West Virginia’s Application for the State Children’s Health Insurance Program

Effective Date: July 1, 1998

Approval Date: As Amended January 1, 2007

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OMB #: 0938-0707 Exp. Date:

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

Preamble

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

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

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

West Virginia’s Application for the State Children’s Health Insurance Program

Effective Date: July 1, 1998

Approval Date: As Amended January 1, 2007

2 Form CMS-R-211

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

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

State/Territory: State of West Virginia . (Name of State/Territory)

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

________________________________________________________________________ (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: Robert W. Ferguson, Jr. Position/Title: Cabinet Secretary, Department of Administration Name: Sharon L. Carte Position/Title: Executive Director, WV Children’s Health Insurance Agency

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

West Virginia’s Application for the State Children’s Health Insurance Program

Effective Date: July 1, 1998

Approval Date: As Amended January 1, 2007 3 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. 7 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.

1.2. 7 Please provide an assurance that expenditures for child health assistance will not be claimed prior to the time that the State has legislative authority to operate the State plan or plan amendment as approved by CMS. (42 CFR 457.40(d))

1.3. 7 Please provide an assurance that the state complies with all applicable civil rights requirements, including title VI of the Civil Rights Act of 1964, title II of the Americans with Disabilities Act of 1990, section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, 45 CFR part 80, part 84, and part 91, and 28 CFR part 35. (42CFR 457.130)

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

Effective date: July 1, 1998

Implementation date: July 1, 1998

As amended April 1, 1999 As amended October 1, 2000 As amended October 23, 2000 As amended July 1, 2002 and with required updates and amendments effective under federal statute August 24, 2001 As amended January 1, 2006 As amended January 1, 2007

(Please see Section 2.1 for a complete description of State Plan Amendments for West Virginia’s Title XXI Program.)

West Virginia’s Application for the State Children’s Health Insurance Program

Effective Date: July 1, 1998

Approval Date: As Amended January 1, 2007 4 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))

West Virginia has two public health insurance programs targeted to low-income children: the West Virginia Medicaid program (WV Medicaid) and the West Virginia Children's Health Insurance Program (WVCHIP). Currently, no public-private partnerships provide creditable coverage.

The WV Medicaid program offers health insurance coverage to all children in the state who meet the following eligibility criteria: ¾ birth to age 1: income up to 150% of the Federal Poverty Level (FPL) ¾ ages 1 through 5: income up to 133% of the FPL ¾ ages 6 through 18: income up to 100% of the FPL

WV Medicaid also uses deductions and disregards in computing income for eligibility determination, as allowed and approved in its State Plan.

WV Medicaid extended 12 month coverage to all eligible children effective June 2001.

State Legislation establishing the West Virginia Children’s Health Insurance Program was signed into law in April 1998; further, this legislation provided for the creation of an oversight body, the Children’s Health Insurance Board whose role is to review and monitor the program’s fiscal standing and approve an annual fiscal plan.

The original baseline for uninsured children in households with family incomes greater than Medicaid eligibility limits and up to 200% Federal Poverty Level (FPL) was 14,000. This was based on Lewin Group, Inc. estimates using the Household and Income and Tax Simulation Model (HITSM) and pooled 1995 and 1996 West Virginia Current Population Survey. The current program has been developed through several phases:

1. WVCHIP was first implemented July 1, 1998 (effective date of July 1, 1998). This is described as Phase I of the program. ¾ This start-up phase was a Medicaid expansion providing coverage for children ages 1 to 5 in families with household incomes greater than 133% and up to 150% FPL. 2. STATE PLAN AMENDMENT #1

WVCHIP Phase II was implemented April 1, 1999 (effective date of April 1, 1999).

West Virginia’s Application for the State Children’s Health Insurance Program

Effective Date: July 1, 1998

Approval Date: As Amended January 1, 2007 5 ¾ This was a benchmark equivalent coverage program whose actuarial-base was the West Virginia Public Employees Insurance Agency Preferred Provider Benefit Plan. ¾ This phase expanded coverage to children from ages 6 to 18 in families with household incomes greater than 100% FPL and up to 150% FPL.

3. STATE PLAN AMENDMENT #2

This State Plan Amendment combined WVCHIP Phase I and Phase II effective October 1, 2000. ¾ The State submitted an amendment June 26, 2000 to withdraw the Phase I Medicaid expansion program and incorporate it into the Phase III benchmark equivalent program. ¾ In September 2000, the State notified the 1425 participants in the Medicaid expansion (Phase I) program of the change through a cover letter. Participants were also provided with a side-by- side comparison of the Phase I program benefits with those of Phase II.

4. STATE PLAN AMENDMENT #3

WVCHIP Phase III was implemented October 23, 2000 (effective date of October 23, 2000). ¾ Eligibility for the benchmark equivalent coverage was expanded to children in families with incomes up to the 200% FPL. ¾ Cost sharing in the form of co-payments for specified services (see Section 8.2) was included for families with household incomes greater than 150% up to 200%.

5. STATE PLAN AMENDMENT #4 ¾ Effective July 1, 2002 the State Plan is amended with required updates and amendments effective under federal statute August 24, 2001 and to expand participation in pharmacy co-payment to families in households with incomes below 150% FPL. It also eliminated the $5 co-payment for generic drug use. ¾ This amendment also includes a lifetime benefit limit of $1 million which is part of the original benchmark program noted above. ¾ This amendment also includes an annual benefit limit of $200,000 per participant.

6. STATE PLAN AMENDMENT #5 ¾ Effective January 1, 2006, the State Plan is amended to reflect a formulary that includes approved generic and/or preferred brand drugs for all therapeutic classes.

¾ There is no coverage for non-listed drugs except where clinical documentation from a physician demonstrates medical necessity. For a few listed therapeutic classes, Over the Counter (OTC) medications approved.

¾ Upon implementation, program participants who are currently taking a drug that is used to treat, or is sensitive to, mental conditions, can continue to have their current prescription(s) covered even if their current medication is not on the Preferred Drug List when it is in one of the

West Virginia’s Application for the State Children’s Health Insurance Program

Effective Date: July 1, 1998

Approval Date: As Amended January 1, 2007 6 following seven drug classes:

Antipsychotics; Serotonin Selective Response Inhibitors (SSRI’s); Central Nervous System Stimulants; Anticonvulsants; Sedative Hypnotics; Aliphatic Phenothiazines; and Attention Deficit Disorder Drugs.

¾ Program participants who are newly prescribed a drug used to treat, or is sensitive to, mental conditions in one of the seven drug classes named above will have coverage from the Preferred Drug List at the time the new prescription is filled, except where there has been a demonstrated need for exception due to medical necessity.

7. STATE PLAN AMENDMENT #6

¾ Effective January 1, 2007, the State Plan is amended to expand coverage to those children in households at or under 220% FPL when they are willing to participate in a premium payment option.

¾ This amendment also modifies cost sharing provisions and cost sharing maximum limits described in Section 8 to permit increased copayments for enrollees at income levels above 200% FPL.

¾ Copayments for non-well visits are modified at all enrollee income levels to afford an incentive for designating and using a medical home.

¾ Children in households between 201% to 220% FPL (WVCHIP Premium) who have had group health care coverage in the 12 month “look back period” are not eligible.

¾ For children in the WVCHIP Premium group (201 to 220% FPL) there is no vision coverage as specified in Section 6.2.12; also dental coverage for this group is limited to $150.00 per child per year as specified in Section 6.2.17.

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

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

Application and Enrollment Process:

¾ West Virginia seeks to enroll all eligible uncovered children in the State’s CHIP and Medicaid programs through a joint application form. The 2-page (back and front) form is accompanied by a 2-page (back and front) information guide, and return mail postage-paid envelope.

¾ WVCHIP maintains a website at www.wvchip.org with an application available for downloading, responses to frequently asked questions; information updates; and a summary of benefits guide. The website also has a Spanish version of the application and directions on where to find help

West Virginia’s Application for the State Children’s Health Insurance Program

Effective Date: July 1, 1998

Approval Date: As Amended January 1, 2007 7 with translation services, if needed. Helpful information such as the current enrollment, an outreach activities calendar, and a contact list of outreach coordinators who can assist with the application is provided. It is also compliant with website requirements at Section 508 of the Rehabilitation Act (29 U.S.C.794d).

¾ In addition to application forms and guides, the WVCHIP maintains and distributes standard informational materials bearing the program logo including: Š Business envelope size insert with the WVCHIP toll-free number, website address and qualifying income guidelines; Š Posters promoting the availability of free/low cost insurance with the CHIP toll- free number and website address; Š Posters with child wellness and immunization schedules (bearing the logo, CHIP Call Center number, and website address; Š Posters with child wellness and immunization schedules (bearing the logo, CHIP Call Center number and website address) are distributed to pediatrician and family practice physician offices, clinics and other health care settings; Š A prevention brochure describing the prevention benefits available through CHIP coverage.

¾ All applications are processed through the electronic eligibility system known as “RAPIDS”, operated by the West Virginia Department of Health Human Resources (WVDHHR); this allows for all CHIP applicants to be screened for Medicaid first. In 2001, about 10,000 children were found eligible for Medicaid as a result of the screening of CHIP applications.

¾ On-going application distribution and application assistance occurs through the CHIP Call Center with a toll-free telephone line. Callers may request mailed applications, or assistance in completing the application with their responses filled in and mailed to them within 24 hours, Spanish and hearing impaired translation services as requested. The CHIP Call Center mails and distributes all standard program material including applications; new enrollee welcome kits with the summary plan description.

¾ Local WVDHHR offices located in 53 of the state’s 55 counties also provide application distribution and assistance. WVDHHR now administers the redetermination or re-enrollment applications through 2 customer call units with toll-free telephone units for quicker turn around.

Cooperative Efforts Through Other State Government Agencies:

¾ Through a cooperative agreement between the WVDHHR and the West Virginia Hospital Association, WVDHHR eligibility workers are outstationed in selected hospitals throughout the state to facilitate outreach and eligibility determination for both WVCHIP and Medicaid.

¾ Within the WVDHHR, the Office of Maternal, Child and Family Health distributes

West Virginia’s Application for the State Children’s Health Insurance Program

Effective Date: July 1, 1998

Approval Date: As Amended January 1, 2007 8 CHIP printed materials to the medical community as part of their outreach and community-based efforts, as do Bureau of Public Health workers.

¾ The Bureau of Employment Programs contacts WVCHIP for participation at workshops for laid-off workers, and “One-Stop” service centers operated by the West Virginia Workforce Investment Board also distributes CHIP information.

¾ The Department of Education has a check-off box on its free and reduced lunch application form that allows parents/guardians to indicate an interest and consent to have the joint CHIP/Medicaid form mailed to them. Addresses are compiled through the Department’s information system which generates a centralized mailing list for all participating local county school Boards. This list is made available to the WVCHIP about two months after the beginning of the school year.

¾ The West Virginia State Supreme Court mandates through an administrative order that family law judges must provide WVCHIP applications and other program information to every parent of a dependent child at the first appearance before the court. This allows WV Family Courts to facilitate children’s access to coverage when considering child support decisions. WVCHIP supplies copies of the joint application to all family law judges and county circuit clerks on an ongoing basis.

¾ As required by recent legislation passed by the West Virginia legislature, the WVCHIP Insurance Board will develop and administer a plan whereby applications for enrollment may be taken by primary care centers or other health care providers and transmitted electronically for eligibility screening.

¾ Members of the Governor’s Health Umbrella Group planned and financed the West Virginia Healthcare Survey, a survey of over 16,000 households. Conducted by the Institute for Health Policy Research at West Virginia University, the survey results for the first report on children show that West Virginia’s rate of insurance coverage from all sources for all children up through age 18 is 93.4%, considerably higher than that reported in other states. Survey sampling was able to identify numbers of uninsured children at the county level enabling better targeting of outreach efforts by WVCHIP and Medicaid.

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: None.

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

The WVCHIP Agency Office and the CHIP Call Center provide referrals to families not

West Virginia’s Application for the State Children’s Health Insurance Program

Effective Date: July 1, 1998

Approval Date: As Amended January 1, 2007 9 meeting either CHIP or Medicaid income limits to primary care networks which include Federally Qualified Health Clinics and Rural Health Clinics which accept payment on a sliding fee scale basis.

Both the CHIP Agency Office and the Call Center also refer families with specialized needs, such as dental services, special needs children, early intervention services to the Office of Maternal, Child and Family Health (OMCFH). OMCFH has provider networks and recruits providers for these specialized program areas.

West Virginia’s Application for the State Children’s Health Insurance Program

Effective Date: July 1, 1998

Approval Date: As Amended January 1, 2007 10 Section 3. Methods of Delivery and Utilization Controls (Section 2102)(a)(4))

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

3.1. Describe the methods of delivery of the child health assistance using Title XXI funds to targeted low-income children. Include a description of the choice of financing and the methods for assuring delivery of the insurance products and delivery of health care services covered by such products to the enrollees, including any variations. (Section 2102)(a)(4) (42CFR 457.490(a)) The State of West Virginia provides health insurance benefits through a plan managed by the Children’s Health Insurance Agency, within the Department of Administration, using the same third- party administrator as the state employee health insurance plan. Primary care centers and school- based health centers, which provide low-income families with health care services, are also included in the provider network to assure access for children in rural areas served by these facilities, as well as emphasis on preventive services.

All services are provided within a fee for service delivery system. All families are asked to designate a medical home for their children and are encouraged to do so through waiving of copayments for non- well visits. Families can change their choice of medical home once each year, and still retain their waived copayment status.

3.2. Describe the utilization controls under the child health assistance provided under the plan for targeted low-income children. Describe the systems designed to ensure that enrollees receiving health care services under the state plan receive only appropriate and medically necessary health care consistent with the benefit package described in the approved state plan. (Section 2102)(a)(4) (42CFR 457.490(b)) The utilization controls used by the Public Employees Insurance Agency (PEIA), which administers the state employee health insurance plan, are also used in the Title XXI program. WVCHIP and PEIA both contract with the same medical benefit manager; they also contract with the same pharmacy benefit manager. These third-party administrators (TPAs) provide the State of West Virginia’s Title XXI program with medical necessity, pre-certification, prior approval, fraud detection, audit and extensive utilization reporting.

The TPA provides the following quality assurance services to the WVCHIP program:

Š Claims audits Š Audits of customer service representatives Š Monitoring of calls from customer service, PPR and membership areas Š Individual audits upon request from management to identify specific processing issues Š Routine QA reports to management for use in evaluating employee and departmental performance Š Monthly management reporting

West Virginia’s Application for the State Children’s Health Insurance Program

Effective Date: July 1, 1998

Approval Date: As Amended January 1, 2007 11

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. 7 Geographic area served by the Plan: State of West Virginia 4.1.2. 7 Age: 0-18 (As amended 4/1/99.) 4.1.3. 7 Income: The family household upper income level for participation in WVCHIP is 220% FPL* effective January 1, 2007.

WVCHIP participating income levels exceed Medicaid limits (as noted in Section 2.1) up to and including 200% FPL as amended (10/23/2000); effective 1/1/2007 coverage is expanded to those families between 201% FPL to 220% FPL household income levels who participate in premium cost sharing through the WVCHIP Premium plan (hereinafter “WVCHIP Premium”).

WVCHIP’s rules for counting income are the same as those under this State’s Title XIX program as set forth in the WV Income Maintenance Manual and include both earned and unearned income to define gross income. Income disregards for premium paying participants at 201% to 220% FPL are the same as those participants below 200% FPL who do not pay premiums. 4.1.4. † Resources (including any standards relating to spend downs and disposition of resources):__________________________ 4.1.5. 7 Residency: State resident 4.1.6. † Disability Status (so long as any standard relating to disability status does not restrict eligibility): _______________________________ 4.1.7.7 Access to or coverage under other health coverage: Any child under a group health plan or under health insurance coverage, as defined in §2791 of the Public Health Service Act (42 USC §300gg-91(a) and (b)(1)) shall not be eligible for the program.

Current or past coverage under an employer group plan for “look back” periods of six and twelve months can exclude an applicant from coverage. Non-premium paying participants are ineligible for coverage if they have had health care coverage in the previous six months; premium paying participants are ineligible for a 12 month period as specified by State statute. (Exceptions for involuntary loss of coverage and lack of cost effective insurance are noted in Section 4.4.4.1.).

* Denotes income as a percentage of federal poverty level as that term is used in 21.10(b)(4) of the Social Security Act.

West Virginia’s Application for the State Children’s Health Insurance Program

Effective Date: July 1, 1998

Approval Date: As Amended January 1, 2007 12

Because part-time, contractual, or temporary public employees receive no subsidy from government sources and parents must pay full premium costs, children of public employees who have otherwise met the eligibility requirements are not excluded from eligibility for coverage under Title XXI.

4.1.8.7 Duration of eligibility: 12 months 4.1.9.7 Other standards (identify and describe): The State specifies on its joint CHIP/Medicaid application form that social security numbers are required for the applicant.

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))

4.2.1.7 These standards do not discriminate on the basis of diagnosis. 4.2.2.7 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. 4.2.3.7 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) Joint Applications: Applicants for Medicaid and WVCHIP are determined eligible by processing joint applications through an automated electronic eligibility determination system termed Recipient Automated Payment Information and Data System (RAPIDS), and by final eligibility worker review at over 50 county offices. WVCHIP establishes eligibility under signed agreement between the WV Department of Administration, of which WVCHIP is a division, and the WV Department of Health and Human Resources (DHHR) which is responsible for the State’s Title XIX Program.

Intake: Paper applications can be received by mail, local office walk-ins, and appointments. Electronic applications can be submitted on personal computers through www.wvinroads.org with followup mailing to submit documentation. Registered community partners such as the program call center, federally qualified health centers, or hospitals can also submit electronic applications via www.wvinroads.org.

Income Review for ≤ below WVCHIP Premium (Up to and Under 200% FPL): Applications are first determined through automated criteria to be within Medicaid income limits (Section 2.1) are then determined Medicaid eligible. Those above Medicaid income limits are then considered for non-premium plan CHIP eligibility up to 200% FPL. The income limit is based on the gross income amount from which standard deductions are allowed for the following: each working parent or legally

West Virginia’s Application for the State Children’s Health Insurance Program

Effective Date: July 1, 1998

Approval Date: As Amended January 1, 2007 13 aged child; child support expenses; and child care expenses. After all qualified income disregards are applied, any income equal to or below 200% FPL is a qualifying income. Coverage is retroactive to the first day of the month of application.

Income Review for above WVCHIP Premium (201% to 220% FPL): The income limit is based first on the gross income from which all gross income above 200% FPL and up to or equal to 220% FPL has been deducted. Then from this gross income amount, standard deductions for each working parent and child; child support expenses; and child care expenses are then applied. These standard deductions are the same for applicants above and below 200% FPL. After all qualified deductions are applied, any income equal to or under 220% FPL is a qualifying income. Applications with income levels above 200% FPL are routed to premium enrollment services; those with incomes above 220% FPL are sent a denial notice generated through RAPIDS.

Willingness to Pay Premium: Applicants (parents/guardians) in the WVCHIP Premium income range are contacted about their willingness to pay a monthly premium. Single Child families are asked to pay a $35 per month premium (or $420 per annum), and Two or More Child families pay $71.00 per month (or $852 per annum). The applicants are advised as to the amount of the premium and the conditions for initial payment and disenrollment upon non-payment of premium. Coverage begins on the first day of the first month after the premium is paid.

Unwillingness to Pay Premium: Applicants above 200% FPL who are contacted by WVCHIP’s premium payment services but respond that they are unwilling to pay or who do not respond after contact are routed through a modified denial process. This information is reported to RAPIDS as a denial.

Six to Twelve Month Coverage Look Back: Applicants at or under 200% FPL are subject to a six month look back period for previous coverage. Applicants above 200% FPL are subject to a 12 month look back period. Local eligibility workers reviewing the insurance history section of the application assure that the 12 month look back period applies only to applicants above 200% FPL and that applicants at or under 200% have only the six month look back period.

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

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

4.4. Describe the procedures that assure that:

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

West Virginia’s Application for the State Children’s Health Insurance Program

Effective Date: July 1, 1998

Approval Date: As Amended January 1, 2007 14 and 2110(b)(2)(B)) (42 CFR 457.310(b) (42CFR 457.350(a)(1)) 457.80(c)(3)) Income limits for eligibility for Title XXI are higher than those for Title XIX, as more fully described in Section 2.1. The DHHR eligibility staff screens applications first for Medicaid eligibility utilizing the RAPIDS. If the child is not Medicaid eligible, the RAPIDS integrated eligibility system automatically checks for WVCHIP eligibility. Income is verified at the time of application with an annual redetermination of eligibility. The same deductions and disregards for income that have been used in Title XIX are also used in Title XXI: for example, the definition of household is the same.

Once eligibility is verified, the child is covered for twelve months. To the extent that new information regarding income exists and the child becomes eligible for Medicaid, the parent/guardian is notified and is given the option to seek Medicaid coverage.

West Virginia’s Information Services and Communication agency (IS&C - the state’s data and information services agency) maintains enrollee data files for both WVCHIP and the Public Employees Insurance Agency (PEIA). At the time of enrollment, IS&C sends a data file of CHIP enrollees that is checked against those of the PEIA for those insured agencies which are state, county, or munipal employers CHIP informs any applicants shown as eligible for coverage under the State’s insurance plan of this coverage and informs them that they will be terminated unless they can show employer documentation permitting an exception.

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)) West Virginia uses the same process mechanisms to determine eligibility for Title XIX and Title XXI. Eligible children will be enrolled in the appropriate program as determined by eligibility criteria.

4.4.3. The State is taking steps to assist in the enrollment in SCHIP of children determined ineligible for Medicaid. (Sections 2102(a)(1) and (2) and 2102(c)(2)) (42CFR 431.636(b)(4)) West Virginia uses the same process mechanisms to determine eligibility for Title XIX and Title XXI. Eligible children will be enrolled in the appropriate program as determined by eligibility criteria.

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

The State of West Virginia assures that insurance provided under Title XXI will not substitute for coverage under group health plans. The State monitors substitution through its application process.

All applicants at or below 200% FPL must specify coverage held for any child in the past

West Virginia’s Application for the State Children’s Health Insurance Program

Effective Date: July 1, 1998

Approval Date: As Amended January 1, 2007 15 six months. All applicants who have held coverage within the past six months receive notices of denial, unless they meet one of the exceptions below.

¾ Employer terminates coverage ¾ Job is involuntarily terminated and family loses benefits ¾ Private insurance not cost-effective; i.e, if employee’s family coverage exceeds 10% of family gross annual income ¾ Loss of coverage for child due to change in employment ¾ Loss of coverage outside the control of an employee ¾ Death of the policyholder

Data for the total number of applicants receiving denials due to the six month substitution elimination period is collected and analyzed.

West Virginia’s Information Services and Communication agency (IS&C - the state’s data and information services agency) maintains enrollee data files for both WVCHIP and the Public Employees Insurance Agency (PEIA). At the time of enrollment, IS&C sends a data file of CHIP enrollees that is checked against those of the PEIA for those insured agencies which are state, county, or munipal employers CHIP informs any applicants shown as eligible for coverage under the State’s employee insurance plan of this coverage and informs them that they will be terminated unless they can show employer documentation permitting an exception.

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

All applicants above 200% FPL must specify coverage held from the previous 12 months. All such applicants receive a denial unless they have documentation to support an exception as listed below. ¾ Employer terminates coverage ¾ Job is involuntarily terminated and family loses benefits ¾ Private insurance not cost-effective; i.e, if employee’s family coverage exceeds 10% of family gross annual income ¾ Loss of coverage for child due to change in employment ¾ Loss of coverage outside the control of an employee ¾ Death of the policyholder

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

West Virginia’s Application for the State Children’s Health Insurance Program

Effective Date: July 1, 1998

Approval Date: As Amended January 1, 2007 16

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)) The State of West Virginia assures the provision of child health assistance to targeted low- income children in the State who are Indians. All children in the state who may be eligible for assistance are targeted through statewide outreach efforts specifically outlined in Section 5. Native Americans are exempt from cost sharing through self-declaration on the WVCHIP application form. This requirement will be addressed by the program's claims processing system and through education of the provider community.

West Virginia’s Application for the State Children’s Health Insurance Program

Effective Date: July 1, 1998

Approval Date: As Amended January 1, 2007 17 Section 5. Outreach (Section 2102(c))

Describe the procedures used by the state to accomplish:

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

Please refer to Section 2.2.1. for a full description of outreach activities through cooperative efforts of other government agencies.

Distribution of CHIP Applications and Information by Community Organizations

¾ CHIP applications and information have been made available through participating community organizations including hospitals, physician practices, pharmacy chains, dental offices, pediatric clinics, primary care centers; also, willing businesses and retailers such as discount stores, grocers, convenience stores, and fast food restaurants have also participated.

¾ The WV Council of Churches, a multi-denominational organization distributed CHIP information materials to its 4000 member churches for inclusion in their weekly bulletins or use in church ministries.

Community-Based Outreach

¾ WVCHIP has provided an aggressive multimedia outreach program including television, radio and print advertisement, participation in local public events such as health fairs, parades, and West Virginia’s many state and local festivals.

¾ WVCHIP coordinates with the West Virginia Governor’s Office to assist Governor Bob Wise who actively promotes the program while attending public events; the Governor walked door- to-door with community volunteers in 15 of West Virginia’s rural counties in 2001.

¾ The West Virginia Healthy Kids Coalition (WVHKC) is comprised of numerous community- based organizations including primary care centers (including Rural Health Centers and FQHCs); Family Resource Centers (FRNs); child care centers; and faith-based organizations. WVCHIP and the WVHKC closely to coordinate and jointly participate in outreach activities throughout the State and in local communities.

¾ With the WV Council of Churches acting as its fiscal agent, the WVHKC has secured grant funding from the Claude Worthington Benedum Foundation and the Robert Wood Johnson Foundation. WVCHIP and WVDHHR officials participate in regular monthly meetings with

West Virginia’s Application for the State Children’s Health Insurance Program

Effective Date: July 1, 1998

Approval Date: As Amended January 1, 2007 18 WVHKC members. Through these meetings and other input, WVHKC serves as a major vehicle for receiving community feedback on CHIP eligibility policies and enrollment/re-enrollment processes, as well as participating in outreach and promoting CHIP at the community level.

¾ Family Resource Networks funded through contracts through the Governor’s Cabinet on Children and Families are community-based organizations which do strategic planning, interagency coordination and on-going evaluation of services for children and families in a designated county or multi-county area of the state. There are 45 FRNs serving all 55 counties. FRNs are also active partners in CHIP outreach and serve as members of the WVHKC.

