHP, PCCM and PCCM Entity Requests for Disenrollment. The State assures that contracts with MCOs, PIHPs, PAHPs, PCCMs and PCCM entities describe the reasons for which an MCO, PIHP, PAHP, PCCM and PCCM entity may request

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disenrollment of an enrollee, if any. (42 CFR 457.1212, cross- referencing to 42 CFR 438.56(b)) Guidance: Reasons for disenrollment by the MCO, PIHP, PAHP, PCCM, and PCCM entity must be specified in the contract with the State. Reasons for disenrollment may not include an adverse change in the enrollee's health status, or because of the enrollee's utilization of medical services, diminished mental capacity, or uncooperative or disruptive behavior resulting from his or her special needs (except when his or her continued enrollment in the MCO, PIHP, PAHP, PCCM or PCCM entity seriously impairs the entity's ability to furnish services to either this particular enrollee or other enrollees). (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(b)(2)) 3.4.2.5 Enrollee Requests for Disenrollment. Guidance: The State may also choose to limit disenrollment from the MCO, PIHP, PAHP, PCCM, or PCCM entity, except for either: 1) for cause, at any time; or 2) without cause during the latter of the 90 days after the beneficiary’s initial enrollment or the State sends the beneficiary notice of that enrollment, at least once every 12 months, upon reenrollment if the temporary loss of CHIP eligibility caused the beneficiary to miss the annual disenrollment opportunity, or when the State imposes the intermediate sanction specified in 42 CFR 438.702(a)(4). (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(c)) Does the State limit disenrollment from an MCO, PIHP, PAHP, PCCM and PCCM entity by an enrollee? (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(c)) Yes No

If the State limits disenrollment by the enrollee from an MCO, PIHP, PAHP, PCCM and PCCM entity, please make the following assurances (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(c)): The State assures that enrollees and their representatives are given written notice of disenrollment rights at least 60 days before the start of each enrollment period. (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(f)(1))

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The State assures that beneficiary requests to disenroll for cause will be permitted at any time by the MCO, PIHP, PAHP, PCCM or PCCM entity. (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(c)(1) and (d)(2)) The State assures that beneficiary requests for disenrollment without cause will be permitted by the MCO, PIHP, PAHP, PCCM or PCCM entity at the following times: • During the 90 days following the date of the beneficiary's initial enrollment into the MCO, PIHP, PAHP, PCCM, or PCCM entity, or during the 90 days following the date the State sends the beneficiary notice of that enrollment, whichever is later; • At least once every 12 months thereafter; If the State plan provides for automatic reenrollment for an individual who loses CHIP eligibility for a period of 2 months or less and the temporary loss of CHIP eligibility has caused the beneficiary to miss the annual disenrollment opportunity; and • When the State imposes the intermediate sanction on the MCO, PIHP, PAHP, PCCM or PCCM entity specified in 42 CFR 438.702(a)(4). (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(c)(2)) 3.4.2.6

The State assures that the State ensures timely access to a State review for any enrollee dissatisfied with a State agency determination that there is not good cause for disenrollment. (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(f)(2)) 3.5 Information Requirements for Enrollees and Potential Enrollees 3.5.1

The State assures that it provides, or ensures its contracted MCOs, PAHPs, PIHPs, PCCMs and PCCM entities provide, all enrollment notices, informational materials, and instructional materials related to enrollees and potential enrollees in accordance with the terms of 42 CFR 457.1207, cross- referencing to 42 CFR 438.10.

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3.5.2

The State assures that all required information provided to enrollees and potential enrollees are in a manner and format that may be easily understood and is readily accessible by such enrollees and potential enrollees. (42 CFR 457.1207, cross-referencing to 42 CFR 438.10(c)(1)) 3.5.3

The State assures that it operates a Web site that provides the content specified in 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(g)-(i) either directly or by linking to individual MCO, PIHP, PAHP and PCCM entity Web sites. 3.5.4

The State assures that it has developed and requires each MCO, PIHP, PAHP and PCCM entity to use: • Definitions for the terms specified under 42 CFR 438.10(c)(4)(i), and Model enrollee handbooks, and model enrollee notices. (42 CFR 457.1207, cross-referencing to 42 CFR 438.10(c)(4)) 3.5.5

If the State, MCOs, PIHPs, PAHPs, PCCMs or PCCM entities provide the information required under 42 CFR 457.1207 electronically, check this box to confirm that the State assures that it meets the requirements under 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(c)(6) for providing the material in an accessible manner. Including that: • The format is readily accessible; • The information is placed in a location on the State, MCO's, PIHP's, PAHP's, or PCCM's, or PCCM entity's Web site that is prominent and readily accessible; • The information is provided in an electronic form which can be electronically retained and printed; • The information is consistent with the content and language requirements in 42 CFR 438.10; and • The enrollee is informed that the information is available in paper form without charge upon request and is provided the information upon request within 5 business days.

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3.5.6

The State assures that it meets the language and format requirements set forth in 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(d), including but not limited to: • Establishing a methodology that identifies the prevalent non-English languages spoken by enrollees and potential enrollees throughout the State, and in each MCO, PIHP, PAHP, or PCCM entity service area; • Making oral interpretation available in all languages and written translation available in each prevalent non-English language; • Requiring each MCO, PIHP, PAHP, and PCCM entity to make its written materials that are critical to obtaining services available in the prevalent non-English languages in its particular service area; • Making interpretation services available to each potential enrollee and requiring each MCO, PIHP, PAHP, and PCCM entity to make those services available free of charge to each enrollee; and • Notifying potential enrollees, and requiring each MCO, PIHP, PAHP, and PCCM entity to notify its enrollees: o That oral interpretation is available for any language and written translation is available in prevalent languages; o That auxiliary aids and services are available upon request and at no cost for enrollees with disabilities; and o How to access the services in 42 CFR 457.1207, cross-referencing 42 CFR 438.10(d)(5)(i) and (ii).

3.5.7

The State assures that the State or its contracted representative provides the information specified in 42 CFR 457.1207, cross-referencing to 438.10(e)(2), and includes the information either in paper or electronic format, to all potential enrollees at the time the potential enrollee becomes eligible to enroll in a voluntary managed care program or is first required to enroll in a mandatory managed care program and within a timeframe that enables the potential enrollee to use the information to choose among the available MCOs, PIHPs, PAHPs, PCCMs and PCCM entities:

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• Information about the potential enrollee's right to disenroll consistent with the requirements of 42 CFR 438.56 and which explains clearly the process for exercising this disenrollment right, as well as the alternatives available to the potential enrollee based on their specific circumstance; • The basic features of managed care; • Which populations are excluded from enrollment in managed care, subject to mandatory enrollment, or free to enroll voluntarily in the program; The service area covered by each MCO, PIHP, PAHP, PCCM, or PCCM entity; • Covered benefits including: o Which benefits are provided by the MCO, PIHP, or PAHP; and which, if any, benefits are provided directly by the State; and o For a counseling or referral service that the MCO, PIHP, or PAHP does not cover because of moral or religious objections, where and how to obtain the service; • The provider directory and formulary information required in 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(h) and (i); • Any cost-sharing for the enrollee that will be imposed by the MCO, PIHP, PAHP, PCCM, or PCCM entity consistent with those set forth in the State plan; • The requirements for each MCO, PIHP or PAHP to provide adequate access to covered services, including the network adequacy standards established in 42 CFR 457.1218, cross-referencing 42 CFR 438.68; • The MCO, PIHP, PAHP, PCCM and PCCM entity's responsibilities for coordination of enrollee care; and • To the extent available, quality and performance indicators for each MCO, PIHP, PAHP and PCCM entity, including enrollee satisfaction. 3.5.8

The State assures that it will provide the information specified in 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(f) to all enrollees of MCOs, PIHPs, PAHPs and PCCM entities, including that the State must notify all

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enrollees of their right to disenroll consistent with the requirements of 42 CFR 438.56 at least annually. 3.5.9

The State assures that each MCO, PIHP, PAHP and PCCM entity will provide the information specified in 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(f) to all enrollees of MCOs, PIHPs, PAHPs and PCCM entities, including that: • The MCO, PIHP, PAHP and, when appropriate, the PCCM entity, must make a good faith effort to give written notice of termination of a contracted provider within the timeframe specified in 42 CFR 438.10(f), and • The MCO, PIHP, PAHP and, when appropriate, the PCCM entity must make available, upon request, any physician incentive plans in place as set forth in 42 CFR 438.3(i). 3.5.10

The State assures that each MCO, PIHP, PAHP and PCCM entity will provide enrollees of that MCO, PIHP, PAHP or PCCM entity an enrollee handbook that meets the requirements as applicable to the MCO, PIHP, PAHP and PCCM entity, specified in 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(g)(1)-(2), within a reasonable time after receiving notice of the beneficiary's enrollment, by a method consistent with 42 CFR 438.10(g)(3), and including the following items: • Information that enables the enrollee to understand how to effectively use the managed care program, which, at a minimum, must include: o Benefits provided by the MCO, PIHP, PAHP or PCCM entity; o How and where to access any benefits provided by the State, including any cost sharing, and how transportation is provided; and o In the case of a counseling or referral service that the MCO, PIHP, PAHP, or PCCM entity does not cover because of moral or religious objections, the MCO, PIHP, PAHP, or PCCM entity

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must inform enrollees that the service is not covered by the MCO, PIHP, PAHP, or PCCM entity and how they can obtain information from the State about how to access these services; • The amount, duration, and scope of benefits available under the contract in sufficient detail to ensure that enrollees understand the benefits to which they are entitled; • Procedures for obtaining benefits, including any requirements for service authorizations and/or referrals for specialty care and for other benefits not furnished by the enrollee's primary care provider; • The extent to which, and how, after-hours and emergency coverage are provided, including: o What constitutes an emergency medical condition and emergency services; o The fact that prior authorization is not required for emergency services; and o The fact that, subject to the provisions of this section, the enrollee has a right to use any hospital or other setting for emergency care; • Any restrictions on the enrollee's freedom of choice among network providers; • The extent to which, and how, enrollees may obtain benefits, including family planning services and supplies from out-of- network providers; • Cost sharing, if any is imposed under the State plan; • Enrollee rights and responsibilities, including the elements specified in 42 CFR §438.100; • The process of selecting and changing the enrollee's primary care provider; • Grievance, appeal, and review procedures and timeframes, consistent with 42 CFR 457.1260, in a State-developed or State-

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approved description, including: The right to file grievances and appeals; o The requirements and timeframes for filing a grievance or appeal; o The availability of assistance in the filing process; and o The right to request a State review after the MCO, PIHP or PAHP has made a determination on an enrollee's appeal which is adverse to the enrollee; • How to access auxiliary aids and services, including additional information in alternative formats or languages; • The toll-free telephone number for member services, medical management, and any other unit providing services directly to enrollees; and • Information on how to report suspected fraud or abuse. 3.5.11

The State assures that each MCO, PIHP, PAHP and PCCM entity will give each enrollee notice of any change that the State defines as significant in the information specified in the enrollee handbook at least 30 days before the intended effective date of the change. (42 CFR 457.1207, cross- referencing to 42 CFR 438.10(g)(4)) 3.5.12

The State assures that each MCO, PIHP, PAHP and when appropriate, PCCM entity, will make available a provider directory for the MCO’s, PIHP’s, PAHP’s or PCCM entity’s network providers, including for physicians (including specialists), hospitals, pharmacies, and behavioral health providers, that includes information as specified in 42 CFR 457.1207, cross- referencing to 42 CFR 438.10(h)(1)-(2) and (4). 3.5.13

The State assures that each MCO, PIHP, PAHP and when appropriate, PCCM entity, will update any information included in a paper provider directory at least monthly and in an electronic provider directories as

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Approval Date:

specified in 42 CFR 438.10(h)(3). (42 CFR 457.1207, cross-referencing to 42 CFR 438.10(h)(3)) 3.5.14

The State assures that each MCO, PIHP, PAHP and when appropriate, PCCM entity, will make available the MCO’s, PIHP’s, PAHP’s, or PCCM entity’s formulary that meets the requirements specified in 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(i), including: • Which medications are covered (both generic and name brand); and • What tier each medication is on. 3.5.15

The State assures that each MCO, PIHP, PAHP, PCCM and PCCM entity follows the requirements for marketing activities under 42 CFR 457.1224, cross-referencing to 42 CFR 438.104 (except 42 CFR 438.104(c)). Guidance: Requirements for marketing activities include, but are not limited to, that the MCO, PIHP, PAHP, PCCM, or PCCM entity does not distribute any marketing materials without first obtaining State approval; distributes the materials to its entire service areas as indicated in the contract; does not seek to influence enrollment in conjunction with the sale or offering of any private insurance; and does not, directly or indirectly, engage in door-to-door, telephone, email, texting, or other cold-call marketing activities. (42 CFR 104(b)) Guidance: Only States with MCOs, PIHPs, or PAHPs need to answer the remaining assurances in Section 3.5 (3.5.16 through 3.5.18). 3.5.16

The State assures that each MCO, PIHP and PAHP protects communications between providers and enrollees under 42 CFR 457.1222, cross-referencing to 42 CFR 438.102. 3.5.17

The State assures that MCOs, PIHPs, and PAHPs have arrangements and procedures that prohibit the MCO, PIHP, and PAHP from conducting any unsolicited personal contact with a potential enrollee by an employee or agent of the MCO, PAHP, or PIHP for the purpose of influencing the individual to enroll with the entity. (42 CFR 457.1280(b)(2)) Guidance: States should also complete Section 3.9, which includes additional provisions about the notice procedures for grievances and appeals.

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3.5.18

The State assures that each contracted MCO, PIHP, and PAHP comply with the notice requirements specified for grievances and appeals in accordance with the terms of 42 CFR 438, Subpart F, except that the terms of 42 CFR 438.420 do not apply and that references to reviews should be read to refer to reviews as described in 42 CFR 457, Subpart K. (42 CFR 457.1260) 3.6 Benefits and Services Guidance: The State should also complete Section 3.10 (Program Integrity). 3.6.1

The State assures that MCO, PIHP, PAHP, PCCM entity, and PCCM contracts involving Indians, Indian health care providers, and Indian managed care entities comply with the requirements of 42 CFR 438.14. (42 CFR 457.1209) 3.6.2

The State assures that all services covered under the State plan are available and accessible to enrollees. (42 CFR 457.1230(a), cross-referencing to 42 CFR 438.206) 3.6.3

The State assures that it: • Publishes the State’s network adequacy standards developed in accordance with 42 CFR 457.1218, cross-referencing 42 CFR 438.68(b)(1) on the Web site required by 42 CFR 438.10; • Makes available, upon request, the State’s network adequacy standards at no cost to enrollees with disabilities in alternate formats or through the provision of auxiliary aids and services. (42 CFR 457.1218, cross-referencing 42 CFR 438.68(e)) Guidance: Only States with MCOs, PIHPs, or PAHPs need to complete the remaining assurances in Section 3.6 (3.6.4 through 3.6.20. 3.6.4

The State assures that each MCO, PAHP and PIHP meet the State’s network adequacy standards. (42 CFR 457.1218, cross-referencing 42 CFR 438.68; 42 CFR 457.1230(a), cross-referencing to 42 CFR 438.206)

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3.6.5

The State assures that each MCO, PIHP, and PAHP includes within its network of credentialed providers: • A sufficient number of providers to provide adequate access to all services covered under the contract for all enrollees, including those with limited English proficiency or physical or mental disabilities; • Women’s health specialists to provide direct access to covered care necessary to provide women’s routine and preventative health care services for female enrollees; and • Family planning providers to ensure timely access to covered services. (42 CFR 457.1230(a), cross-referencing to 42 CFR 438.206(b) 3.6.6

The State assures that each contract under 42 CFR 457.1201 permits an enrollee to choose his or her network provider. (42 CFR 457.1201(j), cross- referencing 42 CFR 438.3(l)) 3.6.7

The State assures that each MCO, PIHP, and PAHP provides for a second opinion from a network provider, or arranges for the enrollee to obtain one outside the network, at no cost. (42 CFR 457.1230(a), cross-referencing to 42 CFR 438.206(b)(3)) 3.6.8

The State assures that each MCO, PIHP, and PAHP ensures that providers, in furnishing services to enrollees, provide timely access to care and services, including by: • Requiring the contract to adequately and timely cover out-of- network services if the provider network is unable to provide necessary services covered under the contract to a particular enrollee and at a cost to the enrollee that is no greater than if the services were furnished within the network; • Requiring the MCO, PIHP and PAHP meet and its network providers to meet State standards for timely access to care and

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services, taking into account the urgency of the need for services; • Ensuring that the hours of operation for a network provider are no less than the hours of operation offered to commercial enrollees or comparable to Medicaid or CHIP Fee-For-Service, if the provider serves only Medicaid or CHIP enrollees; • Ensuring that the MCO, PIHP and PAHP makes available services include in the contract on a 24 hours a day, 7 days a week basis when medically necessary; • Establishing mechanisms to ensure compliance by network providers; • Monitoring network providers regularly to determine compliance; • Taking corrective action if there is a failure to comply by a network provider. (42 CFR 457.1230(a), cross-referencing to 42 CFR 438.206(b)(4) and (5) and (c)) 3.6.9

The State assures that each MCO, PIHP, and PAHP has the capacity to serve the expected enrollment in its service area in accordance with the State's standards for access to care. (42 CFR 457.1230(b), cross-referencing to 42 CFR 438.207) 3.6.10

