Table of Contents State Name: West Virginia State Plan Amendment (SPA) #: 10-02 This file contains the following documents in the order listed:

1) Approval Letter 2) CMS-179 3) Approved SPA Pages

/S/

/S/ /S/

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: West Virginia Attachment 2.2-A

Page & OMB NO: 0938

¢, Optional Coverage of Medically Needy (Continued)

4. Reserved

42 CFR 435.308 5. (X] a Financially eligible individuals who are not described in section C.3. above and who are under the age of .. .

21

20

19

18 or under age 19 who are full-time students in a secondary school or in the equivalent level of vocational or technical training.

be

{ i & Reasonable classifications of financially eligible individuals under the ages of 21, 20, 19 or 18 as specified below:

_ qd) Individuals for whom public agencies are assuming full or partial financial responsibility and who are:

_ (a) In foster homes (and are under the age

of __).

_ (b) In private institutions (and are under the age of __).

TN No: 10-02 Approval DateSEP 3 0 2010 Effective pate Soly | 26/0

Supersedes: 94-15

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT Stale: West Virginia Attachment 2.2-A

Page 6

COVERAGE AND CONDITIONS OF ELIGIBILITY

Citations(s) Groups Covered

A. Mandatory Coverage — Categorically Needy and Other Required Special

Groups (continued)

1902 (e) (4) 12, Deemed Newborns.

Of the Act

42 CFR 435.117 A child born in the United States to a woman who was eligible for and receiving Medicaid (including coverage of an alien for labor and delivery as emergency medical services) for the date of the child’s birth, including retroactively. The child is deemed eligible for one year from birth.

42 CFR 435.120 13. Aged, Blind and Disabled Individuals Receiving Cash Assistance

Xx a. Individuals Receiving SSI. This includes beneficiaries’ eligible spouses and persons receiving SSI benefits pending a final determination of blindness or disability or pending disposal of excess resources under an agreement with the Social Security Administration; and beginning January |, 1981, persons receiving SSI under section 1619(a) of the Act or considered to be receiving SSI under section 1619(b) of the

Act. > X Aged X_ Blind X Disabled

SEP 30 2010

TN No: 10-02 Approval Date: Effective Date: aly | 20/0 Supersedes: 94-15 :

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

150 S. Independence Mall West

Suite 216, The Public Ledger Building

Philadelphia, Pennsylvania 19106-3499

er a

CMS

CENTERS FOR MEDICARE & MEDICAID SERVICES

Region II/Division of Medicaid and Children’s Health Operations

SWIFT # 061420124031

JUL 27 2012

Nancy V. Atkins

Commissioner

Bureau for Medical Services

350 Capitol Street, Room 251 Charleston, West Virginia 25301-3706

RE: West Virginia State Plan Amendment (SPA) 12-008

Dear Ms Atkins:

The Centers for Medicare & Medicaid Services has reviewed West Virginia’s State Plan Amendment (SPA) 12-008, in which you propose to implement a process of screening providers and suppliers and create a temporary enrollment moratorium for certain providers under West Virginia’s Medicaid program, in accordance with Section 6401 of the Affordable Care Act. We find your submission acceptable. Enclosed is a copy of the approved SPA pages and signed CMS-179 form. The effective date is April 1, 2012.

If you have any questions, please contact Margaret Kosherzenko of my staff at (215) 861-4288.

meis Me ugh (2. - Associate Regional Administrator

Enclosures

cc: Alva Page, WV BMS

State: West Virginia

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT Attachment 4.46 Page 1

4.46 Provider Screening and Enrollment

Citation The State Medicaid agency gives the following assurances: 1902(a)(77) 1902(a)(39) 1902(kk); P.L. 111-148 and P.L. 111-152 42 CFR 445 PROVIDER SCREENING Subpart E _X_ Assures that the State Medicaid agency complies with the process for screening providers under section 1902(a)(39), 1902(a)(77) and 1902(kk) of the Act. 42 CFR 455.410 © ENROLLMENT AND SCREENING OF PROVIDERS _X_ Assures enrolled providers will be screened in accordance with 42 CFR 455.400 et seq. _X_ Assures that the State Medicaid agency requires all ordering or referring physicians or other professionals to be enrolled under the State plan or under a waiver of the Plan as a participating provider. 42 CFR 455.412 VERIFICATION OF PROVIDER LICENSES _X_ Assures that the State Medicaid agency has a method for verifying providers licensed by a State and that such providers licenses have not expired or have no current limitations. 42 CFR 455.414 REVALIDATION OF ENROLLMENT _X_ Assures that providers will be revalidated regardless of provider type at least every 5 years 42 CFR 455.416 TERMINATION OR DENIAL OF ENROLLMENT _X_ Assures that the State Medicaid agency will comply with section 1902(a)(39) of the Act and with the requirements outlined in 42 CFR 455.416 for all terminations or denials of provider enrollment. 42 CFR 455.420 REACTIVATION OF PROVIDER ENROLLMENT _X_ Assures that any reactivation of a provider will include re-screening and payment of application fees as required by 42 CFR 455.460. TN No: 12-008 Approval Date. JUL 27 2012 Effective Date. 04/01/2012

Supersedes: NEW

State: West Virginia

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT Attachment 4.46 Page 2

4.46 Provider Screening and Enrollment

Citation Continued... 42 CFR 445.442 APPEAL RIGHTS X_ Assures that all terminated providers and providers denied enrollment as a result of the requirements of 42 CFR 445.416 will have appeal rights available under procedures established by State law or regulation. 42 CFR 445.432 SITE VISITS X_ Assures that pre-enrollment and post-enrollment site visits of providers who are in “moderate” or “high” risk categories will occur. 42 CFR 455.434 CRIMINAL BACKGROUND CHECKS X_ Assures that providers, as a condition of enrollment, will be required to consent to criminal background checks including fingerprints, if required to do so under State law, or by the level of screening based on risk of fraud, waste or abuse for that category of provider. 42 CFR 455.436 FEDERAL DATABASE CHECKS X__ Assures that the State Medicaid agency will perform Federal database checks on all providers or any person with an ownership or controlling interest or who is an agent or managing employee of the provider. 42 CFR 455.440 NATIONAL PROVIDER IDENTIFIER X__ Assures that the State Medicaid agency requires the National Provider Identifier of any ordering or referring physician or other professional to be specified on any claim for payment that is based on an order or referral of the physician or other professional. 42 CFR 455.450 SCREENING LEVELS FOR MEDICIAD PROVIDERS X__ Assures that the State Medicaid agency complies with 1902(a)(77) and 1902(kk) of the Act and with the requirements outlined in 42 CFR 455.450 for screening levels based upon the categorical risk level determined for a provider. 42 CFR 455.460 APPLICATION FEE _X_ Assures that the State Medicaid agency complies with the requirements for collection of the application fee set forth in section 1866(j)(2)(C) of the Act and 42 CFR 455.460. TN No: 12-008 Approval Date. JUL &€ f 2U12 Effective Date. 04/01/2012

Supersedes: NEW

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State: West Virginia Attachment 4.46 ; Page 3

4.46 Provider Screening and Enrollment

Citation Continued...

42 CFR 455.470 TEMPORARY MORATORIUM ON ENROLLMENT OF NEW PROVIDERS OR SUPPLIERS

X _ Assures that the State Medicaid agency complies with any temporary moratorium on the “~~ enrollment of new providers or provider types imposed by the Secretary under section 1866G)(7) and 1902(kk)(4) of the Act, subject to any determination by the State and written notice to the Secretary that such a temporary moratorium would not adversely impact beneficiaries’ access to medical assistance.

TN No: 12-008 Approval Date. JUL 2¢ 2012 Effective Date. 04/01/2012 Supersedes: NEW

DEPARTMENT OF HEALTH AND HUMAN SERVICES HEALTH CARE FINANCING ADMINISTRATION.