¾ The West Virginia Primary Care Outreach Project with a grant from WV Medicaid has trained outreach coordinators at 35 primary care clinics throughout the state to facilitate Medicaid and CHIP outreach and eligibility. Participating centers receive a fee for each Medicaid approved application. Over 1000 children were found eligible for either Medicaid or CHIP through the Project’s efforts in 2001.

West Virginia’s Application for the State Children’s Health Insurance Program

Effective Date: July 1, 1998

Approval Date: As Amended January 1, 2007 19 Section 6. Coverage Requirements for Children’s Health Insurance (Section 2103)

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

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

6.1.1. ∼ Benchmark coverage; (Section 2103(a)(1) and 42 CFR 457.420)

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

6.1.2. 7 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.

A complete description of the WV Public Employees Insurance Agency Preferred Provider Benefit plan, the benchmark equivalent benefit plan, was provided as Attachment 3 of the State Plan Amendment which was effective April 1, 1999. This plan includes a lifetime benefit limit of $1,000,000 (see page 43 of the original Attachment).

An actuarial certification which considers changes to be implemented July 1, 2002 concerning pharmacy co-payment (section 8) and annual and lifetime benefit maximums (section 6) is provided as Attachment # 1 for State Plan Amendment #4.

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

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

West Virginia’s Application for the State Children’s Health Insurance Program

Effective Date: July 1, 1998

Approval Date: As Amended January 1, 2007 20

6.1.4.1. † Coverage the same as Medicaid State plan 6.1.4.2. † Comprehensive coverage for children under a Medicaid Section 1115 demonstration project 6.1.4.3. † Coverage that either includes the full EPSDT benefit or that the state has extended to the entire Medicaid population 6.1.4.4. † Coverage that includes benchmark coverage plus additional coverage 6.1.4.5. † Coverage that is the same as defined by existing comprehensive state-based coverage 6.1.4.6. † Coverage under a group health plan that is substantially equivalent to or greater than benchmark coverage through a benefit by benefit comparison (Please provide a sample of how the comparison will be done) 6.1.4.7. † Other (Describe)

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. 7 Inpatient services (Section 2110(a)(1)) Confinement in a hospital including semi- private room, special care units, confinement for detoxification, and related services and supplies during the confinement. 6.2.2. 7 Outpatient services (Section 2110(a)(2)) Diagnostic services, therapies, laboratory, radiology, and surgeries provided in a hospital, alternative facility or physician’s office are covered. Certain outpatient procedures may require pre-certification. 6.2.3. 7 Physician services (Section 2110(a)(3)) Professional services of a physician or other licensed provider for treatment of an illness, injury or medical condition. Includes outpatient and inpatient services (such as surgery, anesthesia, radiology, and office visits). 6.2.4. 7 Surgical services (Section 2110(a)(4)) 6.2.5. 7 Clinic services (including health center services) and other ambulatory health care services. (Section 2110(a)(5)) Diagnostic services, therapies, laboratory, radiology, and surgeries provided in a hospital outpatient setting or in an ambulatory surgical facility are covered. Immunizations are covered. 6.2.6. 7 Prescription drugs (Section 2110(a)(6)) Prescription benefit services are covered with mandatory generic substitution, including oral contraceptives. Formulary coverage includes generic and brand drugs, with prior approval through a step therapy process for some brand drugs in some drug classes. Non-formulary drugs are at 100% cost to the participant, except where medical necessity

West Virginia’s Application for the State Children’s Health Insurance Program

Effective Date: July 1, 1998

Approval Date: As Amended January 1, 2007 21 is shown for clinical exception.

Effective January 1, 2006, program participants who are currently taking a drug that is used to treat, or is sensitive to, mental conditions, can continue to have their current prescription(s) covered even if their current medication is not on the Preferred Drug List when it is in one of the following seven drug classes:

Antipsychotics; Serotonin Selective Response Inhibitors (SSRI’s); Central Nervous System Stimulants; Anticonvulsants; Sedative Hypnotics; Aliphatic Phenothiazines; and Attention Deficit Disorder Drugs.

Program participants who are newly prescribed a drug used to treat, or is sensitive to, mental conditions in one of the seven drug classes named above will have coverage from the Preferred Drug List at the time the new prescription is filled, except where there has been a demonstrated need for exception due to medical necessity.

6.2.7. 7 Over-the-counter medications (Section 2110(a)(7)) These are permitted in some therapeutic classes as listed on the Preferred Drug List when accompanied by a prescription. 6.2.8. 7 Laboratory and radiological services (Section 2110(a)(8)) 6.2.9. 7 Prenatal care and prepregnancy family services and supplies (Section 2110(a)(9)) Pre- pregnancy family services and supplies, excluding tubal ligations and vasectomies, are covered. Oral contraceptives are included within pharmacy benefit services. Contraceptive devices and contraceptive implants will be covered under medical services. 6.2.10. 7 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)) Partial hospitalization and day programs for mental health and chemical dependency are covered when ordered by a licensed provider. Limited to 30 days per calendar year. May be extended if determined medically necessary. 6.2.11. 7 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) Coverage is limited to 26 visits per calendar year for short-term individual or group outpatient mental health evaluation and referral, diagnostic, therapeutic, and crisis intervention services. May be extended as medically necessary. 6.2.12. 7 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)) Coverage for the initial purchase and reasonable replacement of standard implant and prosthetic devices, and for the rental or purchase (at the Plan’s discretion) of standard durable medical equipment, when prescribed by a physician. Prosthetics and durable medical equipment purchases or rentals must be pre-certified.

Eyeglasses or contacts are limited to $125 per each 12-month period of eligibility for enrollees at or

West Virginia’s Application for the State Children’s Health Insurance Program

Effective Date: July 1, 1998

Approval Date: As Amended January 1, 2007 22 under 200% FPL. This amount may be increased with either prior approval and/or determined medical necessity. Eyeglasses are not covered for enrollees above 200% FPL, but are 100% out of pocket. An actuarial certification is made for changes effective January 1, 2007 for State Plan Amendment #6. Hearing aids are covered if determined to be medically necessary with prior approval. Effective July 1, 2000, all infants at the time of birth will be screened for hearing loss.

All information on children with a medically confirmed hearing loss will be reported to the Office of Maternal and Child Health by the hospital. 6.2.13. 7 Disposable medical supplies (Section 2110(a)(13)) As medically necessary. 6.2.14. 7 Home and community-based health care services (See instructions) (Section 2110(a)(14)) Home health care services are covered. This benefit requires approval for more than five visits and is subject to a maximum of 25 two-hour visits per year. 6.2.15. 7 Nursing care services (See instructions) (Section 2110(a)(15)) Skilled nursing services are limited to an annual maximum of 180 days. 6.2.16. 7 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) A physician shall provide written certification of medically necessary abortions. All services require prior approval unless a medical emergency exists endangering the life of the mother. 6.2.17. 7 Dental services (Section 2110(a)(17)) Routine semi-annual exams, preventive, therapeutic and emergency services are covered. Does not cover cosmetic procedures, orthodontics or dentures, except in the case of mandibular degeneration. WVCHIP Premium enrollees between 201% to 220% FPL have preventive dental services only with a $150 annual limit. All expenses above this limit are at 100% out of pocket. An actuarial certification is made as Attachment #1 for changes effective January 1, 2007 for State Plan Amendment #6. 6.2.18. 7 Inpatient substance abuse treatment services and residential substance abuse treatment services (Section 2110(a)(18)) Inpatient substance abuse treatment is covered when ordered by a licensed provider. Covered benefit up to 30 days per year for inpatient care and limited to 60 visits per year for partial hospitalization and day programs. 6.2.19. 7 Outpatient substance abuse treatment services (Section 2110(a)(19)) Coverage limited to 26 visits per year requiring pre-certification from the third-party administrator. May be extended as medically necessary. 6.2.20. 7 Case management services (Section 2110(a)(20)) Medical case management provided by the third-party administrator. 6.2.21. 7 Care coordination services (Section 2110(a)(21)) 6.2.22. 7 Physical therapy, occupational therapy, and services for individuals with speech, hearing, and language disorders (Section 2110(a)(22)) Physical therapy is a covered benefit to 20 visits maximum per year when ordered by a physician. Additional visits must be pre-certified and case-managed by the third party administrator.

West Virginia’s Application for the State Children’s Health Insurance Program

Effective Date: July 1, 1998

Approval Date: As Amended January 1, 2007 23 Occupational therapy assistance in re-learning daily living/retraining work activities covered to $1,000 maximum per year with prior approval.

Speech therapy covered to $1,000 authorization year maximum when determined medically necessary.

Hearing services covered to include annual exams and hearing aids when determined medically necessary and with prior approval/authorization.

6.2.23. 7 Hospice care (Section 2110(a)(23))

6.2.24. 7 Any other medical, diagnostic, screening, preventive, restorative, remedial, therapeutic, or rehabilitative services. (See instructions) (Section 2110(a)(24)) Eye exams for prescriptive lenses are limited to one visit per year for those enrollees at or under 200% FPL; for those enrollees above 200% FPL all eye exams and prescription lenses are 100% out of pocket.

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

6.2.26. 7 Medical transportation (Section 2110(a)(26)) Ground or air ambulance transportation, when medically necessary, to the nearest facility able to provide necessary treatment.

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))

LIFETIME BENEFIT LIMIT

The benchmark equivalent plan on which WVCHIP was based in its April 1, 1999 State Plan Amendment includes a $1 million dollar lifetime benefit limit. This limit is part of the original benefits description found as ATTACHMENT 3 of the April 1, 1999 SPA (see page 43 of the attachment). While this was publicly discussed and included as part of public Board meetings which adopted the original program benefits design, the State has taken steps to assure that all CHIP participants are aware of this limit through a thirty-day public notice and comment period consistent with notice processes described at Section 9.9. (An actuarial certification is made as ATTACHMENT 1 to State Plan Amendment #5). The third party administrator will notify families when they are within 75% of reaching this limit.

ANNUAL LIMIT FOR MAJOR MEDICAL BENEFITS (excluding pharmacy)

Upon reaching the limit, families will be notified and informed of their appeal right.

Effective July 1, 2002, the Plan is amended to include an annual benefits limit of $200,000 for all major medical costs excluding pharmacy. After an actuarial review of all children whose claims

West Virginia’s Application for the State Children’s Health Insurance Program

24 Effective Date: July 1, 1998

Approval Date: As Amended January 1, 2007

exceeded $50,000 for a one-year period and a 30-day public comment period consistent with notice processes described at Section 9.9, this limit was approved by the WV Children’s Health Insurance Board at its June 19, 2002 meeting. The actuarial review showed that there were 10 individuals in excess of $50,000. The actuarial certification is made as ATTACHMENT 1 for State Plan Amendment #4.

The third party administrator will notify families when they are within 75% of reaching these limits. Families who are eligible will be assisted in obtaining Medicaid coverage. Upon reaching the limit, families will be notified and informed of their appeal right.

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. 7 The state shall not permit the imposition of any pre-existing medical condition exclusion for covered services (Section 2102(b)(1)(B)(ii)); OR 6.3.2. ∼ The state contracts with a group health plan or group health insurance coverage, or contracts with a group health plan to provide family coverage under a waiver (see Section 6.4.2. of the template). Pre-existing medical conditions are permitted to the extent allowed by HIPAA/ERISA (Section 2103(f)). Please describe: Previously 8.6

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))

West Virginia’s Application for the State Children’s Health Insurance Program

25 Effective Date: July 1, 1998

Approval Date: As Amended January 1, 2007

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

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

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))

West Virginia’s Application for the State Children’s Health Insurance Program

26 Effective Date: July 1, 1998

Approval Date: As Amended January 1, 2007

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 West Virginia Children’s Health Insurance Program utilizes the Public Employees Insurance Agency’s claims processing and utilization management contractor, Acordia National, to provide comprehensive quality assurance addressing:

¾ Appropriateness of care ¾ Quality of care ¾ Compliance with immunization schedules; tracking of well-baby and well-child exams ¾ Provision of case management services to children with special needs ¾ Exclusion from the WVCHIP provider network of those providers barred from participation in Medicare/Medicaid

Claims Review: From the claims processing standpoint quality and appropriateness of care review, several sources are utilized: Unbundling code review is integrated into the Acordia National claims system. This alerts the Claims Examiner as to whether the procedure is coded correctly.

For each claims examiner, a standard set of policies is in place to alert the examiner as to whether a claim needs to be sent to the nurse for review. Acordia National also utilizes an over limit review by the nurse for all claims in excess of $10,000 for inpatient treatment and in excess of $7,500 for outpatient procedures.

Clinical Review: Acordia performs provider reviews for utilization activities as well as health care patterns. Guidelines and resources provide case managers with evidence and outcome-based tools that ensure the delivery of high quality care in the most appropriate setting. Milliman and Robertson (M&R) Health Management Guidelines, are the tools utilized to assess quality and appropriateness of care based on national standards. Registered nurses (RN=s) and physician advisors obtain the clinical information from the treating physician using M&R as a guideline and then utilize their medical expertise on a case-by-case basis to determine what is appropriate. If a RN finds the proposed treatment does not fall within the guidelines, the case is then referred to a physician advisor.

West Virginia’s Application for the State Children’s Health Insurance Program

27 Effective Date: July 1, 1998

Approval Date: As Amended January 1, 2007

WVCHIP will pursue the above objectives through a variety of strategies, including:

Š Identification of children with special needs through the pre-certification process, claims review and self-identification by parents and guardians in response to literature sent through the benefit welcome kit Š Tracking of complaint data received by the toll-free number, the WVCHIP central office, and the contract agencies Š An annual satisfaction survey of parents/guardians Š Through discussions with the health care community via provider workshops, newsletters and periodic contacts with their association representatives Š Through consumer education utilizing newsletters to beneficiary families, information dissemination with outreach workers and public relations activities

On a monthly basis, WVCHIP will receive utilization management reports detailing the top diagnostic categories of CHIP beneficiaries from its third-party administrator for utilization management services, which will better position the program to track trends and facilitate the development of appropriate intervention strategies.

WVCHIP will have access to comparative data. Not only will this data enable the program to better assess its standing in relation to national trends, but it will permit a broader discussion on innovative approaches used elsewhere.

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. 7 Quality standards. The same tools in place for the benchmark-equivalent plan will be used for WVCHIP.

7.1.2. 7 Performance measurement. The same tools in place for the benchmark- equivalent plan will be used for WVCHIP.

7.1.3. 7 Information strategies. The same tools in place for the benchmark-equivalent plan will be used for WVCHIP.

7.1.4. 7 Quality improvement strategies. The same tools in place for the benchmark- equivalent plan will be used for WVCHIP.

7.2. Describe the methods used, including monitoring, to assure: (2102(a)(7)(B)) (42CFR 457.495) The State of West Virginia Insurance Commission is responsible for compliance with laws on access and on prudent lay-person standards for emergency care.

West Virginia’s Application for the State Children’s Health Insurance Program

28 Effective Date: July 1, 1998

Approval Date: As Amended January 1, 2007

See section 7.1 for monitoring and complaint tracking related to utilization control strategies.

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

The use of prevention services will be monitored through the following HEDIS measures:

• Well Child Visits measured for birth through six years of age.

• Access to Primary Care Visits measured for children ages 1 to 11 years who had visits coded to primary care services only.

• Dental Visits measured for children ages 4 to 18 who had a dental check-up coded to preventive dental services only.

• Vision Visits measured for children of all ages who received vision services from a physician or opthamologist coded for preventive vision services only.

WVCHIP reports annually on these measures, both in its Annual Framework Report and in the WVCHIP Annual Report submitted to the WV Legislature each year.

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))

WVCHIP’s utilization manager reviews inpatient stays of WVCHIP children for medical appropriateness.

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))

West Virginia’s Application for the State Children’s Health Insurance Program

29 Effective Date: July 1, 1998

Approval Date: As Amended January 1, 2007

WVCHIP reports HEDIS measures annually on the appropriate treatment of two chronic conditions:

Proper Use of Asthma Medications • Reports children with persistent asthma enrolled for the prior year and the current annual report period who were prescribed appropriate medication.

Diabetic Care • Reports the number of children enrolled an entire year with Type 1 and 2 diabetes shown to have had a blood (HbAlc) test; a serum cholesterol level screening; and in eye exam are a screen for kidney disease.

Families are notified of the availability of case management services upon enrollment through their copy of the WVCHIP Summary Plan Description.

Medical case management cases are also identified at the time of pre-admission certification and at all subsequent continued stay reviews Specialists identify potential case management cases as quickly as possible.

Diagnoses identified through the utilization management system that warrant review for chronic, high-cost, or special needs consideration will be referred to an individual case manager who will coordinate care as appropriate. Flagged diagnoses may reflect such conditions as:

• Asthma • Cerebral Palsy • Diabetes • Seizure Disorders • Leukemia • Sickle Cell Anemia • Emotional/Behavioral Conditions

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))

The third party administrator assures that all decisions for prior authorizing health services are made within 14 days of receipt of a request for the services.

West Virginia’s Application for the State Children’s Health Insurance Program

30 Effective Date: July 1, 1998

Approval Date: As Amended January 1, 2007

Section 8. Cost Sharing and Payment (Section 2103(e))

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

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

8.1.1. 7 YES 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: YES – Applicants above the 200% FPL income level who are willing to pay a monthly premium amount are enrolled in WVCHIP Premium (>200% FPL). There is a two rate premium structure: a Single Child rate and a rate for Two or More Child families. These rates are shown in the table below:

WVCHIP Premiums

Enrolled Children per household Monthly Premium Annual Premium Cost 1 $35.00 $420.00 2 or More $71.00 $852.00

8.2.2. Deductibles: None 8.2.3. Coinsurance or copayments: As described below.

West Virginia’s Application for the State Children’s Health Insurance Program

31 Effective Date: July 1, 1998

Approval Date: As Amended January 1, 2007 Copayments Under WVCHIP’s Plan

A) Pharmacy Benefits Copayments

All WVCHIP families participate in a two tier copayment structure for pharmacy benefits under the Plan. Copays are assessed according to family income level as follows:

ABOVE 200% FPL: $0 for generic prescription drugs $15 for formulary drugs (As amended 1/1/2007)

ABOVE 150% FPL: $0 for generic prescription drugs $10.00 for formulary brand drugs (As amended 1/1/2006)

BELOW 150% FPL: $0 for generic prescription drugs $5.00 for formulary brand drugs (As amended 1/1/2006)

B) Non-Well Visit Copayments

Non Well Physician Visits Schedule

All enrollees who do not designate a medical home pay a graduated copayment for non- well physician visits as follows:

Enrollees under 150% FPL income levels: $5.00 per visit (waived when visit is to enrollee’s designated medical home)

Enrollees above 150% FPL income levels: $15.00 per visit (waived when visit is to enrollee’s designated medical home)

Enrollees above 200% FPL income levels: $20.00 per visit (waived when visits are to enrollee’s designated medical home)

C) Other Medical Benefit Copayments Schedule for Enrollees Above 150% FPL

Inpatient Service $25.00 per admission

West Virginia’s Application for the State Children’s Health Insurance Program

32 Effective Date: July 1, 1998

Approval Date: As Amended January 1, 2007 Outpatient Service $25.00 per procedure Emergency Room $35.00 per visit (waived when admitted) Dental Services $0 Vision Services $0 Preventive Services $0

MAXIMUM COPAYMENT LIMITS FOR FAMILIES AT AND UNDER 200% FPL INCOMES

Maximum limits for all pharmacy and medical copayments imposed by the Plan are set as follows:

One Child Family: $100 prescription maximum; $150 medical maximum Two Child Family: $200 prescription maximum; $300 medical maximum Three or More Child Family: $300 prescription maximum; $450 medical maximum

MAXIMUM COPAYMENT LIMITS FOR FAMILIES ABOVE 200% FPL INCOMES

Maximum limits for all pharmacy and medical copayments imposed by the Plan are set as follows:

One Child Family: $150 prescription maximum; $200 medical maximum Two Child Family: $250 prescription maximum; $400 medical maximum Three or More Child Family: $350 prescription maximum; $600 medical maximum

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)) The State informs the public and individuals of cost sharing amounts and any changes to these amounts, including cumulative maximums, through its application form, printed posters available in clinics and other outreach sites, on its website at www.wvchip.org, and to individual participants who receive a benefit plan packet on enrolling and at the time of re-enrollment. Plan participants are notified at least 30 days in advance of proposed changes to cost sharing and asked for comments. Comments are reviewed by the Children’s Health Insurance Board prior to approving proposed changes.

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. 7 Cost-sharing does not favor children from higher income families over lower income families. (Section 2103(e)(1)(B)) (42CFR 457.530) 8.4.2. 7 No cost-sharing applies to well-baby and well-child care, including age-appropriate

West Virginia’s Application for the State Children’s Health Insurance Program

33 Effective Date: July 1, 1998

Approval Date: As Amended January 1, 2007 immunizations. (Section 2103(e)(2)) (42CFR 457.520) 8.4.3 7 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 State (WV) assures that the total cost of premiums and copayments (as described in Sections 8.2.1. and 8.2.3. respecfively) do not exceed 5% of a family’s total annual income as shown in the tables below:

A) Single Child Family Annual Premium/Copayment Maximum Cost

(as a % of family income levels)

At or Under 200% FPL

201% to 220% FPL Famil y Size Annual Premiu m Maximum Copayment Expense Total Expense Income Expense Percent Income Expense Percent 2 $420.00 $350.00 $770.00 $26,400 2.9% $29,040 2.7% 3 $420.00 $350.00 $770.00 $33,200 2.3% $36,520 2.1% 4 $420.00 $350.00 $770.00 $40,000 1.9% $44,000 1.8%

B) Two Child Family Annual Premium/Copayment Maximum Cost

(as a % of family income levels)

At or Under 200% FPL

201% to 220% FPL Famil y Size Annual Premiu m Maximum Copayment Expense Total Expense Income Expense Percent Income Expense Percent 3 $852.00 $650.00 $1,502.00 $33,200 4.5% $36,520 4.1% 4 $852.00 $650.00 $1,502.00 $40,000 3.8% $44,000 3.4% 5 $852.00 $650.00 $1,502.00 $46,800 3.2% $51,480 2.9%

C) Three or More Child Family Annual Premium/Copayment Maximum Cost

West Virginia’s Application for the State Children’s Health Insurance Program

34 Effective Date: July 1, 1998

Approval Date: As Amended January 1, 2007

(as a % of family income levels)

At or Under 200% FPL

201% to 220% FPL Famil y Size Annual Premiu m Maximum Copayment Expense Total Expense Income Expense Percent Income Expense Percent 4 $852.00 $950.00 $1,802.00 $40,000 4.5% $44,000 4.1% 5 $852.00 $950.00 $1,802.00 $46,800 3.9% $51,480 3.5% 6 $852.00 $950.00 $1,802.00 $53,600 3.4% $58,960 3.1%

The State assures that families are exempt from cost sharing upon reaching the maximum co- pays through processes administered by separate medical and pharmacy benefit managers:

Medical Plan Process The claims processing systems used by WVCHIP’s third party administrator (TPA) tracks co- payments as claims are processed by accumulating co-payment amounts on a per patient basis. For families with more than one child, individual children are linked to the family group through a number assigned to the parent/guardian in order to track the family cap. Should a provider attempt to collect a co-payment when the parent/guardian knows the cap has been met, the provider may verify the accumulated amount from an available “fax back” system in which the provider calls a toll-free number. After entering the patient’s ID number, a form with the applicable co-payment is faxed to the provider. Another option is that, upon reaching the maximum, the parent/guardian may use their Explanation of Benefits form, generated by the TPA, to show a provider that their co-pay cap has been met. WVCHIP’s TPA assures that medical and dental claims which are procedure code specific to well-baby, well child, and preventive dental visits, or other preventive services such as immunizations, have no copayments through its claims billing system. The claims processor maintains a separate subgroup file for those enrollees up to and under 150% FPL to assure that copayments amount no higher than those permitted under 457.555 are allowed. WVCHIP also assures that its members are aware of this through its program materials.

Prescription Plan Process The Pharmacy Benefit Manager similarly tracks co-pays through an electronic Point of Sale (POS) system, which is accumulated as each prescription is filled. Upon reaching the cap, the message is conveyed to individual pharmacies through the POS that no co-pay is due, and none is collected.

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)

West Virginia’s Application for the State Children’s Health Insurance Program

35 Effective Date: July 1, 1998

Approval Date: As Amended January 1, 2007 Native Americans are excluded from cost-sharing by self-declaration on the joint CHIP/Medicaid application.

WVCHIP will notify applicants that membership in designated tribes excludes families from cost sharing. Applications can be obtained through a toll-free telephone line for the WVCHIP Call Center or Helpline. Although West Virginia does not have any designated tribes, the Call Center will maintain a list of designated tribes in case applicants do not know if their tribe is a designated tribe. Applicants so choosing to identify themselves as members of a designated tribe will then be issued a card indicating they are exempt from co-pays. When beneficiaries disclose designated tribal membership, it will be accepted unless it is questionable.

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))

WVCHIP does not disenroll participants who fail to make copayments; however, failure to make premium payments within 30 days after the due date is cause for disenrollment. All premiums are due on the first day of each month followed by a fourteen day grace period. WVCHIP’s Premium Payment Services (PPS) will issue notice to any enrolled family who has not paid within the fourteen day grace period that unless payment has been received by the last day of the month, coverage is terminated. Families are notified that if nonpayment is a result of a recent decrease in income, PPS will work with them to facilitate changing to the non-premium payment WVCHIP plan or Medicaid, as appropriate.

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

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

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

8.8.1. 7 No Federal funds will be used toward state matching requirements. (Section 2105(c)(4))

West Virginia’s Application for the State Children’s Health Insurance Program

36 Effective Date: July 1, 1998

Approval Date: As Amended January 1, 2007 (42CFR 457.220) 8.8.2. 7 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. 7 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. 7 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. 7 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. 7 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)

West Virginia’s Application for the State Children’s Health Insurance Program

37 Effective Date: July 1, 1998

Approval Date: As Amended January 1, 2007 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))

1. Expand eligibility to uninsured children from birth through age 18 years whose incomes exceed the limit for Medicaid eligibility up to 200% FPL.

2. Identify previously uninsured children from birth through age 18 years who are potentially eligible for West Virginia’s Title XXI Program through ongoing and new outreach activities. Infants were not previously covered under Phase II of WVCHIP.

3. Children who are enrolled in West Virginia’s Title XXI Program will have an accessible health care source.

4. West Virginia’s Title XXI Program will result in the improved health of children enrolled in the program by focusing on preventive measures as well as acute care services.