The State assures that each MCO, PIHP, and PAHP will be required to submit documentation to the State, at the time of entering into a contract with the State, on an annual basis, and at any time there has been a significant change to the MCO, PIHP, or PAHP’s operations that would affect the adequacy of capacity and services, to demonstrate that each MCO, PIHP, and PAHP for the anticipated number of enrollees for the service area: • Offers an appropriate range of preventative, primary care and specialty services; and • Maintains a provider network that is sufficient in number, mix, and geographic distribution. (42 CFR 457.1230, cross-referencing to 42 CFR 438.207(b))

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Approval Date:

3.6.11

Except that 42 CFR 438.210(a)(5) does not apply to CHIP, the State assures that its contracts with each MCO, PIHP, or PAHP comply with the coverage of services requirements under 42 CFR 438.210, including: • Identifying, defining, and specifying the amount, duration, and scope of each service that the MCO, PIHP, or PAHP is required to offer; and • Permitting an MCO, PIHP, or PAHP to place appropriate limits on a service. (42 CFR 457.1230(d), cross referencing to 42 CFR 438.210(a) except that 438.210(a)(5) does not apply to CHIP contracts) 3.6.12

Except that 438.210(b)(2)(iii) does not apply to CHIP, the State assures that its contracts with each MCO, PIHP, or PAHP comply with the authorization of services requirements under 42 CFR 438.210, including that: • The MCO, PIHP, or PAHP and its subcontractors have in place and follow written policies and procedures; • The MCO, PIHP, or PAHP have in place mechanisms to ensure consistent application of review criteria and consult with the requesting provider when appropriate; and • Any decision to deny a service authorization request or to authorize a service in an amount, duration, or scope that is less than requested be made by an individual with appropriate expertise in addressing the enrollee’s medical, or behavioral health needs. (42 CFR 457.1230(d), cross referencing to 42 CFR 438.210(b), except that 438.210(b)(2)(iii) does not apply to CHIP contracts) 3.6.13

The State assures that its contracts with each MCO, PIHP, or PAHP require each MCO, PIHP, or PAHP to notify the requesting provider and given written notice to the enrollee of any adverse benefit determination to deny a service authorization request, or to authorize a service in an amount,

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duration, or scope that is less than requested. (42 CFR 457.1230(d), cross- referencing to 42 CFR 438.210(c)) 3.6.14

The State assures that its contracts with each MCO, PIHP, or PAHP provide that compensation to individuals or entities that conduct utilization management activities is not structured so as to provide incentives for the individual or entity to deny, limit, or discontinue medically necessary services to any enrollee. (42 CFR 457.1230(d), cross-referencing to 42 CFR 438.210(e)) 3.6.15

The State assures that it has a transition of care policy that meets the requirements of 438.62(b)(1) and requires that each contracted MCO, PIHP, and PAHP implements the policy. (42 CFR 457.1216, cross-referencing to 42 CFR 438.62) 3.6.16

The State assures that each MCO, PIHP, and PAHP has implemented procedures to deliver care to and coordinate services for all enrollees in accordance with 42 CFR 457.1230(c), cross-referencing to 42 CFR 438.208, including: • Ensure that each enrollee has an ongoing source of care appropriate to his or her needs; • Ensure that each enrollee has a person or entity formally designated as primarily responsible for coordinating the services accessed by the enrollee; • Provide the enrollee with information on how to contract their designated person or entity responsible for the enrollee’s coordination of services; • Coordinate the services the MCO, PIHP, or PAHP furnishes to the enrollee between settings of care; with services from any other MCO, PIHP, or PAHP; with fee-for-service services; and with the services the enrollee receives from community and social support providers;

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• Make a best effort to conduct an initial screening of each enrollees needs within 90 days of the effective date of enrollment for all new enrollees; • Share with the State or other MCOs, PIHPs, or PAHPs serving the enrollee the results of any identification and assessment of the enrollee’s needs;

• Ensure that each provider furnishing services to enrollees maintains and shares, as appropriate, an enrollee health record in accordance with professional standards; and • Ensure that each enrollee’s privacy is protected in the process of coordinating care is protected with the requirements of 45 CFR parts 160 and 164 subparts A and E. (42 CFR 457.1230(c), cross- referencing to 42 CFR 438.208(b)) Guidance: For assurances 3.6.17 through 3.6.20, applicability to PIHPs and PAHPs is based a determination by the State in relation to the scope of the entity’s services and on the way the State has organized its delivery of managed care services, whether a particular PIHP or PAHP is required to implement the mechanisms for identifying, assessing, and producing a treatment plan for an individual with special health care needs. (42 CFR 457.1230(c), cross- referencing to 42 CFR 438.208(a)(2)) 3.6.17

The State assures that it has implemented mechanisms for identifying to MCOs, PIHPs, and PAHPs enrollees with special health care needs who are eligible for assessment and treatment services under 42 CFR 457.1230(c), cross-referencing to 42 CFR 438.208(c) and included the mechanism in the State’s quality strategy. 3.6.18

The State assures that each applicable MCO, PIHP, and PAHP implements the mechanisms to comprehensively assess each enrollee identified by the state as having special health care needs. (42 CFR 457.1230(c), cross- referencing to 42 CFR 438.208(c)(2))

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3.6.19

The State assures that each MCO, PIHP, and PAHP will produce a treatment or service plan that meets the following requirements for enrollees identified with special health care needs: • Is in accordance with applicable State quality assurance and utilization review standards; • Reviewed and revised upon reassessment of functional need, at least every 12 months, or when the enrollee’s circumstances or needs change significantly. (42 CFR 457.1230(c), cross-referencing to 42 CFR 438.208(c)(3)) 3.6.20

The State assures that each MCO, PIHP, and PAHP must have a mechanism in place to allow enrollees to directly access a specialist as appropriate for the enrollee's condition and identified needs for enrollees identified with special health care needs who need a course of treatment or regular care monitoring. (42 CFR 457.1230(c), cross-referencing to 42 CFR 438.208(c)(4)) 3.7 Operations 3.7.1

The State assures that it has established a uniform credentialing and recredentialing policy that addresses acute, primary, behavioral, and substance use disorders providers and requires each MCO, PIHP and PAHP to follow those policies. (42 CFR 457.1233(a), cross-referencing 42 CFR 438.214(b)(1)) Guidance: Only States with MCOs, PIHPs, or PAHPs need to answer the remaining assurances in Section 3.7 (3.7.2 through 3.7.9). 3.7.2 The State assures each contracted MCO, PIHP and PAHP will comply with the provider selection requirements in 42 CFR 457.1208 and 457.1233(a), cross-referencing 42 CFR 438.12 and 438.214, including that: Each MCO, PIHP, or PAHP implements written policies and procedures for selection and retention of network providers (42 CFR 457.1233(a), cross-referencing 42 CFR 438.214(a));

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MCO, PIHP, and PAHP network provider selection policies and procedures do not discriminate against particular providers that serve high-risk populations or specialize in conditions that require costly treatment (42 CFR 457.1233(a), cross-referencing 42 CFR 438.214(c)); MCOs, PIHPs, and PAHPs do not discriminate in the participation, reimbursement, or indemnification of any provider who is acting within the scope of his or her license or certification, solely on the basis of that license or certification (42 CFR 457.1208, cross referencing 42 CFR 438.12(a)); If an MCO, PIHP, or PAHP declines to include individual or groups of providers in the MCO, PIHP, or PAHP’s provider network, the MCO, PIHP, and PAHP gives the affected providers written notice of the reason for the decision (42 CFR 457.1208, cross referencing 42 CFR 438.12(a)); and MCOs, PIHPs, and PAHPs do not employ or contract with providers excluded from participation in Federal health care programs under either section 1128 or section 1128A of the Act. (42 CFR 457.1233(a), cross-referencing 42 CFR 438.214(d)).

3.7.3 The State assures that each contracted MCO, PIHP, and PAHP complies with the subcontractual relationships and delegation requirements in 42 CFR 457.1233(b), cross-referencing 42 CFR 438.230, including that: The MCO, PIHP, or PAHP maintains ultimate responsibility for adhering to and otherwise fully complying with all terms and conditions of its contract with the State; All contracts or written arrangements between the MCO, PIHP, or PAHP and any subcontractor specify that all delegated activities or obligations, and related reporting responsibilities, are specified in the contract or written agreement, the subcontractor agrees to perform the delegated activities and reporting responsibilities specified in compliance with the MCO's, PIHP's, or PAHP's contract obligations, and

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the contract or written arrangement must either provide for revocation of the delegation of activities or obligations, or specify other remedies in instances where the State or the MCO, PIHP, or PAHP determine that the subcontractor has not performed satisfactorily; All contracts or written arrangements between the MCO, PIHP, or PAHP and any subcontractor must specify that the subcontractor agrees to comply with all applicable CHIP laws, regulations, including applicable subregulatory guidance and contract provisions; and The subcontractor agrees to the audit provisions in 438.230(c)(3).

3.7.4

The State assures that each contracted MCO and, when applicable, each PIHP and PAHP, adopts and disseminates practice guidelines that are based on valid and reliable clinical evidence or a consensus of providers in the particular field; consider the needs of the MCO's, PIHP's, or PAHP's enrollees; are adopted in consultation with network providers; and are reviewed and updated periodically as appropriate. (42 CFR 457.1233(c), cross referencing 42 CFR 438.236(b) and (c)) 3.7.5

The State assures that each contracted MCO and, when applicable, each PIHP and PAHP makes decisions for utilization management, enrollee education, coverage of services, and other areas to which the guidelines apply are consistent with the practice guidelines. (42 CFR 457.1233(c), cross referencing 42 CFR 438.236(d)) 3.7.6

The State assures that each contracted MCO, PIHP, and PAHP maintains a health information system that collects, analyzes, integrates, and reports data consistent with 42 CFR 438.242. The systems must provide information on areas including, but not limited to, utilization, claims, grievances and appeals, and disenrollments for other than loss of CHIP eligibility. (42 CFR 457.1233(d), cross referencing 42 CFR 438.242)

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3.7.7

The State assures that it reviews and validates the encounter data collected, maintained, and submitted to the State by the MCO, PIHP, or PAHP to ensure it is a complete and accurate representation of the services provided to the enrollees under the contract between the State

and the MCO, PIHP, or PAHP and meets the requirements 42 CFR 438.242 of this section. (42 CFR 457.1233(d), cross referencing 42 CFR 438.242) 3.7.8

The State assures that it will submit to CMS all encounter data collected, maintained, submitted to the State by the MCO, PIHP, and PAHP once the State has reviewed and validated the data based on the requirements of 42 CFR 438.242. (CMS State Medicaid Director Letter #13-004) 3.7.9

The State assures that each contracted MCO, PIHP and PAHP complies with the privacy protections under 42 CFR 457.1110. (42 CFR 457.1233(e)) 3.8 Beneficiary Protections

3.8.1

The State assures that each MCO, PIHP, PAHP, PCCM and PCCM entity has written policies regarding the enrollee rights specified in 42 CFR 438.100. (42 CFR 457.1220, cross-referencing to 42 CFR 438.100(a)(1)) 3.8.2

The State assures that its contracts with an MCO, PIHP, PAHP, PCCM, or PCCM entity include a guarantee that the MCO, PIHP, PAHP, PCCM, or PCCM entity will not avoid costs for services covered in its contract by referring enrollees to publicly supported health care resources. (42 CFR 457.1201(p)) 3.8.3

The State assures that MCOs, PIHPs, and PAHPs do not hold the enrollee liable for the following: • The MCO’s, PIHP’s or PAHP’s debts, in the event of the entity’s solvency. (42 CFR 457.1226, cross-referencing to 42 CFR 438.106(a)) • Covered services provided to the enrollee for which the State does not pay the MCO, PIHP or PAHP or for which the State, MCO, PIHP, or

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PAHP does not pay the individual or the health care provider that furnished the services under a contractual, referral or other arrangement. (42 CFR 457.1226, cross-referencing to 42 CFR 438.106(b)) • Payments for covered services furnished under a contract, referral or other arrangement that are in excess of the amount the enrollee would owe if the MCO, PIHP or PAHP covered the services directly. (42 CFR 457.1226, cross-referencing to 42 CFR 438.106(c)) 3.9 Grievances and Appeals Guidance: Only States with MCOs, PIHPs, or PAHPs need to complete Section 3.9. States with PCCMs and/or PCCM entities should be adhering to the State’s review process for benefits. 3.9.1

The State assures that each MCO, PIHP, and PAHP has a grievance and appeal system in place that allows enrollees to file a grievance and request an appeal. (42 CFR 457.1260, cross-referencing to 42 CFR 438.402(a) and 438.402(c)) 3.9.2

The State assures that each MCO, PIHP, and PAHP has only one level of appeal for enrollees. (42 CFR 457.1260, cross-referencing to 42 CFR 438.402(b)) 3.9.3

The State assures that an enrollee may request a State review after receiving notice that the adverse benefit determination is upheld, or after an MCO, PIHP, or PAHP fails to adhere to the notice and timing requirements in 42 CFR 438.408. (42 CFR 457.1260, cross-referencing to 438.402(c)) 3.9.4. Does the state offer and arrange for an external medical review? Yes No

Guidance: Only states that answered yes to assurance 3.9.4 need to complete the next assurance (3.9.5).

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3.9.5

The State assures that the external medical review is: • At the enrollee's option and not required before or used as a deterrent to proceeding to the State review; • Independent of both the State and MCO, PIHP, or PAHP; • Offered without any cost to the enrollee; and • Not extending any of the timeframes specified in 42 CFR 438.408. (42 CFR 457.1260, cross-referencing to 42 CFR 438.402(a) and 438.402(c)(1)(i)) 3.9.6

The State assures that an enrollee may file a grievance with the MCO, PIHP, or PAHP at any time. (42 CFR 457.1260, cross-referencing to 42 CFR 438.402(a) and 438.402(c)(2)(i)) 3.9.7

The State assures that an enrollee has 60 calendar days from the date on an adverse benefit determination notice to file a request for an appeal to the MCO, PIHP, or PAHP. (42 CFR 457.1260, cross-referencing to 42 CFR 438.402(a) and 438.402(c)(2)(ii)) 3.9.8

The State assures that an enrollee may file a grievance and request an appeal either orally or in writing. (42 CFR 457.1260, cross-referencing to 42 CFR 438.402(a) and 438.402(c)(3)(i)) 3.9.9

The State assures that each MCO, PIHP, and PAHP gives enrollees timely and adequate notice of an adverse benefit determination in writing consistent with the requirements below in Section 3.9.10 and in 42 CFR 438.10. 3.9.10

The State assures that the notice of an adverse benefit determination explains: • The adverse benefit determination. • The reasons for the adverse benefit determination, including the right

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of the enrollee to be provided upon request and free of charge, reasonable access to and copies of all documents, records, and other information relevant to the enrollee's adverse benefit determination. Such information includes medical necessity criteria, and any processes, strategies, or evidentiary standards used in setting coverage limits. • The enrollee's right to request an appeal of the MCO's, PIHP's, or PAHP's adverse benefit determination, including information on exhausting the MCO's, PIHP's, or PAHP's one level of appeal and the right to request a State review. • The procedures for exercising the rights specified above under this assurance. • The circumstances under which an appeal process can be expedited and how to request it. (42 CFR 457.1260, cross-referencing to 42 CFR 438.404(b)) 3.9.11

The State assures that the notice of an adverse benefit determination is provided in a timely manner in accordance with 42 CFR 457.1260. (42 CFR 457.1260, cross-referencing to 42 CFR 438.404(c)) 3.9.12

The State assures that MCOs, PIHPs, and PAHPs give enrollees reasonable assistance in completing forms and taking other procedural steps related to a grievance or appeal. This includes, but is not limited to, auxiliary aids and services upon request, such as providing interpreter services and toll-free numbers that have adequate TTY/TTD and interpreter capability. (42 CFR 457.1260, cross-referencing to 42 CFR 438.406(a)) 3.9.13 The state makes the following assurances related to MCO, PIHP, and PAHP processes for handling enrollee grievances and appeals: Individuals who make decisions on grievances and appeals were neither involved in any previous level of review or decision-making nor a subordinate of any such individual.