FORM APPROVED OMB NO. 0998-0103 1. TRANSMITTAL NUMBER 2” STATE. TRANSMITTAL AND NOTICE OF APPROVAL OF 1 2 - 0 0 8 West Virginia

STATE PLAN MATERIAL FOR: HEALTH CARE FINANCING ADMINISTRATION

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

TO: REGIONAL ADMINISTRATOR

HEALTH CARE FINANCING ADMINISTRATION DEPARTMENT OF HEALTH AND HUMAN SERVICES

4. PROPOSED EFFECTIVE DATE April 1, 2042

TYPE OF PLAN MATERIAL (Check One)

[7] new state PLAN

(C]_ AMENDMENT TO BE CONSIDERED AS NEW PLAN

AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS 1S AN AMENDMENT (5 Tran for gach amendment) 6. FEDERAL STATUTE/REGULATION GITATION: 7, FEDERAL BUDGET IMPACT: Section 6401 of the Affordable Care Act Ihat amends section 1902(a) a FFY 2012 $ Betts g of the Social Security Act. b FEY 20\4 $ Gh

PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT.

Attachment 4 46 Pagas 1, 2 and 3.

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

Attachment 4.46 Pages 1, 2 and 3

10 SUBJECT OF AMENDMENT:

This amendment affects provider screening and other

nis under M

req

44

GOVERNOR'S REVIEW (Check One}; ia GOVERNOR'S OFFICE REPORTED NO COMMENT COMMENTS OF GOVERNOR'S OFFICE ENCLOSED

ia NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL

OTHER, AS SPECIFIED

C]

16. RETURN TO:

Bureau for Medical Services

Nancy V./Atkins, RN, .NP-BC 350 Capitol Street Room 251 14. TITLE Charleston West Virginia 25301

Commissioner 18. DATE SUBMITTED:

4-30-12. (xD 2 FOR REGIONAL OFFICE USE ONLY = 17. DATE RECEIVED 18. DATE APPROVED 4-30-12 JUL 27 2012

PLAN APPROVED - ONE COPY ADLAGHED

4.

EFFECTIVE DATE OF APPROVED MATERIAL:

PPREL 1, 20D

TYPED NAME.

FRANCES To MeCUL LOVE H

ASSOCLATE AEGTONAL ADMTAES TAA

#7 pee Bale and CO crceck , Pen and ink cetleck BASCON budgedimoack for

REMARKS:

2. aNtiowed ts SOA Pa 80.

FORM HCFA-178 (07-62)

INSTRUCTIONS ON BACK

TAR

Table of Contents State Name: West Virginia State Plan Amendment (SPA) #: 12-009 This file contains the following documents in the order listed: 1) Approval Letters 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 150 5. Independence Mall West Suite 216, The Public Ltxlger Building Philadelphia, Pennsylvania 19106-3499 CfNTl!lS FOR MHHCARE & MEDtCAIO SERVICES Re.:gion IIIJDivision of Medicaid and Children's Health Operations SWIFT #092820 124006 DEC 04 2012 Nancy V. Atkins, MSN, RNC, NP Commissioner. Bureau for Medical Services 350 Capitol Street, Room 251 Charleston, West Virginia 25301~3706 Dear Ms. Atkins: We have reviewed State Plan Amendment (SPA) 12-009, Tobacco Cessation for Pregnant Women, in which you propose to provide coverage of prescription and over-the-counter tobacco/smoking cessation covered outpatient dmgs for pregnant women. This SPA also covers face-to-face tobacco cessation counseling services for pregnant women. West Virginia submitted this amendment as verification of coverage for Tobacco Cessation for Pregnant Women as mandated in the Patient Protection and Affordable Care Act. This SPA is acceptable. Therefore, we are approving SPA 12-009 with an effective date of July 1, 2012. Enclosed are the approved SPA pages and signed CMS-179 tbrm. If you have further questions about this SPA, please contact Margaret Kosherzenko of my staff at 2] 5~861-4288. Enclosures /S/

OEPARTWENT Cf HEAl. TH ANO HUMAN SERV.CES t!£A!.lH CARE FltlANONG AO!I.>NlS 1 RA ll(»l fORM AWROIIED OMS NO C-933-61tJ ···--··-·--······----·-·--·-F_-·TRANSMlTTAt NUMBER 2 STATE TRANSMITTAL AND NOTICE OF APPROVAL OF L .. .! ____ L_-__ o o n ~o&t~e!.";.. --l STATE PLAN MATERIAL 113 PROGRJIU IDENTIFlCA'fiON fHlE )(,IX OF THE. SDCW. FOR: HEALTH CARE l'ltiAAClNG AOMINISTAAHO.~ SECURff'f ACT (MEDiCAJO) ··-···············--------1 TO. R€GIOMAI. ADMINISTRATOR ;4 P~OPOSEO EFF!:CTIVE. DAlE HEAlTH CARE FINANCING AOMIHISTRA.nON 1 0110li201~ OEPARTJ,!EHT OF HEAl. TH ANO HUMAN SERVICES S l'YPE CF PLAN MATERIAl.~~- One) D NEW STATE Pt.At~ D MI.£NOMENl TO BE CONSlOf:REO AS NEW PLAN iK) AMENDMENT j ·········--··-""""""! COMPlETE 8\..0~S 6 lHRU 10 lF THIS tS AN AMENOMENl tSa arme Traresmitt.al fw &ath ameOOmrmU ~ 1------=~~~=~~~~...!!.!!~~==r.:...:~~..!!!!.=~=-====!------·j ~ - f"i\O€FW. Sl'AUJlE/REGUlATION CllATION. Sol:llon 4107 otm.t Patielll Pro*fioo llnll Al't<m!llble Ca:s$ A:a. P.L 111· 148. ·v.fllcll amew.ftiO r~ XIX of lhe SOO!Il SooJnty kA 6 PAGE NUMBER OF THE !>LAN SECTION OR ATTACMMENl. Altsd!"""'ll.I·A, Pl(!el.W 2$ •nd . Suppl.,..,r 2"' llltsd!mmrs ll ·A And J.! ·A.~· Jd S~IZ!oM<ttt>mooll. l - AM<l:i . l·ll. Pages30.1~ '0. SUBJECT OF AMENDMEN'r· 7 FEOE!?.AI.. BUOO£·r IMPACT . a. ffY 20t2 $ ------"0 I! f!'Y $ 11ri& amerlCn~MI ~ b!!ing tM»Mlllil U3 vetlflGi~Uoo r,f t:rW()tagllltot l'~ Cmaal.oo (M Pt91i''l)nl Women~ nui!~Jalw l<rlM Pa~nl f'•llledi<>n and Affunj&t!le Ca•ll 11<:t !---------...... -... ·-·-· ---------- ---··-·-·--··----··------ 11. GOIIER.''fOR'S RtVlEW (CM<:i< 000): D GOVERNOR'S OFFICE REPORTED NO COMMENT ~ COMMENTS OF GOVERNOR'S OFFICE ENCLOSED D NO REJ'L y RECEIVED WITHIN 4S DAYS OF SUfli>'HIA!. CJ OTHER AS SPECIFIED. UREOFST7~w rllREWRNTO 13 ---~----.............. •---···---·-···········-·1,· ! i j koot V AlkiOS.. R~ .. J~.:..I'..; · B;.;:C ____________ -i H. TinE. 15. Bureau for Medical SeN~CeS 350 Capito! Street Room 251 Charleston West Vlrgmia 25301 FOR REOIOML OFFICE USE ONlY --·--····- ············ .. -· .. - · 17. OATE RECEIVED 18 OATEAI'I'ROVEO DEC 0 4 2012 --------------~==~~~r.=~~~~~ EFFECTIVE DATE OF Af'I'ROVF.O MATERW .. ! -··· .. ·-·1 }-___ .:f ~J ( ~-·z..-c 1 ·:z._ ·---·-·-······---·····-··-··- rypeoNAME: 1-'-..!:..L.:.-'-""-..::..Z:.:.=..--<...;..Vl;.o:c.""'('""' v:;_;[i..Q l; 6 t!__ .... ·-----~----···-···· .. ..J..u::..t:.l.:~~=-..~~..t::.!.::.:..L..~~~JiJ!l~/],qJ(Ift 2J REMARKS. ' PtiJ All}b :uJ.r< CHR!Yf?e R.EG>~Je..r-rc: u A~>~b CD~·lh.ert:b j _j;:j611\ +I g ~n1o1le d.. Plljes IIA D-.-,£- 14- ! {lrdJ.etl fH.f Ad 111~+ 3, I fl p fl_je a_. l 1:1tiK !I· ~ p::+bw> f4 '1 FORM liCF.o',ml (01·02) A~ove.L PA je£· till a.-..1. I~· ----------···--·...! - ......... ----·-----·--·· msiiWc~&AcK .• ._ ......... - -..-........ . /S/ /S/