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

Performance Goal/Objective 1:

Title XXI benefits will be available to the approximately 14,000 eligible children under the Phase III expansion. Existing data systems and processes will be leveraged for the processing of program applications, recipient information, service utilization, billing and provider information.

Performance Goal/Objective 2:

New initiatives, as well as ongoing outreach efforts, will be implemented. All outreach activities specified in Section 2.2.2. will be in place.

Performance Goal/Objective 3:

All children who are eligible for West Virginia’s Title XXI program will have a system of primary care providers available for immediate access.

Performance Goal/Objective 4:

Over time, West Virginia will show increased access and usage of health care services by children from birth through age 18 through statistical data. This data will reflect an increase in well-child visits as well as immunization rates for children in these coverage groups. Other outcome data will be developed in order to further track usage.

West Virginia’s Application for the State Children’s Health Insurance Program

38 Effective Date: July 1, 1998

Approval Date: As Amended January 1, 2007

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))

¾ Performance Goal 1 is measured by reconciling RAPIDS eligibility data to enrollment data proved by the third-party administrator.

¾ Performance Goal 2 is measured by monthly enrollment reporting compared to the Lewin estimate.

¾ Performance Goal 3 will be measured by data collected in an annual survey, as well as exceptions identified through daily operations.

¾ Performance Goal 4 will be measured by data and analysis provided by the third-party administrator, Acordia National.

Check the applicable suggested performance measurements listed below that the state plans to use: (Section 2107(a)(4)) 9.3.1. 7 The increase in the percentage of Medicaid-eligible children enrolled in Medicaid. 9.3.2. 7 The reduction in the percentage of uninsured children. 9.3.3. 7 The increase in the percentage of children with a usual source of care. 9.3.4. 7 The extent to which outcome measures show progress on one or more of the health problems identified by the state. 9.3.5. 7 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. 7 If not utilizing the entire HEDIS Measurement Set, specify which measures will be collected, such as: 9.3.7.1. 7 Immunizations 9.3.7.2. 7 Well child care 9.3.7.3. 7 Adolescent well visits 9.3.7.4. 7 Satisfaction with care 9.3.7.5. 7 Mental health 9.3.7.6. 7 Dental care 9.3.7.7. ∼ Other, please list: 9.3.8. ∼ Performance measures for special targeted populations.

West Virginia’s Application for the State Children’s Health Insurance Program

39 Effective Date: July 1, 1998

Approval Date: As Amended January 1, 2007

9.4. 7 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. 7 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) Under State law, West Virginia must provide to the State Legislature, on at least a quarterly basis, statistical data on the Children’s Health Insurance Program which will reflect the total number of children enrolled as a result of the expansion, breakdown by age, the average annual cost of coverage per recipient, and the total cost of these services by provider .

West Virginia will also produce reports on a quarterly basis outlining the number of well- child visits, immunizations, emergency visits, and mental health visits. These services will be broken down by provider specialty and will be compared to access standards for the overall Medicaid child population.

State-adopted legislation (W.Va. Code §9-4A-2b) requires that a report be made to the Governor and the State Legislature regarding outreach activities and the quality and effectiveness of the health care delivered to children in the program. Satisfaction surveys and health status indicators are required. Statistical profiles of the families served shall be included.

9.6. 7 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. 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. 7 Section 1902(a)(4)(C) (relating to conflict of interest standards) 9.8.2. 7 Paragraphs (2), (16) and (17) of Section 1903(i) (relating to limitations on payment) 9.8.3. 7 Section 1903(w) (relating to limitations on provider donations and taxes) 9.8.4. 7 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

West Virginia’s Application for the State Children’s Health Insurance Program

40 Effective Date: July 1, 1998

Approval Date: As Amended January 1, 2007 implementation of the plan and the method for insuring ongoing public involvement. (Section 2107(c)) (42CFR 457.120(a) and (b)) WVCHIP Insurance Board meetings are held approximately four times a year. WVCHIP provides notice of Board meetings according to State law through the Secretary of State’s Office. During each Board meeting, time is allotted for public comment and inquiry. Comments are solicited in writing from interested and affected persons.

The WVCHIP state plan amendments are placed in each of the DHHR County offices inviting public comment. Public notice of the state plan amendments will be posted in local Social Security offices.

In addition, press releases are sent to all major daily newspapers in the State.

Providers are notified of plan changes through a quarterly newsletter published by the Public Employees Insurance Agency, the state health insurance agency which provides third-party administrator services for WVCHIP.

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)) West Virginia has no Federal or State recognized tribes. Public hearings and WVCHIP Board meetings are open to all Native American and advocacy organizations, and these groups are included in advance notice of public meetings and invited to participate in the ongoing design of the program.

West Virginia’s Application for the State Children’s Health Insurance Program

41 Effective Date: July 1, 1998

Approval Date: As Amended January 1, 2007 9.9.2. For an amendment relating to eligibility or benefits (including cost sharing and enrollment procedures), please describe how and when prior public notice was provided as required in 457.65(b) through (d).

For State Plan Amendment #6 effective January 1, 2007, the following public notice procedures were followed:

• The proposal was reviewed and approved for a thirty-day comment period at the July 27, 2006 meeting of the West Virginia Children’s Health Insurance Board meeting. All Board meetings are publicly held with notice published through the WV Secretary of State’s office at least 5 days in advance.

• A bulletin announcing the approved proposal was noted in the July 28, 2006 edition of the Charleston Gazette, one of the State’s largest newspapers.

• A draft State Plan Amendment was distributed for describing the proposed changes and posted in all local DHHR offices for a 30 day comment period, and child and health advocacy organizations such as West Virginia Healthy Kids Coalition and West Virginians for Affordable Health Care.

• Other bulletins and announcements were made to health providers: Public Employees Insurance Agency Newsletter American Medical Association Newletter American Academy of Pediatrics e-bulletin (WV Chapter only) WV Primary Care Association Announcement WV Hospital Association Newsletter/e-bulletin WV Academy of Family Physicians e-bulletin

• Notice of the proposed changes and thirty-day comment period was posted on the Agency’s website: www.wvchip.org on October 1, 2006.

• The WV Children’s Health Insurance Board met on October 26, 2006, reviewed any comments received and approved these changes effective January 1, 2007.

West Virginia’s Application for the State Children’s Health Insurance Program

42 Effective Date: July 1, 1998

Approval Date: As Amended January 1, 2007 9.10. Provide a one year projected budget. A suggested financial form for the budget is attached. The budget must describe: (Section 2107(d)) (42CFR 457.140)

¾ An updated budget for Federal Fiscal Year 2007 is provided below:

WVCHIP Budget FFY 2007 *

Federal Fiscal Year Costs Federal Fiscal Year Costs Federal Enhanced Match Rate of 80.97% With Without

Expansion to 220%FPL Expansion to 220%PL Benefit Costs

Insurance payments

Managed care 0 0 per member/per month rate @ # of eligibles 0 0 Fee for Service 44,494,631 43,128,638 Total Benefit Costs 44,494,631 43,128,638 Medical 30,224,919 29,447,777 Pharmacy 9,038,908 8,572,652 Dental 5,230,804 5,108,209 (Offsetting beneficiary cost sharing payments) ** 79,532 0 Net Benefit Costs 44,415,099 43,128,638

Administration Costs

Personnel 478,077 466,863 General administration 296,408 289,455 Contractors/Brokers (e.g., enrollment contractors) 286,846 280,118 Claims Processing 1,845,379 1,802,093 Outreach/marketing costs 280,472 273,893 Other

Total Administration Costs 3,187,183 3,112,423 10% Administrative Cost Ceiling 4,943,848 4,792,071

Federal Share (multiplied by enh-FMAP rate) 38,543,568 37,441,387 State Share *** 9,058,714 8,799,674 TOTAL PROGRAM COSTS 47,602,282 46,241,061

7 Planned use of funds, including -- - Projected amount to be spent on health services; $44,415,099 (including the expansion to 220%FPL) - Projected amount to be spent on administrative costs, such as outreach, child health initiatives, and evaluation; and $3,187,183

West Virginia’s Application for the State Children’s Health Insurance Program

43 Effective Date: July 1, 1998

Approval Date: As Amended January 1, 2007 - Assumptions on which the budget is based, including cost per child and expected enrollment.

Assumption and provisions concerning the budget are noted as follows:

Š During FFY 2007, only three quarters are calculated to have expansion costs (starting January 1, 2007) included in this budget. Š This budget assumes an average monthly enrollment of 24,835 up to 200% FPL, and an average monthly enrollment of 113 from 201-220% FPL. Total member months without expansion is assumed to be 298,020 and 299,037 with expansion. Costs PMPM without expansion are estimated to be $155.16 and $159.19 with expansion. The higher PMPM cost under the expansion includes additional administrative costs associated with developing and implementing a premium collection process and ongoing premium collections, as well as additional amounts for benefit costs due to pent-up demand for medical services for children enrolled from 201-220% FPL. Š None of the copayments shown in Section 8 are offset. Premiums listed in Section 8 are offset. Š An actuarial certification regarding premiums is submitted as Attachment #1 effective January 1, 2007.

⌧ Projected sources of non-Federal plan expenditures, including any requirements for cost- sharing by enrollees.

All non-federal funds are appropriated through State general revenues.

West Virginia’s Application for the State Children’s Health Insurance Program

44 Effective Date: July 1, 1998

Approval Date: As Amended January 1, 2007 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. 7 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. 7 The state assures it will comply with future reporting requirements as they are developed. (42CFR 457.710(e))

10.3. 7 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.

West Virginia’s Application for the State Children’s Health Insurance Program

45 Effective Date: July 1, 1998

Approval Date: As Amended January 1, 2007 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. 7 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. 7 42 CFR Part 455 Subpart B (relating to disclosure of information by providers and fiscal agents) 11.2.2. 7 Section 1124 (relating to disclosure of ownership and related information) 11.2.3. 7 Section 1126 (relating to disclosure of information about certain convicted individuals) 11.2.4. 7 Section 1128A (relating to civil monetary penalties) 11.2.5. 7 Section 1128B (relating to criminal penalties for certain additional charges) 11.2.6. 7 Section 1128E (relating to the National health care fraud and abuse data collection program)

West Virginia’s Application for the State Children’s Health Insurance Program

46 Effective Date: July 1, 1998

Approval Date: As Amended January 1, 2007 Section 12. Applicant and enrollee protections (Sections 2101(a))

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

Eligibility and Enrollment Matters

12.1 Please describe the review process for eligibility and enrollment matters that complies with 42 CFR 457.1120. All WVCHIP applicants and participants have the right of appeal through the same fair hearing process that is utilized by Medicaid participants for eligibility and enrollment matters.

Health Services Matters

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

WVCHIP has a Program Specific Review Process for health services matters that assures the participant’s right of appeal. Plan participants are informed of the appeals process through written materials describing the program and covered benefits (the Summary Plan Description) that each participant receives upon enrollment. In addition, written notice of the appeals process is provided to affected individuals within 5 days of decisions subject to review. These written materials inform participants that they may appeal any health service matter involving the delay, denial, reduction, suspension or termination of a covered service, including a determination of the type or level of services, or a failure to approve or furnish or provide payment for health services in a timely manner.

EXCEPTION: Plan participants are informed that 1) Matters pertaining to eligibility or enrollment are exempt from review through this process. Nor 2) Any matter or issue which can only be remedied through a change in provisions through the State Plan, Federal or State laws requiring a) an automatic change in eligibility or enrollment or b) a change in coverage as described in this benefits package that affects all applicants or enrollees or a group of applicants or enrollees without regard to their individual circumstances.

Step 1: INFORMAL FACT FINDING

Plan participants may initiate appeals regarding claims or service denial by contacting the appropriate third party administrator through a toll-free number to verify whether or not a mistake has been made. All appeals must be initiated within 60 days of the participants’ learning of the health services matter at issue.

West Virginia’s Application for the State Children’s Health Insurance Program

47 Effective Date: July 1, 1998

Approval Date: As Amended January 1, 2007

Step 2: WRITTEN RESPONSE BY THE THIRD PARTY ADMINISTRATOR

Plan participants who disagree with the determination made by the third party administrator at the first step may then appeal in writing within 60 days of the participant’s learning of the health services matter at issue, to the appropriate third party administrator by explaining what the problem is and why they disagree with the first step determination. The third party administrator must respond by either reprocessing the claim for payment issues (if that is the resolution) or sending a letter to the plan participant explaining what actions they are prepared to take or the basis for their action. For all complete case files, a written or processed claim, or Explanation of Benefits statement response will be made within 30 days. The case file is considered complete when the participant has provided documentation pertaining to the health services matter at issue, but not longer than 90 days (except by mutual agreement of the parties).

Step 3: REVIEW BY WVCHIP’s EXECUTIVE DIRECTOR

For issues not resolved at the second step, the third step is to appeal in writing within 60 days of receiving the written decision of the third party administrator to the Executive Director of the West Virginia CHIP.

Plan participants are asked to provide written statements of facts, issues, letters, explanation of benefits and all other information pertinent to the case. Participants may represent themselves or have an authorized representative at each step. The Director will render a written decision to the insured or his/her authorized representative, taking into account all materials presented at the third step, and explain the reason, and whether the original disposition of the claim/denial to be either upheld or modified. For all complete case files, response is made within 30 days. For issues of appeal regarding clinical/medical matters, the Executive Director may consider a physician review by the Medical Director. The Medical Director is the same individual who serves as Medical Director for the Public Employees Insurance Agency.

For those cases involving emergency conditions where the standard time frame could seriously jeopardize the enrollee’s life or health or ability to retain or regain maximum function, an expedited review may take place within 72 hours (or up to a maximum of 14 days, if the enrollee requests an extension). After initiating the first step appeal, participants may go directly to the third step for resolution if necessary.

Premium Assistance Programs

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

WEST VIRGINIA TITLE XXI PROGRAM FACT SHEET

Name of Plan:

West Virginia (WV) CHIP

Date State Plan Submitted:

June 18, 1998 Date State Plan Approved:

September 15, 1998 State plan Effective Date:

July 1, 1998

Date First Amendment Submitted:

December 21, 1998 Date First Amendment Approved:

March 19, 1999 First Amendment Effective Date:

January 1, 1999

Date Second Amendment Submitted:

June 30, 2000 Date Second Amendment Approved:

September 27, 2000 Second Amendment Effective Date:

October 1, 2000

Date Third Amendment Submitted:

July 19, 2000 Date Third Amendment Approved:

October 13, 2000 Third Amendment Effective Date:

November 1, 2000

Date Fourth Amendment Submitted:

July 1, 2002 Date Fourth Amendment Approved:

September 27, 2002

Date Fifth Amendment Submitted

February 10, 2006 Date Fifth Amendment Approved

May 5, 2006 Fifth Amendment Effective Date

January 1, 2006

Date Sixth Amendment Submitted

September 22, 2006 Date Sixth Amendment Approved

December 22, 2006 Sixth Amendment Effective Date:

January 1, 2007

Background

• On June 18, 1998, West Virginia submitted its SCHIP State plan, which expanded Medicaid eligibility for children between the ages of 1 and 5 in families with incomes up to150 percent of the Federal poverty level (FPL).

Amendments

• On December 21, 1998, West Virginia submitted a State plan amendment (SPA) which created a separate child health program covering children between the ages of 6 and 18 in families with incomes equal to or less than 150 percent of FPL.

2 • On June 30, 2000, West Virginia submitted its second SPA to incorporate children from their Medicaid expansion program into the separate child health program effectively eliminating their Medicaid expansion.

• On July 19, 2000, West Virginia submitted its third SPA to expand eligibility in its separate child health program to children under age 19 with income between 150 and 200 percent of the FPL and to impose cost sharing on this population. American Indian/Alaskan Native (AI/AN) enrollees will be exempt from cost-sharing requirements.

• West Virginia submitted its fourth SPA on July 1, 2002. This amendment updates and amends the SCHIP State plan to indicate the State's compliance with the final SCHIP regulations. The amendment also adds cost sharing on pharmaceuticals for enrollees at or below 150 percent of the FPL and changes it for enrollees above 150 percent of the FPL, adds an annual $200,000 limit on benefits, and incorporates a $1,000,000 lifetime limit on benefits.

• West Virginia submitted its fifth SPA on February 10, 2006. This amendment eliminates coverage of drugs excluded from the State’s Preferred Drug List. There are three exceptions to this policy: there is documentation from a physician demonstrating medical necessity; for mental health pharmaceuticals in certain therapeutic drug classes; and, for over-the-counter pharmaceuticals in certain therapeutic drug classes. Prior provisions imposing copayments for these drugs are removed.

• West Virginia submitted its sixth SPA on September 22, 2006. This amendment increases the eligibility level from 200 to 220 percent of the FPL. Children in this income level will also have eligibility, benefit and cost sharing requirements that are different from individuals at or below 200 percent of the FPL. The following applies:

ƒ Waiting period: Families at or below 200 percent of the FPL will continue to be subject to a 6-month waiting period, while families above 200 percent of the FPL will have a 12-month waiting period.

ƒ Benefits: Families at or below 200 percent of the FPL will continue to have comprehensive dental and vision services. Families above 200 percent of the FPL will receive preventative dental services with an annual limit of $150, and will not receive vision services.

ƒ Pharmacy Copayments: There are no copayments for generic drugs. For formulary brand drugs, families at or below 150 percent of the FPL will continue to pay $5 and families above 150 to 200 percent of the FPL will continue to pay $10. Families above 200 percent of the FPL will be required to pay a $15 copayment for formulary brand drugs.

3 ƒ Premiums: Families at or below 200 percent of the FPL continue to not have a premium. Families above 200 percent of the FPL will be required to pay premiums based on a two-tier system. Families with one child will pay a monthly premium of $35 and families with two children or more will pay $71 per month.

ƒ In addition, the entire State plan population will be charged a copayment amount when a child obtains non-preventative care from a provider other than the one designated to serve as the child’s medical home. The copayment amount will vary by FPL, as follows: $5 for individuals at or below 150 percent of FPL, $15 for individuals 150 to 200 percent of the FPL, and $20 for individuals above 200 percent of FPL. Total cost-sharing amounts will continue to adhere to the title XXI cost-sharing limit of 5 percent of family income.

Children Covered Under the Program

• There were 28,307 children enrolled in SCHIP in Federal Fiscal Year (FFY) 2006.

Administration & Health Care Delivery System

• The SCHIP Program is administered by the West Virginia Children's Health Insurance Agency, which is located within the State Department of Administration.

• The Public Employees Insurance Agency is the third-party administrator managing the benefit package.

• With the implementation of West Virginia's second amendment on October 1, 2000, all children enrolled in SCHIP are served through fee for service.

Benefit Package

• The benefit package is a benchmark equivalent package to State employee coverage. Services provided include: inpatient; outpatient; physician; surgical; clinic and other ambulatory care; prescription drugs; laboratory and radiological; prenatal care and pre- pregnancy family services and supplies; inpatient and outpatient mental health; durable medical equipment and medically-related or remedial devices; disposable medical supplies (therapeutic); home and community-based care; nursing care; abortion only to save the mother's life or pregnancy is a result of rape/incest; dental; inpatient, residential, and outpatient substance abuse treatment; case-management services; care coordination; physical and occupational therapy, and services for speech, hearing, and language disorders; hospice care; eye exams for prescriptive lenses; and medically necessary transportation.

• Families at or below 200 percent of the FPL will continue to have comprehensive dental and vision services. Families above 200 percent of the FPL will receive preventative dental services with an annual limit of $150, and will not receive vision services.

• There is a $200,000 annual limit on benefits and a $1,000,000 lifetime limit on benefits.

4

Cost Sharing

• Enrollees at or below 150 percent of the FPL are subject to a $5 copayment for formulary drugs and a $5 copayment for non-preventative care from a provider other than the one designated to serve as the child’s medical home.

• Enrollees above 150 to 200 percent of the FPL are subject to the following copayment schedule: $10 for formulary brand drugs; $15 for non-preventative care from a provider other than the one designated to serve as the child’s medical home; $25 for inpatient admission and outpatient procedures; and, $35 for emergency room services that are waived if the individual is admitted.

• Enrollees above 200 percent of the FPL are subject to the following copayment schedule: $20 for non-preventative care from a provider other than the one designated to serve as the child’s medical home. Families above 200 percent of FPL will be required to pay a $15 copayment for formulary brand drugs.

• In addition, enrollees above 200 percent of the FPL are subject to monthly premiums of $35 for one child or $71 for two or more children. Families at or below 200 percent of the FPL do not have to pay a premium.

• There is no cost sharing for preventive care, dental and vision services.

• The AI/AN population are exempt from cost sharing.

• In families with one child, the copayment maximum for prescriptions is $100 and the medical maximum is $150. In families with two children, the copayment maximum for prescriptions is $200 and the medical maximum is $300. In families with three or more children, the copayment maximum for prescriptions is $300 and the medical maximum is $450.

Crowd-Out Strategy

• Children below 200% of FPL must be uninsured for a period of 6 months prior to application. Children above 200% of FPL must be uninsured for a period of 12 months prior to application. Exceptions are made if the employer terminates coverage; a job is involuntarily terminated and the family loses benefits; private insurance is not cost effective; i.e., if the employees family coverage exceeds 10 percent of family gross annual income; loss of coverage for child is due to a change in employment; or loss of coverage was outside the control of an employee.

• The State monitors substitution through its application process. Applicants must specify whether the applicant child had private group coverage in the previous 6 months. Data on applications that are denied eligibility due to coverage in the prior 6 months is collected and analyzed for trends over time.

5 Coordination between SCHIP and Medicaid

• Eligibility determinations are conducted for both Medicaid and SCHIP by the same State Agency. Applications are first screened for Medicaid eligibility. During this process, the Medicaid eligibility system is queried to ascertain current Medicaid coverage. Only if the child is ineligible for Medicaid services and is not covered by other health insurance will they be allowed to enroll into SCHIP.

Outreach Activities

• The WV CHIP application is distributed by diverse community-based organizations, such as physician and dental offices, hospitals, pharmacy chains, and local businesses. The WV Council of Churches distributes materials to its member churches. The Office of Maternal, Child, and Family Health and the Bureau of Public Health distribute WV CHIP materials to the medical community. Ongoing application distribution and assistance occurs through the WV CHIP Call Center with a toll-free telephone line. Spanish and hearing impaired translation services are available.

• WV CHIP closely coordinates with the West Virginia Healthy Kids Coalition, comprised of numerous community-based organizations, such as primary care centers, Family Resource Centers, child-care centers and faith-based organizations, to coordinate and jointly participate in outreach activities.

• Local WV Department of Health and Human Resources offices located in 53 of the State's 55 counties provide application assistance. Out-stationed workers facilitate outreach and eligibility determination in selected hospitals.

• The Department of Education has a check-off box on its free and reduced lunch application form that allows parents/guardians to consent to have a joint WV CHIP/Medicaid application form mailed to them.

Financial Information

FFY 2006: Enhanced Federal Matching Rates--81.09% State share: $8,384,813 Federal share: $35,676,211 Total program costs: $44,061,024

Date last updated: CMS, CMSO, FCHPG, DSCHI, December 27, 2006

_____________________________________________________________________________

Table of Contents

State/Territory Name: West Virginia

State Plan Amendment (SPA) #: WV-13-0001

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

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

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

Children and Adults Health Programs Group FEB 0 6 2014

Sharon L. Carte, Executive Director

West Virginia Children’s Health Insurance Program 1018 Kanawha Boulevard East, Suite 209 Charleston, WV 25301

Dear Ms. Carte:

I am pleased to inform you that your Children’s Health Insurance Program (CHIP) state plan amendment (SPA) number WV-13-0001 submitted on November 12, 2013, and related to Modified Adjusted Gross Income (MAGI) Eligibility, has been approved with an effective date of January 1, 2014.

MAGI Eligibility & Methods:

In SPA number WV-13-0001, page CS15 provides assurance that the state will apply methodologies based on MAGI for all separate CHIP covered groups. Page CS7 indicates that, using the approved MAGI conversion plan income thresholds, the state will cover targeted low- income children. Page CS10 allows the state to cover children who have access to public employee coverage and includes the supporting documentation. And on page CS13 the state elects to cover as deemed newborns children born to mothers enrolled as targeted low-income children in CHIP. The SPA includes a revised one-year budget which is attached to this letter and should replace the budget in section 9.10 of the current CHIP state plan. The other SPA pages are also attached to this letter and should be incorporated into the current CHIP state plan according to the table below. Where the current CHIP state plan contains relevant information, the new pages should replace and supersede the corresponding information throughout the current state plan.

New State Plan Page Impact on Current State Plan Section

CS15: MAGI-Based Income Methodologies Section 4.3: Add new subsection and supersede information on income eligibility and methods

CS7: Targeted Low-Income Children Sections 4.1.1, 4.1.2, 4.1.3: Supersede all CS10: Children Who Have Access to Public Section 4.1.7: Add new to section in addition to Employee Coverage information on public employees CS10: Maintenance of Agency Contribution Appendix: Add new for this documentation CS13: Deemed Newborns Section 4.3: Add new to section

Page 2 — Ms. Sharon L. Carte

Title XXI Medicaid Expansion

SPA number WV-13-0002 MC2 converts the state’s existing income eligibility standards to modified adjusted gross income (MAGI)-equivalent standards, by age group, for children covered in its title XXI-funded Medicaid program. A copy of the approved state plan page (CS3) is attached, and should be incorporated into the state’s approved CHIP state plan. This page supersedes the current Medicaid expansion Section (4.0) of the current CHIP state plan.

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

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

7500 Security Blvd.

Baltimore, MD 21244-1850

Telephone: (410) 786-8145

Facsimile: (410) 786-5943

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

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

Centers for Medicare & Medicaid Services

Division of Medicaid and Children’s Health Operations The Public Ledger Building, Suite 216

150 South Independence Mall West

Philadelphia, PA 19106

If you have additional questions, please contact Ms. Linda Nablo, Director, Division of State Coverage Programs, at (410) 786-5143.