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Individuals who make decisions on grievances and appeals, if deciding any of the following, are individuals who have the appropriate clinical expertise in treating the enrollee's condition or disease: • An appeal of a denial that is based on lack of medical necessity. • A grievance regarding denial of expedited resolution of an appeal. • A grievance or appeal that involves clinical issues. All comments, documents, records, and other information submitted by the enrollee or their representative will be taken into account, without regard to whether such information was submitted or considered in the initial adverse benefit determination. Enrollees have a reasonable opportunity, in person and in writing, to present evidence and testimony and make legal and factual arguments. Enrollees are provided the enrollee's case file, including medical records, other documents and records, and any new or additional evidence considered, relied upon, or generated by the MCO, PIHP or PAHP (or at the direction of the MCO, PIHP or PAHP) in connection with the appeal of the adverse benefit determination. This information must be provided free of charge and sufficiently in advance of the resolution timeframe for appeals. The enrollee and his or her representative or the legal representative of a deceased enrollee's estate are included as parties to the appeal. (42 CFR 457.1260, cross-referencing to 42 CFR 438.406(b)) 3.9.14

The State assures that standard grievances are resolved (including notice to the affected parties) within 90 calendar days from the day the MCO, PIHP, or PAHP receives the grievance. (42 CFR 457.1260, cross-referencing to 42 CFR 438.408(b)) 3.9.15

The State assures that standard appeals are resolved (including notice to the affected parties) within 30 calendar days from the day the MCO, PIHP, or PAHP receives the appeal. The MCO, PIHP, or PAHP may extend the

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timeframe by up to 14 calendar days if the enrollee requests the extension or the MCO, PIHP, or PAHP shows that there is need for additional information and that the delay is in the enrollee's interest. (42 CFR 457.1260, cross-referencing to 42 CFR 42 CFR 438.408(b) and (c)) 3.9.16

The State assures that each MCO, PIHP, and PAHP establishes and maintains an expedited review process for appeals that is no longer than 72 hours after the MCO, PIHP, or PAHP receives the appeal. The expedited review process applies when the MCO, PIHP, or PAHP determines (for a request from the enrollee) or the provider indicates (in making the request on the enrollee's behalf or supporting the enrollee's request) that taking the time for a standard resolution could seriously jeopardize the enrollee's life, physical or mental health, or ability to attain, maintain, or regain maximum function. (42 CFR 457.1260, cross-referencing to 42 CFR 438.408(b) and (c), and 42 CFR 438.410(a)) 3.9.17

The State assures that if an MCO, PIHP, or PAHP denies a request for expedited resolution of an appeal, it transfers the appeal within the timeframe for standard resolution in accordance with 42 CFR 438.408(b)(2). (42 CFR 457.1260, cross-referencing to 42 CFR 438.410(c)(1)) 3.9.18

The State assures that if the MCO, PIHP, or PAHP extends the timeframes for an appeal not at the request of the enrollee or it denies a request for an expedited resolution of an appeal, it completes all of the following: • Make reasonable efforts to give the enrollee prompt oral notice of the delay. • Within 2 calendar days give the enrollee written notice of the reason for the decision to extend the timeframe and inform the enrollee of the right to file a grievance if he or she disagrees with that decision. • Resolve the appeal as expeditiously as the enrollee's health condition requires and no later than the date the extension expires. (42 CFR 457.1260, cross-referencing to 42 CFR 438.408(c) and 42 CFR

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438.410(c)) 3.9.19

The State assures that if an MCO, PIHP, or PAHP fails to adhere to the notice and timing requirements in this section, the enrollee is deemed to have exhausted the MCO's, PIHP's, or PAHP's appeals process and the enrollee may initiate a State review. (42 CFR 457.1260, cross-referencing to 42 CFR 438.408(c)(3)) 3.9.20

The State assures that has established a method that an MCO, PIHP, and PAHP will use to notify an enrollee of the resolution of a grievance and ensure that such methods meet, at a minimum, the standards described at 42 CFR 438.10. (42 CFR 457.1260, cross referencing to 42 CFR 457.408(d)(1)) 3.9.21

For all appeals, the State assures that each contracted MCO, PIHP, and PAHP provides written notice of resolution in a format and language that, at a minimum, meet the standards described at 42 CFR 438.10. The notice of resolution includes at least the following items: • The results of the resolution process and the date it was completed; and • For appeals not resolved wholly in favor of the enrollees: o The right to request a State review, and how to do so. o The right to request and receive benefits while the hearing is pending, and how to make the request. o That the enrollee may, consistent with State policy, be held liable for the cost of those benefits if the hearing decision upholds the MCO's, PIHP's, or PAHP's adverse benefit determination. (42 CFR 457.1260, cross referencing to 42 CFR 457.408(d)(2)(i) and (e))

3.9.22

For notice of an expedited resolution, the State assures that each contracted MCO, PIHP, or PAHP makes reasonable efforts to provide oral notice, in addition to the written notice of resolution. (42 CFR 457.1260, cross referencing to 42 CFR 457.408(d)(2)(ii)) 3.9.23

The State assures that if it offers an external medical review:

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• The review is at the enrollee's option and is not required before or used as a deterrent to proceeding to the State review; • The review is independent of both the State and MCO, PIHP, or PAHP; and • The review is offered without any cost to the enrollee. (42 CFR 457.1260, cross-referencing to 42 CFR 438.408(f)) 3.9.24

The State assures that MCOs, PIHPs, and PAHPs do not take punitive action against providers who request an expedited resolution or support an enrollee's appeal. (42 CFR 457.1260, cross-referencing to 42 CFR 438.410(b)) 3.9.25

The State assures that MCOs, PIHPs, or PAHPs must provide information specified in 42 CFR 438.10(g)(2)(xi) about the grievance and appeal system to all providers and subcontractors at the time they enter into a contract. This includes: • The right to file grievances and appeals; • The requirements and timeframes for filing a grievance or appeal; • The availability of assistance in the filing process; • The right to request a State review after the MCO, PIHP or PAHP has made a determination on an enrollee's appeal which is adverse to the enrollee; and • The fact that, when requested by the enrollee, benefits that the MCO, PIHP, or PAHP seeks to reduce or terminate will continue if the enrollee files an appeal or a request for State review within the timeframes specified for filing, and that the enrollee may, consistent with State policy, be required to pay the cost of services furnished while the appeal or State review is pending if the final decision is adverse to the enrollee. (42 CFR 457.1260, cross-referencing to 42 CFR 438.414) 3.9.26

The State assures that it requires MCOs, PIHPs, and PAHPs to maintain records of grievances and appeals and reviews the information as part of

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its ongoing monitoring procedures, as well as for updates and revisions to the State quality strategy. The record must be accurately maintained in a manner accessible to the state and available upon request to CMS. (42 CFR 457.1260, cross-referencing to 42 CFR 438.416) 3.9.27

The State assures that if the MCO, PIHP, or PAHP, or the State review officer reverses a decision to deny, limit, or delay services that were not furnished while the appeal was pending, the MCO, PIHP, or PAHP must authorize or provide the disputed services promptly and as expeditiously as the enrollee's health condition requires but no later than 72 hours from the date it receives notice reversing the determination. (42 CFR 457.1260, cross-referencing to 42 CFR 438.424(a)) 3.10 Program Integrity Guidance: The State should complete Section 11 (Program Integrity) in addition to Section 3.10. Guidance: Only States with MCOs, PIHPs, or PAHPs need to answer the first seven assurances (3.10.1 through 3.10.7). 3.10.1 The State assures that any entity seeking to contract as an MCO, PIHP, or PAHP under a separate child health program has administrative and management arrangements or procedures designed to safeguard against fraud and abuse, including: Enforcing MCO, PIHP, and PAHP compliance with all applicable Federal and State statutes, regulations, and standards; Prohibiting MCOs, PIHPs, or PAHPs from conducting any unsolicited personal contact with a potential enrollee by an employee or agent of the MCO, PAHP, or PIHP for the purpose of influencing the individual to enroll with the entity; and Including a mechanism for MCOs, PIHPs, and PAHPs to report to the State, to CMS, or to the Office of Inspector General (OIG) as appropriate, information on violations of law by subcontractors,

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providers, or enrollees of an MCO, PIHP, or PAHP and other individuals. (42 CFR 457.1280)

3.10.2

The State assures that it has in effect safeguards against conflict of interest on the part of State and local officers and employees and agents of the State who have responsibilities relating to the MCO, PIHP, or PAHP contracts or enrollment processes described in 42 CFR 457.1210(a). (42 CFR 457.1214, cross referencing 42 CFR 438.58) 3.10.3

The State assures that it periodically, but no less frequently than once every 3 years, conducts, or contracts for the conduct of, an independent audit of the accuracy, truthfulness, and completeness of the encounter and financial data submitted by, or on behalf of, each MCO, PIHP or PAHP. (42 CFR 457.1285, cross referencing 42 CFR 438.602(e)) 3.10.4

The State assures that it requires MCOs, PIHPs, PAHP, and or subcontractors (only to the extent that the subcontractor is delegated responsibility by the MCO, PIHP, or PAHP for coverage of services and payment of claims) implement and maintain arrangements or procedures that are designed to detect and prevent fraud, waste, and abuse. The arrangements or procedures must include the following: • A compliance program that include all of the elements described in 42 CFR 438.608(a)(1); • Provision for prompt reporting of all overpayments identified or recovered, specifying the overpayments due to potential fraud, to the State; • Provision for prompt notification to the State when it receives information about changes in an enrollee's circumstances that may affect the enrollee's eligibility; • Provision for notification to the State when it receives information about a change in a network provider's circumstances that may affect the network provider's eligibility to participate in the managed care

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program, including the termination of the provider agreement with the MCO, PIHP or PAHP; • Provision for a method to verify, by sampling or other methods, whether services that have been represented to have been delivered by network providers were received by enrollees and the application of such verification processes on a regular basis; • In the case of MCOs, PIHPs, or PAHPs that make or receive annual payments under the contract of at least $5,000,000, provision for written policies for all employees of the entity, and of any contractor or agent, that provide detailed information about the False Claims Act and other Federal and State laws described in section 1902(a)(68) of the Act, including information about rights of employees to be protected as whistleblowers; • Provision for the prompt referral of any potential fraud, waste, or abuse that the MCO, PIHP, or PAHP identifies to the State Medicaid/CHIP program integrity unit or any potential fraud directly to the State Medicaid Fraud Control Unit; and • Provision for the MCO's, PIHP's, or PAHP's suspension of payments to a network provider for which the State determines there is a credible allegation of fraud in accordance with 42 CFR 455.23. (42 CFR 457.1285, cross referencing 42 CFR 438.608(a)) 3.10.5

The State assures that each MCO, PIHP, or PAHP requires and has a mechanism for a network provider to report to the MCO, PIHP or PAHP when it has received an overpayment, to return the overpayment to the MCO, PIHP or PAHP within 60 calendar days after the date on which the overpayment was identified, and to notify the MCO, PIHP or PAHP in writing of the reason for the overpayment. (42 CFR 457.1285, cross referencing 42 CFR 438.608(d)(2))

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3.10.6

The State assures that each MCO, PIHP, or PAHP reports annually to the State on their recoveries of overpayments. (42 CFR 457.1285, cross referencing 42 CFR 438.608(d)(3)) 3.10.7

The State assures that it screens and enrolls, and periodically revalidates, all network providers of MCOs, PIHPs, and PAHPs, in accordance with the requirements of part 455, subparts B and E. This requirement also extends to PCCMs and PCCM entities to the extent that the primary care case manager is not otherwise enrolled with the State to provide services to fee- for-service beneficiaries. (42 CFR 457.1285, cross referencing 42 CFR 438.602(b)(1) and 438.608(b)) 3.10.8

The State assures that it reviews the ownership and control disclosures submitted by the MCO, PIHP, PAHP, PCCM or PCCM entity, and any subcontractors. (42 CFR 457.1285, cross referencing 42 CFR 438.602(c)) 3.10.9

The State assures that it confirms the identity and determines the exclusion status of the MCO, PIHP, PAHP, PCCM or PCCM entity, any subcontractor, as well as any person with an ownership or control interest, or who is an agent or managing employee of the MCO, PIHP, PAHP, PCCM or PCCM entity through routine checks of Federal databases. If the State finds a party that is excluded, the State promptly notifies the MCO, PIHP, PAHP, PCCM, or PCCM entity and takes action consistent with 42 CFR 438.610(c). (42 CFR 457.1285, cross referencing 42 CFR 438.602(d)) 3.10.10

The State assures that it receives and investigates information from whistleblowers relating to the integrity of the MCO, PIHP, PAHP, PCCM, or PCCM entity, subcontractors, or network providers receiving Federal funds under this part. (42 CFR 457.1285, cross referencing 42 CFR 438.602(f)) 3.10.11

The State assures that MCOs, PIHPs, PAHPs, PCCMs, or PCCM entities with which the State contracts are not located outside of the United States and that no claims paid by an MCO, PIHP, or PAHP to a network provider, out-

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of-network provider, subcontractor or financial institution located outside of the U.S. are considered in the development of actuarially sound capitation rates. (42 CFR 457.1285, cross referencing to 42 CFR 438.602(i); Section 1902(a)(80) of the Social Security Act) 3.10.12 The State assures that MCOs, PIHPs, PAHPs, PCCMs, and PCCM entities submit to the State the following data, documentation, and information:

Encounter data in the form and manner described in 42 CFR 438.818.

Data on the basis of which the State determines the compliance of the MCO, PIHP, or PAHP with the medical loss ratio requirement described in 42 CFR 438.8.

Data on the basis of which the State determines that the MCO, PIHP or PAHP has made adequate provision against the risk of insolvency as required under 42 CFR 438.116.

Documentation described in 42 CFR 438.207(b) on which the State bases its certification that the MCO, PIHP or PAHP has complied with the State's requirements for availability and accessibility of services, including the adequacy of the provider network, as set forth in 42 CFR 438.206.

Information on ownership and control described in 42 CFR 455.104 of this chapter from MCOs, PIHPs, PAHPs, PCCMs, PCCM entities, and subcontractors as governed by 42 CFR 438.230.

The annual report of overpayment recoveries as required in 42 CFR 438.608(d)(3). (42 CFR 457.1285, cross referencing 42 CFR 438.604(a))

3.10.13 The State assures that:

It requires that the data, documentation, or information submitted in accordance with 42 CFR 457.1285, cross referencing 42 CFR 438.604(a), is certified in a manner that the MCO's, PIHP's, PAHP's, PCCM's, or PCCM entity's Chief Executive Officer or Chief Financial

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Officer is ultimately responsible for the certification. (42 CFR 457.1285, cross referencing 42 CFR 438.606(a))

It requires that the certification includes an attestation that, based on best information, knowledge, and belief, the data, documentation, and information specified in 42 CFR 438.604 are accurate, complete, and truthful. (42 CFR 457.1285, cross referencing 42 CFR 438.606(b)); and

It requires the MCO, PIHP, PAHP, PCCM, or PCCM entity to submit the certification concurrently with the submission of the data, documentation, or information required in 42 CFR 438.604(a) and (b). (42 CFR 457.1285, cross referencing 42 CFR 438.604(c))

3.10.14

The State assures that each MCO, PIHP, PAHP, PCCM, PCCM entity, and any subcontractors provides: written disclosure of any prohibited affiliation under 42 CFR 438.610, written disclosure of and information on ownership and control required under 42 CFR 455.104, and reports to the State within 60 calendar days when it has identified the capitation payments or other payments in excess of amounts specified in the contract. (42 CFR 457.1285, cross referencing 42 CFR 438.608(c)) 3.10.15

The State assures that services are provided in an effective and efficient manner. (Section 2101(a)) 3.10.16

The State assures that it operates a Web site that provides: • The documentation on which the State bases its certification that the MCO, PIHP or PAHP has complied with the State's requirements for availability and accessibility of services; • Information on ownership and control of MCOs, PIHPs, PAHPs, PCCMs, PCCM entities, and subcontractors; and • The results of any audits conducted under 42 CFR 438.602(e). (42 CFR 457.1285, cross-referencing to 42 CFR 438.602(g)).

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3.11 Sanctions Guidance: Only States with MCOs need to answer the next three assurances (3.11.1 through 3.11.3). Intermediate sanctions are defined at 42 CFR 438.702(a)(4) as: (1) Civil money penalties; (2) Appointment of temporary management (for an MCO); (3) Granting enrollees the right to terminate enrollment without cause; (4) Suspension of all new enrollment; and (5) Suspension of payment for beneficiaries.

3.11.1

The State assures that it has established intermediate sanctions that it may impose if it makes the determination that an MCO has acted or failed to act in a manner specified in 438.700(b)-(d). (42 CFR 457.1270, cross referencing 42 CFR 438.700) 3.11.2

The State assures that it will impose temporary management if it finds that an MCO has repeatedly failed to meet substantive requirements of part 457 subpart L. (42 CFR 457.1270, cross referencing 42 CFR 438.706(b)) 3.11.3

The State assures that if it imposes temporary management on an MCO, the State allows enrollees the right to terminate enrollment without cause and notifies the affected enrollees of their right to terminate enrollment. (42 CFR 457.1270, cross referencing 42 CFR 438.706(b)) Guidance: Only states with PCCMs, or PCCM entities need to answer the next assurance (3.11.4). 3.11.4 Does the State establish intermediate sanctions for PCCMs or PCCM entities? Yes No

Guidance: Only states with MCOs and states that answered yes to assurance 3.11.4 need to complete the next three assurances (3.11.5 through 3.11.7). 3.11.5

The State assures that before it imposes intermediate sanctions, it gives the affected entity timely written notice. (42 CFR 457.1270, cross referencing 42 CFR 438.710(a))

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3.11.6

The State assures that if it intends to terminate an MCO, PCCM, or PCCM entity, it provides a pre-termination hearing and written notice of the decision as specified in 42 CFR 438.710(b). If the decision to terminate is affirmed, the State assures that it gives enrollees of the MCO, PCCM or PCCM entity notice of the termination and information, consistent with 42 CFR 438.10, on their options for receiving CHIP services following the effective date of termination. (42 CFR 457.1270, cross referencing 42 CFR 438.710(b)) 3.11.7

The State assures that it will give CMS written notice that complies with 42 CFR 438.724 whenever it imposes or lifts a sanction for one of the violations listed in 42 CFR 438.700. (42 CFR 457.1270, cross referencing 42 CFR 438.724) 3.12 Quality Measurement and Improvement; External Quality Review Guidance: The State should complete Sections 7 (Quality and Appropriateness of Care) and 9 (Strategic Objectives and Performance Goals and Plan Administration) in addition to Section 3.12. Guidance: States with MCO(s), PIHP(s), PAHP(s), or certain PCCM entity/ies (PCCM entities whose contract with the State provides for shared savings, incentive payments or other financial reward for improved quality outcomes - see 42 CFR 457.1240(f)) - should complete the applicable sub- sections for each entity type in this section, regarding 42 CFR 457.1240 and 1250.