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: West Virginia Revision: HCFA-PM-91-4 (BPD} August 1991 AMOUNT, DURATION, AND SCOPE OF MEDICAL Attachment 3.1-A Page2 OMS No.: 0938- AND REMEDIAL CARE AND SERVlCES PROVIDED TO THECA TEGORICALL Y NEEDY 4.a. Nursing facility services (other than services in an institution .for mental diseases) f()r individual.s 21 years of age or older. Provided: D No Limitations I X ! With Limitations* 4.b. Early and periodic screening, diagnostic and treatment services for individuals under 21 years of age, and treatment of conditions found.* Provided: I X I No Limitations [ ] With Limitations * 4.c. Family planning services and supplies tor individuals of child-bearing age. Provided: [] . N L" . . !Vl w·· h I . . . * L.... 'o umtat10ns ~ 1t _,tmltatwns 4.d. 'fobacco Cessation Counseling Services for Pregnant Women: l. Face-to-Face Tobacco Cessation Counseling Services for Pregnant Women: Provided: ! X I No Limitations D With Limitations * *Recommended benefit package should include at least four (4) counseling sessions per quit attempt, with a minimum of two (2) quit attempts per 12 month period. Any counseling bene.tit package that does not meet this standard should be described below. Please describe any .limitations: 2. Face-to-Face Counseling Services provided by: (i) By or under supervision of a physician; (ii) By any other health care professional who is legally authorized to furnish such services under State law and who is authorized to provide Medicaid coverable services other than tobacco cessation services; or (iii) Any other health care professional l.egally authorized to provide tobacco cessation services under State law and who is specitically designated by the Secretary in regulations. 5.a. Physicians' services whether furnished in the oft1ce, the patient's home, a hospital, a nursing facility or elsewhere. Provided: [ .l No Limitations !Xl With Limitations * TN No: _ _1_2_-0_0_9 .......................... Approval Date: ~.S.~ .... 9 .. ~ ..... Z{U2Effective Date: 07/0l/12 ····················-····--·····---·····----··---- Supersedes: 92-00! ----·········-·-·····················

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: West Virginia Revision: HCFA-PM-91-4 (BPD) August 1991 Attachment 3.1-A Page 2a OMB No.: 0938- 5.b. Medical and surgical services furnished by a dentist (in accordance with section 1905(a)(5)(B) of the Act). Provided: [ ] No Limitations [KJ With Limitations * 6. Medical care and any other type of remedial care recognized under State law, furnished by licensed practitioners within the scope of their practice as defined by State law. a. Podiatrists • services. Provided: D No Limitations I X J With Limitations * TN No: . ..l.~_::Q9.2 ....... ...... ... Approval Date: 0 ~-~-----~.1 .... ?_01_2_ Effective Date: _Q.Z!.:Q..!!.L? _____ _ Supersedes: NEW -····--····--

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: West Virginia Supplement 2 to Attachments 3.1-A and 3.1-8 Page 3d 12. a. Prescribed Drugs All covered outpatient drugs, whether legend or non-legend, must be prescribed by a physician, or other practitioner qualified under State law. Applicable State and Federal law governing dispensing of drugs and biological must be followed. The prescribed use of the covered outpatient drug must be for a medically accepted indication as defined in Social Security Act §1927(k)(6). b. Coverage of Smokingrr obacco Cessation products (1} The Medicaid agency provides coverage of selected prescription tobacco/smoking cessation covered outpatient drugs, bupropion and legend nicotine replacement therapy, for all Medicaid recipients except for full benefit dual eligible beneficiaries who receive this coverage under the Medicare Prescription Drug Benefit-Part D. (2) The Medicaid agency provides coverage of over-the-counter {OTC) tobacco/smoking cessation covered outpatient drugs for all Medicaid recipients except for beneficiaries residing in skilled and intermediate nursing facilities. (3) The Medicaid agency provides coverage of prescription tobacco/smoking cessation covered outpatient drugs, bupropion and legend nicotine replacement therapy, and over-the-counter (OTC) · tobacco/smoking cessation covered outpatient drugs for pregnant women as recommended in "Treating Tobacco Use and Dependence: 2008 Update: a Clinical Practice Guideline" published by the Public Health Service in May 2008 or any subsequent modification of such guideline. TN No: 12-009 Approval Date: DEC 0 4 2012 Effective Date: 07/01!1 2 --- --------- Supersedes: 09-04 .

Table of Contents State Name: West Virginia State Plan Amendment (SPA) #: 13-0009 This file contains the following documents in the order listed:

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

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 150 S. Independence Mall West Suite 216, The Public Ledger Building Philadelphia, Pennsylvania 19106-3499 CENTERS FOR MEDICARE & MEDICAID SERVICES Region Ill/Division of Medicaid and Children's Health Operations SWIFf #122320134045 MAR 17 2014 Nancy V. Atkins, MSN, RNC, NP Commissioner Bureau for Medical Services 350 Capitol Street, Room 251 Charleston, West Virginia 25301-3706 RE: West Virginia State Plan Amendment (SPA) 13-0009 Dear Commissioner Atkins: Enclosed for your records is an approved copy of West Virginia's Alternative Benefit Plan (ABP) State Plan Amendment 13-0009. This ABP, which was submitted on December 20,2013, meets all federal statutory and regulatory requirements for establishing an ABP. All requirements pertaining to ABPs must be met including, but not limited to: benefits, payment rates, reimbursement methodologies, cost-sharing State Plan pages, and (if applicable) managed care service delivery systems (waivers and contracts). Amendments to the State's approved Medicaid program (SPAs, waivers, contracts) may require corresponding amendments to the ABP if the change to the benefit in the approved State Plan will be mirrored in the ABP .. This ABP SPA is approved effective January 1, 2014, as requested by West Virginia. Enclosed is a copy of the CMS Summary Page (CMS-179 form) and the approved State Plan pages. Congratulations to you and your staff for your hard work and strong collaboration. If you have any questions, please contact Margaret Kosherzenko at 215-861-4288 or by email at Margaret.Kosherzenko@cms.hhs.gov. Enclosures cc: Alva Page, BMS Sarah Young, BMS Sincerely,

WV.0654.R00.00 - Jan 01, 2014 Page | of 2

Medicaid Alternative Benefit Plan: Summary Page (CMS 179)

State/Territory name: West Virginia

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-13-0009 |

Proposed Effective Date 01/01/2014 (mn/dd/yyyy)

Federal Statute/Regulation Citation ACA

Federal Budget Impact Federal Fiscal Year Amount

First Year 20107 5 000

Second Year 2015 $0.00

Subject of Amendment Alternate Benefit Plan

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

<<? Comments of Governor's office received Describe:

No reply received within 45 days of submittal

® Other, as specified Describe: Not Required

Signature of State Agency Official

Submitted By: Sarah Young Last Revision Date: Mar 11, 2014 Submit Date: Dec 20, 2013

http://157.199.11 3.99/MMDL/faces/protected/abp/d01/print/Pri... 03/14/2014

WV.0654.ROO.OO- Jan 01, 2014 Page 2 of2 http://157.199.113.99/MMDL/faces/protected/abp/dOl/print/Pri... 03/17/2014

Alternative Benefit Plan

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

Attachment 3.1-L [ |

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

Alternative Benefit Plan Population Name: Adult Expansion Group

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

Eligibility Groups Included in the Alternative Benefit Plan Population:

Enrollment is Eligibility Group: mandatory or voluntary? + |ladult Group Mandatory X Enrollment is available for all individuals in these eligibility group(s). Geographic Area ‘The Alternative Benefit Plan population will include individuals from the entire state/territory. Yes

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

RA Discl: it

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 5 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments conceming the accuracy of

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

V.20130724

Page 1 of 1 TN No. 13-0009 Approval Date: 03/17/2014 Effective Date: 01/01/2014 West Virginia ABP1-1

Supersedes: New

CMS Alternative Benefit Plan

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

AACA) spore

Attachment 3.1-L [|

The state/territory has fully aligned its benefits in the Alternative Benefit Plan using Essential Health Benefits and subject to 1937 requirements with its Alternative Benefit Plan that is the state’s approved Medicaid state plan that is not subject to 1937 No requirements. Therefore the state/territory is deemed to have met the requirements for voluntary choice of benefit package for

individuals exempt from mandatory participation in a section 1937 Alternative Benefit Plan.