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

Sincerely,

Eliot Fishman Director

cc: Francis McCullough, ARA, CMS Region III, Philadelphia

logged in as TONIABROWN(CMS CO Staff) read only mode application rev p01 Children's Health Insurance Program Eligibility WV.0495.R00.00 - Jan 01, 2014 Home Logout Finder Save Print Help Control Panel General Information File Management Tribal Input Summary State/Territory name: West Virginia State Funds: $ Federal Funds: $ Submitted By: Stacey Shamblin Last Revision Date: Jan 9, 2014 Submit Date: Nov 12, 2013 Children's Health Insurance Program Eligibility: Summary Page Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. WV-13-0002 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 457320(a)(2) and (3) Federal Budget Impact This SPA has a budget impact. Total budget impact: Subject of Amendment Please provide a brief summary of SPA changes. Character Count:217 out of 2000 State option to create Medicaid expansion for children 6 - 18 up to 133% FPL Instructions with August 15, 2013 budget submissions required budgeted amounts for this change be reflected on Medicaid budget b i i Signature of State Agency Official Page 1 of 2 Children's Health Insurance Program Eligibility: CMS 179 05/04/2014 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

FAQs | Site Map | Contact | Medicaid.gov | CMS.gov Page 2 of 2 Children's Health Insurance Program Eligibility: CMS 179 05/04/2014 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

coms CHIP Eligibility

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

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

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

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

Must be under age 19.

Income Standards

Income standards are applied statewide.

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

Statewide Income Standards

Begin with lowest age range first.

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

From Age To Age Above (% FPL) Up to & including (% FPL) 1 158 300 6 141 300 19 133 300 x.

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

Special Program for Children with Disabilities

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

FEB 0 6 2014 Effective Date: January 1, 2014

Page 1 of 2

SPA# WV-13-0001 Approval Date:

Cems 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.

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SPA# WV-13-0001 Approval Date: FEB 0 6 2014

Effective Date: January 1, 2014 Page 2 of 2

CcMs. CHIP Eligibility

OMB Control Number: 0938-1148

Sec. 2110(b)(2)(B) and (b)(6) of the SSA

im Children Who Have Access to Public Employee Coverage - Otherwise eligible targeted low-income children who have access to public employee coverage on the basis of a family member's employment.

The CHIP Agency operates this covered group in accordance with the following provisions: Select one of the following conditions as described in Section 2110(b)(6) of the Social Security Act: @ Maintenance of agency contribution as provided in 2110(b)(6)(B) of the SSA. C) Hardship criteria as provided in section 2110(b)(6)(C) of the Social Security Act. Coverage under this option is extended to children whose household income is: Select one of the options for the income standard when compared to Targeted Low Income Children @ The same as the standards for Targeted Low-Income Children C) Lower than the income standards for Targeted Low-Income Children

Indicate whether coverage under this option is extended to all children who have access to public employee coverage, or only certain children:

@: All children who have access to public employee coverage

C: Certain children who have access to public employee coverage:

[ Attach methodology the state has used to calculate maintenance of agency contribution.

An attachment is submitted.

The state provides assurance that the state will, on an annual basis, recalculate expenditures for each participating public agency to determine if the maintenance effort condition continues to be met.

Children who are eligible for public employee health benefits coverage who are not described above are excluded from eligibility under the plan.

Children considered to have access to public employee coverage, and therefore not excluded from CHIP through this option, otherwise meet the definition of targeted low-income child provided at 42 CFR 457.310.

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.20131007 F EB 0 6 2014 Effective Date: January 1, 2014 Page 1 of |

SPA# WV-13-0001 Approval Date:

West Virginia CHIP CHIP CS10 Analysis - Children Who Have Access To Public Employee Coverage

Maintenance of Public Agency Contributions to Employee Dependent Coverage 1997 — 2013

Annual Annual State Employee Employee 1997 State Fiscal and Dependent and Dependent Agency Expenditure Year Costs Premiums Expenditures CPI-U (Medical) Increased by CPI 1997 $3,214.71 $770.09 $2,444.62 $2,444.62 1998 3,414.02 741.61 2,672.44 3.22% 2,523.34 1999 4,130.97 741.61 3,389.36 3.49% 2,611.40 2000 4,081.40 741.61 3,339.78 4.06% 2,717.42 2001 4,909.92 869.10 4,040.83 4.61% 2,842.70 2002 5,221.71 1,106.91 4,114.80 4.71% 2,976.59 2003 5,400.62 1,432.47 3,968.15 4.02% 3,096.25 2004 5,925.99 1,794.84 4,131.15 4.40% 3,232.48 2005 6,669.91 1,792.08 4,877.83 4.22% 3,368.89 2006 6,915.44 1,947.00 4,968.44 4.01% 3,503.98 2007 7,159.42 2,200.95 4,958.47 4.42% 3,658.86 2008 7,644.34 2,191.84 5,452.50 3.71% 3,794.60 2009 7,977.54 2,186.32 5,791.22 3.17% 3,914.89 2010 8,143.65 2,383.09 5,760.56 3.49% 4,051.52 2011 8,850.79 2,477.01 6,373.78 2.92% 4,169.83 2012 9,434.85 2,635.55 6,799.30 3.95% 4,334.54 2013 9,207.23 2,629.97 6,577.26 2.15% 4,427.73 SPA# WV-13-0001 Approval Date: FEB 0 6 2044 Effective Date: January 1, 2014

CCRC Actuaries, LLC 9/26/2013

West Virginia CHIP CHIP CS10 Analysis - Children Who Have Access To Public Employee Coverage

Maintenance of Public Agency Contributions to Employee Dependent Coverage 1997 — 2013

Annual Annual State Employee Employee 1997 State Fiscal and Dependent and Dependent Agency Expenditure Year Costs Premiums Expenditures CPI-U (Medical) Increased by CPI 1997 $3,214.71 $770.09 $2,444.62 $2,444.62 1998 , 3,414.02 741.61 2,672.41 3.22% 2,523.34 1999 4,130.97 741.61 3,389.36 3.49% 2,611.40 2000 4,081.40 741.61 3,339.78 4.06% 2,717.42 2001 4,909.92 869.10 4,040.83 4.61% 2,842.70 2002 5,221.71 1,106.91 4,114.80 4.71% 2,976.59 2003 5,400.62 1,432.47 3,968.15 4.02% 3,096.25 2004 5,925.99 1,794.84 4,131.15 4.40% 3,232.48 2005 6,669.91 1,792.08 4,877.83 4.22% 3,368.89 2006 6,915.44 1,947.00 4,968.44 4.01% 3,503.98 2007 7,159.42 2,200.95 4,958.47 4.42% 3,658.86 2008 7,644.34 2,191.84 5,452.50 3.71% 3,794.60 2009 7,977.54 2,186.32 5,791.22 3.17% 3,914.89 2010 8,143.65 2,383.09 5,760.56 3.49% 4,051.52 2011 8,850.79 2,477.01 6,373.78 2.92% 4,169.83 2012 9,434.85 2,635.55 6,799.30 3.95% 4,334.54 2013 9,207.23 2,629.97 6,577.26 2.15% 4,427.73 SPA# WV-13-0001 Approval Date: FEB 0 6 2014 Effective Date: January 1, 2014

CCRC Actuaries, LLC . 9/26/2013

Cems CHIP Eligibility

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

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

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

The state operates this covered group in accordance with the following provisions:

[li] The child was born to an eligible targeted low-income pregnant woman under section 2112 of the SSA.

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

The state elects the following option(s):

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

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

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

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

V.20130917

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SPA# WV-13-0001 Approval Date: Effective Date: January 1, 2014

Page | of |

CccmMs CHIP Eligibility

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

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

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

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

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

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

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

Household income includes actually available cash support, exceeding nominal amounts, provided

by the person claiming an individual described at §435.603(f)(2)(i) as a tax dependent. Pres

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

An attachment is submitted.

PRA Disclosure Statement

SPA# WV-13-0001 Approval Date: FEB 0 6 2014 Effective Date: January 1, 2014 Page 1 of 2

cemMs 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.

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Cems. CHIP Eligibility

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

42 CFR 457.320(a)(2) and (3)

Income eligibility for children under the Medicaid Expansion is determined in accordance with the following income standards: There should be no overlaps or gaps for the ages entered.

Age and Household Income Ranges

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

+ lie 19 108 133 xX

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.

FEB 0 6 2014

SPA# WV-13-0002 Approval Date: Effective Date: January 1, 2014 Page 1 of I

_____________________________________________________________________________

Table of Contents

State/Territory Name: West Virginia

State Plan Amendment (SPA) #: WV-13-0002 MC2

(In addition to the SPA noted above, this package contains other state plan amendment approvals)

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

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

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

Children and Adults Health Programs Group FEB 0 6 2014

Sharon L. Carte, Executive Director

West Virginia Children’s Health Insurance Program 1018 Kanawha Boulevard East, Suite 209 Charleston, WV 25301

Dear Ms. Carte:

I am pleased to inform you that your Children’s Health Insurance Program (CHIP) state plan amendment (SPA) number WV-13-0001 submitted on November 12, 2013, and related to Modified Adjusted Gross Income (MAGI) Eligibility, has been approved with an effective date of January 1, 2014.

MAGI Eligibility & Methods:

In SPA number WV-13-0001, page CS15 provides assurance that the state will apply methodologies based on MAGI for all separate CHIP covered groups. Page CS7 indicates that, using the approved MAGI conversion plan income thresholds, the state will cover targeted low- income children. Page CS10 allows the state to cover children who have access to public employee coverage and includes the supporting documentation. And on page CS13 the state elects to cover as deemed newborns children born to mothers enrolled as targeted low-income children in CHIP. The SPA includes a revised one-year budget which is attached to this letter and should replace the budget in section 9.10 of the current CHIP state plan. The other SPA pages are also attached to this letter and should be incorporated into the current CHIP state plan according to the table below. Where the current CHIP state plan contains relevant information, the new pages should replace and supersede the corresponding information throughout the current state plan.

New State Plan Page Impact on Current State Plan Section

CS15: MAGI-Based Income Methodologies Section 4.3: Add new subsection and supersede information on income eligibility and methods

CS7: Targeted Low-Income Children Sections 4.1.1, 4.1.2, 4.1.3: Supersede all CS10: Children Who Have Access to Public Section 4.1.7: Add new to section in addition to Employee Coverage information on public employees CS10: Maintenance of Agency Contribution Appendix: Add new for this documentation CS13: Deemed Newborns Section 4.3: Add new to section

Page 2 — Ms. Sharon L. Carte

Title XXI Medicaid Expansion

SPA number WV-13-0002 MC2 converts the state’s existing income eligibility standards to modified adjusted gross income (MAGI)-equivalent standards, by age group, for children covered in its title XXI-funded Medicaid program. A copy of the approved state plan page (CS3) is attached, and should be incorporated into the state’s approved CHIP state plan. This page supersedes the current Medicaid expansion Section (4.0) of the current CHIP state plan.

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

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

7500 Security Blvd.

Baltimore, MD 21244-1850

Telephone: (410) 786-8145

Facsimile: (410) 786-5943

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

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

Centers for Medicare & Medicaid Services

Division of Medicaid and Children’s Health Operations The Public Ledger Building, Suite 216

150 South Independence Mall West

Philadelphia, PA 19106

If you have additional questions, please contact Ms. Linda Nablo, Director, Division of State Coverage Programs, at (410) 786-5143.

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

Sincerely,

1ot Fishman Director

cc: Francis McCullough, ARA, CMS Region III, Philadelphia

logged in as TONIABROWN(CMS CO Staff) read only mode application rev p01 Children's Health Insurance Program Eligibility WV.0495.R00.00 - Jan 01, 2014 Home Logout Finder Save Print Help Control Panel General Information File Management Tribal Input Summary State/Territory name: West Virginia State Funds: $ Federal Funds: $ Submitted By: Stacey Shamblin Last Revision Date: Jan 9, 2014 Submit Date: Nov 12, 2013 Children's Health Insurance Program Eligibility: Summary Page Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. WV-13-0002 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 457320(a)(2) and (3) Federal Budget Impact This SPA has a budget impact. Total budget impact: Subject of Amendment Please provide a brief summary of SPA changes. Character Count:217 out of 2000 State option to create Medicaid expansion for children 6 - 18 up to 133% FPL Instructions with August 15, 2013 budget submissions required budgeted amounts for this change be reflected on Medicaid budget b i i Signature of State Agency Official Page 1 of 2 Children's Health Insurance Program Eligibility: CMS 179 05/06/2014 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

FAQs | Site Map | Contact | Medicaid.gov | CMS.gov Page 2 of 2 Children's Health Insurance Program Eligibility: CMS 179 05/06/2014 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

coms CHIP Eligibility

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

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

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

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

Must be under age 19.

Income Standards

Income standards are applied statewide.

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

Statewide Income Standards

Begin with lowest age range first.

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

From Age To Age Above (% FPL) Up to & including (% FPL) 1 158 300 6 141 300 19 133 300 x.

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

Special Program for Children with Disabilities

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

FEB 0 6 2014 Effective Date: January 1, 2014

Page 1 of 2

SPA# WV-13-0001 Approval Date:

Cems 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.

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CcMs. CHIP Eligibility

OMB Control Number: 0938-1148

Sec. 2110(b)(2)(B) and (b)(6) of the SSA

im Children Who Have Access to Public Employee Coverage - Otherwise eligible targeted low-income children who have access to public employee coverage on the basis of a family member's employment.

The CHIP Agency operates this covered group in accordance with the following provisions: Select one of the following conditions as described in Section 2110(b)(6) of the Social Security Act: @ Maintenance of agency contribution as provided in 2110(b)(6)(B) of the SSA. C) Hardship criteria as provided in section 2110(b)(6)(C) of the Social Security Act. Coverage under this option is extended to children whose household income is: Select one of the options for the income standard when compared to Targeted Low Income Children @ The same as the standards for Targeted Low-Income Children C) Lower than the income standards for Targeted Low-Income Children

Indicate whether coverage under this option is extended to all children who have access to public employee coverage, or only certain children:

@: All children who have access to public employee coverage

C: Certain children who have access to public employee coverage:

[ Attach methodology the state has used to calculate maintenance of agency contribution.

An attachment is submitted.

The state provides assurance that the state will, on an annual basis, recalculate expenditures for each participating public agency to determine if the maintenance effort condition continues to be met.

Children who are eligible for public employee health benefits coverage who are not described above are excluded from eligibility under the plan.

Children considered to have access to public employee coverage, and therefore not excluded from CHIP through this option, otherwise meet the definition of targeted low-income child provided at 42 CFR 457.310.

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.20131007 F EB 0 6 2014 Effective Date: January 1, 2014 Page 1 of |

SPA# WV-13-0001 Approval Date:

West Virginia CHIP CHIP CS10 Analysis - Children Who Have Access To Public Employee Coverage

Maintenance of Public Agency Contributions to Employee Dependent Coverage 1997 — 2013

Annual Annual State Employee Employee 1997 State Fiscal and Dependent and Dependent Agency Expenditure Year Costs Premiums Expenditures CPI-U (Medical) Increased by CPI 1997 $3,214.71 $770.09 $2,444.62 $2,444.62 1998 3,414.02 741.61 2,672.44 3.22% 2,523.34 1999 4,130.97 741.61 3,389.36 3.49% 2,611.40 2000 4,081.40 741.61 3,339.78 4.06% 2,717.42 2001 4,909.92 869.10 4,040.83 4.61% 2,842.70 2002 5,221.71 1,106.91 4,114.80 4.71% 2,976.59 2003 5,400.62 1,432.47 3,968.15 4.02% 3,096.25 2004 5,925.99 1,794.84 4,131.15 4.40% 3,232.48 2005 6,669.91 1,792.08 4,877.83 4.22% 3,368.89 2006 6,915.44 1,947.00 4,968.44 4.01% 3,503.98 2007 7,159.42 2,200.95 4,958.47 4.42% 3,658.86 2008 7,644.34 2,191.84 5,452.50 3.71% 3,794.60 2009 7,977.54 2,186.32 5,791.22 3.17% 3,914.89 2010 8,143.65 2,383.09 5,760.56 3.49% 4,051.52 2011 8,850.79 2,477.01 6,373.78 2.92% 4,169.83 2012 9,434.85 2,635.55 6,799.30 3.95% 4,334.54 2013 9,207.23 2,629.97 6,577.26 2.15% 4,427.73 SPA# WV-13-0001 Approval Date: FEB 0 6 2044 Effective Date: January 1, 2014

CCRC Actuaries, LLC 9/26/2013

West Virginia CHIP CHIP CS10 Analysis - Children Who Have Access To Public Employee Coverage

Maintenance of Public Agency Contributions to Employee Dependent Coverage 1997 — 2013

Annual Annual State Employee Employee 1997 State Fiscal and Dependent and Dependent Agency Expenditure Year Costs Premiums Expenditures CPI-U (Medical) Increased by CPI 1997 $3,214.71 $770.09 $2,444.62 $2,444.62 1998 , 3,414.02 741.61 2,672.41 3.22% 2,523.34 1999 4,130.97 741.61 3,389.36 3.49% 2,611.40 2000 4,081.40 741.61 3,339.78 4.06% 2,717.42 2001 4,909.92 869.10 4,040.83 4.61% 2,842.70 2002 5,221.71 1,106.91 4,114.80 4.71% 2,976.59 2003 5,400.62 1,432.47 3,968.15 4.02% 3,096.25 2004 5,925.99 1,794.84 4,131.15 4.40% 3,232.48 2005 6,669.91 1,792.08 4,877.83 4.22% 3,368.89 2006 6,915.44 1,947.00 4,968.44 4.01% 3,503.98 2007 7,159.42 2,200.95 4,958.47 4.42% 3,658.86 2008 7,644.34 2,191.84 5,452.50 3.71% 3,794.60 2009 7,977.54 2,186.32 5,791.22 3.17% 3,914.89 2010 8,143.65 2,383.09 5,760.56 3.49% 4,051.52 2011 8,850.79 2,477.01 6,373.78 2.92% 4,169.83 2012 9,434.85 2,635.55 6,799.30 3.95% 4,334.54 2013 9,207.23 2,629.97 6,577.26 2.15% 4,427.73 SPA# WV-13-0001 Approval Date: FEB 0 6 2014 Effective Date: January 1, 2014

CCRC Actuaries, LLC . 9/26/2013

Cems CHIP Eligibility

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

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

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

The state operates this covered group in accordance with the following provisions:

[li] The child was born to an eligible targeted low-income pregnant woman under section 2112 of the SSA.

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

The state elects the following option(s):

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

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

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

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

V.20130917

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SPA# WV-13-0001 Approval Date: Effective Date: January 1, 2014

Page | of |

CccmMs CHIP Eligibility

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

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

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

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

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

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

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

Household income includes actually available cash support, exceeding nominal amounts, provided

by the person claiming an individual described at §435.603(f)(2)(i) as a tax dependent. Pres

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

An attachment is submitted.

PRA Disclosure Statement

SPA# WV-13-0001 Approval Date: FEB 0 6 2014 Effective Date: January 1, 2014 Page 1 of 2

cemMs 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.

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Cems. CHIP Eligibility

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

42 CFR 457.320(a)(2) and (3)

Income eligibility for children under the Medicaid Expansion is determined in accordance with the following income standards: There should be no overlaps or gaps for the ages entered.

Age and Household Income Ranges

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

+ lie 19 108 133 xX

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.

FEB 0 6 2014

SPA# WV-13-0002 Approval Date: Effective Date: January 1, 2014 Page 1 of I

_____________________________________________________________________________

Table of Contents

State/Territory Name: West Virginia

State Plan Amendment (SPA) #: WV-13-0003

(In addition to the SPA noted above, this package contains other state plan amendment approvals)

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

DEPARTMENT OF HEALTH & HUMAN SERVICES

Centers for Medicare & Medicaid Services Oe

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

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

Children and Adults Health Programs Group

FEB 0 7 2014

Sharon L. Carte, Executive Director

West Virginia Children’s Health Insurance Program 1018 Kanawha Boulevard East, Suite 209 Charleston, WV 25301

Dear Ms. Carte:

Iam pleased to inform you that your Children’s Health Insurance Program (CHIP) state plan amendments (SPA) number WV-13-0003 and WV-13-0005 submitted on November 12, 2013, and related to Modified Adjusted Gross Income (MAGDJ Eligibility, has been approved with an effective date of January 1, 2014.

Establish 2101(f) Group:

SPA number WV-13-0003 describes the state’s plan to provide coverage in its separate CHIP, established in accordance with 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 state plan page (CS14) is attached, and should be incorporated within a separate subsection under Section 4.1 of West Virginia’s approved CHIP state plan.

Non-Financial Eligibility:

SPA number WV-13-0005S 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 West Virginia'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 Security Section 4.1.9.1 Number CS20: Non-Financial Eligibility — Substitution of Section 4.4.4 Coverage CS21: Non-Payment of Premiums Section 8.7 CS27: General Eligibility — Continuous Eligibility _| Section 4.1.8

Page 2 — Ms. Sharon L. Carte

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

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

7500 Security Blvd.

Baltimore, MD 21244-1850

Telephone: (410) 786-8145

Facsimile: (410) 786-5943

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

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

Centers for Medicare & Medicaid Services

Division of Medicaid and Children’s Health Operations The Public Ledger Building, Suite 216

150 South Independence Mall West

Philadelphia, PA 19106

If you have additional questions, please contact Ms. Linda Nablo, Director, Division of State Coverage Programs, at (410) 786-5143.

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

Sincerely,

Ehot Fishman Director

cc: Francis McCullough, ARA, CMS Region III, Philadelphia

logged in as TONIABROWN(CMS CO Staff) read only mode application rev p01 Children's Health Insurance Program Eligibility WV.0496.R00.00 - Jan 01, 2014 Home Logout Finder Save Print Help Control Panel General Information File Management Tribal Input Summary State/Territory name: West Virginia State Funds: $ Federal Funds: $ Submitted By: Stacey Shamblin Last Revision Date: Nov 12, 2013 Submit Date: Nov 12, 2013 Children's Health Insurance Program Eligibility: Summary Page Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. WV-13-0003 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 457.310(d) Federal Budget Impact This SPA has a budget impact. Total budget impact: Subject of Amendment Please provide a brief summary of SPA changes. Character Count:180 out of 2000 To allow WVCHIP to cover children who lose Medicaid due to loss of income disregards due to MAGI conversion. State anticipates no significant budget impact as a result of the SPA. Signature of State Agency Official Page 1 of 2 Children's Health Insurance Program Eligibility: CMS 179 05/04/2014 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

FAQs | Site Map | Contact | Medicaid.gov | CMS.gov Page 2 of 2 Children's Health Insurance Program Eligibility: CMS 179 05/04/2014 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

CHIP Eligibility

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

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

[M 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:

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

The state assures that separate CHIP coverage will be provided for children ineligible for Medicaid due to the elimination of income disregards in accordance with 42 CFR 457.310(d). Coverage for this population will cease when the last child protected

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

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.

Oo 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.

© Other.

Describe the benefits provided to this population:

O 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.

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

Describe premiums and cost sharing required of this population:

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

FEB 07 26%

SPA# WV-13-0003 Approval Date: Effective Date: January 1, 2014 Page 1 of 2

CHIP Eligibility

@ Premiums and cost sharing are the same as for targeted low-income children in the state's separate CHIP. CONo premiums, copayments, deductibles, coinsurance or other cost sharing is required.

© 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.

V.20130917

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CHIP Eligibility

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

42 CFR 457.320

Residency

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

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

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

1, Intends to reside in the state, including without a fixed address, or

2. Has entered the state with a job commitment or seeking employment, whether or not currently employed. {MA 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.

im 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

[MA 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 fl residence.

If the state covers pregnant women, a pregnant woman is considered to be a resident under the following conditions: [Hf] 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.

rt 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

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

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

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

SPA# WV-13-0005 Approval Date: FEB 0 7 2014

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CHIP Eligibility

One or more interstate agreement(s). No

A policy related to individuals in the state only for educational purposes. No

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

Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. V.20130917

FEB 0 7 2014 Effective Date: January 1, 2014

Page 2 of 2

SPA# WV-13-0005 Approval Date:

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.

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

Who are citizens or nationals of the United States; or

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

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

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

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

The agency begins to furnish benefits to otherwise eligible individuals during the reasonable opportunity period on a date INo earlier than the date the notice is received by the individual.

The CHIP Agency elects the option to provide CHIP coverage to otherwise eligible children up to age 19, lawfully residing Ves in the United States, as provided in Section 2107(e)(1)(J) of the SSA (Section 214 of CHIPRA 2009, P.L. 111-3).

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

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

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- No Income Pregnant Women.

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

[An individual is considered to be lawfully present in the United States if he or she is: “3 Ana FEB O07 201+ SPA# WV-13-0005 Approval Date:, Effective Date: January 1, 2014 Page | of 3

CHIP Eligibility

1. A qualified non-citizen as defined in 8 U.S.C. 1641(b) and (c);

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

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

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

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

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

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

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

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

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

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

(i) Has been granted employment authorization; or

(ii) Is under the age of 14 and has had an application pending for at least 180 days; 6. Has been granted withholding of removal under the Convention Against Torture; 7. 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)).

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.

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CHIP Eligibility

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CHIP Eligibility

OMB Control Number: 0938-1148 Expirati

42 CFR 457.340(b)

date: 10/31/2014

Social Security Number

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

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

Individuals refusing to obtain a social security number (SSN) because of well established religious objections, or Individuals who are not eligible for an SSN, or Individuals who are issued an SSN only for a valid non-work purpose.

ry 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.

[lM] The CHIP Agency informs individuals required to provide their SSN: By what statutory authority the number is solicited; and How the state will use the SSN.

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

and 1137 of the Social Security Act and the Privacy Act of 1974.

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

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

SSN. Yes

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

mw 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

FEB 0 7 2014

SPA# WV-13-0005 Approval Date: Effective Date: January 1, 2014 Page 1 of 2

CHIP Eligibility

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

V.20130917

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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:

|

[Bl Substitution of coverage prevention strategy:

Name of policy

Description

‘ost Enrollment Data Matches with 4 Commercial Insurance Files

WVCHIP has vendor match monthly CHIP enrollment ee files with other insurance databases. Matches are EB followed-up with family contact and if other coverage

is verified, the child's WVCHIP coverage is zB terminated. ;

Applications that indicate enrollment in another group health plan are denied at application. B

Claims Processing - Indication of Other 4 Payer Source

Claims that indicate payments from other insurance ; are denied and WVCHIP follows up with family to ee verify other coverage. If other coverage is verified, : the child is terminated from WVCHIP.

The single streamlined application asks applicants to report any health coverage. If the family reports "creditable" health coverage, the child will be found ineligible. To be eligible, the child must not be Ee insured by a group health plan. There is no waiting period for children. To determine the percent of enrollees who dropped group health insurance without good cause in order to be eligible for WVCHIP, p monthly reports will be generated that compare the number of children denied due to other insurance, ee reapplied and approved for WVCHIP who no longer report other insurance within a six month period. If substitution exceeds 10%, WVCHIP will collaborate with CMS to identify a strategy to reduce substitution.

O provided in section 2110(b)(5) of the SSA.