3.12.1 Quality Strategy Guidance: All states with MCOs, PIHPs, PAHPs, PCCMs, or PCCM entities need to complete section 3.12.1.

3.12.1.1

The State assures that it will draft and implement a written quality strategy for assessing and improving the quality of health care and services furnished CHIP enrollees as described in 42 CFR 438.340(a). The quality strategy must include the following items: • The State-defined network adequacy and availability of services standards for MCOs, PIHPs, and PAHPs required by 42 CFR 438.68 and 438.206 and examples of evidence-based clinical

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practice guidelines the State requires in accordance with 42 CFR 438.236; • A description of: The quality metrics and performance targets to be used in measuring the performance and improvement of each MCO, PIHP, and PAHP with which the State contracts, including but not limited to, the performance measures reported in accordance with 42 CFR 438.330(c); and o The performance improvement projects to be implemented in accordance with 42 CFR 438.330(d), including a description of any interventions the State proposes to improve access, quality, or timeliness of care for beneficiaries enrolled in an MCO, PIHP, or PAHP; • Arrangements for annual, external independent reviews, in accordance with 42 CFR 438.350, of the quality outcomes and timeliness of, and access to, the services covered under each contract; • A description of the State's transition of care policy required under 42 CFR 438.62(b)(3); • The State's plan to identify, evaluate, and reduce, to the extent practicable, health disparities based on age, race, ethnicity, sex, and primary language; • For MCOs, appropriate use of intermediate sanctions that, at a minimum, meet the requirements of subpart I of 42 CFR Part 438; • A description of how the State will assess the performance and quality outcomes achieved by each PCCM entity; • The mechanisms implemented by the State to comply with 42 CFR 438.208(c)(1) (relating to the identification of persons with special health care needs); Identification of the external quality review (EQR)-related activities for which the State has exercised the option under 42 CFR

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438.360 (relating to nonduplication of EQR-related activities), and explain the rationale for the State's determination that the private accreditation activity is comparable to such EQR- related activities; • Identification of which quality measures and performance outcomes the State will publish at least annually on the Web site required under 42 CFR 438.10(c)(3); and • The State's definition of a “significant change” for the purposes of updating the quality strategy under 42 CFR 438.340(c)(3)(ii). (42 CFR 457.1240(e), cross referencing to 42 CFR 438.340(b)) 3.12.1.2 The State assures that the goals and objectives for continuous quality improvement in the quality strategy are measurable and take into consideration the health status of all populations in the State served by the MCO, PIHP, and PAHP. (42 CFR 457.1240(e), cross referencing to 42 CFR 438.340(b)(2)) 3.12.1.3 The State assures that for purposes of the quality strategy, the State provides the demographic information for each CHIP enrollee to the MCO, PIHP or PAHP at the time of enrollment. (42 CFR 457.1240(e), cross referencing to 42 CFR 438.340(b)(6)) 3.12.1.4 The State assures that it will review and update the quality strategy as needed, but no less than once every 3 years. (42 CFR 457.1240(e), cross referencing to 42 CFR 438.340(c)(2)) 3.12.1.5 The State assures that its review and updates to the quality strategy will include an evaluation of the effectiveness of the quality strategy conducted within the previous 3 years and the recom-mendations provided pursuant to 42 CFR 438.364(a)(4). (42 CFR 457.1240(e), cross referencing to 42 CFR 438.340(c)(2)(i) and (iii). 3.12.1.6 The State assures that it will submit to CMS:

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• A copy of the initial quality strategy for CMS comment and feedback prior to adopting it in final; and • A copy of the revised strategy whenever significant changes are made to the document, or whenever significant changes occur within the State's CHIP program, including after the review and update required every 3 years. (42 CFR 457.1240(e), cross referencing to 42 CFR 438.340(c)(3)) 3.12.1.7 Before submitting the strategy to CMS for review, the State assures

that when it drafts or revises the State’s quality strategy it will: • Make the strategy available for public comment; and • If the State enrolls Indians in the MCO, PIHP, or PAHP, consult with Tribes in accordance with the State's Tribal consultation policy. (42 CFR 457.1240(e), cross referencing to 42 CFR 438.340(c)(1)) 3.12.1.8 The State assures that it makes the results of the review of the quality strategy (including the effectiveness evaluation) and the final quality strategy available on the Web site required under 42 CFR 438.10(c)(3). (42 CFR 457.1240(e), cross referencing to 42 CFR 438.340(c)(2)(ii) and (d)) 3.12.2 Quality Assessment and Performance Improvement Program 3.12.2.1 Quality Assessment and Performance Improvement Program: Measures and Projects Guidance: Only states with MCOs, PIHPs, or PAHPs need to complete the next two assurances (3.12.2.1.1 and 3.12.2.1.2). 3.12.2.1.1 The State assures that it requires that each MCO, PIHP,

and PAHP establish and implement an ongoing compre-

hensive quality assessment and performance improvement program for the services it furnishes to its enrollees as

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provided in 42 CFR 438.330, except that the terms of 42 CFR 438.330(d)(4) (related to dual eligibles) do not apply. The elements of the assessment and program include at least: • Standard performance measures specified by the State; • Any measures and programs required by CMS (42 CFR 438.330(a)(2); • Performance improvement projects that focus on clinical and non-clinical areas, as specified in 42 CFR 438.330(d); • Collection and submission of performance measurement data in accordance with 42 CFR 438.330(c); • Mechanisms to detect both underutilization and overutilization of services; and • Mechanisms to assess the quality and appropriateness of care furnished to enrollees with special health care needs, as defined by the State in the quality strategy under 42 CFR 457.1240(e) and Section 3.12.1 of this template). (42 CFR 457.1240(b), cross referencing to 42 CFR 438.330(b) and (c)(1)). Guidance: A State may request an exemption from including the performance measures or performance improvement programs established by CMS under 42 CFR 438.330(a)(2), by submitting a written request to CMS explaining the basis for such request. 3.12.2.1.2 The State assures that each MCO, PIHP, and PAHP’s performance improvement projects are designed to achieve significant improvement, sustained over time, in health outcomes and enrollee satisfaction. The performance improvement projects include at least the following elements: • Measurement of performance using objective quality indicators; • Implementation of interventions to achieve improvement in the access to and quality of care; • Evaluation of the effectiveness of the interventions based

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on the performance measures specified in 42 CFR 438.330(d)(2)(i); and • Planning and initiation of activities for increasing or sustaining improvement. (42 CFR 457.1240(b), cross referencing to 42 CFR 438.330(d)(2)) Guidance: Only states with a PCCM entity whose contract with the State provides for shared savings, incentive payments or other financial reward for improved quality outcomes need to, complete the next assurance (3.12.2.1.3).

3.12.2.1.3 The State assures that it requires that each PCCM entity establishes and implements an ongoing comprehensive quality assessment and performance improvement program for the services it furnishes to its enrollees as provided in 42 CFR 438.330, except that the terms of 42 CFR 438.330(d)(4) (related to dual eligibles) do not apply. The assessment and program must include: • Standard performance measures specified by the State; • Mechanisms to detect both underutilization and overutilization of services; and • Collection and submission of performance measurement data in accordance with 42 CFR 438.330(c). (42 CFR 457.1240(a) and (b), cross referencing to 42 CFR 438.330(b)(3) and (c)) 3.12.2.2 Quality Assessment and Performance Improvement Program: Reporting and Effectiveness Guidance: Only states with MCOs, PIHPs, or PAHPs need to complete Section 3.12.2.2. 3.12.2.2.1 The State assures that each MCO, PIHP, and PAHP reports on the status and results of each performance improvement project conducted by the MCO, PIHP, and PAHP to the State

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as required by the State, but not less than once per year. (42 CFR 457.1240(b), cross referencing to 42 CFR 438.330(d)(3)) 3.12.2.2.2 The State assures that it annually requires each MCO, PIHP, and PAHP to:

1) Measure and report to the State on its performance using the standard measures required by the State;

2) Submit to the State data specified by the State to calculate the MCO's, PIHP's, or PAHP's performance using the standard measures identified by the State; or

3) Perform a combination of options (1) and (2) of this assurance. (42 CFR 457.1240(b), cross referencing to 42 CFR 438.330(c)(2)) 3.12.2.2.3 The State assures that the State reviews, at least annually, the impact and effectiveness of the quality assessment and performance improvement program of each MCO, PIHP, PAHP and PCCM entity. The State’s review must include: • The MCO's, PIHP's, PAHP's, and PCCM entity's performance on the measures on which it is required to report; and • The outcomes and trended results of each MCO's, PIHP's, and PAHP's performance improvement projects. (42 CFR 457.1240(b), cross referencing to 42 CFR 438.330(e)(1)) 3.12.3 Accreditation Guidance: Only states with MCOs, PIHPs, or PAHPs need to complete Section 3.12.3. 3.12.3.1 The State assures that it requires each MCO, PIHP, and PAHP to inform the state whether it has been accredited by a private independent accrediting entity, and, if the MCO, PIHP, or PAHP has received accreditation by a private independent accrediting agency, that the MCO, PIHP, and PAHP authorizes the private independent accrediting entity to provide the State a copy of its recent

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accreditation review that includes the MCO, PIHP, and PAHP’s accreditation status, survey type, and level (as applicable); accreditation results, including recommended actions or improvements, corrective action plans, and summaries of findings; and expiration date of the accreditation. (42 CFR 457.1240(c), cross referencing to 42 CFR 438.332(a) and (b)). 3.12.3.2 The State assures that it will make the accreditation status for each contracted MCO, PIHP, and PAHP available on the Web site required under 42 CFR 438.10(c)(3), including whether each MCO, PIHP, and PAHP has been accredited and, if applicable, the name of the accrediting entity, accreditation program, and accreditation level; and update this information at least annually. (42 CFR 457.1240(c), cross referencing to 42 CFR 438.332(c)) 3.12.4 Quality Rating Guidance: Only states with MCOs, PIHPs, or PAHPs need to complete Section 3.12.4.

The State assures that it will implement and operate a quality rating system that

issues an annual quality rating for each MCO, PIHP, and PAHP, which the State will prominently display on the Web site required under 42 CFR 438.10(c)(3), in accordance with the requirements set forth in 42 CFR 438.334. (42 CFR 457.1240(d)) Guidance: States will be required to comply with this assurance within 3 years after CMS, in consultation with States and other Stakeholders and after providing public notice and opportunity for comment, has identified performance measures and a methodology for a Medicaid and CHIP managed care quality rating system in the Federal Register. 3.12.5 Quality Review Guidance: All states with MCOs, PIHPs, PAHPs, PCCMs or PCCM entities need to complete Sections 3.12.5 and 3.12.5.1.

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The State assures that each contract with a MCO, PIHP, PAHP, or PCCM entity requires that a qualified EQRO performs an annual external quality review (EQR) for each contracting MCO, PIHP, PAHP or PCCM entity, except as provided in 42 CFR 438.362. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.350(a)) 3.12.5.1 External Quality Review Organization 3.12.5.1.1 The State assures that it contracts with at least one external quality review organization (EQRO) to conduct either EQR alone or EQR and other EQR-related activities. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.356(a)) 3.12.5.1.2 The State assures that any EQRO used by the State to comply with 42 CFR 457.1250 must meet the competence and independence requirements of 42 CFR 438.354 and, if the EQRO uses subcontractors, that the EQRO is accountable for and oversees all subcontractor functions. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.354 and 42 CFR 438.356(b) through (d)) 3.12.5.2 External Quality Review-Related Activities Guidance: Only states with MCOs, PIHPs, or PAHPs need to complete the next three assurances (3.12.5.2.1 through 3.12.5.2.3). Under 42 CFR 457.1250(a), the State, or its agent or EQRO, must conduct the EQR-related activity under 42 CFR 438.358(b)(1)(iv) regarding validation of the MCO, PIHP, or PAHP’s network adequacy during the preceding 12 months; however, the State may permit its contracted MCO, PIHP, and PAHPs to use information from a private accreditation review in lieu of any or all the EQR-related activities under 42 CFR 438.358(b)(1)(i) through (iii) (relating to the validation of performance improvement projects, validation of performance measures, and compliance review). 3.12.5.2.1 The State assures that the mandatory EQR-related activities described in 42 CFR 438.358(b)(1)(i) through (iv) (relating to the validation of performance improvement projects,

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validation of performance measures, compliance review, and validation of network adequacy) will be conducted on all MCOs, PIHPs, or PAHPs. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.358(b)(1))

3.12.5.2.2 The State assures that if it elects to use nonduplication for any or all of the three mandatory EQR-related activities described at 42 CFR 438.358(b)(1)(i) – (iii), the State will document the use of nonduplication in the State’s quality strategy. (42 CFR 457.1250(a), cross referencing 438.360, 438.358(b)(1)(i) through (b)(1)(iii), and 438.340) 3.12.5.2.3 The State assures that if the State elects to use nonduplication for any or all of the three mandatory EQR- related activities described at 42 CFR 438.358(b)(1)(i) – (iii), the State will ensure that all information from a Medicare or private accreditation review for an MCO, PIHP, or PAHP will be furnished to the EQRO for analysis and inclusion in the EQR technical report described in 42 CFR 438.364. ((42 CFR 457.1250(a), cross referencing to 42 CFR 438.360(b)) Guidance: Only states with PCCM entities need to complete the next assurance (3.12.5.2.4). 3.12.5.2.4

The State assures that the mandatory EQR-related activities described in 42 CFR 438.358(b)(2) (cross-referencing 42 CFR 438.358(b)(1)(ii) and (b)(1)(iii)) will be conducted on all PCCM entities, which include: • Validation of PCCM entity performance measures required in accordance with 42 CFR 438.330(b)(2) or PCCM entity performance measures calculated by the State during the preceding 12 months; and • A review, conducted within the previous 3-year period, to determine the PCCM entity’s compliance with the

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standards set forth in subpart D of 42 CFR part 438 and the quality assessment and performance improvement requirements described in 42 CFR 438.330. (42 CFR 457.1250(a), cross referencing to 438.358(b)(2))

3.12.5.3 External Quality Review Report Guidance: All states with MCOs, PIHPs, PAHPs, PCCMs or PCCM entities need to complete Sections 3.12.5.3.

3.12.5.3.1 The State assures that data obtained from the mandatory and optional, if applicable, EQR-related activities in 42 CFR 438.358 is used for the annual EQR to comply with 42 CFR 438.350 and must include, at a minimum, the elements in §438.364(a)(2)(i) through (iv). (42 CFR 457.1250(a), cross referencing to 42 CFR 438.358(a)(2))

3.12.5.3.2 The State assures that only a qualified EQRO will produce the EQR technical report (42 CFR 438.364(c)(1)).

3.12.5.3.3 The State assures that in order for the qualified EQRO to perform an annual EQR for each contracting MCO, PIHP, PAHP or PCCM entity under 42 CFR 438.350(a) that the following conditions are met: • The EQRO has sufficient information to use in performing the review; • The information used to carry out the review must be obtained from the EQR-related activities described in 42 CFR 438.358 and, if applicable, from a private accreditation review as described in 42 CFR 438.360; • For each EQR-related activity (mandatory or optional), the information gathered for use in the EQR must include the

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elements described in 42 CFR 438.364(a)(2)(i) through (iv); and • The information provided to the EQRO in accordance with 42 CFR 438.350(b) is obtained through methods consistent with the protocols established by the Secretary in accordance with 42 CFR 438.352. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.350(b) through (e)) 3.12.5.3.4

The State assures that the results of the reviews performed by a qualified EQRO of each contracting MCO, PIHP, PAHP, and PCCM entity are made available as specified in 42 CFR 438.364 in an annual detailed technical report that summarizes findings on access and quality of care. The report includes at least the following items: • A description of the manner in which the data from all activities conducted in accordance with 42 CFR 438.358 were aggregated and analyzed, and conclusions were drawn as to the quality, timeliness, and access to the care furnished by the MCO, PIHP, PAHP, or PCCM entity (described in 42 CFR 438.310(c)(2)); • For each EQR-related activity (mandatory or optional) conducted in accordance with 42 CFR 438.358: o Objectives; o Technical methods of data collection and analysis; o Description of data obtained, including validated performance measurement data for each activity conducted in accordance with 42 CFR 438.358(b)(1)(i) and (ii); and o Conclusions drawn from the data; • An assessment of each MCO's, PIHP's, PAHP's, or PCCM entity's strengths and weaknesses for the quality, timeliness, and access to health care services furnished to

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CHIP beneficiaries; • Recommendations for improving the quality of health care services furnished by each MCO, PIHP, PAHP, or

PCCM entity, including how the State can target goals and objectives in the quality strategy, under 42 CFR 438.340, to better support improvement in the quality, timeliness, and access to health care services furnished to CHIP beneficiaries; Methodologically appropriate, comparative information about all MCOs, PIHPs, PAHPs, and PCCM entities, consistent with guidance included in the EQR protocols issued in accordance with 42 CFR 438.352(e); and • An assessment of the degree to which each MCO, PIHP, PAHP, or PCCM entity has addressed effectively the recommendations for quality improvement made by the EQRO during the previous year's EQR. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.350(f) and 438.364(a)) 3.12.5.3.5 The State assures that it does not substantively revise the content of the final EQR technical report without evidence of error or omission. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.364(b)) 3.12.5.3.6 The State assures that it finalizes the annual EQR technical report by April 30th of each year. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.364(c)(1)) 3.12.5.3.7 The State assures that it posts the most recent copy of the annual EQR technical report on the Web site required under

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42 CFR 438.10(c)(3) by April 30th of each year. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.364(c)(2)(i)) 3.12.5.3.8 The State assures that it provides printed or electronic copies of the information specified in 42 CFR 438.364(a) for the annual EQR technical report, upon request, to interested parties such as participating health care providers, enrollees and potential enrollees of the MCO, PIHP, PAHP, or PCCM, beneficiary advocacy groups, and members of the general public. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.364(c)(2)(ii)) 3.12.5.3.9 The State assures that it makes the information specified in 42 CFR 438.364(a) for the annual EQR technical report available in alternative formats for persons with disabilities, when requested. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.364(c)(3)) 3.12.5.3.10

The State assures that information released under 42 CFR 438.364 for the annual EQR technical report does not disclose the identity or other protected health information of any patient. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.364(d)) Section 4. Eligibility Standards and Methodology

Guidance: States electing to use funds provided under Title XXI only to provide expanded eligibility under the State’s Medicaid plan or combination plan should check the appropriate box and provide the ages and income level for each eligibility group. If the State is electing to take up the option to expand Medicaid eligibility as allowed under section 214 of CHIPRA regarding lawfully residing, complete section 4.1-LR as well as update the budget to reflect the additional costs if the state will claim title XXI match for these children until and if the time comes that the children are eligible for Medicaid.