These assurances must be made by the state/territory if the Adult eligibility group is included in the ABP Population.

The state/territory shall enroll all participants in the "Individuals at or below 133% FPL Age 19 through 64" (section 1902(a)(10)(A) (i)(VIID) eligibility group in the Alternative Benefit Plan specified in this state plan amendment, except as follows: A beneficiary in the eligibility group at section 1902(a)(10)(A)(i)(VILI) who is determined to meet one of the exemption criteria at 45 CFR 440.315 will receive a choice of a benefit package that is either an Alternative Benefit Plan that includes Essential Health Benefits and is subject to all 1937 requirements or an Alternative Benefit Plan that is the state/territory’s approved Medicaid state plan not subject to 1937 requirements. The state/territory’s approved Medicaid state plan includes all approved state plan programs based on any state

plan authority, and approved 1915(c) waivers, if the state has amended them to include the eligibility group at section 1902(a)(10)(A) (VID. .

The state/territory must have a process in place to identify individuals that meet the exemption criteria and the State/territory must comply with requirements related to providing the option of enrollment in an Alternative Benefit Plan defined using section 1937

requirements, or an Alternative Benefit Plan defined as the state/territory's approved Medicaid state plan that is not subject to section 1937 requirements.

Once an individual is identified, the state/territory assures it will effectively inform the individual of the following:

a) Enrollment in the specified Alternative Benefit Plan is voluntary;

b) The individual may disenroll from the Alternative Benefit Plan defined subject to section 1937 requirements at any time and

instead receive an Alternative Benefit Plan defined as the approved state/territory Medicaid state plan that is not subject to section 1937 requirements; and

c) What the process is for transferring to the state plan-based Alternative Benefit Plan.

The state/territory assures it will inform the individual of:

a) The benefits available as Alternative Benefit Plan coverage defined using section 1937 requirements as compared to Alternative

Benefit Plan coverage defined as the state/territory's approved Medicaid state plan and not subject to section 1937 requirements; and

b) The costs of the different benefit packages and a comparison of how the Alternative Benefit Plan subject to 1937 requirements differs from the Alternative Benefit Plan defined as the approved Medicaid state/territory plan benefits.

How will the state/territory inform individuals about their options for enrollment? (Check all that apply)

Letter

C0 Email ( Other Page 1 of 3 TN No. 13-0009 Approval Date: 03/17/2014 Effective Date: 01/01/2014 West Virginia ABP2a-1

Supersedes: New

Alternative Benefit Plan

Provide a copy of the letter, email text or other communication text that will be used to inform individuals about their options for enrollment.

An attachment is submitted. -

When did/will the state/territory inform the individuals?

During the full application process, whether the application is completed in the Marketplace or in the county office, if a member answers YES the following question : "Does this person (or you, depending on the person completing the form) have a physical, mental, or emotional health condition that causes limitations in activities (like bathing, dressing, daily chores, etc.) or live in a medical facility or nursing home?" it will trigger a "Medical Frailty Notice" along with the Medicaid eligibility determination notice informing them they have the right to choose between the Alternative Benefit Plan (ABP) and the state's Traditional Plan.

Every member will receive a copy of their Rights and Responsibilities including information about medical frailty and how to get more information regarding their coverage options. A copy of the Rights and Responsibilities is also provided to every member at the time of their annual redetermination or in the event they have an eligibility category change.

West Virginia provides copies of "Your Guide to Medicaid" which also has information about medical frailty and who to contact if a member falls into the description. Additionally, anytime a member goes to a county office they are given a copy of the Rights and Responsibilities to sign acknowledging receipt and a copy is placed in their case file.

Please describe the state/territory's process for allowing individuals in the Section 1902(a)(10)(A)(@)(VIID) eligibility group who meet exemption criteria to disenroll from the Alternative Benefit Plan defined using section 1937 requirements and enroll in the Alternative Benefit Plan defined as the state/territory's approved Medicaid state plan.

During the full application process, whether the application is completed in the Marketplace or in the county office, if a member answers YES the following question : "Does this person (or you, depending on the person completing the form) have a physical, mental, or emotional health condition that causes limitations in activities (like bathing, dressing, daily chores, etc.) or live in a medical facility or nursing home?" it will trigger a "Medical Frailty Notice" along with the Medicaid eligibility determination notice informing them they have the right to choose between the Alternative Benefit Plan (ABP) and the state's Traditional Plan.

Regardless of how the member answers the aforementioned question, every member will receive a copy of their Rights and Responsibilities including information about medical frailty and how to get more information regarding their coverage options. A copy of the Rights and Responsibilities is also provided to every member at the time of their annual redetermination or in the event they have an eligibility category change.

West Virginia provides copies of "Your Guide to Medicaid" which also has information about medical frailty and who to contact if a member falls into the description. Additionally, anytime a member goes to a county office they are given a copy of the Rights and Responsibilities to sign acknowledging receipt and a copy is placed in their case file. County workers and fiscal agent member help line staff are well informed about the rights and responsibilities and are able to assist members with the necessary information to change their choice of benefit plan packages if they so choose.

A Medicaid member can self-identify at any time during their eligibility period as having a chronic substance use disorder, serious and complex medical condition, or a physical, behavioral, intellectual, or developmental disorder and can discuss coverage options with their doctor, contact Member Services or visit the fiscal agent website for additional information.

The state/territory assures it will document in the exempt individual's eligibility file that the individual: a) Was informed in accordance with this section prior to enrollment; b) Was given ample time to arrive at an informed choice; and

c) Chose to enroll in Alternative Benefit Plan coverage subject to section 1937 requirements or defined as the state/territory's approved Medicaid state plan, which is not subject to section 1937 requirements.

Page 2 of 3

TN No. 13-0009 Approval Date: 03/17/2014 Effective Date: 01/01/2014 West Virginia ABP2a-2 Supersedes: New

Alternative Benefit Plan

Where will the information be documented? (Check all that apply) (7) In the eligibility system. (7 In the hard copy of the case record. Other

Describe:

Letter will be scanned and stored in the Fiscal Agent's letter repository.

What documentation will be maintained in the eligibility file? (Check all that apply) Copy of correspondence sent to the individual. Signed documentation from the individual consenting to enrollment in the Alternative Benefit Plan.

(7 Other

The state/territory assures that it will maintain data that tracks the total number of individuals who have voluntarily enrolled in either Alternative Benefit Plan coverage subject to section 1937 requirements or Alternative Benefit Plan coverage defined as the state/ territory's approved Medicaid state plan, which is not subject to section 1937 requirements.

Other information related to benefit package selection assurances for exempt participants (optional):

Disclosur temen'

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148, The time required to complete this information collection is estimated to average 5 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

V.20130807

Page 3 of 3

TN No. 13-0009 Approval Date: 03/17/2014 Effective Date: 01/01/2014 West Virginia ABP2a-3

Supersedes: New

Alternative Benefit Plan

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

These assurances must be made by the state/territory if enrollment is mandatory for any of the target populations or sub-populations.