A waiting period during which an individual is ineligible due to having dropped group health coverage. ho | (1 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:

The other coverage exclusion does not apply to children who are otherwise eligible for dental only supplemental coverage as

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

SPA# WV-13-0005

pen —p—-7—9N4E Approval pate FEB UP CUM

Effective Date: January 1, 2014 Page | of 2

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.20130917

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CHIP Eligibility

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

42 CFR 457.570

Non-Payment of Premiums

Does the state impose premiums or enrollment fees? FY es

Can non-payment of premiums or enrollment fees result in loss of CHIP eligibility? (No

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

V.20130917

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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

© 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:

[BM] Atthe end ofthe |12 | months continuous eligibility period.

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

Ty 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.

[Mj The child dies. [ll] 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

Child gains coverage under another group insurance plan.

PRA Disclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 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.

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_____________________________________________________________________________

Table of Contents

State/Territory Name: West Virginia

State Plan Amendment (SPA) #: WV-13-0005

(In addition to the SPA noted above, this package contains other state plan amendment approvals)

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

DEPARTMENT OF HEALTH & HUMAN SERVICES

Centers for Medicare & Medicaid Services Oe

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

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

Children and Adults Health Programs Group

FEB 0 7 2014

Sharon L. Carte, Executive Director

West Virginia Children’s Health Insurance Program 1018 Kanawha Boulevard East, Suite 209 Charleston, WV 25301

Dear Ms. Carte:

Iam pleased to inform you that your Children’s Health Insurance Program (CHIP) state plan amendments (SPA) number WV-13-0003 and WV-13-0005 submitted on November 12, 2013, and related to Modified Adjusted Gross Income (MAGDJ Eligibility, has been approved with an effective date of January 1, 2014.

Establish 2101(f) Group:

SPA number WV-13-0003 describes the state’s plan to provide coverage in its separate CHIP, established in accordance with 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 state plan page (CS14) is attached, and should be incorporated within a separate subsection under Section 4.1 of West Virginia’s approved CHIP state plan.

Non-Financial Eligibility:

SPA number WV-13-0005S 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 West Virginia'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 Security Section 4.1.9.1 Number CS20: Non-Financial Eligibility — Substitution of Section 4.4.4 Coverage CS21: Non-Payment of Premiums Section 8.7 CS27: General Eligibility — Continuous Eligibility _| Section 4.1.8

Page 2 — Ms. Sharon L. Carte

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

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

7500 Security Blvd.

Baltimore, MD 21244-1850

Telephone: (410) 786-8145

Facsimile: (410) 786-5943

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

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

Centers for Medicare & Medicaid Services

Division of Medicaid and Children’s Health Operations The Public Ledger Building, Suite 216

150 South Independence Mall West

Philadelphia, PA 19106

If you have additional questions, please contact Ms. Linda Nablo, Director, Division of State Coverage Programs, at (410) 786-5143.

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

Sincerely,

Eliot Fishman Director

cc: Francis McCullough, ARA, CMS Region III, Philadelphia

logged in as TONIABROWN(CMS CO Staff) read only mode application rev p01 Children's Health Insurance Program Eligibility WV.0498.R00.00 - Jan 01, 2014 Home Logout Finder Save Print Help Control Panel General Information File Management Tribal Input Summary State/Territory name: West Virginia State Funds: $ Federal Funds: $ Submitted By: Stacey Shamblin Last Revision Date: Feb 4, 2014 Submit Date: Nov 12, 2013 Children's Health Insurance Program Eligibility: Summary Page Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. WV-13-0005 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 457.320(b)(6),(c),(d);457.380;457.340(b),(d)(3);457.350(i);457.805;457.570;457.342;435 Federal Budget Impact This SPA has a budget impact. Total budget impact: Subject of Amendment Please provide a brief summary of SPA changes. Character Count:31 out of 2000 Minimal budget impact expected. Signature of State Agency Official Page 1 of 2 Children's Health Insurance Program Eligibility: CMS 179 05/04/2014 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01/pages/chp_179.jsp

FAQs | Site Map | Contact | Medicaid.gov | CMS.gov Page 2 of 2 Children's Health Insurance Program Eligibility: CMS 179 05/04/2014 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01/pages/chp_179.jsp

CHIP Eligibility

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

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

[M 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:

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

The state assures that separate CHIP coverage will be provided for children ineligible for Medicaid due to the elimination of income disregards in accordance with 42 CFR 457.310(d). Coverage for this population will cease when the last child protected

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

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.

Oo 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.

© Other.

Describe the benefits provided to this population:

O 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.

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

Describe premiums and cost sharing required of this population:

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

FEB 07 26%

SPA# WV-13-0003 Approval Date: Effective Date: January 1, 2014 Page 1 of 2

CHIP Eligibility

@ Premiums and cost sharing are the same as for targeted low-income children in the state's separate CHIP. CONo premiums, copayments, deductibles, coinsurance or other cost sharing is required.

© 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.

V.20130917

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CHIP Eligibility

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

42 CFR 457.320

Residency

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

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

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

1, Intends to reside in the state, including without a fixed address, or

2. Has entered the state with a job commitment or seeking employment, whether or not currently employed. {MA 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.

im 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

[MA 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 fl residence.

If the state covers pregnant women, a pregnant woman is considered to be a resident under the following conditions: [Hf] 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.

rt 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

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

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

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

SPA# WV-13-0005 Approval Date: FEB 0 7 2014

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CHIP Eligibility

One or more interstate agreement(s). No

A policy related to individuals in the state only for educational purposes. No

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

Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. V.20130917

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Page 2 of 2

SPA# WV-13-0005 Approval Date:

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.

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

Who are citizens or nationals of the United States; or

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

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

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

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

The agency begins to furnish benefits to otherwise eligible individuals during the reasonable opportunity period on a date INo earlier than the date the notice is received by the individual.

The CHIP Agency elects the option to provide CHIP coverage to otherwise eligible children up to age 19, lawfully residing Ves in the United States, as provided in Section 2107(e)(1)(J) of the SSA (Section 214 of CHIPRA 2009, P.L. 111-3).

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

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

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- No Income Pregnant Women.

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

[An individual is considered to be lawfully present in the United States if he or she is: “3 Ana FEB O07 201+ SPA# WV-13-0005 Approval Date:, Effective Date: January 1, 2014 Page | of 3

CHIP Eligibility

1. A qualified non-citizen as defined in 8 U.S.C. 1641(b) and (c);

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

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

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

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

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

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

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

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

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

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

(i) Has been granted employment authorization; or

(ii) Is under the age of 14 and has had an application pending for at least 180 days; 6. Has been granted withholding of removal under the Convention Against Torture; 7. 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)).

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.

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CHIP Eligibility

OMB Control Number: 0938-1148 Expirati

42 CFR 457.340(b)

date: 10/31/2014

Social Security Number

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

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

Individuals refusing to obtain a social security number (SSN) because of well established religious objections, or Individuals who are not eligible for an SSN, or Individuals who are issued an SSN only for a valid non-work purpose.

ry 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.

[lM] The CHIP Agency informs individuals required to provide their SSN: By what statutory authority the number is solicited; and How the state will use the SSN.

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

and 1137 of the Social Security Act and the Privacy Act of 1974.

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

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

SSN. Yes

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

mw 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

FEB 0 7 2014

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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.

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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:

|

[Bl Substitution of coverage prevention strategy:

Name of policy

Description

‘ost Enrollment Data Matches with 4 Commercial Insurance Files

WVCHIP has vendor match monthly CHIP enrollment ee files with other insurance databases. Matches are EB followed-up with family contact and if other coverage

is verified, the child's WVCHIP coverage is zB terminated. ;

Applications that indicate enrollment in another group health plan are denied at application. B

Claims Processing - Indication of Other 4 Payer Source

Claims that indicate payments from other insurance ; are denied and WVCHIP follows up with family to ee verify other coverage. If other coverage is verified, : the child is terminated from WVCHIP.

The single streamlined application asks applicants to report any health coverage. If the family reports "creditable" health coverage, the child will be found ineligible. To be eligible, the child must not be Ee insured by a group health plan. There is no waiting period for children. To determine the percent of enrollees who dropped group health insurance without good cause in order to be eligible for WVCHIP, p monthly reports will be generated that compare the number of children denied due to other insurance, ee reapplied and approved for WVCHIP who no longer report other insurance within a six month period. If substitution exceeds 10%, WVCHIP will collaborate with CMS to identify a strategy to reduce substitution.

O provided in section 2110(b)(5) of the SSA.

A waiting period during which an individual is ineligible due to having dropped group health coverage. ho | (1 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:

The other coverage exclusion does not apply to children who are otherwise eligible for dental only supplemental coverage as

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

SPA# WV-13-0005

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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.

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

42 CFR 457.570

Non-Payment of Premiums

Does the state impose premiums or enrollment fees? FY es

Can non-payment of premiums or enrollment fees result in loss of CHIP eligibility? (No

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

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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

© 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:

[BM] Atthe end ofthe |12 | months continuous eligibility period.

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

Ty 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.

[Mj The child dies. [ll] 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

Child gains coverage under another group insurance plan.

PRA Disclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 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.

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_____________________________________________________________________________ Table of Contents State/Territory Name: West Virginia State Plan Amendments (SPA) #: WV-18-0003 This file contains the following documents in the order listed: 1) Approval Letter 2) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop 32-01-16 Baltimore, MD 21244-1850 lvts ctNftRs foR MtDtcABt & MtDtcAtf, sttvtcts CENIIN TON MEDICAID & CHIP SERYICES Children and Adults Health Proqrams DEC 0 6 20ft Stacey L. Shamblin Acting Executive Director West Virginia Children's Health Insurance Program 350 Capitol Street, Room 251 Charleston, WV 25301 Dear Ms. Shamblin: Your title XXI Children's Health Insurance Program (CHIP) state plan amendment (SPA) WV- 18-0003, submitted to the Centers for Medicare & Medicaid Services (CMS) on June 2g,20lg with additional information submitted on November 15, 2018, has been approved. Through this SPA, West Virginia implements mental health parity requirements in section 2103(c)(7) of the Social Security Act (the Act) and regulation at 42 CFR 457.496 to ensure that financial requirements and treatment limitations applied to mental health (MH) and substance use disorder (SUD) benefits are no more restrictive than those applied to medical/surgical (M/S) benefits. This SPA has an effective date of October 2,2017. Section 2103(c)(7)(A) of 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 it provides both N{/S and MH/SUD benefits, a state must demonstrate that financial requirements and treatment limitations applied to MH/SUD benefits covered under the state child health plan comply with these requirements. West Virginia demonstrated compliance by providing the necessary assurances and supporting documentation that the state's application of non-quantitative treatment limitations and financial requirements to MH/SUD benefits are consistent with section 2r03(c)(7)(A) of the Act. This approval relates only to benefits provided under the CHIP state plan; Medicaid benefits will be analy zed separately. Your title XXI project officer is Ms. Joyce Jordan. She is available to answer questions concerning this amendment and other CHlP-related issues. Ms. Jordan's contact information is as follows:

Page 2- Ms. Stacey L. Shamblin Centers for Medicare & Medicaid Services Cel)ter for Medicaid and CHIP Services Mail Stop S2"01-16 7500 Security Boulevard Baltimore, MD 21244-1850 Telephone: (410) 786-3413 E-mail: Joyce.Jordan@crns.hhs.gov Official communications regarding program matters should be sent simultaneously to Ms. Jordan and to Mr. Francis McCullough, Associate Regional Administrator (ARA) in our Philadelphia Regional Office. Mr. McCullough's address is: Centers for Medicare & Medicaid Services Philadelphia Regional Office Division of Medicaid and Children's Health Operations The Public Ledger Building, Suite 216 150 South Independence Mall West Philadelphia, PA 19106 If you have additional questions, pleas·e contact Ms. Amy Lutzky, Director, Division of State Coverage Programs at (410) 786-0721. We look forward to continuing to work with you andyour staff: ''; ;. cc: ,, Aime Marie Costello ?:L41 Director Mr. Francis McCullough; ARA, CMS Region III, Philadelphia /signed Anne Marie Costello/

#12 Effective: October 1,2013 lmplemented: October 1, 201-3 Centers (FQHC's) and Rural Health Centers (RHC's), lncorporates the MAGI-based eligibility process requ¡rements in accordance with the Affordable Care Act. Coverage for eligible PEIA children. #13 Effective: Januar[ I,2074 f mplemented: January 1,2O'J.4 SPA #14 Purpose of SPA: Mcntal Hcalth PaliLv Proposed effective date: October' 2. 201 7 Proposed implementation date: Octobcr 2, 201 7 1.4- TC Tribal Consultation (Section 2l 07(e)(l )(C)) Desclibe the consultation process that occurred specifically for the development and submission of this State Plan Amendment, when it occurred and who was involved. TN No: Approval Date Effective Date Section 2. General Backsround and Description of Annroach to Children's Health Insurance Coverage and Coordination Guidance: The dernograghic 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 infonnation are ase breakouts. income brackets. definitions of insurability. and eeograohic location. as well as race and ethnicity. The State should describe its information sources and the assumptions it uses for the development of its description. o Pooulation . Number of uninsured o Race demographics o Age Demosraohics ¡ 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 exlent feasible, distinguish between creditable coverage under public health insurance programs and public-private partnerships (See Section l0 for annual repoft requirements). (Section l0

Section 6.4.2.). nre-existing condition limits are allowed to the extent permitted b), HIPAA/ERISA. If the State is contracting with a eroup health olan or provides benefits throush grouo health coveraqe, describe briefly any limitations on pre-existing conditions. (Formerlv 8.6.) 6.2- MHPAEA Section 2103(c)(6)(A) ofthe 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) ofthe 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 art'angement, this requirement applies to both the state and managed care plans. These requirements are also applicable to any additional benefits provided voluntalily to the child health plan population by managed care entities and will be considered as part of CMS's contract review process at 42 CFR 4s7.1201(l). 6.2.1- MHPAEA. Before cornpleting a parity analysis, the State must determine whether each covered benefit is a rnedical/surgical, rnental 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. (42 CFR 457.496(Ð(1)(i)) 6.2.1.1- MIIPAEA 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 ofthe standard elected must be used. Ifdifferent standards are used for 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. ffi lnternational Classification of Disease (lCD) I Diagnostic and Statistical Manual of Mental Disorders (DSM) ! State guidelines (Describe: ) I Other (Describe: ) 6.2.1.2- MHPAEA Does the State provide mental health and/or substance use disorder benefits? ffi Yes !No Guidance: Ifthe State does not provide anv mental health or substance use disorder benefits. the mental health paritv requirements do not applv ((42 CFR 457.496(fl11)). 5t

Continue on to Section 6.3. 6.2.2- MHPAEA Section 2103(c)(6)(B) of the Social Security Act (the Act) provides that to the extent a State child health plan includes coverage of early and periodic screening, diagnostic, and treatment selvices (EPSDT) defined in section 1905(r) ofthe Act and provided in accordance with section 1902(a)(43) ofthe Act, the plan shall be deemed to satisfy the parity requirements ofsection 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 ofEPSDT 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 XNo I Guidance: If the State child health plan do¿s ¿al provide EPSDT consistent with Medicaid statutory requirements at sections 1902(aX43) and 19051r) of the Act. please eo to Section 6.2.3- MHPAEA to complete the required paritv analysis of the State child health plan. If the state d¿¿s provide EPSDT benefits consistent with Medicaid requirements. olease continue this section to demonstrate compliance with the statutory requirements of section 2103(cX6XB) of the Act and the mental health naritv resulations of 42 CFR 457.496(b) related to deemed compliance. Please nrovide suofiorting documentation. such as contract language, Drovider manuals. and/or member handbooks describins the state's provision ofEPSDT. 6,2.2.2- MHP AEA EPSDT benefits are provided to the following: ! All children covered under the State child health plan. I A subset ofchildren covered under the State child health plan. Please describe the different populations (ifapplicable) covered under the State child health plan that are provided EPSDT benefìts consistent with Medicaid statutory requirements. Guidance: If onlv a subset of children are nrovided EPSDT benefits under the State child health plan. 42 CFR 457.4961bX3) Iimits deemed compliance to those children onlv and Section 6.2.3- MHPAEA must be comnleted as well as the JZ

required Darify analvsis 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) ofthe Act (42 CFR 457.496(b)). The State assures each ofthe following for children eligible for EPSDT under the separate State child health plan: I 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 services, whether or not those services are covered under the Medicaid state plan. (Section l90s(r)) ! All items and services described in section 1905(a) ofthe 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 sewices are covered under the Medicaid State plan. (Section 1905(r)(5)) I 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)) I 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 sewices necessary to coffect or ameliorate any medical or physical condition or illness. (Section 1905(r)(5)) ! enSOf benefits are not excluded on the basis ofany condition, disorder, or diagnosis. (Section 1905(rX5)) 53

! The provision ofall requested EPSDT screening services, as well as any corrective treatments needed based on those screening services, are provided or arranged for as necessary. (Section 1 902(a)(43)) n 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 ofservices available to them. (Section 1902(a)(a3)(A)) Guidance: For states seeking deemed compliance for their entire State child health nlan nopulation. please continue to Section 6.3. If not all of the covered nopulations are offered EPSDT. the State must conduct a paritv analvsis ofthe benefit nackases nrovided to those ponulations. Please continue to 6.2.3- MHPAEA. Mental Health Paritv Analvsis Requirements for States Not Providins EPSDT to All Covered Ponulations Guidance: The State must complete a paritv analvsis for each population under the State child health plan that is not provided the EPSDT benefit consistent with the requirements 42 CFR 457.496(b). If the State nrovides benefits or limitations that varv within the child or preenant woman populations. states should perform a paritv analvsis for each of the benelit packages. For examnle. ifdifferent financial reouirements are applied according to a beneficiarv's income. a separate parify analysis is needed for the benefit packaqe provided at each income level. Please ensure that chanees made to benefit limitations under the State child health plan as a result of the paritv analvsis are also made in Section 6.2. ó.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. (42 CFR 4s7.4e6(d)(2)(ä); 42 cFF. 457.496(dX3XiiXB)) 6.2.3.1 MHPAEA Please describe below the standard(s) used to place covered benefits into one of the foul classifications. 6.2.3.1.1MHPAEA The State assures that: I The State has classified all benefits covered under the State plan into one of the four classifications. 54

ffi The same reasonable standards are used for determining the classification for a rnental health or substance use disorder benefit as are used for determining the classification of med icallsurgical benefits. Ihc state soltccl all nroclicitl/sLrtgicnl and Ml liSì.il) clailns into one ol'[ìrr¡r cllissilicat.iolls (irrpaticnt. rlufp¿lienl. clllclilcnc!'. and Iìx) to conclucf ils par-itv anolvsis. l) Inpâ1ic:ll1: I acility clairns rvhctc nrcr¡bcr was conJincd to â hos[ritâl as cvi(lcncecl bJ- room and lroatcl lccorcl. ?) Outpaticnf; Scrr'ìccs rvele 1ìlrl.hcr classilietl into ol'lìcc r'ìstts and other outl)aticnl scrv iccs. a) Out¡raticnt-O ll'icc Visits: l)rolcssional clairrs rcgardlcss of ¡lìacc ol'sct'vice. h) OuLpr ticnt-Ot hcr': I;aciIit¡, cl¿inrs fì¡r'scl'viccs turl pcrlìrrnrctl in l.hc lìnelgcncr, l)c¡taltrnt:nI zurrl rro cvitlcncc ol'an inpalìcrr1 ¿clnrission, .ì) IinrcLgcncl,(.'alc: liaciìil1,clajnr lor ser-vice ¡:rerfìrlmcd in an enrelgcncv roolr thal di(l no1 havr: al associ¿r1cd hospilaf adrrrission. 4) l)r'cscripLion l)r'ugs: OlaÌrns fìil dlLrg.s thal rcqrÌirc u prcsc-.r'iption billcd t.o thc Phalmac¡, llenclll lvlânaser (l'llNi).'l-hìs docs not inclLrclc rhLrgs pn>vided in outpûlicrì1 or irlt)alicul l'acilitios nor.phvsician adrn ìrristen:-tl drugs. (llairns lvcrc lìnther catqqorizcd by thc nrc:mbcr's crlrclltrcnt glou¡r ((ìold. Illuc, ancl PlcnriLrr.n) índìcatìng clif'f'olcnL cosl.-shaling lcvcls lrascd on là.nlilv incontc. 6,2,3,1,2- MHPAEA Does the State use sub-classifications to distinguish between office visits and other outpatient services? ffi Yes !No 6.2.3.1.2.1- MHPAEA If the State uses sub-classifications to distinguish between outpatient office visits and othet outpatient services, the State assures the following: ffi 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 DurDoses of this section. anv reference to "classification(s)o' includes sub-classification(s) in states usins sub-

classifications to distinguish between outDatient office visits from other outpatient services. 6.2.3.2 MHPAEA The State assures that: ffi 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 142 CFR 457.496(f)(2)). However if a state does provide anv mental health or substance use disorder benefits. 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 nlan (42 CFR 4s7.496(dX2)tii). Annual and Assreeate Lifetime Dollar 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. (42 CFR 457.496(c) 6.2.4.1- MHPAEA Please indicate whether the State applies an aggregùte 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. I Aggregate lifetime dollar limit is applied ! Aggregate annual dollar limit is applied ffi No dollar lirnit is applied Guidance: A monetary coveraee limit that applies to ø// CHIP services orovided under the State child health nlan is not subiect to narity requirements. If there are no agereeate lifetime or annual dollar limits on anv mental health or substance use disorder benefits. please go to section 6,2.5- MHPAEA. 6,2.4.2- Ìù/IHP AEA Are there any rnedical/surgical benefits covered under the State child health plan that have either an aggregate lifetime dollar limitoran annual dollar limit? Ifyes, please specify what type of Iimits apply. I Ves (Type(s) of limit: ) 56

XNo Guidance: If no aeeregate lifetime dollar limit is anplied to medical/ sureical benefits. the State mav not impose an aggregate lifetime dollar limit on ¿øv mental health or substance use disorder benefits. If no assresate annual dollar limit is applied to medical/sursical benefits" the State mav not imnose an aqgregate annual dollar limit on ¿¿y mental health or substance use disorder benelits. (42 CFR 457.496(cX1)) 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 ofall medical/surgical benefits covered under the State plan (42 CFR457.496(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 tho State plan for the State plan year or portion ofthe plan year after a change in benefits that affects the applicability ofthe aggregate lifetime or annual dollar limits. (42 CFR as7.a96(c)(3)) I The State assures that it has developed a reasonable methodology to calculate the portion ofcovered medical/surgical benefits which are subject to the aggregate lifetime and/or annual dollar limit, as applicable. Guidance: Please include the state's methodologv to calculate the nortion of covered medical/surgical benefits which are subiect to the aqereeate lifetime and/or annual dollar limit and the results as an attachment to the State child health olan. 6.2.4.3.1- MHPAEA Please indicate the poftion of the total costs for medical and surgical benefits covered under the State plan which are subject to a lifetime dollar limit: ! Less than l/3 ! At least l/3 and less than 2/3 E 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 l/3 ! At least 1/3 and less than 2/3 57

n At least 2/3 Guidance: If an aesreeate lifetime limit is apnlied to less than one-third of all medical/sursical benefits. the State mav not imoose an asgregate lifetime limit on ¿øy mental health or substance use disorder benefits. If an annual dollar limit is applied to less than one-third ofall medical sursical benefits. the State mav not impose an annual dollar limit on aøy mental health or substance use disorder benefits (42 CFR 457.4961cX1)). Skip to section 6.2.5- MHPAEA. Ifthe State apÞlies an aseresate lifetime or annual dollar limit to at least one-third of all medical/surgical benefits. nlease continue below to provide the assurances related to the determination of the portion of total costs for medical/sursical benefits that are subiect to either an annual or lifetime limit. 6.2.4.3.2.1- MHPAEA If the State anplies an aqsresate lifetime or annual dollar limit to at least l/3 and less than 2/3 ofall medical/surgical benefits, the State assures the following (42 CFP. 457 .496(cXaXiXB)); (42 CFR as7 .ae6(c)()(ü)): ! 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 methodoloey for calculatins the average limit for medical/sureical benefits must be consistent with 42 CFR 457.496(cX4Xi)lB) and 42 CFR 457.496(cX4)lii). Please include the state's methodoloqv and results as an attachment to the State child health plan. 6.2.4.3.2.2- MHPAEA lf at leas| 2/3 of all medical/surgical benefits are subject to an annual or lifetime limit, the State assures either ofthe following (42 cFR as7 .ae6@)(2)(i)); (42 CFP. 4s7 .496(c)(2)(ii)): I 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 58

fl The aggregate lifetime or annual dollar limit placed on mental health and substance use disorder benefìts 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 substanca use disorder benefits in any classification of benefits? Ifyes, specify the classification(s) of benefits in which the State applies one or more QTLs on any mental health or substance use disorder benefits. L__j Yes (Specrty: XNo Guidance: Ifthe state does not anply anv tvne ofOTLs on anv mental health or substance use disorder benefits in anv classification. the state meets parity reouirements for OTLs and should continue to Section 6.2.6 - MHPAEA. If the state does anplv OTLs to anv mental health or substance use disorder benefits. the state must conduct a Þaritv analvsis. 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 OTLs on anv medical/sursical benelits. the State mav not impose quantitative treatment limitations on mental health or substance use disorder benefits. please so 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 portion of medical and surgical benefìts in the classification 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 sulgical benefits within a classification which are subject to the type ofquantitative treatment limitation for the plan year (or poftion of the plan year after a mid-year change affecting the applicability of a type ofquantitative 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 ofthis 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 59

be made by MCEs contracting \ /ith the State. (42 CFP. 457 .496(dX3XiXC) I The State assures it has applied a reasonable methodology to detelmine the dollar amounts used in the ratio described above for each classification within which the State applies QTLs to mental health or substance use disorder benefits. (42 CFR 4s7.4e6(dX3XiXE) Guidance: Please include the state's methodologv and results 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 ofQTL to "substantially all" (defined as at least two-thirds) ofthe medical/surgical benefits within the same classification? (42 CFP. 457.496(dX3XiXA)) ! ves !No Guidance: If the State does not apply a tvne of OTL to substantiallv all medical/sursical benefits in a given classification of benefits. the State mav øol imnose that tvpe of OTL on mental health or substance use disorder benefits in that classification. 142 CFR 457.496(dX3XiXA)l 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 ofthat type which is applied to medical/surgical benefits in the classification. The "predominant level" ofa type ofQTL in a classification is the level (or least restrictive ofa combination of levels) that applies to more than one-halfofthe medical/surgical benefits iq that classification, as described in 42 CFR 457 .496(dX3)(iXB). The portion of medical/surgical benefits in a classification to which a given level ofa 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 42 CFR 457.496(dX3XiXC). 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 benefits within a classifìcation are subject to a type ofquantitative treatment limitation also is applied in determining the dollar amounts used to determine the predominant level ofa type ofquantitative treatment limitation applied to medical/surgical benefits within a classification. (42 CFP' 457 .496(dX3XD(E) OU

f] 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 predominant level ofthat type which is applied by the State to medical/surgical benefits within the same classification. (42 CFR 4s7 .4e6(d)(2)(i)) Guidance: Ifthere is no sinsle level ofa tvpe ofOTL that exceeds the one- half threshold. the State may combine levels within a tvpe of OTL such that the combined levels are apnlied to at least halfofall medical/sursical benefits within a classification¡ the predominant level is the least restrictive level of the levels combined to meet the one-half threshold. 142 CFR 4s7.496(dX3XillBX2)) 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. (42 CFR a57.a96@)GÐ; (42 CFR 457.496(d)(5)) 6.2.6.1 - MHPAEA If the State imposes any NQTLs, complete this subsection. If the State does not irnpose NQTLs, please go to Section 6.2.7-MHPAEA. ffi The State assures that the processes, strategies, evidentiary standards or other factors used in the application ofany 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 manasement standards to limit or exclude benefits based on medical necessitv. restrictions based on seosranhic location. provider specialtv, or other criteria to limit the scope or duration of benefits and provider network design (ex: preferred providers vs. narticinating providersl. Additional examoles of possible NOTLs are provided in 42 CFR 457.496(dX4Xii). States will need to provide a summarv of its NOTL analvsis. as well as supporting documentation as requested. 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 pr.oviders. 6.2.6.2.1- MHPAEA Does the State or MCE contracting with the State provide coverage of medical or surgical benefits provided by out-of-network providers? ! Yes 6l