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4.0.

Medicaid Expansion

4.0.1. Ages of each eligibility group and the income standard for that group:

4.1.

Separate Program Check all standards that will apply to the State plan. (42CFR 457.305(a) and 457.320(a))

4.1.0 Describe how the State meets the citizenship verification requirements. Include whether or not State has opted to use SSA verification option. The state uses the federal hub and the SSA verification option. In instances where citizenship is not verified by these means the client is approved for coverage based on their attestation and given a reasonable opportunity to provide verification. 4.1.1 Geographic area served by the Plan if less than Statewide:

4.1.2 Ages of each eligibility group, including unborn children and pregnant women (if applicable) and the income standard for that group: Birth through eighteen. SEE CS7 4.1.2.1-PC Age: conception through birth (SHO #02-004, issued November 12, 2002). SEE CS9 4.1.3 Income of each separate eligibility group (if applicable):

Birth through Eighteen – 312%FPL 4.1.3.1-PC 0% of the FPL (and not eligible for Medicaid) through

193% of the FPL (SHO #02-004, issued November 12, 2002) SEE CS7, CS9, and CS15. 4.1.4 Resources of each separate eligibility group (including any standards relating to spend downs and disposition of resources):

There is no resource limit. 4.1.5 Residency (so long as residency requirement is not based on length of time in state): SEE CS17

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4.1.6 Disability Status (so long as any standard relating to disability status does not restrict eligibility): 4.1.7 Access to or coverage under other health coverage: CHIP coverage is not available to children who are otherwise eligible for Medicaid or who have “creditable coverage.” SEE CS10 4.1.8 Duration of eligibility, not to exceed 12 months: SEE CS27 4.1.9 Other Standards- Identify and describe other standards for or affecting eligibility, including those standards in 457.310 and 457.320 that are not addressed above. For instance:

Citizenship and immigration status. SEE CS18.

Guidance: States may only require the SSN of the child who is applying for coverage. If SSNs are required and the State covers unborn children, indicate that the unborn children are exempt from providing a SSN. Other standards include, but are not limited to presumptive eligibility and deemed newborns.

4.1.9.1 States should specify whether Social Security Numbers (SSN) are required.

SSNs are required for children birth through eighteen. SEE CS19.

Guidance: States should describe their continuous eligibility process and populations that can be continuously eligible.

4.1.9.2 Continuous eligibility

SEE CS27.

4.1-PW Pregnant Women Option (section 2112)- The State includes eligibility for one or more populations of targeted low-income pregnant women under the plan. Describe the population of pregnant women that the State proposes to cover in this section. Include all eligibility criteria, such as those described in the above categories (for instance, income and resources) that will be applied to this population. Use the same reference number system for those criteria (for example,

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4.1.1-P for a geographic restriction). Please remember to update sections 8.1.1-PW, 8.1.2-PW, and 9.10 when electing this option.

Guidance: States have the option to cover groups of “lawfully residing” children and/or pregnant women. States may elect to cover (1) “lawfully residing” children described at section 2107(e)(1)(J) of the Act; (2) “lawfully residing” pregnant women described at section 2107(e)(1)(J) of the Act; or (3) both. A state electing to cover children and/or pregnant women who are considered lawfully residing in the U.S. must offer coverage to all such individuals who meet the definition of lawfully residing, and may not cover a subgroup or only certain groups. In addition, states may not cover these new groups only in CHIP, but must also extend the coverage option to Medicaid. States will need to update their budget to reflect the additional costs for coverage of these children. If a State has been covering these children with State only funds, it is helpful to indicate that so CMS understands the basis for the enrollment estimates and the projected cost of providing coverage. Please remember to update section 9.10 when electing this option.

4.1- LR Lawfully Residing Option (Sections 2107(e)(1)(J) and 1903(v)(4)(A); (CHIPRA # 17, SHO # 10-006 issued July 1, 2010) Check if the State is electing the option under section 214 of the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA) regarding lawfully residing to provide coverage to the following otherwise eligible pregnant women and children as specified below who are lawfully residing in the United States including the following: A child or pregnant woman shall be considered lawfully present if he or she is: (1) A qualified alien as defined in section 431 of PRWORA (8 U.S.C. §1641); (2) An alien in nonimmigrant status who has not violated the terms of the status under which he or she was admitted or to which he or she has changed after admission; (3) An alien who has been paroled into the United States pursuant to section 212(d)(5) of the Immigration and Nationality Act (INA) (8 U.S.C. §1182(d)(5)) for less than 1 year, except for an alien paroled for prosecution, for deferred inspection or pending removal proceedings;

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(4) An alien who belongs to one of the following classes: (i) Aliens currently in temporary resident status pursuant to section 210 or 245A of the INA (8 U.S.C. §§1160 or 1255a, respectively); (ii) Aliens currently under Temporary Protected Status (TPS) pursuant to section 244 of the INA (8 U.S.C. §1254a), and pending applicants for TPS who have been granted employment authorization; (iii) Aliens who have been granted employment authorization under 8 CFR 274a.12(c)(9), (10), (16), (18), (20), (22), or (24); (iv) Family Unity beneficiaries pursuant to section 301 of Pub. L. 101- 649, as amended; (v) Aliens currently under Deferred Enforced Departure (DED) pursuant to a decision made by the President; (vi) Aliens currently in deferred action status; or (vii) Aliens whose visa petition has been approved and who have a pending application for adjustment of status; (5) A pending applicant for asylum under section 208(a) of the INA (8 U.S.C. § 1158) or for withholding of removal under section 241(b)(3) of the INA (8 U.S.C. § 1231) or under the Convention Against Torture who has been granted employment authorization, and such an applicant under the age of 14 who has had an application pending for at least180 days; (6) An alien who has been granted withholding of removal under the Convention Against Torture; (7) A child who has a pending application for Special Immigrant Juvenile status as described in section 101(a)(27)(J) of the INA (8 U.S.C. §1101(a)(27)(J)); (8) An alien who is lawfully present in the Commonwealth of the Northern Mariana Islands under 48 U.S.C. § 1806(e); or (9) An alien who is lawfully present in American Samoa under the immigration laws of American Samoa.

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Elected for pregnant women. Elected for children under age 19. SEE CS18

4.1.1-LR The State provides assurance that for an individual whom it enrolls in Medicaid under the CHIPRA Lawfully Residing option, it has verified, at the time of the individual’s initial eligibility determination and at the time of the eligibility redetermination, that the individual continues to be lawfully residing in the United States. The State must first attempt to verify this status using information provided at the time of initial application. If the State cannot do so from the information readily available, it must require the individual to provide documentation or further evidence to verify satisfactory immigration status in the same manner as it would for anyone else claiming satisfactory immigration status under section 1137(d) of the Act. SEE CS18.

4.1-DS Supplemental Dental (Section 2103(c)(5) - A child who is eligible to enroll in dental-only supplemental coverage, effective January 1, 2009. Eligibility is limited to only targeted low-income children who are otherwise eligible for CHIP but for the fact that they are enrolled in a group health plan or health insurance offered through an employer. The State’s CHIP plan income eligibility level is at least the highest income eligibility standard under its approved State child health plan (or under a waiver) as of January 1, 2009. All who meet the eligibility standards and apply for dental-only supplemental coverage shall be provided benefits. States choosing this option must report these children separately in SEDS. Please update sections 1.1-DS, 4.2-DS, and 9.10 when electing this option.

4.2. Assurances The State assures by checking the box below that it has made the following findings with respect to the eligibility standards in its plan: (Section 2102(b)(1)(B) and 42 CFR 457.320(b))

4.2.1. These standards do not discriminate on the basis of diagnosis.

4.2.2. Within a defined group of covered targeted low-income children, these

standards do not cover children of higher income families without covering

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children with a lower family income. This applies to pregnant women included

in the State plan as well as targeted low-income children.

4.2.3. These standards do not deny eligibility based on a child having a pre- existing medical condition. This applies to pregnant women as well as targeted low-income children.

4.2-DS Supplemental Dental - Please update sections 1.1-DS, 4.1-DS, and 9.10 when electing this option. For dental-only supplemental coverage, the State assures that it has made the following findings with standards in its plan: (Section 2102(b)(1)(B) and 42 CFR 457.320(b))

4.2.1-DS These standards do not discriminate on the basis of diagnosis.

4.2.2-DS Within a defined group of covered targeted low-income children,

these standards do not cover children of higher income families without covering children with a lower family income.

4.2.3-DS These standards do not deny eligibility based on a child having a pre-existing medical condition.

4.3. Methodology. Describe the methods of establishing and continuing eligibility and enrollment. The description should address the procedures for applying the eligibility standards, the organization and infrastructure responsible for making and reviewing eligibility determinations, and the process for enrollment of individuals receiving covered services, and whether the State uses the same application form for Medicaid and/or other public benefit programs. (Section 2102)(b)(2)) (42CFR, 457.350)

State delay in processing applications: The requirements related to timely processing of applications may be temporarily waived for CHIP applicants during the Federal COVID-19 public health emergency. State delay in processing renewals and extension of renewals deadlines for families. The requirements related to timely processing of renewals and/or deadlines for families to respond to renewal requests may be temporarily waived for CHIP beneficiaries during the federal COVID-19 public health emergency.

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Extend the reasonable opportunity period: The state may provide 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 during the federal COVID-19 public health emergency.

Suspend processing of some changes in circumstance: The state will temporarily delay acting on certain changes in circumstances for CHIP beneficiaries whom the state determines are impacted by a federally-declared disaster area such that processing the change in a timely manner is not feasible. The state will continue to act on the changes in circumstance described in 42 CFR 457.342(a), which cross-reference 435.926(d).

Families now apply and renew their coverage through Washington states’ Health Benefit Exchange at www.wahealthplanfinder.org. They may also use a streamlined paper application submitted to the Exchange for data entry of the information on the application.

Ex Parte renewals are completed using electronic data-matching with the federal hub. If the electronic match confirms eligibility, then CHIP coverage is continued without the need for any further information or forms. If the electronic data match fails, then the family is sent a letter advising them to go to the www.wahealthplanfinder.org to renew their coverage. They also receive a paper renewal form that they may complete and return to the state’s Health Benefit Exchange to have renewal data entered into the system.

Data entered into the www.wahealthplanfinder.org web application is transferred to the Automated Client Eligibility System (ACES). ACES transfers eligibility information to the state’s Medical Management Information System (MMIS) “ProviderOne”. MMIS information is used to enroll clients into managed care.

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The application requires the citizenship status and Social Security Number (SSN) of only those children for whom the family is seeking benefits. Adults, and other children listed on the application for whom the family is not applying, are not required to declare their citizenship status or provide an SSN.

When the family applies via www.wahealthplanfinder.org (HPF) web portal, data such as the SSN is transmitted to other available state and federal data exchanges. The information from these exchanges may then be used as electronic proof of eligibility requirements. One such system is the SVES data match with the Social Security Administration (SSA). SSN information is entered into the HPF system during the application process, and transmitted to the federal hub in real time. Verification of citizenship and enumeration is federally verified and transmitted back to the HPF system and the application is processed in real time. For continuing enrollment, the Agency will employ an ex parte renewal process that notifies families of their ongoing eligibility every twelve months when the family’s circumstances are electronically verified. The renewal letter is generated and mailed to the head of household approximately six weeks prior to the end of the client’s 12 month certification period. The family is directed to update their information in the HPF system; call the Agency on a statewide 800#, or complete and return the paper renewal form with current information such as household members, income, and health insurance status. The information is input into the HPF and eligibility is automatically reviewed first for Medicaid, and then reviewed for CHIP eligibility if the recipient is not Medicaid eligible. CHIP applicants have the same appeal rights as Medicaid applicants. Applicants who are denied eligibility are sent a letter with information on their rights for an Administrative Hearing. Clients may call the Office of Administrative Hearings (OAH) to set up a hearing. OAH notifies the client and the agency’s Administrative Hearing Coordinator. The Coordinator prepares the case and sets up a pre-hearing conference as a way to settle the dispute or collect information. Cases that are not resolved in the pre- hearing conference proceed to an Administrative Hearing. At the Administrative Hearing, an Administrative Law Judge gathers information from the client and agency staff.

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Hearings can be conducted via telephone or in person. The Judge’s decision is mailed to the client and the Administrative Hearings Coordinator. Either party may appeal the decision for additional review and if need be, to the courts.

Guidance: The box below should be checked as related to children and pregnant women. Please note: A State providing dental-only supplemental coverage may not have a waiting list or limit eligibility in any way.

4.3.1. Limitation on Enrollment Describe the processes, if any, that a State will use for instituting enrollment caps, establishing waiting lists, and deciding which children will be given priority for enrollment. If this section does not apply to your state, check the box below. (Section 2102(b)(2)) (42CFR, 457.305(b))

Check here if this section does not apply to your State.

Guidance: Note that for purposes of presumptive eligibility, States do not need to verify the citizenship status of the child. States electing this option should indicate so in the State plan. (42 CFR 457.355)

4.3.2. Check if the State elects to provide presumptive eligibility for children that meets the requirements of section 1920A of the Act. (Section 2107(e)(1)(L)); (42 CFR 457.355) SEE CS28.

Guidance: Describe how the State intends to implement the Express Lane option. Include information on the identified Express Lane agency or agencies, and whether the State will be using the Express Lane eligibility option for the initial eligibility determinations, redeterminations, or both.

4.3.3-EL Express Lane Eligibility Check here if the state elects the option to rely on a finding from an Express Lane agency when determining whether a child satisfies one or more components of CHIP eligibility. The state agrees to comply with the requirements of sections 2107(e)(1)(E) and 1902(e)(13) of the Act for this option. Please update sections 4.4-EL, 5.2-EL, 9.10, and 12.1 when electing this option. This authority may not apply to eligibility determinations made before February 4, 2009, or after September 30, 2013. (Section 2107(e)(1)(E))

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4.3.3.1-EL Also indicate whether the Express Lane option is applied to (1) initial eligibility determination, (2) redetermination, or (3) both.

4.3.3.2-EL List the public agencies approved by the State as Express Lane agencies.

4.3.3.3-EL List the components/components of CHIP eligibility that are determined under the Express Lane. In this section, specify any differences in budget unit, deeming, income exclusions, income disregards, or other methodology between CHIP eligibility determinations for such children and the determination under the Express Lane option.

4.3.3.3-EL List the component/components of CHIP eligibility that are determined under the Express Lane.

4.3.3.4-EL Describe the option used to satisfy the screen and enrollment requirements before a child may be enrolled under title XXI.

Guidance: States should describe the process they use to screen and enroll children required under section 2102(b)(3)(A) and (B) of the Social Security Act and 42 CFR 457.350(a) and 457.80(c). Describe the screening threshold set as a percentage of the Federal poverty level (FPL) that exceeds the highest Medicaid income threshold applicable to a child by a minimum of 30 percentage points. (NOTE: The State may set this threshold higher than 30 percentage points to account for any differences between the income calculation methodologies used by an Express Lane agency and those used by the State for its Medicaid program. The State may set one screening threshold for all children, based on the highest Medicaid income threshold, or it may set more than one screening threshold, based on its existing, age-related Medicaid eligibility thresholds.) Include the screening threshold(s) expressed as a percentage of the FPL, and provide an explanation of how this was calculated. Describe whether the State is temporarily enrolling children in CHIP, based on the income finding from an Express Lane agency, pending the completion of the screen and enroll process.