Attachment 3.1-L [|

‘When mandatorily enrolling eligibility groups in an Alternative Benefit Plan (Benchmark or Benchmark-Equivalent Plan) that could have exempt individuals, prior to enrollment:

The state/territory assures it will appropriately identify any individuals in the eligibility groups that are exempt from mandatory enrollment in an Alternative Benefit Plan or individuals who meet the exemption criteria and are given a choice of Alternative Benefit

Plan coverage defined using section 1937 requirements or Alternative Benefit Plan coverage defined as the state/territory's approved Medicaid state plan, not subject to section 1937 requirements.

How will the state/territory identify these individuals? (Check all that apply) [7 Review of eligibility criteria (e.g., age, disorder/diagnosis/condition)

Self-identification

Describe:

During the full application process, whether the application is completed in the Marketplace or in the county office, ifa member answers YES the following question : "Does this person (or you, depending on the person completing the form) have a physical, mental, or emotional health condition that causes limitations in activities (like bathing, dressing, daily chores, etc.) or live in a medical facility or nursing home?" it will trigger a "Medical Frailty Notice" along with the Medicaid eligibility

determination notice informing them they have the right to choose between the Alternative Benefit Plan (ABP) and the state's Traditional Plan.

Regardless of how the member answers the aforementioned question, every member will receive a copy of their Rights and Responsibilities including information about medical frailty and how to get more information regarding their coverage options.

‘A copy of the Rights and Responsibilities is also provided to every member at the time of their annual redetermination or in the event they have an eligibility category change.

Additionally, West Virginia provides copies of "Your Guide to Medicaid" which also has information about medical frailty and who to contact if member falls into the description. Additionally, anytime a member goes to a county office they are given a copy of the Rights and Responsibilities to sign acknowledging receipt and a copy is placed in their case file. County workers and fiscal agent member help line staff are well informed about the rights and responsibilities and are able to assist members with the necessary information to change their choice of benefit plan packages if they so choose.

A Medicaid member can self-identify at any time during their eligibility period as having a chronic substance use disorder, serious and complex medical condition, or a physical, behavioral, intellectual, or developmental disorder and can discuss coverage options with their doctor, contact Member Services or visit the fiscal agent website for additional information.

[BMS will also conduct provider outreach activities for medical frailty during the annual provider workshops across the state.

(7) Other

The state/territory must inform the individual they are exempt or meet the exemption criteria and the state/territory must comply with

all requirements related to voluntary enrollment or, for beneficiaries in the “Individuals at or below 133% FPL Age 19 through 64” eligibility group, optional enrollment in Alternative Benefit Plan coverage defined using section 1937 requirements or Alternative Benefit Plan coverage defined as the state/territory's approved Medicaid state plan.

Page 1 of 3

TN No. 13-0009 Approval Date: 03/17/2014 Effective Date: 01/01/2014 Supersedes: New ABP2c-1 West Virginia

CMs Alternative Benefit Plan

The state/territory assures that for individuals who have become exempt from enrollment in an Alternative Benefit Plan, the state/ territory must inform the individual they are now exempt and the state/territory must comply with all requirements related to voluntary enrollment or, for beneficiaries in the “Individuals at or below 133% FPL Age 19 through 64” eligibility group, optional enrollment in Alternative Benefit Plan coverage defined using section 1937 requirements, or Alternative Benefit Plan coverage defined as the state/territory's approved Medicaid state plan. a

How will the state/territory identify if an individual becomes exempt? (Check all that apply)

[7] Review of claims data

Self-identification

[7] Review at the time of eligibility redetermination (7 Provider identification

Change in eligibility group

(7 Other

How frequently will the state/territory review the Alternative Benefit Plan population to determine if individuals are exempt from mandatory enrollment or meet the exemption criteria?

C Monthly C Quarterly C Annually @ Ad hoc basis C Other

The state/territory assures that it will promptly process all requests made by exempt individuals for disenrollment from the Alternative Benefit Plan and has in place a process that ensures exempt individuals have access to all standard state/territory plan services or, for beneficiaries in the “Individuals at or below 133% FPL Age 19 through 64” eligibility group, optional enrollment in Alternative Benefit Plan coverage defined using section 1937 requirements, or Alternative Benefit Plan coverage defined as the state/territory's approved Medicaid state plan.

Describe the process for processing requests made by exempt individuals to be disenrolled from the Alternative Benefit Plan:

Individuals who self-identify as medically frail at the time of. application, will return the notice included with their eligibility

determination in order to notify the State that they would like to be disenrolled form the ABP. Instructions for completing this process are included in their eligibility determination notice.

Individuals seeking exemption from the Alternative Benefits Plan at any time during their period of eligibility will notify the Bureau for Medical Services or their designee who will initiate the change process. The appropriate contact information for the Bureau is included in their eligibility determination notice, the rights and responsibilities section of the Medicaid application, and in the "Your Guide to West Virginia Medicaid" document. Once the applicant makes the request, the same notice delivered as a part of medically frail individuals’ eligibility notice will be sent to the member. They must complete the form and return it to the Bureau to complete the process. All requests to disenroll from the ABP must be submitted in writing to the Bureau.

At any time whether an individual answers the trigger question on the application or calls to self-identify as meeting the medically frail criteria, they will have access to choice counseling by a variety of avenues. County workers and fiscal agent member help line staff are well informed about the rights and responsibilities and are able to assist members with the necessary information to change their choice.

Page 2 of 3

TN No. 13-0009 Approval Date: 03/17/2014 Effective Date: 01/01/2014 Supersedes: New ABP2c-2 West Virginia

Alternative Benefit Plan

jot benefit plan packages if they so choose.

Other Information Related to Enrollment Assurance for Mandatory Participants (optional):

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1 148. The time required to complete this information collection is estimated to average 5 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form,

please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

V.20130807

Page 3 of 3

TN No. 13-0009 Supersedes: New West Virginia

Approval Date: 03/17/2014

Effective Date: 01/01/2014 ABP2c-3

Alternative Benefit Plan

OMB Control Number: 0938-1148

Attachment 3.1-L []

OMB Expiration date: 10/31/2014

Select one of the following:

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

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

Name of benefit package: [WV Health Bridge Plan

Selection of the Section 1937 Coverage Option

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

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

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

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

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

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

@ Secretary-Approved Coverage.

C The state/territory offers benefits based on the approved state plan.

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

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

The ABP benefit package closely mirrors the WV Medicaid State Plan coverage. Any differences or limitations are noted in ABPS. An overview of the two plans comparison shows the following differences between: PT/OT - in the traditional Medicaid State plan a beneficiary receives 20 visits per year combined with PA required for overage and in the ABP the limit is increased to 30 visits combined per year; Home Health in the traditional Medicaid State Plan is 60 visits/year with additional PA for overage and in the ABP, 100 vi sits/year; and Personal Care Services and long term institutional services (NF and ICF/IID) are covered under the traditional State plan land not covered under the ABP.

Selection of Base Benchmark Plan

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

The Base Benchmark Plan is the same as the Section 1937 Coverage option. |No

Indicate which Benchmark Plan described at 45 CFR 156. 100(a) the state/territory will use as its Base Benchmark Plan:

Page 1 of 2

TN No. 13-0009 Approval Date: 03/17/2014 Effective Date: 01/01/2014 West Virginia ABP3-1 Supersedes: New

CMS Alternative Benefit Plan

@ Largest plan by enrollment of the three largest small group insurance products in the state's small group market. C Any of the largest three state employee health benefit plans by enrollment. C Any of the largest three national FEHBP plan options open to Federal employees in all geographies by enrollment.

C Largest insured commercial non-Medicaid HMO.

Plan name: |Highmark WV Benchmark Plan

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

1. The state assures that all services in the base benchmark have been accounted for throughout the benefit chart found in ABPS. 2. The state assures the accuracy of all information in ABP5 depicting amount, duration and scope parameters of services authorized in the currently approved Medicaid state plan.