XNo Guidance: The State can answer no if the State or MCE onlv provides out of network selwices in specific circumstances. such as emergencv care. or when the network is unable to provide a necessary service covered under the contract. 6.2.6,2.2- MHPAEA If yes, the State must provide access to out-of-network providers for mental health or substance use disorder benefits. Please assure the following: ! The State attests that when determining access to out-of-network ptoviders 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 detennine 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 ofpayment or reimbursement for mental health or substance use disorder services (42 CFP. 457 .496(e)) in addition to existing notice requirements at 42 CFR 457.1180. 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: fi state ! Managed Care entities ! eotn ! other Guidance: If other is selected. nlease specifv the entitv. 6,2.7.2- Iû/IHPAEA 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: I state 62

6.3 ! Managed Care entities E soth I other Guid¿nce: If other is selected. please specifv the entitv. The State assures that, with respect to pre-existing medical conditions, one ofthe following two statements applies to its plan: (42 CFR 457.480) The State shall not pelmit the imposition ofany pre-existing medical condition exclusion for covered services (Section 2102(b)(l )(B)(ii)); OR The State contracts with a group health plan or group health insurance coverage, or contracts with a group health plan to plovide family coverage under a waiver (see Section 6.6.2. (formerly 6.4.2) ofthe template). Pre-existing medical conditions are permitted to the extent allowed by HIPAA/ERISA. (Formerly 8.6.) (Section 2l 03(f)) Describe: 6.3.1. x 6.3.2.2 Guidance: States may request two additional ourchase options in Title XXI: cost effective coverage through a community-based health delivery system and foi the purchase of familv coverage. (Section 2105(cX2) and (3)) (42 CFR 457.1005 and 457.1010) 6.4. Additional Purchase Options- Ifthe 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 4s7.100s and 457.1010) 6.4.1. E Cost Effective Coverage- Payment may be made to a State in excess ofthe l0 percent limitation on use offunds for payments for: l) other child health assistance for targeted low-income children; 2) expenditures for health services initiatives under the plan for improving the health ofchildren (including targeted low-income children and other low-income children); 3) expenditules for outreach activities as provided in Section 2102(c)(l) under the plan; and 4) other reasonable costs incurred by the State to administer the plan, if it demonstrates the following (42CFR 457.1 005(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)(D) (42 CFR 4s7. l00s(b)) 63

S,2.2-DSn Deductibles: 8.2.3-DS ! Coinsurance or copayments: 8.2.4-DS I other: 8.3. Describe how the public will be notified, including the public schedule, of this cost sharing (including the cumulative maximum) and changes to these amounts and any differences based on income. (Section 2103(e)(1)(A)) (42 CFR 457.505(b) 'l'he State inl'orms the public and individuals olcost sharing amounts and any changes to tÌlese aÍì'ìounts. including cumulalive r¡aximums, through its application fortn, printecf posters availatrle in clinics and other outreaclr sites, on its website at www.chip.wv.gov. aud to individual pal'licipants who rcceive a Surnnrary PIau Descliption (SPD) on enrolling and at thc time ofre-enrollnrcnt. Plan part¡oipants ale notificd at lcast 30 days in advance ofprop<lsecl cltanges to cost sharing and asl<ed fdr co:nnrenls. Comments arc reviewed by the Children's.Flealth lnsurance Board prior to approving ¡rroposed changes. Guidance: The Stdte should be able to demonstrate upon request its rationale andjustification regarding these assurances. This section also addresses limitations on pa),ments for cedain expenditures and requirements for maintenance of effort. 8.4. The State assures that it has made the following findings with respect to the cost sharing in its plan: (Section 2103(e)) s.4.1. x s.4.2. x s.43 x Cost-sharing does not favor children from higher income families over lower income families. (Section 2103(e)(lXB) (42 CFR 457.530) No cost-sharing applies to well-baby and well-child care, including age- appropriate immunizations. (Section 2103(e)(2)) (42 CFP' 457 .520) No additional cost-sharing applies to the costs ofemergency medical seruices delivered outside the network. (Section 2103(e)(l)(A) (42 CFR 457.515(Ð) 8.4.1- MHPAEA ffi There is nå separate accumulation of cumulative financial requiremehts, as defined in 42 CFR 457 .496(a), for mental health and substance abuse disorder benefits compared to medical/suÍgical benefits. (42 CFR 457 .496(dX3Xiii) S.4.2- MHPAEA ffi If applicable, any different levels of financial requirements that are applied to different tiers ofprescription drugs are determined based on reasonable factors, regardless of whether a drug is generally prescribed for medical/surgical benefìts or mental health/substance use disorder benefits. (42 CFP* 457 .496(dX3XiD(A) 8.4.3- MHPAEA ffi Cost sharing applied to benefits provided under the State child health plan will remain capped at fìve percent of the beneficiary's income as required by 42 CFP.457.560 (42 CFR 4s7.4e6(dX3XiXD). 76

8.4.4- MHPAEA Does the State apply financiâl requirements to any mental health or substance use disorder benefits? Ifyes, specify the classification(s) ofbenefits in which the State applies financial requirements on any mental health or substance use disorder benefits. I Yes (Specify:-Copaynren Ls alc requircd l'ol br¿nci tÍ ugs. rnult-i-sour.ce drugs. non- medìcal honlc visits. in¡;atient visits. oLrLpaticnt surgeries- þlR scrviccs. ¿urcl some clelltal scrv ices.) ENo Guidance: For the purooses of paritv. financial requirements include deductibles, coDayments. coinsurance. and out of pocket maximums: premiums are excluded from the definition, Ifthe state does not annlv financial requirements on any mentâl health or substance use disorder benefits. the state meets paritv requirements for fìnancial requirements. Ifthe state does applv financial requirements to mental health or substance use disorder benelits. the state must conduct a paritv analvsis. Please continue below. Please ensure that chanqes made to financial requirements under the State child health plan as a result ofthe paritv analysis are also made in Section 8.2. 8.4.5- MHPAEA Does the State apply any type of financial requirements on any medical/surgical benefits? fi ves nNo Guidance: If the State does not annlv financial requirements on anv medical/sursical benefits. the State may not imoose financial requirements on mental health or substance use disorder benefits. 8.4.6- MHPAEA Within each classification of benefits in which the State applies a type of financial requirement on any mental health or substance use disorder benefits, the State must determine the portion of medical and surgical benefìts in the class which are subject to the limitation. ffi The State assures it has applied a reasonable methodology to determine the dollar amounts used in the ratio described above (Section 6.2.5.2-MHPAEA) for each classificatiorr or within which the State applies financial requirements to mental health or substance use disorder benefirs. (42 CFR 457.496(dX3XiXE) 77

Guidance: Please include the state's methodologv and results ofthe parity analvsis as an attachment to the State child health plan. 8.4.7- MHPAEA For each type of financial requirement applied to any mental health or substance use disorder benefits within a given classification, does the State apply the same type offinancial requirement to at least two{hirds ("substantially all") of all the medical/surgical benefits within the same classification? (42 CFP. 457 .496(dX3XiXA) ffi Yes !No Guidancei Ifthe State does not apnly a type of linancial requirement to substantiallv all medical/surgical benefits in a given classification of benefits. the State mav z¿l impose financial requirements on mental health or substance use disorder benefits in that classification. 142 CFR 457.496ldX3XiXA)l 8.4.8- MHPAEA For each type of financial requirement applied to substantially all medical/surgical benefits in a classification, the State must determine the predominant level (as defined in 42 CFR 457.496(dX3XÐ@) of that type which is applied to medical/sulgical benefits in the classification. For each type offinancial requirement applied to substantially all rnedical/surgical benefits in a classification, the State assures: ffi The same reasonable methodology applied in determining the dollar amounts used in determining whether substantially all medical/surgical benefits within a classification are subject to a type offinancial requirement also is applied in deterrnining the dollar amounts used to determine the predominant level of a type of financial requirement applied to medical/surgical benefits within a classification. (42 CFR 457 .496(dX3XiXE) ffi The level of each type of financial requirement applied by the State to mental health or substance use disorder benefits in any classification is no more restrictive than the predominant level ofthat type which is applied by the State to medical/surgical benefits within the same classification. (42 CFR 457 .496(dX2Xi)) Guidance: If there is no single level of a type of financial requirement that exceeds the one-half threshold. the State mav combine levels within a tvne of financial requirement such that the combined levels are applied to at least halfofall medical/sursical benefits within a classification: the nredominant level is the least restrictive level of the levels combined to meet the one-half threshold. 142 CFR 4s7.496(d)ßXil(BX2)) Describe how the State will ensure that the annual aggregate cost-sharing for a family 8.5. 78

_____________________________________________________________________________ Table of Contents State/Territory Name: West Virginia State Plan Amendments (SPA) #: WV-19-0005 This file contains the following documents in the order listed: 1) Approval Letter 2) State Plan Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES

Centers for Medicare & Medicaid Services

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

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

Children and Adults Health Programs Group

SEP 2 7 2019

Jean Kranz,

Executive Director

West Virginia Children’s Health Insurance Program 350 Capitol Street, Room 251

Charleston, WV 25301

Dear Ms. Kranz:

Your title XXI Children’s Health Insurance Program (CHIP) state plan amendment (SPA) number WV-19-0005, with an effective date of July 1, 2019, has been approved. This SPA permits West Virginia to implement a health services initiative (HSI to support the West Virginia Poison Center.

Section 2105(a)(1)(D)(ii) of the Social Security Act (the Act) and 42 CFR §457.10 authorize use of title XXI administrative funding for expenditures for HSIs under the plan for improving the health of children, including targeted low-income children and other low-income

children. Consistent with section 2105(c)(6)(B) of the Act and 42 CFR §457.626, title XXI funds used to support an HSI cannot supplant Medicaid or other sources of federal funding.

The state shall ensure that the remaining title XXI funding, within the state’s 10 percent administrative limit, is sufficient to continue the proper administration of the CHIP program. If such funds become less than sufficient, the state agrees to redirect title XXI funds from the support of this HSI to the administration of the CHIP program. The state shall report annually to CMS the expenditures funded by the HSI for each federal fiscal year.

Your title XXI project officer is Ticia Jones. 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 7500 Security Blvd., Mail Stop: S2-01-16 Baltimore, MD 21244-1850

Telephone: (410) 786-8145

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

Official communication regarding program matters should be submitted simultaneously to Ticia Jones and Francis McCullough, Director, Division of Medicaid Field Operations East. Francis McCullough’s address is:

Page 2 Ms. Jean Kranz Centers for Medicare & Medicaid Services Division of Medicaid Field Operations East JFK Federal Building, Suite 2325 Boston, MA 02203-0003 We look forward to continuing to work with you and your staff. Sirfrely, Anne Marie Costello Director cc: Francis McCullough, Director, Division of Medicaid Field Operations East /signed Anne Marie Costello/

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

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

State/Territory: State of West Virginia (Name of State/Territory)

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

Bill Crouch, State of West Virginia, Signed Big (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: Jean Kranz Position/Title: Executive Director Name: Jeremiah Samples Position/Title: Deputy Secretary, DHHR Name: Bill Crouch Position/Title: Cabinet Secretary, DHHR

*Disclosure. In accordance with 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 (CMS-10398 #34). The time required to complete this information collection is estimated to average 80 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, write to: CMS, 7500 Security Blvd., Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

8 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: July 1, 1998

Implementation Date: July 1, 1998

SPA #16 Purpose of SPA: WV-19-0005 Poison Treatment Advice and Prevention Proposed effective date: July 1, 2019

Proposed implementation date: July 1, 2019

Effective: July 1, 1998 Implemented: July 1, 1998 A Medicaid expansion for children ages 1 to 5 from 134% up to 150% PFL

Amendments General Description #1 Effective: April 1, 1999 Implemented: April 1, 1999 Expanded coverage for children ages 6 to 18 from 101% to 150% FPL under a benchmark coverage program based on state’s public employees insurance program

#2

Effective: October 1, 2000 Implemented: October 1, 2000

Combines Medicaid expansion (Phase 1- Ages 1 to 5) with benchmark coverage (Phase II – Ages 6 to 18) into one program under benchmark coverage

#3

Effective: November 1, 2000 Implemented: October 23, 2000

Expands coverage to 200% FPL and includes cost sharing through copayments

#4

Effective: July 1, 2002 Implemented: July 1, 2002

Technical amendments to comply with federal statute of August 24, 2001. Also, expansion of pharmacy copayments to families below 150% FPL; and inclusion of annual and lifetime benefit limits.

9 #5 Effective: January 1, 2006 Implemented: January 1, 2006 Institutes a formulary for generic and/or preferred brand drugs for all therapeutic classes (with medical necessity exceptions when demonstrated by physicians) and grandfathering exceptions to changes for seven drug classes related to mental conditions. #6 Effective: January 1, 2007 Implemented: January 1, 2007 Expansion from 201% to 220% FPL through the addition of premium sharing with a limited dental benefit. Also, copayments for sick visits are excluded when a medical home is designated.

#7

Submitted: June 11, 2007 Withdrawn: August 31, 2007

A special Health Services Initiative to allow for paid comprehensive wellness exams for uninsured children about to enter Kindergarten which included a basic coverage guarantee for subsequent diagnosis and treatment related to any conditions detected as a result of the exams and/or related screens.

#8

Effective: September 1, 2008 Implemented: January 1, 2008

A special Health Services Initiative allowing for paid comprehensive wellness exams for uninsured children about to enter Kindergarten which includes referral but no coverage guarantee for subsequent diagnosis and treatment related to conditions detected as a result of the exam and/or related screens.

#9

Effective: January 1, 2009 Implemented: January 1, 2009

Expanded coverage from 220% to 250% FPL through premium sharing. Also, eliminated use of income disregards when determining maximum upper income limit.

#10

Effective: July 1, 2010 Implemented: July 1, 2010

This amendment combines provisions made effective the prior year to comply with CHIPRA provisions along with an expansion of CHIP dental services to the premium sharing group (above 200% FPL income) which had previously had a maximum $150 annual limit.

Effective: July 1, 2011 Implemented: July 1, 2011

Expanded coverage from 251% FPL to a maximum gross income limit of 300% FPL. Makes other changes to comply with CHIPRA provisions including elimination of annual and lifetime plan limits, and assurance of mental health parity accompanied by service limit changes necessary for this

10 assurance. #11 Effective: October 1, 2011 Implemented: October 1, 2011 To change to a prospective payment system reimbursement methodology for Federally Qualified Health Centers (FQHC’s) and Rural Health Centers (RHC’s). #12 Effective: October 1, 2013 Implemented: October 1, 2013 Incorporates the MAGI-based eligibility process requirements in accordance with the Affordable Care Act. #13 Effective: January 1, 2014 Implemented: January 1, 2014 Coverage for eligible PEIA children. #14 Effective: October 2, 2017 Implemented: October 2, 2017 Approved: December 6, 2018 Mental Health Parity #15 #16 Effective: July 1, 2019 Implemented: July 1, 2019 Approved: ???? Effective: July 1, 2019 Implemented: July 1, 2019 Approved: ???? Managed Care WV-19-0005 Poison Treatment Advice and Prevention 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. TN No: Approval Date Effective Date 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 its description.

17 health services 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)

Poison Treatment Advice and Prevention. West Virginia will use CHIP HSI funds, within the 10 percent federal administrative expenditures cap allowed for states, to support the West Virginia Poison Center (WVPC).

The WVPC provides 24-hours per day, 7 days a week, emergency telephone poisoning/overdose assessment, treatment, and referral recommendations to both the public and health care professionals in WV. Emergency phone lines are staffed by nurses with additional toxicology training, Specialists in Poison Information (SPIs), who must pass a national certification examination to become Certified Specialists in Poison Information (CSPI) to maintain employment. At all times, SPIs and CSPIs are backed up by a team of Medical Toxicologists (physicians with board certification in emergency medicine and additional board certification in medical toxicology) and a Clinical Toxicologist (a fellowship-trained Doctor of Pharmacy with board certification as an applied toxicologist).

Types of poisonings/overdoses managed by the WVPC include: unintentional poisonings (e.g., accidental ingestions of drugs, cleaners, household products); therapeutic errors; drug/product misuse exposures; self-harm exposures; environmental exposures (e.g., carbon monoxide poisonings, chemical spills); biologic exposures (e.g., snakebites, spider bites, stings, plant or mushroom ingestions); substance abuse toxicity; chronic lead poisoning; and occupational exposures (at the worksite or occupational chemicals migrating into the home).

The service is available to all citizens and health care professionals in all of WV’s 55 counties. Over 16,000 exposure case records are generated each year in addition to over 5,000 information case records. Exposure cases result in approximately 19,000 follow-up calls by the Poison Specialists for continued evaluation and management recommendations. For non-English speaking residents, the WVPC has a contract with an agency that can translate over 150 languages; the WVPC can also communicate with the deaf community via telecommunications devices for the deaf and hearing impaired (TDD).

According to the US Census Bureau, 2017 American Community Survey estimates, approximately 20.5% of WV total population is under 18. 66% of WV children are in households with incomes at 300% FPL or lower. In calendar years 2016 through 2018 the WVPC reported that children under 19 averaged 60% of all case exposure records with 45% of all case exposure records involving children under age 6. CHIP funding under this HSI is targeted to cover the cost of providing WVPC services to the approximately 40% (66% of 60%) of cases that involve children under age 19 in families at or below 300% FPL.

18 For every $1 spent on poison control efforts, there is a return on investment of $18. In WV, the savings is approximately $25 to $30 million each year. Nationally, poison centers saved $1.8 billion in medical costs in the United States in 2016. Costs are saved by managing poisonings at home, decreasing unnecessary ambulance rides, decreasing hospital days, and decreasing hospital transfer costs. Decreasing hospital transfer costs is especially important for children in WV due to the number of hospitals in the state that do not routinely care for pediatric patients.

The WVPC toll-free number is promoted throughout the state via poison center publications, the WVPC website, WV emergency number listings, pediatrician offices, listed in all West Virginia telephone directories.

The WVPC Director has a strong working relationship with the WV Office of Healthy Schools. Through this affiliation, students in 755 WV schools, throughout all of WV’s 55 counties, receive WVPC awareness information. Public schools in WV are required to report use of naloxone or epinephrine auto-injectors and any poisonings, overdoses, or therapeutic errors to the WVPC. Other WVPC collaborations, overseen by the WVPC Community Outreach Coordinator, include: WV Birth to Three, Parents as Teachers, Help Me Grow, the Family Resource Network, and the Bureau for Children and Families through River Valley Child Development Services. The WVPC also consults with the Violence and Injury Prevention Program. The WVPC Director is a regular participant in the Emergency Medical Services for Children (EMSC) Advisory Committee.

The WVPC Community Outreach Coordinator, runs the WVPC poison prevention and outreach program. In addition to brochures on core poison prevention information, the WVPC created brochures as a result of poisoning trends seen in WV. For example, brochures aimed at children and adolescents cover jimson weed abuse, caffeine overuse, and inhalant abuse. For smaller children, brochures covering prevention of poisonous plant exposures are popular. Brochures on poisonous snakes of WV and bites & stings are also commonly requested. The WVPC also created a “Letter to Grandparents” to warn grandparents about the risks their medications can pose for their grandchildren. Monthly and emergency press releases are used to inform the public about real-time poisoning concerns that have been identified via real-time review of emergency telephone case records. Educational materials targeted to families are disseminated widely at various settings and programs that include not only the collaborative partners identified above, but also schools, Head Start programs, daycares, local health departments, Mothers of Preshoolers (MOPS) groups, community baby showers, community based health fairs (many rural areas have large health fairs that reach many families), and mailings to public libraries and pediatrician offices.

CHIP provides $225,000 in annual funding that is used 90% for the call center operations ($203,000) and 10% for materials ($22,000), with all funds targeting services for children at or below 300% FPL. WVPC has annual costs of approximately $1.3 million. CHIP HSI funding covers around 17% of total WVPC costs and 29% of costs attributable to providing services to children under 19 (60% of $1.3 million, or $780,000). Further prorating WVPC costs to the 66% of WV children at or below 300% FPL, (66% of $780,000, or $514,000), CHIP HSI funding contributes 44% of the total WVPC serving this targeted child population.

19 Funding under this HSI will not supplant or match CHIP federal funds with other Federal funds, nor will it allow other Federal funds to supplant or match CHIP Federal funds. Funding under this HSI is dedicated to children 18 years of age or younger. “Kids First”: A Health Services Initiative The goal of this initiative is to assure that West Virginia children start Kindergarten healthy and ready to learn. The Kids First Initiative is a collaborative among three state government agencies; Department of Education, Department of Administration, and Department of Health and Human Resources, that enlists the West Virginia medical community, families, and community-based supports to improve child health and early learning. All West Virginia children entering kindergarten will receive a health screen to identify risks to healthy growth and development. The West Virginia medical community, which includes private practicing physicians, community health centers, hospital-based clinics, and local health departments, is a participating partner in Kids First. Medical clinicians will be offering wellness screenings at their service sites, or alternate school settings, using the Kids First protocol, which meets the Bright Futures, American Academy of Pediatric standards. The offering of wellness screens in children’s medical homes supports West Virginia’s efforts to encourage primary medical homes for all children. For populations who do not receive wellness screenings in their selected medical homes, screenings will be made available by participating community medical providers on-site at Kindergarten Round-ups (enrollment). On-site school screenings will be offered to all unscreened children presenting to Kindergarten regardless of insurance status. Caveat: WVCHIP resources will not be used to offset screening costs for children who are insured, nor will they be used to supplant school funding or resources for wellness screenings. The school is serving as an additional screening site for children who were not screened prior to Kindergarten Round-ups and is offered at the school for the convenience of parents and participating providers. No funds to providers for this project will come from schools, or their districts. Conversely, no funds from WVCHIP, Title XXI , will go to schools to cover costs of alternate service sites for wellness screenings, or for the screening services. Payments for wellness screenings for insured kids, including those covered by WVCHIP or Medicaid, will be made by the appropriate payer according to its benefit plan. WVCHIP, Title XXI Health Service Initiative (HSI) funding will pay for screening services for uninsured children only. Parents of children who are covered by private insurance are responsible to pay for the screen if the private insurance does not cover the cost for any reason. The West Virginia Office of Maternal, Child, and Family Health (OMCFH) will act as a “central depository” for provider billings of these wellness exams for uninsured children. OMCFH will access Medicaid and WVCHIP enrollment files to determine if the child was subsequently enrolled in either program. If so, the claim form for the exam will be forwarded to the appropriate Agency for payment. The remaining claim forms will then be forwarded to WVCHIP to check against commercial insurance files. If it is determined the child has commercial insurance, the claim will be returned to the provider instructing them

129 STATE: WV FFY Budget – without HSI FFY Budget – with HSI Federal Fiscal Year 2019 2019 State’s enhanced FMAP rate 93.96% 93.96% Benefit Costs Insurance payments 0 0 Managed care 20,700,000 20,700,000 per member/per month rate Varies Varies Fee for Service 51,071,891 51,071,891 Total Benefit Costs 71,771,891 71,771,891 (Offsetting beneficiary cost sharing payments) (1,529,958) (1,529,958) Net Benefit Costs 70,241,933 70,241,933 Cost of Proposed SPA Changes – Benefit 0 0 Administration Costs Personnel 625,500 625,500 General administration 585,000 585,000 Contractors/Brokers 1,000,000 1,000,000 Claims Processing 4,500,000 4,500,000 Outreach/marketing costs 471,749 471,749 Health Services Initiatives 0 225,000 Other 0 0 Total Administration Costs 7,182,249 7,407,249 10% Administrative Cap 7,804,659 7,804,659 Cost of Proposed SPA Changes 0 225,0000 Federal Share 72,747,761 72,959,171 State Share 4,676,421 4,690,011 Total Costs of Approved CHIP Plan 77,424,182 77,649,182 NOTE: Include the costs associated with the current SPA. The Source of State Share Funds: General appropriations Section 10. Annual Reports and Evaluations Guidance: The National Academy for State Health Policy (NASHP), CMS and the states developed framework for the annual report that states have the option to use to complete the required evaluation report. The framework recognizes the diversity in State approaches to

_____________________________________________________________________________ Table of Contents State/Territory Name: West Virginia State Plan Amendments (SPA) #: WV-19-0006 This file contains the following documents in the order listed: 1) Approval Letter 2) State Plan Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES

Centers for Medicare & Medicaid Services

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

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

Children and Adults Health Programs Group

OCT 1 1 2019

Jean Kranz

Executive Director

West Virginia Children’s Health Insurance Program 350 Capitol Street, Room 251

Charleston, WV 25301

Dear Ms. Kranz:

Your title XXI Children’s Health Insurance Program (CHIP) state plan amendment (SPA) number WV-19-0006 has been approved. This SPA permits West Virginia to provide coverage to uninsured pregnant women over age 18, with family income up to 300 percent of the federal poverty level. The effective date of this amendment is July 1, 2019.