In this section, states should describe their eligibility screening process in a way that addresses the five assurances specified below. The State should consider including important definitions, the relationship with affected Federal, State and local agencies, and other applicable criteria that will describe the State’s ability to make assurances. (Sections 2102(b)(3)(A) and 2110(b)(2)(B)), (42 CFR 457.310(b)(2), 42CFR 457.350(a)(1) and 457.80(c)(3))

4.4. Eligibility screening and coordination with other health coverage programs

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States must describe how they will assure that: 4.4.1. only targeted low-income children who are ineligible for Medicaid or

not covered under a group health plan or health insurance (including

access to a State health benefits plan) are furnished child health assistance under the plan. (Sections 2102(b)(3)(A), 2110(b)(2)(B)) (42 CFR 457.310(b), 42 CFR 457.350(a)(1) and 42 CFR 457.80(c)(3)) Confirm that the State does not apply a waiting period for pregnant women. SEE CS10

The state does not apply a waiting period for pregnant women.

4.4.2. children found through the screening process to be potentially eligible for medical assistance under the State Medicaid plan are enrolled for assistance under such plan; (Section 2102(b)(3)(B)) (42CFR, 457.350(a)(2))

4.4.3. children found through the screening process to be ineligible for Medicaid are enrolled in CHIP; (Sections 2102(a)(1) and (2) and 2102(c)(2))(42CFR 431.636(b)(4))

4.4.4. the insurance provided under the State child health plan does not substitute for coverage under group health plans. (Section 2102(b)(3)(C)) (42CFR, 457.805) Suspend waiting periods: The waiting period policy will be temporarily suspended for CHIP applicants during the Federal COVID-19 public health emergency. See CS20

4.4.4.1. (formerly 4.4.4.4) If the State provides coverage under a premium assistance program, describe: 1) the minimum period without coverage under a group health plan. This should include any allowable exceptions to the waiting period; 2) the expected minimum level of contribution employers will make; and 3) how cost-effectiveness is determined. (42CFR 457.810(a)-(c))

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

Guidance: When the State is using an income finding from an Express Lane agency, the State must still comply with screen and enroll requirements before enrolling children in CHIP. The State may either continue its current screen and enroll process, or elect one of two new options to fulfill these requirements.

4.4-EL The State should designate the option it will be using to carry out screen and enroll requirements:

The State will continue to use the screen and enroll procedures required under section 2102(b)(3)(A) and (B) of the Social Security Act and 42 CFR 457.350(a) and 42 CFR 457.80(c). Describe this process. The State is establishing a screening threshold set as a percentage of the Federal poverty level (FPL) that exceeds the highest Medicaid income threshold applicable to a child by a minimum of 30 percentage points. (NOTE: The State may set this threshold higher than 30 percentage points to account for any differences between the income calculation methodologies used by the Express Lane agency and those used by the State for its Medicaid program. The State may set one screening threshold for all children, based on the highest Medicaid income threshold, or it may set more than one screening threshold, based on its existing, age-related Medicaid eligibility thresholds.) Include the screening threshold(s) expressed as a percentage of the FPL, and provide an explanation of how this was calculated.

The State is temporarily enrolling children in CHIP, based on the income finding from the Express Lane agency, pending the completion of the screen and enroll process. Section 5. Outreach and Coordination 5.1. (formerly 2.2) Describe the current State efforts to provide or obtain creditable health coverage for uninsured children by addressing sections 5.1.1 and 5.1.2.

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(Section 2102)(a)(2) (42CFR 457.80(b))

Guidance: The information below may include whether the state elects express lane eligibility a description of the State’s outreach efforts through Medicaid and state-only programs. 5.1.1. (formerly 2.2.1.) The steps the State is currently taking to identify and enroll all uninsured children who are eligible to participate in public health insurance programs (i.e., Medicaid and state-only child health insurance):

Washington operates several programs to provide healthcare coverage to low income children. The largest of these programs is Medicaid, which provides coverage to approximately 800,000 U.S. citizen and legal alien children annually, in households with incomes up to 210% FPL3. Washington’s CHIP program began in 2001 and currently provides coverage to approximately 42,000 U.S. citizen and legal alien children annually in households with incomes between 210% - 312% FPL. Washington’s CHIP coverage also provides coverage for over 11,000 low-income unborn children annually whose mothers do not qualify for Medicaid, but have household income below 193% FPL. In 2006, Washington reinstated its entirely state funded Children’s Health program for low- income children who do not qualify for Medicaid or CHIP based on their citizenship status. Currently the program provides coverage to over 18,000 low-income children annually. The Children’s Health program mirrors Medicaid and CHIP in its construction. As in the CHIP program, children in households with income between 210% and 312% FPL are required to pay a premium. To facilitate the success of these programs, Washington has engaged in a number of enrollment and retention strategies to ensure a high penetration rate into Medicaid and CHIP eligible populations. Among our best practices are: • Continuous Eligibility – Once a child is found eligible for medical assistance, the child remains continuously eligible for a full twelve months, regardless of changes in the household income. • No asset test - There is no resource test applied to eligibility for children’s medical programs.

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• No interview requirement – Families do not need a face- to- face interview. Application can be made through the mail, by phone, or by electronic submission through www.wahealthplanfinder.org. • Simplified Application –Families may apply for healthcare coverage including CHIP, through our state-based exchange using a single application. This application may be submitted as a paper application, or by calling the Exchange, or electronically at www.wahealthplanfinder.org • Joint Application – Applications for medical assistance are automatically considered for Medicaid, CHIP, and state-funded programs. • Application Assisters –Our state-based Exchange has contracted with 10 lead organizations who subcontract with various community-based organizations to serve as in-person assisters directly assisting families with completion of an electronic application at www.wahealthplanfinder.org, or the streamlined paper application. • Premium Payment Program – Parents may be reimbursed for the cost of employer- sponsored insurance to cover their Medicaid eligible child. • Renewal contacts – The Agency provides the renewal dates to managed care organizations (MCO) who have volunteered to assist their enrollees with the renewal process. MCO staff contact the families by phone and assist them with completing the annual renewal form electronically.

Guidance: The State may address the coordination between the public-private outreach and the public health programs that is occurring statewide. This section will provide a historic record of the steps the State is taking to identify and enroll all uninsured children from the time the State’s plan was initially approved. States do not have to rewrite his section but may instead update this section as appropriate.

5.1.2. (formerly 2.2.2.) The steps the State is currently taking to identify and enroll all uninsured children who are eligible to participate in health insurance programs that involve a public-private partnership: Washington State continues to participate in the national Healthy Kids Now! (HKN!) toll-free 800#. This number provides information on Medicaid and CHIP eligibility for those clients who might qualify for services. Washington also funds a toll-free 800# through WithinReach

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providing information, application assistance, and referral services. Washington’s CHIP eligibility is determined within the structure of our state-based Health Benefit Exchange, www.wahealthplanfinder.org. We continue to work closely with community partner agencies, medical providers, schools, and civic organizations to publicize and promote the Washington Apple Health for Kids program.

(Guidance: The State should describe below how its Title XXI program will closely coordinate the enrollment with Medicaid because under Title XXI, children identified as Medicaid-eligible are required to be enrolled in Medicaid. Specific information related to Medicaid screen and enroll procedures is requested in Section 4.4. (42CFR 457.80(c))

5.2. (formerly 2.3) Describe how CHIP coordinates with other public and private health insurance programs, other sources of health benefits coverage for children, other relevant child health programs, (such as title V), that provide health care services for low-income children to increase the number of children with creditable health coverage. (Section 2102(a)(3), 2102(b)(3)(E) and 2102(c)(2)) (42CFR 457.80(c)). This item requires a brief overview of how Title XXI efforts – particularly new enrollment outreach efforts – will be coordinated with and improve upon existing State efforts. As of October 1, 2013 Washington employs an electronic application process that will allow families to apply online, over-the-phone, or in-person and receive a “real-time” eligibility decision on their application through our state-based exchange www.wahealthplanfinder.org. Families may also apply by mailing or faxing in a streamlined paper application, but the determination is not made in “real time” when a paper application is used. The Washington Healthplanfinder system has dramatically improved the delivery of affordable health care by speeding up the process of receiving an eligibility decision, and reducing the number of administrative barriers. Not only are families able to apply on-line, but the system conducts electronic verifications of identity, citizenship status, enumeration, and income. Self-attestation is allowed in the determination of eligibility, and previously required verifications are followed up on as needed in post-eligibility. When a family applies for coverage, eligibility is determined across the spectrum of Medicaid, CHIP, state-funded, and premium tax-credit programs.

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5.2-EL The State should include a description of its election of the Express Lane eligibility option to provide a simplified eligibility determination process and expedited enrollment of eligible children into Medicaid or CHIP.

Guidance: Outreach strategies may include, but are not limited to, community outreach workers, outstationed eligibility workers, translation and transportation services, assistance with enrollment forms, case management and other targeting activities to inform families of low-income children of the availability of the health insurance program under the plan or other private or public health coverage.

The description should include information on how the State will inform the target of the availability of the programs, including American Indians and Alaska Natives, and assist them in enrolling in the appropriate program.

5.3. Strategies: Describe the procedures used by the State to accomplish outreach to families of children likely to be eligible for child health assistance or other public or private health coverage to inform them of the availability of the programs, and to assist them in enrolling their children in such a program. (Section 2102(c)(1)) (42CFR 457.90)

The state has an ongoing publicity campaign to promote Washington Apple Health coverage. The campaign targets back to school and open enrollment time periods. Representatives of the Health Care Authority also participate in health fairs and local community outreach events.

Section 6. Coverage Requirements for Children’s Health Insurance

Check here if the State elects to use funds provided under Title XXI only to provide expanded eligibility under the State’s Medicaid plan and proceed to Section 7 since children covered under a Medicaid expansion program will receive all Medicaid covered services including EPSDT. 6.1. The State elects to provide the following forms of coverage to children: (Check all that apply.) (Section 2103(c)); (42CFR 457.410(a))

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Guidance: Benchmark coverage is substantially equal to the benefits coverage in a benchmark benefit package (FEHBP-equivalent coverage, State employee coverage, and/or the HMO coverage plan that has the largest insured commercial, non-Medicaid enrollment in the state). If box below is checked, either 6.1.1.1., 6.1.1.2., or 6.1.1.3. must also be checked. (Section 2103(a)(1)) 6.1.1.

Benchmark coverage; (Section 2103(a)(1) and 42 CFR 457.420)

Guidance: Check box below if the benchmark benefit package to be offered by the State is the standard Blue Cross/Blue Shield preferred provider option service benefit plan, as described in and offered under Section 8903(1) of Title 5, United States Code. (Section 2103(b)(1) (42 CFR 457.420(b))

6.1.1.1.

FEHBP-equivalent coverage; (Section 2103(b)(1) (42 CFR 457.420(a)) (If checked, attach copy of the plan.)

Guidance: Check box below if the benchmark benefit package to be offered by the State is State employee coverage, meaning a coverage plan that is offered and generally available to State employees in the state. (Section 2103(b)(2))

6.1.1.2.

State employee coverage; (Section 2103(b)(2)) (If checked, identify the plan and attach a copy of the benefits description.

Guidance: Check box below if the benchmark benefit package to be offered by the State is offered by a health maintenance organization (as defined in Section 2791(b)(3) of the Public Health Services Act) and has the largest insured commercial, non-Medicaid enrollment of covered lives of such coverage plans offered by an HMO in the state. (Section 2103(b)(3) (42 CFR 457.420(c)))

6.1.1.3.

HMO with largest insured commercial enrollment (Section 2103(b)(3)) (If checked, identify the plan and attach a copy of the benefits description.)

Guidance: States choosing Benchmark-equivalent coverage must check the box below and ensure that the coverage meets the following requirements:  the coverage includes benefits for items and services within each of the categories of basic services described in 42 CFR 457.430:

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• dental services • inpatient and outpatient hospital services, • physicians’ services, • surgical and medical services, • laboratory and x-ray services, • well-baby and well-child care, including age-appropriate immunizations, and • emergency services;  the coverage has an aggregate actuarial value that is at least actuarially equivalent to one of the benchmark benefit packages (FEHBP-equivalent coverage, State employee coverage, or coverage offered through an HMO coverage plan that has the largest insured commercial enrollment in the state); and  the coverage has an actuarial value that is equal to at least 75 percent of the actuarial value of the additional categories in such package, if offered, as described in 42 CFR 457.430: • coverage of prescription drugs, • mental health services, • vision services and • hearing services. If 6.1.2. is checked, a signed actuarial memorandum must be attached. The actuary who prepares the opinion must select and specify the standardized set and population to be used under paragraphs (b)(3) and (b)(4) of 42 CFR 457.431. The State must provide sufficient detail to explain the basis of the methodologies used to estimate the actuarial value or, if requested by CMS, to replicate the State results.

The actuarial report must be prepared by an individual who is a member of the American Academy of Actuaries. This report must be prepared in accordance with the principles and standards of the American Academy of Actuaries. In preparing the report, the actuary must use generally accepted actuarial principles and methodologies, use a standardized set of utilization and price factors, use a standardized population that is representative of privately insured children of the age of children who are expected to be covered under the State child health plan, apply the same principles and factors in comparing the value of different coverage (or categories of services), without taking into account any differences in coverage based on the method of delivery or means of cost control or utilization used, and take into account the ability of a State to reduce benefits by taking into account the increase in actuarial value of benefits coverage offered under the State child health plan that results from the limitations on cost sharing under such coverage. (Section 2103(a)(2))

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6.1.2.

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

Guidance: A State approved under the provision below, may modify its program from time to time so

long as it continues to provide coverage at least equal to the lower of the actuarial value

of the coverage under the program as of August 5, 1997, or one of the benchmark

programs. If “existing comprehensive state-based coverage” is modified, an actuarial

opinion documenting that the actuarial value of the modification is greater than the value

as of August 5, 1997, or one of the benchmark plans must be attached. Also, the fiscal

year 1996 State expenditures for “existing comprehensive state-based coverage” must

be described in the space provided for all states. (Section 2103(a)(3))

6.1.3.

Existing Comprehensive State-Based Coverage; (Section 2103(a)(3) and 42 CFR 457.440) This option is only applicable to New York, Florida, and Pennsylvania. Attach a description of the benefits package, administration, and date of enactment. If existing comprehensive State-based coverage is modified, provide an actuarial opinion documenting that the actuarial value of the modification is greater than the value as of August 5, 1997 or one of the benchmark plans. Describe the fiscal year 1996 State expenditures for existing comprehensive state-based coverage.

Guidance: Secretary-approved coverage refers to any other health benefits coverage deemed appropriate and acceptable by the Secretary upon application by a state. (Section 2103(a)(4)) (42 CFR 457.250)

6.1.4.

Secretary-approved Coverage. (Section 2103(a)(4)) (42 CFR 457.450)

Guidance: Section 1905(r) of the Act defines EPSDT to require coverage of (1) any medically necessary screening, and diagnostic services, including vision, hearing, and dental screening and diagnostic services, consistent with a periodicity schedule based on current and reasonable medical practice standards or the health needs of an individual child to determine if a suspected condition or illness exists; and (2) all services listed in section

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1905(a) of the Act that are necessary to correct or ameliorate any defects and mental and physical illnesses or conditions discovered by the screening services, whether or not those services are covered under the Medicaid state plan. Section 1902(a)(43) of the Act requires that the State (1) provide and arrange for all necessary services, including supportive services, such as transportation, needed to receive medical care included within the scope of the EPSDT benefit and (2) inform eligible beneficiaries about the services available under the EPSDT benefit.

If the coverage provided does not meet all of the statutory requirements for EPSDT contained in sections 1902(a)(43) and 1905(r) of the Act, do not check this box.

6.1.4.1.

Coverage of all benefits that are provided to children under the same as Medicaid State plan, including Early Periodic Screening Diagnosis and Treatment (EPSDT) Washington’s CHIP will provide the same scope of coverage as provided under its Medicaid program. The chart below lists the general categories of medically necessary services available to children eligible for Categorically Needy (CN) Medicaid under Title XIX of the Social Security Act (SSA) and CHIP under Title XXI of the SSA. 6.1.4.2. Comprehensive coverage for children under a Medicaid Section 1115 demonstration waiver 6.1.4.3. Coverage that the State has extended to the entire Medicaid population

Guidance: Check below if the coverage offered includes benchmark coverage, as specified

in 42 CFR 457.420, plus additional coverage. Under this option, the State must

clearly demonstrate that the coverage it provides includes the same coverage as

the benchmark package, and also describes the services that are being added

to the benchmark package.

6.1.4.4. Coverage that includes benchmark coverage plus additional coverage

6.1.4.5. Coverage that is the same as defined by existing comprehensive state-based coverage applicable only New York, Pennsylvania, or

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Florida (under 457.440)

Guidance: Check below if the State is purchasing coverage through a group health plan, and intends to demonstrate that the group health plan is substantially equivalent to or greater than to coverage under one of the benchmark plans specified in 457.420, through use of a benefit-by-benefit comparison of the coverage. Provide a sample of the comparison format that will be used. Under this option, if coverage for any benefit does not meet or exceed the coverage for that benefit under the benchmark, the State must provide an actuarial analysis as described in 457.431 to determine actuarial equivalence.