PRA Disclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 5 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

V.20130801

Page 2 of 2

TN No. 13-0009 Approval Date: 03/17/2014 Effective Date: 01/01/2014 West Virginia ABP3-2 Supersedes: New

Alternative Benefit Plan

OMB Control Number: 0938-1148 Attachment 3.1-L. [| OMB Expiration date: 10/31/2014 ABP4

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

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

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

Other Information Related to Cost Sharing Requirements (optional):

RA Disclosur nt

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a

valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete

this information collection is estimated to average 5 hours per response, including the time to review instructions, search existing data Tesources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of

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

V.20130807 Page 1 of 1 TN No. 13-0009 Approval Date: 03/17/2014 Effective Date: 01/01/2014 West Virginia

ABP4-1 Supersedes: New

ccCmMSsS Alternative Benefit Plan

OMB Control Number: 0938-1148 Attachment 3.1-L [] OMB Expiration date: 10/31/2014

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

Benefits Included in Alternative Benefit Plan

Enter the specific name of the base benchmark plan selected:

Highmark West Virginia: Super Blue Plus 2000

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

Secretary-Approved

TN No. 13-0009 West Virginia Supersedes: New

Page 1 of 27

Approval Date: 03/17/2014 Effective Date: 01/01/2014

ABP5-1

Alternative Benefit Plan

[m] Essential Health Benefit 1: Ambulatory patient services Collapse All [7] Benefit Provided: Source: Physician Services State Plan 1905(a) Remove

Authorization: Provider Qualifications: ‘None Medicaid State Plan Amount Limit: Duration Limit:

(None None

Scope Limit:

None

benchmark plan:

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

Medical Office Visit / Office Consultation (Includes Specialist/Specialist Virtual Visit) — Applies to Charges for Visit only. Does not apply to other Services received during Visit.

Benefit Provided:

Source:

Podiatry: Other Licensed Practitioner

State Plan 1905(a)

Authorization: Provider Qualifications: Prior Authorization Medicaid State Plan Amount Limit: Duration Limit:

None None

Scope Limit:

None

benchmark plan:

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

Benefit Provided:

Source:

Chiropractic: Other Licensed Practitioner

State Plan 1905(a)

Authorization:

Provider Qualifications:

Authorization required in excess of limitation

Medicaid State Plan

Amount Limit:

Duration Limit:

24 treatments/year None Scope Limit:

Page 2 of 27 TN No. 13-0009 Approval Date: 03/17/2014 Effective Date: 01/01/2014

West Virginia Supersedes: New

ABP5-2

Alternative Benefit Plan

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

benchmark plan:

Coverage of chiropractic services is limited to one treatment per day and not more than 12 treatments without prior Authorization. An additional 12 treatments per calendar year if medically necessary and Prior Authorized. 6 additional treatments per calendar year can be prior authorized if OT and PT services have not been utilized in combination with chiropractic services. Limits in the State Plan refer to the adult population only. Children are covered by EPSDT and are not subject to the hard limit applied to adults. Medicaid will require that prior approval for all ages be obtained by the provider for medically necessary services which are not covered or exceed the benefit limit addressed in the State Plan.

Benefit Provided: Source: Diagnostic x-ray State Plan 1905(a) Remove Authorization: Provider Qualifications: Other Medicaid State Plan Amount Limit: Duration Limit: ‘None None Scope Limit: None

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

For radiology services requiring prior authorization for medical necessity by the Utilization Management Contractor (UMC), the referring/treating provider must submit the appropriate CPT code with clinical documentation and any other pertinent information to be used for clinical justification of services by the UMC.

Benefit Provided: Source:

Outpatient Hospital Services State Plan 1905(a) Authorization: Provider Qualifications: Other Medicaid State Plan Amount Limit: Duration Limit:

None None Scope Limit: (None

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

Certain services require Prior Authorization and concurrent review for further services if identified as a high utilization/abuse. If services have been identified as having a high rate of utilization/abuse they will receive a more intense review and PA process.

An example of hospital outpatient services that require a PA would be surgical procedures: acne surgery - criteria requires review of less invasive procedures to ensure medical necessity; reconstruction procedures

Page 3 of 27 TN No. 13-0009 Approval Date: 03/17/2014 Effective Date: 01/01/2014 West Virginia ABP5-3 Supersedes: New

(aw, nose, brow repair) to ensure medical necessity and not cosmetic; all unlisted surgical procedures to ensure there is no appropriate CPT code and that the procedure is not experimental/research. Remove = Benefit Provided: Source: Hospice State Plan 1905(a) Remove Authorization: Provider Qualifications: Prior Authorization Medicaid State Plan Amount Limit: Duration Limit: None None Scope Limit: (None Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: If a person revokes 3 times they are no longer eligible for hospice. Add Page 4 of 27 TN No. 13-0009 Approval Date: 03/17/2014 Effective Date: 01/01/2014 West Virginia ABP5-4

Supersedes: New

Ss

STS IO MEOCARE 4 ASPET SSC

Alternative Benefit Plan

[i] Essential Health Benefit 2: Emergency services

Collapse All [[]

Benefit Provided:

Source:

Outpatient Hospital Services/Emergency Room

State Plan 1905(a)

Remove

Authorization: Provider Qualifications: None Medicaid State Plan Amount Limit: Duration Limit:

None None

Scope Limit:

None

benchmark plan:

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

Benefit Provided:

Source:

Any other medical care/Transportation

State Plan 1905(a)

Remove

Authorization: Provider Qualifications: (None Medicaid State Plan Amount Limit: Duration Limit:

None None

Scope Limit:

None

benchmark plan:

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

Must be to nearest appropriate provider

Add

TN No. 13-0009 West Virginia Supersedes: New

Approval Date: 03/17/2014 ABP5-5

Page 5 of 27

Effective Date: 01/01/2014

Alternative Benefit Plan

TATE ICR ASSIA A TEAL INIT

[i Essential Health Benefit 3: Hospitalization Collapse All [7] Benefit Provided: Source: Inpatient Hospital Services State Plan 1905(a) [ Remove | Authorization: Provider Qualifications: Prior Authorization Medicaid State Plan Amount Limit: Duration Limit: ‘None ‘None

Scope Limit:

‘None

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

All inpatient services require prior authorization (PA). The State has a retroactive PA process in place for all inpatient hospital care as a result of entrance through ER (to include emergency and non-emergency) visits that result in inpatient care. This retroactive prior authorization process allows the facility 10 days to submit necessary information to determine medical necessity required for processing to allow authorization for these services.

In the event that the authorized inpatient stay exceeds the original authorization in scope, the provider will be required to submit an additional request for authorization for the continued stay or service modifications.

Page 6 of 27

TN No. 13-0009 Approval Date: 03/17/2014 Effective Date: 01/01/2014

West Virginia ABP5-6 Supersedes: New

= Alternative Benefit Plan

SN CORS ORR RUSTED INES

[ml] Essential Health Benefit 4: Maternity and newborn care Collapse All [] Benefit Provided: Source: Hospital Inpatient Services/maternity State Plan 1905(a) [ Remove | Authorization: Provider Qualifications: None Medicaid State Plan Amount Limit: Duration Limit: ‘None None Scope Limit: ‘None

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

Hospital Inpatient/maternity medical and surgical services for pregnancy and complications of pregnancy and miscarriage. The services for this benefit also include physician services covered in EHB 1

Benefit Provided: Source: Hospital Outpatient Services/Maternity State Plan 1905(a) [ Remove | Authorization: Provider Qualifications: ‘None Medicaid State Plan Amount Limit: Duration Limit: (None None Scope Limit: None

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

Outpatient/maternity medical and surgical services for pregnancy and complications of pregnancy and miscarriage. The services for this benefit also include physician services covered in EHB 1

Add

Page 7 of 27 TN No. 13-0009 Approval Date: 03/17/2014 Effective Date: 01/01/2014 West Virginia ABP5-7 Supersedes: New

Alternative Benefit Plan

Ss

STASI IR SARTO SRINETS

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

am behavioral health treatment

Collapse All [7]

Benefit Provided: Source: Physician: Outpatient Psychiatric Treatment State Plan 1905(a) [ Remove | Authorization: Provider Qualifications: Prior Authorization Medicaid State Plan Amount Limit: Duration Limit: 12 sessions per year (None Scope Limit: (None

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

Services require Prior Authorization and concurrent review for further services if identified as a high utilization/abuse.