Through this SPA, the state has adopted the option at section 2107(e)(1)(N) of the Social Security Act (the Act), which allows the state to extend this coverage to otherwise eligible lawfully residing, non-citizen pregnant women. It has also adopted the option at section 2112(d)(2) of the Act, which allows the state to extend coverage to pregnant women who have access to state employee coverage.

With the addition of targeted low-income pregnant women under CHIP, the deemed newborn requirements described in section 2112(e) of the Act, implementing regulations at 42 CFR 457.360, and section CS13 of the CHIP state plan are now applicable to the newborns of targeted low-income pregnant women.

Your title XXI project officer is Ticia Jones. 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 7500 Security Blvd., Mail Stop: S2-01-16 Baltimore, MD 21244-1850

Telephone: (410) 786-8145

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

Official communication regarding program matters should be submitted simultaneously to Ticia Jones and Francis McCullough, Director, Division of Medicaid Field Operations East. Francis McCullough’s address is:

Page 2 — Ms. Jean Kranz. Centers for Medicare & Medicaid Services Division of Medicaid Field Operations East JFK Federal Building, Suite 2325 Boston, MA 02203-0003 We look forward to continuing to work with you and your staff. Sincerely,

/signed Anne Marie Costello/

Ahne Marie Costello Director

ce: Francis McCullough, Director, Division of Medicaid Field Operations East

CHIP Eligibility

CDIEPNEE TERE SAEAOC AME £ AMRIT RIAN

State Name:| West Virginia OMB Control Number: 0938-1148

Transmittal Number: WV - 19 - 0006

Section 2112 of the SSA

ial Targeted Low-Income Pregnant Women - Uninsured pregnant women who do not have access to public employee coverage and whose household income is within standards established by the state.

The CHIP Agency operates this covered group in accordance with the following provisions: Age Standards for Pregnant Women The state provides coverage to pregnant women:

Select an age range:

(©: From age 19, up to the following age: 55

(> With no age restriction. C Another age range:

If there is no age restriction or if the age range overlaps with the qualifying ages for children, describe how the determination is made as to whether the applicant will be provided coverage as a child or as a pregnant woman.

[i] Must be pregnant or post-partum

Income Standards

Pregnant women coverage may only be provided if children's qualifying income standard under the plan is at least up to 200% of FP. for all age ranges.

c

Income standard is applied statewide es

Are there any exceptions, e.g. populations in a county which may qualify under either a statewide income standard or a county income standard? °

Statewide Income Standard

CHIP coverage for pregnant women may only be provided if the qualifying income standard under Medicaid for pregnant women is at least up to 185%.

The highest income level for pregnant women cannot be higher than the highest income level for children.

Above 185} % FPL up to and including 300] % FPL

(rt 4 8A4an SPA# WV-19-0006 Approval Date: cri TV aug

Effective Date: July 1, 2019

: 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.20181 119

OCT 1 1 2019

SPA# WV-19-0006 Approval Date: Effective Date: July 1, 2019 Page 2 of 2

CHIP Eligibility

State Name:| West Virginia | OMB Control Number: 0938-1148

Transmittal Numbe:

WV - 19 - 0006

Sec. 2110(b)(2)(B) and (b)(6) of the SSA

i

Pregnant Women Who Have Access to Public Employee Coverage - Otherwise eligible targeted low-income pregnant women who have access to public employee coverage on the basis of their, or a family member’s employment.

The CHIP Agency operates this covered group in accordance with the following provisions: Select one of the following conditions as described in Section 2110(b)(6) of the Social Security Act: @ Maintenance of agency contribution as provided in 2110(6)(6)(B) of the SSA.

C: Hardship criteria as provided in section 2110(b)(6)(C) of the Social Security Act.

Coverage under this option is extended to pregnant women whose household income is: Select one of the options for the income standard when compared to Targeted Low-Income Pregnant Women

@ The same as the standards for Targeted Low-Income Pregnant Women. © Lower than the income standards for Targeted Low-Income Pregnant Women.

Indicate whether coverage under this option is extended to all pregnant women who have access to public employee coverage, or only certain pregnant women:

@ All pregnant women who have access to public employee coverage. C:> Certain pregnant women who have access to public employee coverage:

[li] Attach methodology the state has used to calculate maintenance of agency contribution.

The state provides assurance that the state will, on an annual basis, recalculate expenditures for each participating public agency to determine if the maintenance of effort condition continues to be met.

[lH] Age Standard

Select an age standard:

@ Same as the age criteria used for Targeted Low-Income Pregnant Women.

C> Different than the age criteria used for Targeted Low-Income Pregnant Women. {Must be pregnant or in a post-partum period.

Pregnant women considered to have access to public employee coverage, and therefore not excluded from CHIP through this option, otherwise meet the definition of targeted low-income pregnant woman in accordance with section 21 12(d)(2) of the SSA.

PRA Disclosure Statement

SPA# WV-19-0006 Approval Date: ocT 1 i 2019 Effective Date: July 1, 2019 Page 1 of 2

CHIP Eligibility

Peirce seein siaens MEN

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.20181119

OCT { | 2019 Effective Date: July 1, 2019

Page 2 of 2

SPA# WV-19-0006 Approval Date:

STATE OF WEST VIRGINIA

West Virginia

Children's Health

Insurance Program

CHILDREN’S HEALTH INSURANCE PROGRAM

CMS Maintenance of Effort Agency Contributions Analysis

Pregnant Women Who Have Access to Public Employee Coverage

September 9, 2019

West Virginia Children’s Health Insurance Program Report of Independent Actuary

CMS Maintenance of Effort Agency Contributions Analysis

Pregnant Women Who Have Access to Public Employee Coverage

OVERVIEW

Continuing Care Actuaries, LLC (“Continuing Care Actuaries”) was engaged by the West Virginia Children’s Health Insurance Program (“CHIP Program”) to assist the West Virginia CHIP Board in the analysis of actual and projected plan experience. The CHIP Program management team asked Continuing Care Actuaries to prepare the required maintenance of effort with respect to Agency contributions for public employees and dependent coverage analysis for pregnant women who have access to public employee coverage. The West Virginia Public Employees Insurance Agency (“PEJA”) currently provides insurance coverage for State Employees, Teachers and Local Agencies in West Virginia and is the source of the bulk of the data used in this analysis. This analysis was based on PEIA experience in providing pregnancy benefits through Employee and Dependent coverage.

The purpose of this analysis is to compare the State Agency contributions under Employee and Dependent coverages from State Fiscal Year 1997 to date to the 1997 State Expenditures updated by the CPI-U (Medical) trend as reported by the federal government. First aggregate Employee and Dependent costs were developed and divided by enrollment to yield per capita costs. These costs were offset by the annual Employee and Dependent Premiums to yield the Agency Expenditures for 1997 and succeeding years. The final piece of the analysis was to compare Agency Expenditures to the CPI-U adjusted 1997 State Expenditures for 1998 through 2019. The results show that the PEIA Agency Expenditures on a per capita basis always exceed the CPI-U Adjusted 1997 State Expenditures for each year in the study period. The detailed results of this analysis are attached on the following page.

PREGNANCY BENEFITS

PEIA provides comprehensive pregnancy benefits which include:

e Maternity services for routine prenatal care, delivery and follow-up are paid at 100% of allowed charges under a global fee after the deductible has been met.

e Obstetrical profiles and ultrasounds are also paid at 100% of allowed charges under a global fee.

e Maternity-related professional and facility services, including prenatal care, midwife services and birthing centers. Maternity related services are covered for the employee and covered dependents.

Continuing Care Actuaries, LLC

Maternity management provides prenatal education and high-risk pregnancy identification to help mothers carry their babies to term. This program increases the number of healthy, full-term deliveries and decreases the cost of long-term hospital stays for both mothers and babies

PEIA provies a pre-pregnancy coaching program which helps women learn about risks and take action to prevent serious and costly medical complications before they become pregnant.

Transition of Care pregnancy benefits to allow for changes in physicians.

PEIA complies with the Statement of Rights under the Newborns’ and Mothers’ Health Protection Act. PEIA’s maternity benefit meets or exceeds all of the requirements of the Act. Under federal law, PEIA does not restrict benefits for any hospital length of stay in connection with childbirth to less than 48 hours following a vaginal delivery, or less than 96 hours following a delivery by Cesarean section.

PEIA also provides 100% coverage for the prescription tobacco cessation medications during pregnancy.

Continuing Care Actuaries, LLC

CMS — PREGNANT WOMEN WHO HAVE ACCESS TO PUBLIC EMPLOYEE COVERAGE

Maintenance of Effort Condition to Individual and Family Coverage

State Annual Annual 1997 State Fiscal Employee Employee Agency | Medicai Expenditure Year Costs Premiums Expenditures | CPI-U Increased by CPI 1997 S 2,508.23 | S$ 491.56 $2,016.68 $2,016.68 1998 $ 2,625.96 | _ $ 481.90 2,144.05 3.22% 2,081.61 1999 $ 3,177.61 | S$ 505.59 2,672.02 3.49% 2,154.26 2000 S 3,149.44} S 504.43 2,645.01 4.06% 2,241.72 2001 Ss 3,934.88 | $ 623.50 3,311.39 4.61% 2,345.07 2002 s 4,249.59 | § 872.57 3,377.02 4.71% 2,455.52 2003 S 4,392.64 | $ 1,077.55 3,315.09 4.02% 2,554.23 2004 $ 4,815.64} $ 1,351.38 3,464.26 4.40% 2,666.62 2005 $ 5,326.46 | S$ 1,348.12 3,978.34 4.22% 2,779.15 2006 $ 5,519.65 | S$ 1,465.19 4,054.46 4.01% 2,890.59 2007 § 5,683.16 | S$ 1,641.55 4,041.60 4.42% 3,018.36 2008 S 6,039.18 | S$ 1,638.84 4,400.33 3.71% 3,130.34 2009 S 6,280.77 | $ 1,633.70 4,647.07 3.17% 3,229.57 2010 $s 6,382.30 | $ 1,765.07 4,617.23 3.49% 3,342.28 2011 $ 6,922.75 | S$ 1,837.88 5,084.87 2.92% 3,439.88 2012 $ 7,379.38 | S$ 2,004.75 |. 5,374.63 3.95% 3,575.75 2013 $ 6,742.30 | $ 2,010.64 4,731.66 2.15% 3,652.63 2014 $ 7,389.54 | S$ 2,013.92 5,375.62 2.58% 3,746.93 2015 s 8,374.20 | $ 1,901.64 6,472.56 4.07% 3,899.57 2016 Ss 7,802.80 | $ 1,897.59 5,905.21 1.78% 3,968.97 2017 5 7,782.04 | § 2,132.58 5,649.46 2.01% 4,048.77 2018 s 7,098.22 | S$ 2,131.92 4,966.30 2.01% 4,130.18 2019 Ss 7,555.84 | $ 2,108.73 5,447.11 0.00% 4,130.18

Continuing Care Actuaries, LLC

STATEMENT OF ACTUARIAL OPINION

I, Dave Bond, Managing Partner of Continuing Care Actuaries, LLC, hereby certify that I am a Fellow of the Society of Actuaries and a Member of the American Academy of Actuaries. | meet the actuarial qualification standards to render Statements of Actuarial Opinion for Children Health Insurance Program and other self-insured entities. I have been retained by West Virginia CHIP to render a Statement of Actuarial Opinion regarding the methods and underlying assumptions developed and used in this analysis.

This Statement of Actuarial Opinion was prepared in a manner consistent with the Code of Professional Conduct and Qualification Standards of the American Academy of Actuaries, and the Standards of Practice of the Actuarial Standards Board. Concerning the projection of health care expenses, I am of the opinion that the data and assumptions used are appropriate.

Tue Bom

Dave Bond

Fellow of the Society of Actuaries

Member of the American Academy of Actuaries Managing Partner

Continuing Care Actuaries, LLC

Reisterstown, Maryland

September 9, 2019

1 4.

A} pi

——

Chris Borcik

Fellow of the Society of Actuaries

Member of the American Academy of Actuaries Principal

Continuing Care Actuaries, LLC

Reisterstown, Maryland

September 9, 2019

Continuing Care Actuaries, LLC

CMS CHIP Eligibility

TT AICTE ARN 9 SARTRE RAYON

State Name:|West Virginia OMB Control Number: 0938-1148 wv

Transmittal Numb

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

(Citizenship

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

{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 requirements of 1903(x), 1137(d), and 1902(ee) of the Act, and 42 CFR 435.406, 407, 956 and 457.380.

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

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

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

. an . pare No earlier than the date the notice is received by the individual.

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.

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.

Yes

Otherwise eligible pregnant women means pregnant women who meet the eligibility requirements of targeted low-income pregnant women with the exception of non-citizen status.

SPA# WV-19-0006 Approval Date: OcT 1 ! 2019 Effective Date: July 1, 2019 Page 1 of 3

CHIP Eligibility

CLARE SE ASAE SRIRICA HR BURNET

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

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

a {l] 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 | year, except for an individual paroled for prosecution, for deferred inspection or pending removal proceedings;

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

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

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

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

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

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

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

5, Is an individual with a pending application for asylum under 8 U.S.C. 1158, or for withholding of removal under 8 U.S.C.123 1,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)(); 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)).

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.

OCT 1 T 2019

SPA# WV-19-0006 Approval Date: Effective Date: July 1, 2019 Page 2 of 3

ems. 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 contro! 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.20160722

SPA# WV-19-0006 Approval Date: OcT L 1 2019 Effective Date: July 1, 2019

Page 3 of 3

Table of Contents

State/Territory Name: West Virginia

State Plan Amendment (SPA) #: WV-20-0005

This file contains the following documents in the order listed:

1) Approval Letter 2) State Plan Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop: S2-01-16 Baltimore, Maryland 21244-1850 Children and Adults Health Programs Group July 9, 2021 Jean Kranz, Executive Director West Virginia Children’s Health Insurance Program 350 Capitol Street, Room 251 Charleston, WV 25301 Dear Ms. Kranz: Your title XXI Children’s Health Insurance Program (CHIP) State Plan Amendment (SPA) number WV-20-0005, submitted June 29, 2020 with additional information received on July 8, 2021 has been approved. Through this SPA, West Virginia has demonstrated compliance with section 5022 of the Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities (SUPPORT) Act. This SPA has an effective date of October 24, 2019, except as noted below. Section 5022 of the SUPPORT Act added Section 2103(c)(5) to the Social Security Act (the Act) and requires child health and pregnancy related assistance to include coverage of services necessary to prevent, diagnose, and treat a broad range of behavioral health symptoms and disorders. Additionally, Section 2103(c)(5)(B) of the Act requires that behavioral health services be delivered in a culturally and linguistically appropriate manner. West Virginia demonstrated compliance by providing the necessary assurances and benefit descriptions that the state covers a range of behavioral health services in a culturally and linguistically appropriate manner. In addition, West Virginia is revising its utilization management (UM) contract to include the UM vendor’s involvement in the development and oversight of a CHIP beneficiary’s plan of care as a component of the case management benefit by early 2022. Your Project Officer is Ms. Ticia Jones. She is available to answer your questions concerning this amendment and other CHIP-related matters. Ms. Jones’ contact information is as follows: Centers for Medicare & Medicaid Services Center for Medicaid and CHIP Services 7500 Security Boulevard, Mail Stop S2-01-16 Baltimore, MD 21244-1850 Telephone: (410) 786-8145 E-mail: Ticia.Jones@cms.hhs.gov

Page 2- Ms. Jean Kranz If you have additional questions, please contact Meg Barry, Division Director, Division of State Coverage Programs, at (410) 786-1536. We look forward to continuing to work with you and your staff. Sincerely, Amy Lutzky Deputy Director /Signed by Amy Lutzky/

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

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

State/Territory: West Virginia (Name of State/Territory)

As a condition for receipt of Federal undex 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: Jean Kranz Position/Title: _ Executive Director Name: Jeremiah Samples Position/Title: _ Deputy Secretary, DHHR Name: Bill Crouch Position/Title: _ Cabinet Secretary, DHHR

Disclosure Statement This information is being collected to pursuant to 42 U.S.C. 1397aa, which requires states to submit a State Child Health Plan in order to receive federal funding. This mandatory information collection will be used to demonstrate compliance with all requirements of title XXI of the Act and implementing regulations at 42 CFR part 457. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid Office of Management and Budget (OMB) control number. The valid OMB control number for this information collection is 0938-1148 (CMS-10398 #34). Public burden for all of the collection of information requirements under this control number is estimated to average 80 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to CMS, 7500 Security Boulevard, Attn: Paperwork Reduction Act Reports Clearance Officer, Mail Stop C4-26- 05, Baltimore, Maryland 21244-1850.

2 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

3 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.

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

4 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 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)

5

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.

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

6 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

7 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))

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)

8 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: July 1, 1998

Implementation Date: July 1, 1998

SPA #17 Purpose of SPA: WV-20-0003 Disaster Relief Proposed effective date: March 1, 2020

Proposed implementation date: March 1, 2020

Effective: July 1, 1998 Implemented: July 1, 1998 A Medicaid expansion for children ages 1 to 5 from 134% up to 150% PFL

Amendments General Description #1 Effective: April 1, 1999 Implemented: April 1, 1999 Expanded coverage for children ages 6 to 18 from 101% to 150% FPL under a benchmark coverage program based on state’s public employees insurance program

#2

Effective: October 1, 2000 Implemented: October 1, 2000

Combines Medicaid expansion (Phase 1- Ages 1 to 5) with benchmark coverage (Phase II – Ages 6 to 18) into one program under benchmark coverage

#3

Effective: November 1, 2000 Implemented: October 23, 2000

Expands coverage to 200% FPL and includes cost sharing through copayments

#4

Effective: July 1, 2002 Implemented: July 1, 2002

Technical amendments to comply with federal statute of August 24, 2001. Also, expansion of pharmacy copayments to families below 150% FPL; and inclusion of annual and lifetime benefit limits.

9

#5

Effective: January 1, 2006 Implemented: January 1, 2006

Institutes a formulary for generic and/or preferred brand drugs for all therapeutic classes (with medical necessity exceptions when demonstrated by physicians) and grandfathering exceptions to changes for seven drug classes related to mental conditions. #6 Effective: January 1, 2007 Implemented: January 1, 2007 Expansion from 201% to 220% FPL through the addition of premium sharing with a limited dental benefit. Also, copayments for sick visits are excluded when a medical home is designated.

#7

Submitted: June 11, 2007 Withdrawn: August 31, 2007

A special Health Services Initiative to allow for paid comprehensive wellness exams for uninsured children about to enter Kindergarten which included a basic coverage guarantee for subsequent diagnosis and treatment related to any conditions detected as a result of the exams and/or related screens.

#8

Effective: September 1, 2008 Implemented: January 1, 2008

A special Health Services Initiative allowing for paid comprehensive wellness exams for uninsured children about to enter Kindergarten which includes referral but no coverage guarantee for subsequent diagnosis and treatment related to conditions detected as a result of the exam and/or related screens.

#9

Effective: January 1, 2009 Implemented: January 1, 2009

Expanded coverage from 220% to 250% FPL through premium sharing. Also, eliminated use of income disregards when determining maximum upper income limit.

#10

Effective: July 1, 2010 Implemented: July 1, 2010

This amendment combines provisions made effective the prior year to comply with CHIPRA provisions along with an expansion of CHIP dental services to the premium sharing group (above 200% FPL income) which had previously had a maximum $150 annual limit.

Effective: July 1, 2011 Implemented: July 1, 2011

Expanded coverage from 251% FPL to a maximum gross income limit of 300% FPL. Makes other changes to comply with CHIPRA provisions including elimination of annual and lifetime plan limits, and assurance of mental

10 health parity accompanied by service limit changes necessary for this assurance.

#11

Effective: October 1, 2011 Implemented: October 1, 2011

To change to a prospective payment system reimbursement methodology for Federally Qualified Health Centers (FQHC’s) and Rural Health Centers (RHC’s). #12 Effective: October 1, 2013 Implemented: October 1, 2013 Incorporates the MAGI-based eligibility process requirements in accordance with the Affordable Care Act.

#13

Effective: January 1, 2014 Implemented: January 1, 2014

Coverage for eligible PEIA children.

#14

Effective: October 2, 2017 Implemented: October 2, 2017 Approved: December 6, 2018

Mental Health Parity

#15

#16

Effective: July 1, 2019 Implemented: July 1, 2019 Approved: September 27, 2019

Effective: July 1, 2019 Implemented: July 1, 2019 Approved: October 11, 2019

WV-19-0005 Poison Treatment Advice and Prevention

WV-19-0006 Coverage for Pregnant Women #17

#18

Effective: March 1, 2020 Implemented: March 1, 2020 Approved:

Effective: October 24, 2019 Implemented: October 24, 2019 Approved:

WV-20-0003 Disaster Relief In the event of a disaster, the State will notify CMS of its intent to provide temporary adjustments to the following policies: timely processing of renewals, continuous eligibility, and cost-sharing (premiums and copayments).

WV-20-0005 SUPPORT ACT To demonstrate WVCHIP compliance with Section 5002 of the SUPPORT ACT

11 MAGI SPA Roster

Transmittal Number SPA Group

PDF

Description Superseded Plan Section(s) WV-13-0001 Effective/Implementation Date: January 1, 2014 MAGI Eligibility & Methods CS7

CS13

CS15

CS10 Eligibility – Targeted Low Income Children

Eligibility - Deemed Newborns

MAGI-Based Income Methodologies

Eligibility – Children Who Have Access to Public Employee Coverage Supersedes the current sections Geographic Area 4.1.1; Age 4.1.2; and Income 4.1.3

Incorporate under section 4.3

Incorporate within a separate subsection under section 4.3 Supersedes language in regard to dependents of public employees in Section 4.1.9 WV-13-0002 Effective/Implementation Date: January 1, 2014 XXI Medicaid Expansion CS3 Eligibility for Medicaid Expansion Program Supersedes the current Medicaid expansion section 4.0 WV-13-0003 Effective/Implementation Date: January 1, 2014 Establish 2101(f) Group CS14 Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards Incorporate within subsection 4.4.1

12 WV-13-0004 Effective/Implementation Date: October 1, 2013 Eligibility Processing CS24 Eligibility Process Supersedes the current sections 4.3 and 4.4 WV-13-0005 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 4.1.0; 4.1.1-LR Supersedes the current section 4.1.9 Supersedes the current section 4.4.4

Supersedes the current section 8.7 Supersedes the current section 4.1.8 WV-19-0006 Effective/Implementation Date: July 1, 2019 MAGI Eligibility & Methods CS8

CS11 Eligibility– Targeted Low Income Pregnant Women

Eligibility – Pregnant Women Who Have Access to Public Employee Coverage Incorporate under section 4.1-PW, 4.1.3

Incorporate under section 4.1-PW, 4.1.7

13 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.

There are no federally recognized tribes in West Virginia.

TN No: Approval Date Effective Date

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 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))

West Virginia has two public health insurance programs targeted to low-income children: the West Virginia Medicaid program (WV Medicaid) and the West Virginia Children's Health Insurance Program (WVCHIP). Currently, no public-private partnerships provide creditable coverage.

The WV Medicaid program offers health insurance coverage to all children in the state who meet the following eligibility net income criteria: • birth to age 1: income up to 150% of the Federal Poverty Level (FPL) • ages 1 through 5: income up to 133% of the FPL • ages 6 through 18: income up to 133% of the FPL

WV Medicaid also uses deductions and disregards in computing income for eligibility

14 determination, as allowed and approved in its State Plan, and as described in Section 4.3. of this Plan.

WV Medicaid extended 12 months coverage to all eligible children effective June 2001.

State Legislation establishing the West Virginia Children’s Health Insurance Program was signed into law in April 1998; further, this legislation provided for the creation of an oversight body, the Children’s Health Insurance Board whose role is to review and monitor the program’s fiscal standing and approve an annual fiscal plan.

The original baseline for uninsured children in households with family incomes greater than Medicaid eligibility limits and up to 200% Federal Poverty Level (FPL) was 14,000. This was based on Lewin Group, Inc. estimates using the Household and Income and Tax Simulation Model (HITSM) and pooled 1995 and 1996 West Virginia Current Population Survey. The current program has been developed through several phases:

1. WVCHIP was first implemented July 1, 1998 (effective date of July 1, 1998). This is described as Phase I of the program. • This start-up phase was a Medicaid expansion providing coverage for children ages 1 to 5 in families with household incomes greater than 133% and up to 150% FPL.

2. STATE PLAN AMENDMENT #1

WVCHIP Phase II was implemented April 1, 1999 (effective date of April 1, 1999). • This was a benchmark equivalent coverage program whose actuarial-base was the West Virginia Public Employees Insurance Agency Preferred Provider Benefit Plan. • This phase expanded coverage to children from ages 6 to 18 in families with household incomes greater than 100% FPL and up to 150% FPL.

3. STATE PLAN AMENDMENT #2

This State Plan Amendment combined WVCHIP Phase I and Phase II effective October 1, 2000. • The State submitted an amendment June 26, 2000 to withdraw the Phase I Medicaid expansion program and incorporate it into the Phase III benchmark equivalent program. • In September 2000, the State notified the 1425 participants in the Medicaid expansion (Phase I) program of the change through a cover letter. Participants were also provided with a side-by- side comparison of the Phase I program benefits with those of Phase II.

4. STATE PLAN AMENDMENT #3

WVCHIP Phase III was implemented October 23, 2000 (effective date of October 23, 2000). • Eligibility for the benchmark equivalent coverage was expanded to children in families

15 with incomes up to the 200% FPL. • Cost sharing in the form of co-payments for specified services (see Section 8.2) was included for families with household incomes greater than 150% up to 200%.

5. STATE PLAN AMENDMENT #4 • Effective July 1, 2002 the State Plan is amended with required updates and amendments effective under federal statute August 24, 2001 and to expand participation in pharmacy co-payment to families in households with incomes below 150% FPL. It also eliminated the $5 co-payment for generic drug use. • This amendment also includes a lifetime benefit limit of $1 million which is part of the original benchmark program noted above. • This amendment also includes an annual benefit limit of $200,000 per participant.

6. STATE PLAN AMENDMENT #5 • Effective January 1, 2006, the State Plan is amended to reflect a formulary that includes approved generic and/or preferred brand drugs for all therapeutic classes.

• There is no coverage for non-listed drugs except where clinical documentation from a physician demonstrates medical necessity. For a few listed therapeutic classes, Over the Counter (OTC) medications approved.