6.1.4.6. Coverage under a group health plan that is substantially equivalent to or greater than benchmark coverage through a benefit by benefit comparison (Provide a sample of how the comparison will be done)

Guidance: Check below if the State elects to provide a source of coverage that is not

described above. Describe the coverage that will be offered, including any

benefit limitations or exclusions. 6.1.4.7.

Other (Describe)

SERVICE

MEDICAID CN

CHIP Advanced RN Practitioner Services

Yes

Yes Ambulance/Ground and Air

Yes

Yes Anesthesia Services

Yes

Yes Audiology

Yes

Yes Blood/Blood Administration

Yes

Yes Case Management – Maternity

L

L Chiropractic Care

Yes

Yes Clinic Services

Yes

Yes Community Mental Health Centers

Yes

Yes Dental Services

Yes

Yes Dentures Only

Yes

Yes Detox (3 days)

Yes

Yes Drugs and Pharmaceutical Supplies

Yes

Yes Elective Surgery

Yes

Yes

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Emergency Room Services

Yes

Yes Emergency Surgery

Yes

Yes Eyeglasses and Exams

Yes

Yes Family Planning Services

Yes

Yes Healthy Kids (EPSDT)

Yes

Yes Hearing Aid

Yes

Yes Hospice

Yes

Yes Home Health Services

Yes

Yes Indian Health Clinics

Yes

Yes Inpatient Hospital Care

Yes

Yes Intermediate Care Facility/Services for MR

Yes

Yes Involuntary Commitment

Yes

Yes Maternity Support Services

Yes

Yes Medical Equipment, Durable (DME)

Yes

Yes Mental Health (Outpatient Services)

Yes

Yes Midwife Services

Yes

Yes Neuromuscular Centers

Yes

Yes Nursing Facility Services

Yes

Yes Nutrition Therapy

Yes

Yes Optometry

Yes

Yes Organ Transplants

Yes

Yes Out-of-State Care

Yes

Yes Outpatient Hospital Care

Yes

Yes Oxygen/Respiratory Therapy

Yes

Yes Pain Management (Chronic)

Yes

Yes Personal Care Services

Yes

Yes Physical/Occupational/Speech Therapy

Yes

Yes

Physical Medicine and Rehabilitation

Yes

Yes Physician

Yes

Yes Podiatry

Yes

Yes Private Duty Nursing

L

L Prosthetic Devices/Mobility Aids

Yes

Yes Psychiatric Services

Yes

Yes Psychological Evaluation

L

L Rural Health Services & FQHC

Yes

Yes

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Substance Abuse/Outpatient

Yes

Yes Surgical Appliances

Yes

Yes Total Enteral/Parenteral Nutrition

Yes

Yes Transportation Other than Ambulance

Yes

Yes X-Ray and Lab Services

Yes

Yes Key: Yes: Service is covered (may require prior approval or have other requirements). L: Limited coverage

Guidance: All forms of coverage that the State elects to provide to children in its plan must be checked. The State should also describe the scope, amount and duration of services covered under its plan, as well as any exclusions or limitations. States that choose to cover unborn children under the State plan should include a separate section 6.2 that specifies benefits for the unborn child population. (Section 2110(a)) (42CFR, 457.490)

If the state elects to cover the new option of targeted low income pregnant women, but chooses to provide a different benefit package for these pregnant women under the CHIP plan, the state must include a separate section 6.2 describing the benefit package for pregnant women. (Section 2112)

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

6.2.1.

Inpatient services (Section 2110(a)(1)) 6.2.2.

Outpatient services (Section 2110(a)(2)) 6.2.3.

Physician services (Section 2110(a)(3)) 6.2.4.

Surgical services (Section 2110(a)(4)) 6.2.5.

Clinic services (including health center services) and other ambulatory health care services. (Section 2110(a)(5)) 6.2.6.

Prescription drugs (Section 2110(a)(6)) 6.2.7.

Over-the-counter medications (Section 2110(a)(7)) 6.2.8.

Laboratory and radiological services (Section 2110(a)(8)) 6.2.9.

Prenatal care and pre-pregnancy family services and supplies (Section 2110(a)(9))

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6.2.10.

Inpatient mental health services, other than services described in 6.2.18., but including services furnished in a state-operated mental hospital and including residential or other 24-hour therapeutically planned structural services (Section 2110(a)(10)) 6.2.11.

Outpatient mental health services, other than services described in 6.2.19, but including services furnished in a state-operated mental hospital and including community-based services (Section 2110(a)(11)) 6.2.12.

Durable medical equipment and other medically-related or remedial devices (such as prosthetic devices, implants, eyeglasses, hearing aids, dental devices, and adaptive devices) (Section 2110(a)(12)) 6.2.13.

Disposable medical supplies (Section 2110(a)(13))

Guidance: Home and community based services may include supportive services such as home health nursing services, home health aide services, personal care, assistance with activities of daily living, chore services, day care services, respite care services, training for family members, and minor modifications to the home. 6.2.14.

Home and community-based health care services (Section 2110(a)(14))

Guidance: Nursing services may include nurse practitioner services, nurse midwife services, advanced practice nurse services, private duty nursing care, pediatric nurse services, and respiratory care services in a home, school or other setting.

6.2.15.

Nursing care services (Section 2110(a)(15)) 6.2.16.

Abortion only if necessary to save the life of the mother or if the pregnancy is the result of an act of rape or incest (Section 2110(a)(16) 6.2.17.

Dental services (Section 2110(a)(17)) States updating their dental benefits must complete 6.2-DC (CHIPRA # 7, SHO # #09-012 issued October 7, 2009)

6.2.18.

Vision screenings and services (Section 2110(a)(24)) 6.2.19.

Hearing screenings and services (Section 2110(a)(24)) 6.2.20.

Inpatient substance abuse treatment services and residential substance abuse treatment services (Section 2110(a)(18)) 6.2.21.

Outpatient substance abuse treatment services (Section 2110(a)(19))

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6.2.22.

Case management services (Section 2110(a)(20)) 6.2.23.

Care coordination services (Section 2110(a)(21)) 6.2.24.

Physical therapy, occupational therapy, and services for individuals with speech, hearing, and language disorders (Section 2110(a)(22)) 6.2.25.

Hospice care (Section 2110(a)(23))

Guidance: See guidance for section 6.1.4.1 for a guidance on the statutory requirements for EPSDT under sections 1905(r) and 1902(a)(43) of the Act. If the benefit being provided does not meet the EPSDT statutory requirements, do not check this box.

6.2.26. EPSDT consistent with requirements of sections 1905(r) and 1902(a)(43) of the Act

Guidance: Any other medical, diagnostic, screening, preventive, restorative, remedial, therapeutic or rehabilitative service may be provided, whether in a facility, home, school, or other setting, if recognized by State law and only if the service is: 1) prescribed by or furnished by a physician or other licensed or registered practitioner within the scope of practice as prescribed by State law; 2) performed under the general supervision or at the direction of a physician; or 3) furnished by a health care facility that is operated by a State or local government or is licensed under State law and operating within the scope of the license.

6.2.27.

Any other medical, diagnostic, screening, preventive, restorative, remedial, therapeutic, or rehabilitative services. (Section 2110(a)(24)) 6.2.28.

Premiums for private health care insurance coverage (Section 2110(a)(25)) 6.2.29.

Medical transportation (Section 2110(a)(26))

Guidance: Enabling services, such as transportation, translation, and outreach services, may be offered only if designed to increase the accessibility of primary and preventive health care services for eligible low-income individuals.

6.2.30.

Enabling services (such as transportation, translation, and outreach services) (Section 2110(a)(27)) 6.2.31.

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

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6.2-DC Dental Coverage (CHIPRA # 7, SHO # #09-012 issued October 7, 2009) The State will provide dental coverage to children through one of the following. Please update Sections 9.10 and 10.3-DC when electing this option. Dental services provided to children eligible for dental-only supplemental services must receive the same dental services as provided to otherwise eligible CHIP children (Section 2103(a)(5)): The state adopted the Washington Medicaid dental benefit package for CHIP. This includes EPSDT coverage. The state assures dental services represented by the following categories of common dental terminology (CDT) codes are included in the dental benefit. A comprehensive description of covered services and schedules can be found at: https://www.hca.wa.gov/assets/billers-and-providers/Dental-related-serv-bg.pdf.

6.2.1-DC State Specific Dental Benefit Package. The State assures dental services represented by the following categories of common dental terminology (CDT*) codes are included in the dental benefits: 1. Diagnostic (i.e., clinical exams, x-rays) (CDT codes: D0100-D0999) (must follow periodicity schedule) 2. Preventive (i.e., dental prophylaxis, topical fluoride treatments, sealants) (CDT codes: D1000-D1999) (must follow periodicity schedule) 3. Restorative (i.e., fillings, crowns) (CDT codes: D2000-D2999) * Current Dental Terminology, © 2010 American Dental Association. All rights reserved 4. Endodontic (i.e., root canals) (CDT codes: D3000-D3999) 5. Periodontic (treatment of gum disease) (CDT codes: D4000-D4999) 6. Prosthodontic (dentures) (CDT codes: D5000-D5899, D5900-D5999, and D6200- D6999) 7. Oral and Maxillofacial Surgery (i.e., extractions of teeth and other oral surgical procedures) (CDT codes: D7000-D7999) 8. Orthodontics (i.e., braces) (CDT codes: D8000-D8999) 9. Emergency Dental Services

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6.2.1.1-DC Periodicity Schedule. The State has adopted the following periodicity

schedule: State-developed Medicaid-specific American Academy of Pediatric Dentistry Other Nationally recognized periodicity schedule Other (description attached) Dental services: D9992-care coordination allowed specifically for phone triage during the Federal COVID-19 pandemic. This is a temporary code and is not considered tele- dentistry. *Not to be used for normal operations such as appointment scheduling (20- 001).

EPSDT 6.2.2-DC Benchmark coverage; (Section 2103(c)(5), 42 CFR 457.410, and 42 CFR 457.420) 6.2.2.1-DC FEHBP-equivalent coverage; (Section 2103(c)(5)(C)(i)) (If checked, attach copy of the dental supplemental plan benefits description and the applicable CDT codes. If the State chooses to provide supplemental services, also attach a description of the services and applicable CDT* codes) 6.2.2.2-DC

State employee coverage; (Section 2103(c)(5)(C)(ii)) (If checked, identify the plan and attach a copy of the benefits description and the applicable CDT codes. If the State chooses to provide supplemental services, * Current Dental Terminology, © 2010 American Dental Association. All rights reserved also attach a description of the services and applicable CDT codes) 6.2.2.3-DC

HMO with largest insured commercial enrollment (Section 2103(c)(5)(C)(iii)) (If checked, identify the plan and attach a copy of the benefits description and the applicable CDT codes. If the State chooses to provide supplemental services, also attach a description of the services and applicable CDT codes)

6.2-DS Supplemental Dental Coverage- The State will provide dental coverage to children

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eligible for dental-only supplemental services. Children eligible for this option must receive the same dental services as provided to otherwise eligible CHIP children (Section 2110(b)(5)(C)(ii)). Please update Sections 1.1-DS, 4.1-DS, 4.2-DS, and 9.10 when electing this option.

Guidance: Under Title XXI, pre-existing condition exclusions are not allowed, with the only exception being in relation to another law in existence (HIPAA/ERISA). Indicate that the plan adheres to this requirement by checking the applicable description.

In the event that the State provides benefits through a group health plan or group health coverage, or provides family coverage through a group health plan under a waiver (see Section 6.4.2.), pre-existing condition limits are allowed to the extent permitted by HIPAA/ERISA. If the State is contracting with a group health plan or provides benefits through group health coverage, describe briefly any limitations on pre-existing conditions. (Formerly 8.6.)

6.2- MHPAEA Section 2103(c)(6)(A) of the Social Security Act requires that, to the extent that it provides both medical/surgical benefits and mental health or substance use disorder benefits, a State child health plan ensures that financial requirements and treatment limitations applicable to mental health and substance use disorder benefits comply with the mental health parity requirements of section 2705(a) of the Public Health Service Act in the same manner that such requirements apply to a group health plan. If the state child health plan provides for delivery of services through a managed care arrangement, this requirement applies to both the state and managed care plans. These requirements are also applicable to any additional benefits provided voluntarily to the child health plan population by managed care entities and will be considered as part of CMS’s contract review process at 457.1201(l).

6.2.1- MHPAEA Before completing a parity analysis, the State must determine whether each covered benefit is a medical/surgical, mental health, or substance use disorder benefit based on a standard that is consistent with state and federal law and generally recognized independent standards of medical practice (§457.496(f)(1)(i)).

6.2.1.1- MHPAEA Please choose the standard(s) the state uses to determine whether a covered benefit is a medical/surgical benefit, mental health benefit, or substance use disorder benefit. The most current version of the standard elected must be used. If

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different standards are used for the different benefit types, please specify the benefit type(s) to which each standard is applied. If “Other” is selected, please provide a description of that standard. International Classification of Disease (ICD) Diagnostic and Statistical Manual of Mental Disorders (DSM) State guidelines Other (Describe: ) 6.2.1.2- MHPAEA Does the State provide mental health and/or substance use disorder benefits? Yes No Guidance: If the State does not provide any mental health or substance use disorder benefits, the mental health parity requirements do not apply ((§457.496(f)(1)). Continue on to Section 6.3.

6.2.2- MHPAEA Section 2103(c)(6)(B) of the Act provides that to the extent a State child health plan includes coverage of early and periodic screening, diagnostic, and treatment services (EPSDT) defined in section 1905(r) of the Act and provided in accordance with section 1902(a)(43) of the Act, the plan shall be deemed to satisfy the parity requirements of section 2103(c)(6)(A) of the Act. 6.2.2.1- MHPAEA Does the State child health plan provide coverage of EPSDT? The State must provide for coverage of EPSDT benefits, consistent with Medicaid statutory requirements, as indicated in section 6.2.26 of the State child health plan in order to answer “yes.”

Yes No

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Guidance: If the State child health plan does not provide EPSDT consistent with Medicaid statutory requirements at sections 1902(a)(43) and 1905(r) of the Act, please go to Section 6.2.3- MHPAEA to complete the required parity analysis of the State child health plan.

If the state does provide EPSDT benefits consistent with Medicaid requirements, please continue this section to demonstrate compliance with the statutory requirements of section 2103(c)(6)(B) of the Act and the mental health parity regulations of §457.496(b) related to deemed compliance.

6.2.2.2- MHPAEA EPSDT benefits are provided to the following:

All children covered under the State child health plan A subset of children covered under the State child health plan. Please describe the different populations (if applicable) covered under the State child health plan that are provided EPSDT benefits consistent with Medicaid statutory requirements. Children birth to age 19. Guidance: If only a subset of children are provided EPSDT benefits under the State child health plan, §457.496(b)(3) limits deemed compliance to those children only and you must complete Section 6.2.3- MHPAEA to complete the required parity analysis for the other children.

6.2.2.3- MHPAEA To be deemed compliant with the MHPAEA parity requirements, States must provide EPSDT in accordance with sections 1902(a)(43) and 1905(r) of the Act (§457.496(b)(2)). The State assures each of the following for children eligible for EPSDT under the separate State child health plan:

All screening services, including screenings for mental health and substance use disorder conditions, are provided at intervals that align with a periodicity schedule that meets reasonable standards of medical or dental practice as well as when medically necessary to determine the existence of suspected illness or conditions (Section 1905(r)). All diagnostic services described in 1905(a) of the Act are provided as needed to diagnose suspected conditions or illnesses discovered through screening

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services, whether or not those services are covered under the Medicaid state plan (Section 1905(r)). All items and services described in section 1905(a) of the Act are provided when needed to correct or ameliorate a defect or any physical or mental illnesses and conditions discovered by the screening services, whether or not such services are covered under the Medicaid State plan (Section 1905(r)(5)). Treatment limitations applied to services provided under the EPSDT benefit are not limited based on a monetary cap or budgetary constraints and may be exceeded as medically necessary to correct or ameliorate a medical or physical condition or illness (Section 1905(r)(5)). Non-quantitative treatment limitations, such as definitions of medical necessity or criteria for medical necessity, are applied in an individualized manner that does not preclude coverage of any items or services necessary to correct or ameliorate any medical or physical condition or illness (Section 1905(r)(5)). EPSDT benefits are not excluded on the basis of any condition, disorder, or diagnosis (Section 1905(r)(5)). The provision of all requested EPSDT screening services, as well as any corrective treatments needed based on those screening services, are provided or arranged for as necessary (Section 1902(a)(43)). All families with children eligible for the EPSDT benefit under the separate State child health plan are provided information and informed about the full range of services available to them (Section 1902(a)(43)(A)). Guidance: For states seeking deemed compliance for their entire State child health plan population, please continue to Section 6.3. If not all of the covered populations are offered EPSDT, the State must conduct a parity analysis of the benefit packages provided to those populations. Please continue to 6.2.3- MHPAEA.

Mental Health Parity Analysis Requirements for States Not Providing EPSDT to All Covered Populations

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Guidance: The State must complete a parity analysis for each population under the State child health plan that is not provided the EPSDT benefit consistent with the requirements §457.496(b). If the State provides benefits or limitations that vary within the child or pregnant woman populations, states should perform a parity analysis for each of the benefit packages. For example, if different financial requirements are applied according to a beneficiary’s income, a separate parity analysis is needed for the benefit package provided at each income level.