Benefit Provided: Source: Rehab: Rehabilitative Psychiatric Treatment State Plan 1905(a) [Remove | Authorization: Provider Qualifications: Prior Authorization Medicaid State Plan Amount Limit: Duration Limit: (None (None Scope Limit: None

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

‘These services are aimed at those with severe mental illness. Full clinical review prior authorization is required for all services with no hard limits. WV has two levels of prior authorization, an initial level and a second more intense level for both MH and substance abuse services. In West Virginia most of these types of services are provided in the community mental health centers. These centers provide both individual and group psychotherapy services.

At the State discretion services may require Prior Authorization if services have been identified as having a high rate of utilization/abuse.

Benefit Provided: Source: Inpatient Hospital: Psychiatric Hospital Care State Plan 1905(a) Authorization: Provider Qualifications: Prior Authorization Medicaid State Plan Page 8 of 27 TN No. 13-0009 Approval Date: 03/17/2014 Effective Date: 01/01/2014 West Virginia ABP5-8

Supersedes: New

Alternative Benefit Plan

Amount Limit: Duration Limit: ‘None Remove |

5 day stay

Scope Limit:

None

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

Inpatient Hospital Services require Prior Authorization and concurrent review for further services. These services are not provided in facilities that are IMDs.

Add

Page 9 of 27 TN No. 13-0009 Approval Date: 03/17/2014 Effective Date: 01/01/2014 West Virginia ABP5-9 Supersedes: New

Ss

UA READER AMMEN

Alternative Benefit Plan

[i Essential Health Benefit 6: Prescription drugs

Benefit Provided:

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

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

Limit on days supply

(1) Limit on number of prescriptions (1 Limit on brand drugs

Other coverage limits

Preferred drug list

Provider Qualifications:

Yes

State licensed

Coverage that exceeds the minimum requirements or other:

Medicaid state plan for prescribed drugs.

The State of West Virginia's ABP prescription drug benefit plan is the same as under the approved

TN No. 13-0009 West Virginia Supersedes: New

Approval Date: 03/17/2014 ABP5-10

Page 10 of 27 Effective Date: 01/01/2014

= Alternative Benefit Plan

ee eee

[m] Essential Health Benefit 7: Rehabilitative and habilitative services and devices Collapse All [7] Benefit Provided: Source: Physical Therapy Base Benchmark Commercial HMO Remove Authorization: Provider Qualifications: Prior Authorization Selected Public Employee/Commercial Plan Amount Limit: Duration Limit: 30 visits/yr combined PT/OT rehab/hab ‘None

Scope Limit:

(None

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

PA for 6 visits, must have plan of care and additional more intensive PA for up to 24 visits (PA Process is from the State Plan). Visit totals include PT and OT combined for rehabilitative and habilitative services The Physical Therapy rehabilitative and habilitative services are a combination of the WV State Plan PA

to these limitations.

process and the base benchmark benefit limitations, EPDST services for children under 21 are not subject

Benefit Provided: Source: (Occupational Therapy Base Benchmark Commercial HMO Remove Authorization: Provider Qualifications: Prior Authorization Selected Public Employee/Commercial Plan Amount Limit: Duration Limit: 30 visits/yr combined PT/OT rehab/hab None Scope Limit: None

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

PA for 6 visits, must have plan of care and additional more intensive PA for up to 24 visits (PA process is in the State Plan). Visit totals include PT and OT combined for rehabilitative and habilitative.

‘The Occupational Therapy rehabilitative and habilitative services are a combination of the WV State Plan PA process and the base benchmark benefit limitations. EPDST services for children under 21 are not subject to these limitations.

Benefit Provided: Source: PT and related services: Speech Therapy State Plan 1905(a) Authorization: Provider Qualifications: Prior Authorization Medicaid State Plan Page 11 of 27 TN No. 13-0009 Approval Date: 03/17/2014 Effective Date: 01/01/2014 West Virginia ABP5-11

Supersedes: New

sS Alternative Benefit Plan

HAA TORARTRANE ARDENT

Amount Limit: Duration Limit:

20 visits per year ‘None

Remove |

Scope Limit: ~

None

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

PA is required for every member to commence the first 20 ST visits but for additional visits past the 20 limit a more subsequent intense review is required for both rehabilitative and habilitative services. Services limits for members in the ABP population are combined for hab/rehab to reach the limit per year.

Benefit Provided: Source:

Rehab: Cardiac rehabilitation State Plan 1905(a)

Remove

Authorization: Provider Qualifications:

Prior Authorization Medicaid State Plan

Amount Limit: Duration Limit: 36 sessions in a 12 week period ‘None

Scope Limit:

‘None

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

Additional cardiac rehabilitation services may be medically necessary when the member has any of the following conditions:

Another documented myocardial infarction or extension of initial infarction, or

Another cardiovascular surgery or angioplasty; or

New evidence of ischemia or an exercise test, including thallium scan, or

New clinically significant coronary lesions documented by cardiac catheterization.

Benefit Provided: Source:

Rehab: Pulmonary Rehabilitation

State Plan 1905(a)

Authorization: Provider Qualifications:

Prior Authorization Medicaid State Plan

Amount Limit: Duration Limit:

20 sessions None

Scope Limit:

None

Page 12 of 27 TN No. 13-0009 Approval Date: 03/17/2014 Effective Date: 01/01/2014 West Virginia ABP5-12

Supersedes: New

sS Alternative Benefit Plan

CM CCER AEE SSETET ABS A AGRO BENECES

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

Pulmonary Rehabilitation Services require Prior Authorization and concurrent review for further services.

+

Remove

Benefit Provided: Source: Home Health: Durable medical equipment State Plan 1905(a) Remove Authorization: Provider Qualifications: Prior Authorization Medicaid State Plan Amount Limit: Duration Limit: ‘None ‘None Scope Limit: (None

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

Durable medical equipment must be prescribed by a Physician or Professional Other Provider acting within the scope of their license.

Benefit Provided: Source: Orthotics and prosthetics State Plan 1905(a) [ Remove | Authorization: Provider Qualifications: Prior Authorization Medicaid State Plan Amount Limit: Duration Limit: ‘None None Scope Limit: None

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

Orthotics and prosthetics must be prescribed by a Physician or Professional Other Provider acting within the scope of their license.

Benefit Provided: Source: Home Health Base Benchmark Commercial HMO Authorization: Provider Qualifications: Prior Authorization Selected Public Employee/Commercial Plan Amount Limit: Duration Limit: 100 visits per year ‘None Page 13 of 27 TN No. 13-0009 Approval Date: 03/17/2014 Effective Date: 01/01/2014 West Virginia ABP5-13

Supersedes: New

sS Alternative Benefit Plan

TASS TORRE ATT 8 RTCA SIONS

Scope Limit: (None Remove Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Review for the first 60 visits, beyond 60 visits full clinical criteria review required. 100 visits per year will be a hard limit on this service. Children are covered by EPSDT and are not subject to the hard limit applied to adults for this service. Benefit Provided: Source: Other Services: Rehabilitation Hospital Services State Plan 1905(a) Remove Authorization: Provider Qualifications: Prior Authorization Medicaid State Plan Amount Limit: Duration Limit: (None None Scope Limit: ‘None Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Inpatient Rehab Hospital Services require Prior Authorization and concurrent review for further services, If services are identified as having a high rate of utilization/abuse of services or over utilization they may require an additional level of review. All services require prior authorization for payment. Add

Page 14 of 27

TN No. 13-0009 Approval Date: 03/17/2014 Effective Date: 01/01/2014

West Virginia ABP5-14 Supersedes: New

Alternative Benefit Plan

[li] Essential Health Benefit 8: Laboratory services Collapse All [7] Benefit Provided: Source: Laboratory Services and Testing State Plan 1905(a) Remove Authorization: Provider Qualifications: Prior Authorization Medicaid State Plan Amount Limit: Duration Limit: (None ‘None Scope Limit: ‘None

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

Laboratory services are limited to those tests identified by CMS for which the individual provider is CLIA certified. Not all laboratory services require a PA, but many do require a PA to be reimbursed.