• Upon implementation, program participants who are currently taking a drug that is used to treat, or is sensitive to, mental conditions, can continue to have their current prescription(s) covered even if their current medication is not on the Preferred Drug List when it is in one of the following seven drug classes:

Antipsychotics; Serotonin Selective Response Inhibitors (SSRI’s); Central Nervous System Stimulants; Anticonvulsants; Sedative Hypnotics; Aliphatic Phenothiazines; and Attention Deficit Disorder Drugs.

• Program participants who are newly prescribed a drug used to treat, or is sensitive to, mental conditions in one of the seven drug classes named above will have coverage from the Preferred Drug List at the time the new prescription is filled, except where there has been a demonstrated need for exception due to medical necessity.

7. STATE PLAN AMENDMENT #6 • Effective January 1, 2007, the State Plan is amended to expand coverage to those children in households at or under 220% FPL net income when they are willing to participate in a premium payment option. • This amendment also modifies cost sharing provisions and cost sharing maximum limits described in Section 8 to permit increased copayments for enrollees at income levels above 200% FPL. • Copayments for non-well visits are modified at all enrollee income levels to afford an incentive for designating and using a medical home.

16 • Children in households between 201% to 220% FPL (WVCHIP Premium) who have had group health care coverage in the 12 month “look back period” are not eligible. • For children in the WVCHIP Premium group (201 to 220% FPL) there is no vision coverage as specified in Section 6.2.12; also dental coverage for this group is limited to $150.00 per child per year as specified in Section 6.2.17.

8. STATE PLAN AMENDMENT #7

• A special health services initiative to allow for payment of comprehensive wellness exams for uninsured children about to enter Kindergarten was submitted on June 11, 2007 and withdrawn on August 31, 2007.

9. STATE PLAN AMENDMENT #8

 Effective January 1, 2008, the state plan is amended at Section 3.1 to allow a special health service initiative (HSI), named Kids First, that assures Comprehensive Wellness Exams performed at either local school sites or in provider offices are reimbursed for the estimated five percent of children ages four to five who are entering kindergarten without any health insurance. Of the approximately 21,000 children entering kindergarten, the age at which compulsory school attendance begins in this state, about 1,100 are estimated to be without any insurance. These exams performed by medical providers will be offered on site at schools, school based health clinics or in provider offices, and Title XXI funds will be used to reimburse exam costs.

 In order to promote participation by medical providers and parents, exams will be offered on site at schools at Kindergarten Round-ups. Local education authorities for West Virginia’s 55 school districts will draw up Memoranda of Understanding with all providers of medical services willing and available to provide exams on site at school or in their medical office and to provide follow-up services to children at either sliding fee-scale or reduced cost, regardless of insurance status.

 The kindergarten entry point will also be used as an opportunity to provide all families information about the joint application process through the state’s WVCHIP and Medicaid programs, and to assist them in obtaining a medical home.

 In this initiative the costs of any services resulting from any exam findings are to be paid by the parent. To facilitate access to health services a service practitioner directory will be prepared to include information about existing health resources including offerings of sliding fee schedules by the community health centers network.

• Children whose insurance plan does not cover these same wellness exams may be offered the exam, but there will be no reimbursement using Title XXI HSI funds. All claimed expenditures for this initiative are subject to WVCHIP’s ten-percent administrative cap of total expenditures. A revised budget is submitted as part of this plan amendment.

17 The goal of Kids First is to assure that as many children in West Virginia as possible have the same opportunity to enter school healthy and ready to learn by providing a wellness exam performed by a medical practitioner. Many children with commercial insurance, as well as those enrolled in either WVCHIP or Medicaid, already have access to this special preventive service. Under this initiative, children without insurance will be also be able to access this important exam.

10. STATE PLAN AMENDMENT #9

• Effective January 1, 2009, the State Plan is amended at Sections 4.2 through 4.4 to expand coverage to children in families with household incomes up to and including 250% FPL in gross income through disregarding all gross income from 200% up to and including 250% FPL to meet the targeted low income child criteria at 42 CFR 457.310 This expansion also makes the following provisions:

 The same standard income deductions as used by West Virginia’s Title XIX program to calculate net income are used to assign participants to copayment levels and to determine premium payment participation, also referred to as enrollment groups.

 No changes are made to cost sharing amounts and provisions in Section 8.2.1, or to premium sharing costs or provisions in Section 8.2.3.

 Substitution of Coverage requirements remain the same, that is, applicants with net household incomes over 200% FPL are subject to a twelve (12) month look back review period, and are not eligible if they have had creditable group health coverage during the look back period. Applicants with net household incomes at or below 200% FPL are subject to a six (6) month look back period. Exceptions to the look back period remain the same as specified in Section 4.4.4.2.

 Clarification: To determine WVCHIP eligibility, the State will use one income criterion only based on gross income. Families with gross incomes up to and including 250% FPL may be eligible for WVCHIP. Net income refers to gross income minus applicable Medicaid deductions. Net income is used to determine the child’s enrollment group.

 A revised budget is submitted as part of this amendment reflecting funding for the additional projected population to be covered

11. STATE PLAN AMENDMENT #10

This state plan amendment provides coverage for children in families with gross incomes up to 300% FPL. It also makes necessary changes to assure covered services and other provisions are in compliance with the Children’s Health Insurance Program Reauthorization Act (specifically dental services and mental health parity) and the Patient Protection and Affordable Care Act (removal of lifetime and annual benefit limits).

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Changes to Section 4: Eligibility Standards and Methodology include:

• Expansion to 300% FPL: Effective July 1, 2011 the State Plan is amended at Section 4.13 to expand coverage to children in families with household gross incomes from 250% to 300% FPL by disregarding all gross income over 200% up to and including 300% FPL income levels to meet targeted low income criteria at CFR 457.310. • A reduction in waiting periods is described in Section 4 Eligibility Standards and Methodology [4.17; 4.3; and 4.4.4]. This change reduces the waiting period from six (6) months to three (3) months for all applicants with incomes at or below 200% FPL and from twelve (12) months to three (3) months for those applicants with incomes over 200% FPL to 300% FPL. Methods for Monitoring Substitution [Section 4.4.4.1] remain the same except for notational changes in the waiting period duration. Section 6 Coverage Requirements for Children’s Health Insurance is amended to make changes necessary to comply with provisions of the Children’s Health Insurance Program Reauthorization Act of 2009. The Lifetime Benefit Limit of $1 million dollars is eliminated, as is the $200,000 annual limit in accordance with provisions in the Patient Protection and Affordable Care Act. Other Specific Coverage changes in this section include: • Mental Health Parity: Effective July 1, 2011, coverage limits for all services, both mental health and non mental health related services have been reviewed to assure compliance with the mental health parity requirements of CHIPRA, Section 502. The Actuarial Certification includes the elimination of service limits for inpatient and outpatient mental health services [6.210 and 6.2.11] as well as inpatient substance abuse treatment services and outpatient substance abuse services [6.2.18 and 6.2.19]. • Section 6.2.12 eliminates the limitation on eyeglasses or contacts lenses to enrollees over 200% FPL net income in order to assure all enrollees have the same coverage for eyeglasses or contacts up to $125 per year effective July 1, 2010. • Section 6.2.17 eliminates the annual limit of $150 preventive dental services to those enrollees with incomes over 200% FPL who then have the same dental coverage as those enrollees at or below 200% FPL effective July 1, 2010. • Section 6.2-D provides for the coverage of dental services necessary to prevent disease and promote oral health, restore oral structures to health and function, and treat emergency conditions, and specifies the periodicity schedule. The actuarial certification is attached to this amendment as Attachment #1 includes these changes effective July 1, 2010. • Section 6.2.22 eliminates the 20 visits per year limit for physical therapy,

19 occupational therapy, and speech therapy services effective July 1, 2011. • Section 6.2.24 The limitation on eye exams for enrollees over 200% FPL and above is eliminated to provide the same coverage to all enrollees for eye exams (one visit per year) and prescriptive lenses (i.e. one set per year) effective July 1, 2010. • Section 6.2.28 Early Intervention Services provided by the state’s Birth- To-Three Program under the Individuals with Disabilities in Education Act are added to coverage for children ages birth through three years who have been assessed and met medical necessity criteria for developmental delay(s). Both assessments and services must be provided from a network of early intervention service providers certified by the WV Birth-to-Three Program effective July 1, 2010. Section 8 Cost Sharing and Payment is amended at 8.2.3 and 8.5 to reflect copayment requirements for non-preventive dental services; and at 8.7 to assure a 30-day grace period for members required to make premium payments.

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 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)

Poison Treatment Advice and Prevention. West Virginia will use CHIP HSI funds, within the 10 percent federal administrative expenditures cap allowed for states, to support the West Virginia Poison Center (WVPC).

The WVPC provides 24-hours per day, 7 days a week, emergency telephone poisoning/overdose assessment, treatment, and referral recommendations to both the public and health care professionals in WV. Emergency phone lines are staffed by nurses with additional toxicology training, Specialists in Poison Information (SPIs), who must pass a national certification examination to become Certified Specialists in Poison Information (CSPI) to maintain employment. At all times, SPIs and CSPIs are backed up by a team of Medical Toxicologists (physicians with board certification in emergency medicine and additional board certification in medical toxicology) and a Clinical Toxicologist (a fellowship-trained Doctor of Pharmacy with board certification as an applied toxicologist).

Types of poisonings/overdoses managed by the WVPC include: unintentional poisonings (e.g., accidental ingestions of drugs, cleaners, household products); therapeutic errors; drug/product misuse exposures; self-harm exposures; environmental exposures (e.g., carbon monoxide poisonings, chemical

20 spills); biologic exposures (e.g., snakebites, spider bites, stings, plant or mushroom ingestions); substance abuse toxicity; chronic lead poisoning; and occupational exposures (at the worksite or occupational chemicals migrating into the home).

The service is available to all citizens and health care professionals in all of WV’s 55 counties. Over 16,000 exposure case records are generated each year in addition to over 5,000 information case records. Exposure cases result in approximately 19,000 follow-up calls by the Poison Specialists for continued evaluation and management recommendations. For non-English speaking residents, the WVPC has a contract with an agency that can translate over 150 languages; the WVPC can also communicate with the deaf community via telecommunications devices for the deaf and hearing impaired (TDD).

According to the US Census Bureau, 2017 American Community Survey estimates, approximately 20.5% of WV total population is under 18. 66% of WV children are in households with incomes at 300% FPL or lower. In calendar years 2016 through 2018 the WVPC reported that children under 19 averaged 60% of all case exposure records with 45% of all case exposure records involving children under age 6. CHIP funding under this HSI is targeted to cover the cost of providing WVPC services to the approximately 40% (66% of 60%) of cases that involve children under age 19 in families at or below 300% FPL.

For every $1 spent on poison control efforts, there is a return on investment of $18. In WV, the savings is approximately $25 to $30 million each year. Nationally, poison centers saved $1.8 billion in medical costs in the United States in 2016. Costs are saved by managing poisonings at home, decreasing unnecessary ambulance rides, decreasing hospital days, and decreasing hospital transfer costs. Decreasing hospital transfer costs is especially important for children in WV due to the number of hospitals in the state that do not routinely care for pediatric patients.

The WVPC toll-free number is promoted throughout the state via poison center publications, the WVPC website, WV emergency number listings, pediatrician offices, listed in all West Virginia telephone directories.

The WVPC Director has a strong working relationship with the WV Office of Healthy Schools. Through this affiliation, students in 755 WV schools, throughout all of WV’s 55 counties, receive WVPC awareness information. Public schools in WV are required to report use of naloxone or epinephrine auto-injectors and any poisonings, overdoses, or therapeutic errors to the WVPC. Other WVPC collaborations, overseen by the WVPC Community Outreach Coordinator, include: WV Birth to Three, Parents as Teachers, Help Me Grow, the Family Resource Network, and the Bureau for Children and Families through River Valley Child Development Services. The WVPC also consults with the Violence and Injury Prevention Program. The WVPC Director is a regular participant in the Emergency Medical Services for Children (EMSC) Advisory Committee.

The WVPC Community Outreach Coordinator, runs the WVPC poison prevention and outreach program. In addition to brochures on core poison prevention information, the WVPC created brochures as a result of poisoning trends seen in WV. For example, brochures aimed at children and adolescents

21 cover jimson weed abuse, caffeine overuse, and inhalant abuse. For smaller children, brochures covering prevention of poisonous plant exposures are popular. Brochures on poisonous snakes of WV and bites & stings are also commonly requested. The WVPC also created a “Letter to Grandparents” to warn grandparents about the risks their medications can pose for their grandchildren. Monthly and emergency press releases are used to inform the public about real-time poisoning concerns that have been identified via real-time review of emergency telephone case records. Educational materials targeted to families are disseminated widely at various settings and programs that include not only the collaborative partners identified above, but also schools, Head Start programs, daycares, local health departments, Mothers of Preshoolers (MOPS) groups, community baby showers, community based health fairs (many rural areas have large health fairs that reach many families), and mailings to public libraries and pediatrician offices.

CHIP provides $225,000 in annual funding that is used 90% for the call center operations ($203,000) and 10% for materials ($22,000), with all funds targeting services for children at or below 300% FPL. WVPC has annual costs of approximately $1.3 million. CHIP HSI funding covers around 17% of total WVPC costs and 29% of costs attributable to providing services to children under 19 (60% of $1.3 million, or $780,000). Further prorating WVPC costs to the 66% of WV children at or below 300% FPL, (66% of $780,000, or $514,000), CHIP HSI funding contributes 44% of the total WVPC serving this targeted child population.

Funding under this HSI will not supplant or match CHIP federal funds with other Federal funds, nor will it allow other Federal funds to supplant or match CHIP Federal funds. Funding under this HSI is dedicated to children 18 years of age or younger.

“Kids First”: A Health Services Initiative. The goal of this initiative is to assure that West Virginia children start Kindergarten healthy and ready to learn.

The Kids First Initiative is a collaborative among three state government agencies; Department of Education, Department of Administration, and Department of Health and Human Resources, that enlists the West Virginia medical community, families, and community-based supports to improve child health and early learning.

All West Virginia children entering kindergarten will receive a health screen to identify risks to healthy growth and development. The West Virginia medical community, which includes private practicing physicians, community health centers, hospital-based clinics, and local health departments, is a participating partner in Kids First. Medical clinicians will be offering wellness screenings at their service sites, or alternate school settings, using the Kids First protocol, which meets the Bright Futures, American Academy of Pediatric standards. The offering of wellness screens in children’s medical homes supports West Virginia’s efforts to encourage primary medical homes for all children.

For populations who do not receive wellness screenings in their selected medical homes, screenings will be made available by participating community medical providers on-site at Kindergarten Round-ups (enrollment). On-site school screenings will be offered to all unscreened children presenting to

22 Kindergarten regardless of insurance status. Caveat: WVCHIP resources will not be used to offset screening costs for children who are insured, nor will they be used to supplant school funding or resources for wellness screenings. The school is serving as an additional screening site for children who were not screened prior to Kindergarten Round-ups and is offered at the school for the convenience of parents and participating providers. No funds to providers for this project will come from schools, or their districts. Conversely, no funds from WVCHIP, Title XXI , will go to schools to cover costs of alternate service sites for wellness screenings, or for the screening services. Payments for wellness screenings for insured kids, including those covered by WVCHIP or Medicaid, will be made by the appropriate payer according to its benefit plan. WVCHIP, Title XXI Health Service Initiative (HSI) funding will pay for screening services for uninsured children only. Parents of children who are covered by private insurance are responsible to pay for the screen if the private insurance does not cover the cost for any reason. The West Virginia Office of Maternal, Child, and Family Health (OMCFH) will act as a “central depository” for provider billings of these wellness exams for uninsured children. OMCFH will access Medicaid and WVCHIP enrollment files to determine if the child was subsequently enrolled in either program. If so, the claim form for the exam will be forwarded to the appropriate Agency for payment. The remaining claim forms will then be forwarded to WVCHIP to check against commercial insurance files. If it is determined the child has commercial insurance, the claim will be returned to the provider instructing them to bill the appropriate party. WVCHIP will pay the wellness exam claims for all children identified as uninsured through this process using Title XXI HSI funding subject to the 10% administrative cap.

Schools currently advertise Kindergarten enrollment events in local newspapers and media outlets as well as notices sent home to parents and day care centers. All of these efforts will continue with costs covered by local school districts. Promotional costs within the Kids First budget will be used for printing additional promotional materials to encourage Kids First health screens prior to kindergarten entry.

Existing state government resources will be used to bring community stakeholders together. We plan to utilize public service announcements and promotion through the annual “State of the State” address by the Governor. The West Virginia Chapter of the American Academy of Pediatrics will encourage participation by their membership. WVCHIP, Medicaid, PEIA and BlueCross BlueShield insurers and the Community Health Center Network will notify their age-eligible children through direct mailings, encouraging well-child exams.

To assure that every child eligible for government sponsored health coverage is identified, uninsured children who present at the school without having been screened will be evaluated for WVCHIP/Medicaid eligibility at Kindergarten Round-ups. School sites will offer on-line eligibility access and hard copy applications for families wishing to apply for government sponsored health services.

Parents of uninsured children who are identified with deficits by the wellness screenings will be referred to existing programs and services available in the community to address deficits utilizing the referral network established by the schools. Information will be made available by a brochure and also a document outlining a referral network will be made available online. The network will include participating medical providers that agree to offer services to families on a sliding fee scale. Parents are responsible to cover costs of any follow-up services that may be needed.

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HealthCheck In WV

The HealthCheck exam enjoys widespread acceptance by physicians, many of whom use it for all children regardless of payer source. In at least one WV county, it is already the preferred protocol to document compliance with screening requirements. The current HealthCheck document form is a single page that covers all American Academy of Pediatrics “Bright Futures” guidelines. The form has been also redesigned to allow parents to share information required by education authorities without divulging other more sensitive information, if they wish. This modification preserves family privacy without diminishing the form’s usefulness as a medical record.

WV Kindergarten Entry

In West Virginia, kindergarten is mandatory under school law and WV’s most recent kindergarten enrollment was 21,173. Each year school districts hold kindergarten pre-enrollment orientations (“Round-ups”) in the six months preceding kindergarten entry to orient children and their families, to document children’s immunizations, and to provide those health screens as required under the state’s school law. Current estimates show that 5% (or about 1,100) of WV children entering kindergarten will not have any source of insurance coverage. Both the “Round-ups” and the actual kindergarten entry dates serve as points of entry at which schools can confirm whether or not children have had a HealthCheck exam and allow parents to provide documentation of such.

Role of WV Public Payers

In West Virginia, three state public payers, WV Medicaid, WVCHIP, and the WV Public Employees Insurance Agency, cover more than two thirds of children in the state. All three payers cover comprehensive prevention screens that meet either the HealthCheck protocols or the requirements of comprehensive wellness exams as described in the Current Procedure Terminology found for preventive medicine under CPT codes 99381-99385 for new patients & 99391-99395 for established patients. The 3 payers will assist the initiative in these ways:

1) Adoption of the HealthCheck protocol as a requisite part of the medical record for billing of CPT codes by WVCHIP and the PEIA, with the HealthCheck form or an approved equivalent thereof required as documentation;

2) Providing initial reminder notices to parents of all age appropriate children actively enrolled to assure that a HealthCheck exam is obtained in the months prior to kindergarten entry, and to encourage them to provide the necessary physician documentation to school authorities.

3) Each year on or around March 1, state payers will identify to school authorities those children of qualifying age who have had a HealthCheck exam since September 1 of the prior year.

4) No later than June 30 each year, after each school district has held its “Round-ups,” they will identify by district those children NOT yet having presented a HealthCheck form to help assure that those children with demonstrated coverage are excluded from the estimate of children requiring a

24 HealthCheck exam, for kindergarten entry that year.

Role of Participating Providers In order to help assure that parents of uninsured children may gain access to a variety of providers who have agreed to participate in the Kids First Initiative, including those offering sliding fee scales, the Office of Maternal Child and Family Health will assist local education authorities by providing a participating provider directory for each of the eight educational regions of the state. These directories will include providers such as primary care practices, dentists, optical services practitioners: eye, ear, nose and throat specialists and audiologists, along with 32 federally qualified community health centers operating at over 120 sites which include school based clinics which can play a key role in providing on site exams and follow-up services necessary to correct or ameliorate any conditions or deficits identified through screening exams.

As children and their parent(s) present at kindergarten orientation or “Round-ups”, four scenarios are envisioned:

1) The insured child has been screened and provides (or mails) a copy of the HealthCheck protocol to school authorities.

2) The child has insurance, but has not had a HealthCheck screen since the start of the current school year (September 1); the parent chooses to have a screening at the school and allows insurance to be billed, or the parent opts to have the child’s medical home provider perform the screen at his/her office and returns with HealthCheck documentation. The provider bills the appropriate insurance.

3) The child is uninsured and the parent agrees to an on-site HealthCheck exam at no cost. The family is provided a joint WVCHIP/Medicaid application and is screened for program eligibility. The appropriate program will cover costs of the exams for children subsequently enrolled as a result of this process. For those children deemed uninsured, WVCHIP Title XXI HSI funds will be used to reimburse medical providers for the exam services.

4) The child has insurance, but well-child exams are not covered. Parents are responsible to pay for the exam for this child. They will be referred to providers who have signed the Memorandum of Understanding with the school district offering exam services on a sliding fee scale or “pro bono.”

Any child’s family choosing not to participate in Healthcheck screening will be provided with the standard school screening as required under WV Code, also referred to as a “limited-domain” screen. No Title XXI HSI funds are used to provide “limited domain” screens, nor to reimburse schools for the use of their facilities to provide well-child exams on-site.

During the orientation, school personnel will provide copies of the joint WVCHIP/Medicaid applications and/or online application assistance when feasible. Families will also be provided with an informational brochure on the availability of health care resources in their region with special attention

25 to the availability of those with sliding fee scales. Families will be encouraged to establish a medical home for regular prevention.

Role of WV Department of Education and Local Education Authorities • Assure that each school district has a Memorandum of Understanding (MOU) identifying its panel of providers responsible for providing HealthCheck exams for children at school sites.

• Provide regional workshops on developing the MOU in West Virginia’s eight educational regions.

• Assure that participating providers educate parents about the medical home concept and its benefits for children, and assist with linking and enrolling them with one, if desired.

• Provide and coordinate data, reporting and information flow as required among WVCHIP, other state payers, the WV Department of Education’s Office of Healthy Schools, and WV DHHR’s HealthCheck Program.

• Under the local Memorandum of Understanding, it is the responsibility of participating providers to assist in locating services beyond their service capacity/scope or outside its own referral network. Providers will work to locate such needed services from any other provider or network within the state, and will also ask for assistance from programs operated by the state that may assist in locating these services. For example, a provider sees a child with a resulting finding that the child has a jaw misalignment making chewing difficult and that the correction of this is beyond their service capacity both within the center itself and its network, it can then turn to the statewide HealthCheck program and other programs within the Bureau for Public Health which will make inquiry to all participating providers or any other network which it finds can provide the service.

• Collect and report data for the 55 school districts on the numbers of uninsured and insured children who 1) present a documented Healthcheck exam given prior to Kindergarten Roundups and 2) those who receive a Healthcheck exam at in the school or school based clinic during each school district’s Roundup period

Role of Commercial Payers

The state solicits commercial payers who at present reimburse for comprehensive well child exams to voluntarily assist in promoting this initiative through the issuance of reminder notices to parents and publicizing of the Kids First initiative.

For those children with commercial insurance whose coverage excludes such exams or whose use of cost sharing may discourage parents to seek such exams, referrals will be made to the same list of Kids First participating providers in their locale. All HealthCheck exam service claims provided under this initiative will be electronically crossed checked for other insurance sources.

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Data Collection and Tracking

The state will establish data collection and tracking to determine the effectiveness of this initiative. Commercial payers will be solicited to share any data or quality measures concerning well child visits they can provide as part of this effort. Parents are encouraged to share copies of HealthCheck forms completed for exams furnished on-site at the school with their child’s regular medical provider.

Services Exclusion

This initiative specifically excludes consideration of any coverage for inpatient services or long- term care services or treatment of catastrophic illnesses or any follow-up services resulting from exams

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.

There are no federally recognized tribes in West Virginia. Section 3. Methods of Delivery and Utilization Controls

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

27 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)

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. 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. 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

28 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)) • The State of West Virginia provides health insurance benefits through a plan managed by the Children’s Health Insurance Agency, within the Department of Health and Human Resources, using the same fiscal agent as the state Medicaid program. Pharmacy benefits are administered by a Pharmacy Benefit Manager (PBM) used by the state employees’ insurance agency. Primary care centers and school-based health centers, which provide low-income families with health care services, are also included in the provider network to assure access for children in rural areas served by these facilities, as well as emphasis on preventive services.

• All services are provided within a fee for service delivery system. All families are asked to designate a medical home for their children and are encouraged to do so through waiving of copayments for non-well visits. Families can change their choice of medical home once each year, and still retain their waived copayment status.

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,

29 such as through fee-for-service. Examples of carved out services may include transportation and dental, among others. 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:

Prepaid inpatient health plan (PIHP) (42 CFR 457.10) Capitation payment Other (please explain)

Describe population served:

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. 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)

30 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 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).

31 • The information requirements in 42 CFR 457.1207 (see Section 3.5 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)) 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.

32 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)) 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)) 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

33 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. If the answer to the assurance above is yes for any or all managed care entities, please answer the next assurance: 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 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

34 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

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)) 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))

35 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 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

36

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)) 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. 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))

37 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. 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

38 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: • 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,

39 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 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 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

40 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-approved description, including: o 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

41 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 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.

42 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) 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)

43 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 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:

44 • 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)) 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, 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))

45 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; • 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

46 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)) 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)); MCO, PIHP, and PAHP network provider selection policies and procedures do not discriminate against particular providers that serve high-risk

47 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 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

48 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) 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.

49 (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 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). 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))

50 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 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))

51 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. 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 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

52 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 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.

53 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: • 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 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)

54 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, 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,

55 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 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))

56 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-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.

57

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 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

58 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)). 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))

59 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 practice guidelines the State requires in accordance with 42 CFR 438.236; • A description of: o 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

60 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 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))

61 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 recommendations 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: • 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 comprehensive quality assessment and performance improvement program for the services it furnishes to its enrollees as provided in 42 CFR

62 438.330, 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 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

63 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 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

64 • 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 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

65 Guidance: All states with MCOs, PIHPs, PAHPs, PCCMs or PCCM entities need to complete Sections 3.12.5 and 3.12.5.1.

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, 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))

66 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 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))