6.2.3- MHPAEA In order to conduct the parity analysis, the State must place all medical/surgical and mental health and substance use disorder benefits covered under the State child health plan into one of four classifications: Inpatient, outpatient, emergency care, and prescription drugs (§§457.496(d)(2)(ii); 457.496(d)(3)(ii)(B)).

6.2.3.1 MHPAEA Please describe below the standard(s) used to place covered benefits into one of the four classifications. The state classified services in the four categories based on the approach described in the CMS Parity Comliance Toolkit and guidance provide through the CMS/SAMHSA technical assistance process and the CMS parity academy. Washington State’s Parity Analysis States: Federal parity regulations allow states some latitude in placement of benefits within each of these categories. Washington State developed a preliminary list of benefits in each category based on current state plan services. The state then consulted with MCOs and BHOs to ensure the list was accurate and complete. Before sending out parity questionnaires, the state created a list of services covered under each category. This helped ensure consistency among MCOs and BHOs when answering questions about each benefit category. The definitions for each category are: • Outpatient: Routine services that occur in an outpatient setting and are not included in the emergency category. • Inpatient: Any non-emergency service that involves the individual staying overnight at a facility. This includes inpatient MH and SUD treatment and crisis stabilization services occurring in a facility. • Emergency: Services or items delivered in an emergency department (ED) setting or emergency/crisis stabilization services, not requiring an overnight stay, which are not delivered in an inpatient setting. • Pharmacy: Covered medications, drugs and associated supplies requiring a prescription.

6.2.3.1.1 MHPAEA The state assures that:

The State has classified all benefits covered under the State plan into one of the four classifications. The same reasonable standards are used for determining the classification for a mental health or substance use disorder benefit as are used for determining the classification of medical/surgical benefits. 6.2.3.1.2- MHPAEA Does the state use sub-classifications to distinguish between

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office visits and other outpatient services? Yes No 6.2.3.1.2.1- MHPAEA If the State uses sub-classifications to distinguish between outpatient office visits and other outpatient services, the State assures the following: The sub-classifications are only used to distinguish office visits from other outpatient items and services, and are not used to distinguish between similar services on other bases (ex: generalist vs. specialist visits). Guidance: For purposes of this section, any reference to “classification(s)” includes sub-classification(s) in states using sub-classifications to distinguish between outpatient office visits from other outpatient services.

6.2.3.2 MHPAEA The State assures that: Mental health/ substance use disorder benefits are provided in all classifications in which medical/surgical benefits are provided under the State child health plan. Guidance: States are not required to cover mental health or substance use disorder benefits. However if a state does provide any mental health or substance use disorders, those mental health or substance use disorder benefits must be provided in all the same classifications in which medical/surgical benefits are covered under the State child health plan.

Annual and Aggregate Lifetime Limits 6.2.4- MHPAEA A State that provides both medical/surgical benefits and mental health and/or substance use disorder benefits must comply with parity requirements related to annual and aggregate lifetime dollar limits for benefits covered under the State child health plan (§457.496(c)). 6.2.4.1- MHPAEA Please indicate whether the State applies an aggregate lifetime dollar limit and/or an annual dollar limit on any mental health or substance abuse disorder benefits covered under the State child health plan.

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Aggregate lifetime dollar limit is applied Aggregate annual dollar limit is applied No dollar limit is applied

Guidance: If there are no aggregate lifetime or annual dollar limit on any mental health or substance use disorder benefits, please go to section 6.2.5- MHPAEA.

6.2.4.2- MHPAEA Are there any medical/surgical benefits covered under the State child health plan that have either an aggregate lifetime dollar limit or an annual dollar limit? If yes, please specify what type of limits apply. Yes (Type(s) of limit: ) No

Guidance: If no aggregate lifetime dollar limit is applied to medical/ surgical benefits, the State may not impose an aggregate lifetime dollar limit on any mental health or substance use disorder benefits. If no aggregate annual dollar limit is applied to medical/surgical benefits, the State may not impose an aggregate annual dollar limit on any mental health or substance use disorder benefits (§457.496(c)(1)).

6.2.4.3 – MHPAEA. States applying an aggregate lifetime or annual dollar limit on medical/surgical benefits and mental health or substance use disorder benefits must determine whether the portion of the medical/surgical benefits to which the limit applies is less than one-third, at least one-third but less than two-thirds, or at least two-thirds of all medical/surgical benefits covered under the State plan (457.496(c)). The portion of medical/surgical benefits subject to the limit is based on the dollar amount expected to be paid for all medical/surgical benefits under the State plan for the State plan year or portion of the plan year after a change in benefits that affects the applicability of the aggregate lifetime or annual dollar limits (457.496(c)(3)). The State assures that it has developed a reasonable methodology to calculate the portion of covered medical/surgical benefits which are subject to the aggregate lifetime and/or annual dollar limit, as applicable. Guidance: Please include the state’s methodology to calculate the portion of covered medical/surgical

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benefits which are subject to the aggregate lifetime and/or annual dollar limit, as applicable, as an attachment to the State child health plan.

6.2.4.3.1- MHPAEA Please indicate the portion of the total costs for medical and surgical benefits covered under the State plan which are subject to a lifetime dollar limit: Less than 1/3 At least 1/3 and less than 2/3 At least 2/3 6.2.4.3.2- MHPAEA Please indicate the portion of the total costs for medical and surgical benefits covered under the State plan which are subject to an annual dollar limit: Less than 1/3 At least 1/3 and less than 2/3 At least 2/3

Guidance: If an aggregate lifetime limit is applied to less than one-third of all medical/surgical benefits, the State may not impose an aggregate lifetime limit on any mental health or substance use disorder benefits. If an annual dollar limit is applied to less than one-third of all medical surgical benefits, the State may not impose an annual dollar limit on any mental health or substance use disorder benefits (§457.496(c)(1)). Skip to section 6.2.5-MHPAEA.

If the State applies an aggregate lifetime or annual dollar limit to at least one-third of all medical/surgical benefits, please continue below to provide the assurances related to the determination of the portion of total costs for medical/surgical benefits that are subject to either an annual or lifetime limit.

6.2.4.3.2.1- MHPAEA If the State applies an aggregate lifetime or annual dollar limit to at least1/3 and less than 2/3 of all medical/surgical benefits, the State assures the following (§§457.496(c)(4)(i)(B); 457.496(c)(4)(ii)):

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The State applies an aggregate lifetime or annual dollar limit on mental health or substance use disorder benefits that is no more restrictive than an average limit calculated for medical/surgical benefits. Guidance: The state’s methodology for calculating the average limit for medical/surgical benefits must be consistent with §§457.496(c)(4)(i)(B) and 457.496(c)(4)(ii). Please include the state’s methodology as an attachment to the State child health plan.

6.2.4.3.2.2- MHPAEA If at least 2/3 of all medical/surgical benefits are subject to an annual or lifetime limit, the State assures either of the following (§457.496(c)(2)(i); (§457.496(c)(2)(ii)): The aggregate lifetime or annual dollar limit is applied to both medical/surgical benefits and mental health and substance use disorder benefits in a manner that does not distinguish between medical/surgical benefits and mental health and substance use disorder benefits; or The aggregate lifetime or annual dollar limit placed on mental health and substance use disorder benefits is no more restrictive than the aggregate lifetime or annual dollar limit on medical/surgical benefits. Quantitative Treatment Limitations

6.2.5- MHPAEA Does the State apply quantitative treatment limitations (QTLs) on any mental health or substance use disorder benefits in any classification of benefits? If yes, specify the classification(s) of benefits in which the State applies one or more QTLs on any mental health or substance use disorder benefits.

Yes (Specify: ) No

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Guidance: If the state does not apply any type of QTLs on any mental health or substance use disorder benefits in any classification, the state meets parity requirements for QTLs and should continue to Section 6.2.6 - MHPAEA. If the state does apply financial requirements to any mental health or substance use disorder benefits, the state must conduct a parity analysis. Please continue.

6.2.5.1- MHPAEA Does the State apply any type of QTL on any medical/surgical benefits?

Yes No

Guidance: If the State does not apply QTLs on any medical/surgical benefits, the State may not impose quantitative treatment limitations on mental health or substance use disorder benefits, please go to Section 6.2.6- MHPAEA related to non-quantitative treatment limitations.

6.2.5.2- MHPAEA Within each classification of benefits in which the State applies a type of QTL on any mental health or substance use disorder benefits, the State must determine the proportion of medical and surgical benefits in the class which are subject to the limitation. More specifically, the State must determine the ratio of (a) the dollar amount of all payments expected to be paid under the State plan for medical and surgical benefits within a classification which are subject to the type quantitative treatment limitation for the plan year (or portion of the plan year after a mid-year change affecting the applicability of a type of quantitative treatment limitation to any medical/surgical benefits in the class) to (b) the dollar amount expected to be paid for all medical and surgical benefits within the classification for the plan year. For purposes of this paragraph all payments expected to be paid under the State plan includes payments expected to be made directly by the State and payments which are expected to be made by MCEs contracting with the State. (§457.496(d)(3)(i)(C))

The State assures it has applied a reasonable methodology to determine the dollar amounts used in the ratio described above for each classification within

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which the State applies QTLs to mental health or substance use disorder benefits. (§457.496(d)(3)(i)(E)) Guidance: Please include the state’s methodology as an attachment to the State child health plan.

6.2.5.3- MHPAEA For each type of QTL applied to any mental health or substance use disorder benefits within a given classification, does the State apply the same type of QTL to “substantially all” (defined as at least two-thirds) of the medical/surgical benefits within the same classification? (§457.496(d)(3)(i)(A))

Yes No Guidance: If the State does not apply a type of QTL to substantially all medical/surgical benefits in a given classification of benefits, the State may not impose that type of QTL on mental health or substance use disorder benefits in that classification. (§457.496(d)(3)(i)(A))

6.2.5.3.1- MHPAEA For each type of QTL applied to mental health or substance use disorder benefits, the State must determine the predominant level of that type which is applied to medical/surgical benefits in the classification. The “predominant level” of a type of QTL in a classification is the level (or least restrictive of a combination of levels) that applies to more than one-half of the medical/surgical benefits in that classification, as described in §§457.496(d)(3)(i)(B). The portion of medical/surgical benefits in a classification to which a given level of a QTL type is applied is based on the dollar amount of payments expected to be paid for medical/surgical benefits subject to that level as compared to all medical/surgical benefits in the classification, as described in §457.496(d)(3)(i)(C). For each type of quantitative treatment limitation applied to mental health or substance use disorder benefits, the State assures:

The same reasonable methodology applied in determining the dollar amounts used to determine whether substantially all medical/surgical

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benefits within a classification are subject to a type of quantitative treatment limitation also is applied in determining the dollar amounts used to determine the predominant level of a type of quantitative treatment limitation applied to medical/surgical benefits within a classification. (§457.496(d)(3)(i)(E)) The level of each type of quantitative treatment limitation applied by the State to mental health or substance use disorder benefits in any classification is no more restrictive than the predominate level of that type which is applied by the State to medical/surgical benefits within the same classification. (§457.496(d)(2)(i)) Guidance: If there is no single level of a type of QTL that exceeds the one-half threshold, the State may combine levels within a type of QTL such that the combined levels are applied to at least half of all medical/surgical benefits within a classification; the predominate level is the least restrictive level of the levels combined to meet the one-half threshold (§457.496(d)(3)(i)(B)(2)).

Non-Quantitative Treatment Limitations 6.2.6- MHPAEA The State may utilize non-quantitative treatment limitations (NQTLs) for mental health or substance use disorder benefits, but the State must ensure that those NQTLs comply with all the mental health parity requirements (§§457.496(d)(4); 457.496(d)(5)).

6.2.6.1 – MHPAEA If the State imposes any NQTLs, complete this subsection. If the State does not impose NQTLs, please go to Section 6.2.7-MHPAEA.

The State assures that the processes, strategies, evidentiary standards or other factors used in the application of any NQTL to mental health or substance use disorder benefits are no more stringent than the processes, strategies, evidentiary standards or other factors used in the application of NQTLs to medical/surgical benefits within the same classification. Guidance: Examples of NQTLs include medical management standards to limit or exclude benefits based on medical necessity, restrictions based on geographic location, provider specialty, or other

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criteria to limit the scope or duration of benefits, provider reimbursement rates and provider network design (ex: preferred providers vs. participating providers). Additional examples of possible NQTLs are provided in §457.496(d)(4)(ii).

6.2.6.2 – MHPAEA The State or MCE contracting with the State must comply with parity if they provide coverage of medical or surgical benefits furnished by out-of-network providers.

6.2.6.2.1- MHPAEA Does the state or MCE contracting with the State provide

coverage of services provided by out of network providers? Yes No 6.2.6.2.2- MHPAEA If yes, please assure the following: The State attests that when determining access to out-of-network providers within a benefit classification, the processes, strategies, evidentiary standards, or other factors used to determine access to those providers for mental health/ substance use disorder benefits are comparable to and applied no more stringently than the processes, strategies, evidentiary standards or other factors used to determine access for out- of-network providers for medical/surgical benefits. Availability of Plan Information 6.2.7- MHPAEA The State must provide beneficiaries, potential enrollees, and providers with information related to medical necessity criteria and denials of payment or reimbursement for mental health or substance use disorder services.

6.2.7.1- MHPAEA Medical necessity criteria determinations must be made available to any current or potential enrollee or contracting provider, upon request. The state attests that the following entities provide this information: State Managed Care entities

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Both

6.2.7.2- MHPAEA Reason for any denial for reimbursement or payment for

mental health or substance use disorder benefits must be made available to the

enrollee by the health plan or the State. The state attests that the following

entities provide denial information: State Managed Care entities Both

6.3. The State assures that, with respect to pre-existing medical conditions, one of

the following two statements applies to its plan: (42CFR 457.480) 6.3.1.

The State shall not permit the imposition of any pre-existing medical condition exclusion for covered services (Section 2102(b)(1)(B)(ii)); OR 6.3.2.

The State contracts with a group health plan or group health insurance coverage, or contracts with a group health plan to provide family coverage under a waiver (see Section 6.6.2. (formerly 6.4.2) of the template). Pre- existing medical conditions are permitted to the extent allowed by HIPAA/ERISA. (Formerly 8.6.) (Section 2103(f)) Describe:

Guidance: States may request two additional purchase options in Title XXI: cost effective coverage through a community-based health delivery system and for the purchase of family coverage. (Section 2105(c)(2) and (3)) (457.1005 and 457.1010)

6.4. Additional Purchase Options- If the State wishes to provide services under the plan through cost effective alternatives or the purchase of family coverage, it must request the appropriate option. To be approved, the State must address the following: (Section 2105(c)(2) and (3)) (42 CFR 457.1005 and 457.1010) 6.4.1.

Cost Effective Coverage- Payment may be made to a State in excess of the 10 percent limitation on use of funds for payments for: 1) other child health assistance for targeted low-income children; 2) expenditures for health

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services initiatives under the plan for improving the health of children (including targeted low-income children and other low-income children); 3) expenditures for outreach activities as provided in Section 2102(c)(1) under the plan; and 4) other reasonable costs incurred by the State to administer the plan, if it demonstrates the following (42CFR 457.1005(a)):

6.4.1.1. Coverage provided to targeted low-income children through such

expenditures must meet the coverage requirements above; Describe the coverage provided by the alternative delivery system. The State may cross reference Section 6.2.1 - 6.2.28. (Section 2105(c)(2)(B)(i)) (42CFR 457.1005(b))

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

Guidance: Check below if the State is requesting to provide cost-effective coverage through a community- based health delivery system. This allows the State to waive the 10 percent limitation on expenditures not used for Medicaid or health insurance assistance if coverage provided to targeted low-income children through such expenditures meets the requirements of Section 2103; the cost of such coverage is not greater, on an average per child basis, than the cost of coverage that would otherwise be provided under Section 2103; and such coverage is provided through the use of a community-based health delivery system, such as through contracts with health centers receiving funds under Section 330 of the Public Health Services Act or with hospitals such as those that receive disproportionate share payment adjustments under Section 1886(c)(5)(F) or 1923.

If the cost-effective alternative waiver is requested, the State must demonstrate that payments in excess of the 10 percent limitation will be used for other child health assistance for targeted low- income children; expenditures for health services initiatives under the plan for improving the health of children (including targeted low-income children and other low-income children); expenditures for outreach activities as provided in Section 2102(c)(1) under the plan; and other reasonable costs incurred by the State to administer the plan. (42CFR, 457.1005(a))

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

Guidance: Check 6.4.2.if the State is requesting to purchase family coverage. Any State requesting to purchase such coverage will need to include information that establishes to the Secretary’s satisfaction that: 1) when compared to the amount of money that would have been paid to cover only the children involved with a comparable package, the purchase of family coverage is cost effective; and 2) the purchase of family coverage is not a substitution for coverage already being provided to the child. (Section 2105(c)(3)) (42CFR 457.1010)

6.4.2.

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

6.4.2.1. Purchase of family coverage is cost-effective. The State’s cost of purchasing family coverage, including administrative expenditures, that includes coverage for the targeted low-income children involved or the family involved (as applicable) under premium assistance programs must not be greater than the cost of obtaining coverage under the State plan for all eligible targeted low-income children or families involved; and (2) The State may base its demonstration of cost effectiveness on an assessment of the cost of coverage, including administrative costs, for children or families