Laboratory services require a written practitioner’s order which includes the original signature of the member’s treating provider, date ordered, member’s diagnosis, and the specific test or procedure requested.

Page 15 of 27 TN No. 13-0009 Approval Date: 03/17/2014 Effective Date: 01/01/2014 West Virginia ABPS5-15, Supersedes: New

MARSTON A MTD ER

Alternative Benefit Plan

[i] Essential Health Benefit 9: Preventive and wellness services and chronic disease management

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

Collapse All [7]

Benefit Provided:

Source:

Preventative Services: Diabetes Education

State Plan 1905(a)

Remove

Authorization: Provider Qualifications: (None Medicaid State Plan Amount Limit: Duration Limit:

None (None

Scope Limit:

None

benchmark plan:

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

Add,

TN No. 13-0009 West Virginia Supersedes: New

Approval Date: 03/17/2014 ABP5-16

Page 16 of 27 Effective Date: 01/01/2014

Alternative Benefit Plan

[i] Essential Health Benefit 10: Pediatric services including oral and vision care Collapse All [7] Benefit Provided: Source: Medicaid State Plan EPSDT Benefits State Plan 1905(a) [Remove | Authorization: Provider Qualifications: Authorization required in excess of limitation Medicaid State Plan Amount Limit: Duration Limit: ‘None ‘None

Scope Limit:

‘None

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

Page 17 of 27 TN No. 13-0009 Approval Date: 03/17/2014 Effective Date: 01/01/2014 West Virginia ABP5-17 Supersedes: New

—

TNC TOENEEAERES HART ARASERVECES

Alternative Benefit Plan

[1] Other Covered Benefits from Base Benchmark Collapse All [7]

Page 18 of 27 TN No. 13-0009 Approval Date: 03/17/2014 Effective Date: 01/01/2014

West Virginia ABP5-18

Supersedes: New

Alternative Benefit Plan

Collapse All [7]

Base Benchmark Benefits Not Covered due to Substitution or Duplication Base Benchmark Benefit that was Substituted: Source: Base Benchmark

Primary Care Visits to Treat an Injury or Illness

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

Remove

Duplication: Combined into one benefit titled Physician Services under Essential Health Benefit 1.

Base Benchmark Benefit that was Substituted: Source: Base Benchmark

Specialist Visit

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

Duplication: Combined into one benefit titled Physician Services under Essential Health Benefit 1.

Base Benchmark Benefit that was Substituted: Source: | Base Benchmark

Primary Care Well Visits

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

Remove

Duplication: These services are provided for ages under 21 (19-20) per the Medicaid State Plan EPSDT Benefits . EPSDT coverage in Essential Health Benefit 10 is for all children under 21. These services are also duplicated in Physician Services under Essential Health Benefit 1 for all members 21-64.

Base Benchmark Benefit that was Substituted: Source: Base Benchmark

Other Practitioner Office Visit

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

Remove

Duplication: Podiatry: Other Licensed Practitioner under Essential Health Benefit 1.

Duplication: Chiropractic: Other Licensed Practitioner under Essential Health Benefit 1. Under the Base benchmark plan Limitations are for Physician and Outpatient Facility Services combined (per benefit period). Under the Base Benchmark Chiropractic (Spinal Manipulations, OT, PT, RT and SP) have a combined limit of 30 visits/benefit period.

Base Benchmark Benefit that was Substituted: Source: Base Benchmark

Diagnostic Test (X-Ray and Lab Testing)

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

Remove

Duplication: Diagnostic x-ray under Essential Health Benefit 1 and Laboratory Services and Testing under Essential Health Benefit 8.

Base Benchmark Benefit that was Substituted: Source: Base Benchmark

Outpatient Hospital / Facility Services

Page 19 of 27

TN No. 13-0009 Approval Date: 03/17/2014 Effective Date: 01/01/2014

West Virginia ABP5-19 Supersedes: New

Alternative Benefit Plan

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

Duplication: Outpatient Hospital Services under Essential Health Benefit 1.

Remove

Base Benchmark Benefit that was Substituted: Source: Base Benchmark

Hospice

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

Duplication: Hospice under Essential Health Benefit 1.

! I

Remove

Base Benchmark Benefit that was Substituted: Source: Base Benchmark

Emergency Room Services

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

Duplication: Outpatient Hospital Services/Emergency Room under Essential Health Benefit 2.

Remove

Base Benchmark Benefit that was Substituted: Source: Base Benchmark

Emergency Transportation/Ambulance

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

Duplication: Any other medical care/Transportation under Essential Health Benefit 2.

Remove

Base Benchmark Benefit that was Substituted: Source:

Base Benchmark Inpatient Hospital/Facility Services ase Bench

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

Duplication: Inpatient Hospital Services under Essential Health Benefit 3.

Remove

Base Benchmark Benefit that was Substituted: Source:

Base Benchmark Birthing Center Care/Maternity Services 2

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

Duplication: Hospital Inpatient Services/maternity under Essential Health Benefit 4.

Remove

Base Benchmark Benefit that was Substituted: Source: 7" Base Benchmark Maternity Care Page 20 of 27 TN No. 13-0009 Approval Date: 03/17/2014 Effective Date: 01/01/2014 West Virginia ABP5-20

Supersedes: New

sS Alternative Benefit Plan

ANESTH A AST ASR IEA

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

Remove Duplication: Outpatient Hospital Services/maternity under Essential Health Benefit 4. Base Benchmark Benefit that was Substituted: Source: , 7 Base Benchmark Outpatient Mental Health Services ase Benenmar! Remove

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

Duplication: Physician Outpatient Psychiatric Treatment under Essential Health Benefit 5.

Base Benchmark Benefit that was Substituted: Source: Base Benchmark

Outpatient Substance Abuse Services

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

Duplication: Physician Outpatient Psychiatric Treatment under Essential Health Benefit 5.

Base Benchmark Benefit that was Substituted: Source: Base Benchmark

Rehabilitative Psychiatric Treatment

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

Duplication: Rehab: Rehabilitative Psychiatric Treatment under Essential Health Benefit 5.

Remove

Base Benchmark Benefit that was Substituted: Source: Base Benchmark

Inpatient Mental Health Care Services

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

Duplication: Inpatient Hospital Psychiatric Care under Essential Health Benefit 5.

Remove

Base Benchmark Benefit that was Substituted: Source: Base Benchmark

Inpatient Substance Abuse Case Services

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

Duplication: Inpatient Hospital: Psychiatric Hospital Care under Essential Health Benefits 5

Base Benchmark Benefit that was Substituted: Source: Base Benchmark

Prescription Drugs/Retail Pharmacy

Page 21 of 27

TN No. 13-0009 Approval Date: 03/17/2014 Effective Date: 01/01/2014

West Virginia ABP5-21 Supersedes: New

sS Alternative Benefit Plan

REACT & AED ALE SEIEY

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

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

Duplication: Prescription Drugs under Essential Health Benefit 6 Base Benchmark Benefit that was Substituted: Source:

hm: Speech Therapy Base Benchmark Remove

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

Duplication: PT and related services: Speech Therapy under Essential Health Benefit 7.

Base Benchmark Benefit that was Substituted: Source:

Base Benchmark Respiratory, Hyperbaric and Pulmonary Therapy sere an

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

Duplication: This one service under the Base Benchmark is duplicated under both Rehab: Cardiac Rehabilitation and Rehab: Pulmonary Rehabilitation under Essential Health Benefit 7.

Base Benchmark Benefit that was Substituted: Source:

Base Benchmark Durable medical equipment and Oxygen at home enchman Remove

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

Duplication: Home Health; Durable medical equipment under Essential Health Benefit 7.

Base Benchmark Benefit that was Substituted: Source:

Base Benchmark Orthotic Devices and Prosthetic Appliances ene

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

Duplication: Orthotics and prosthetics under Essential Health Benefit 7.

Base Benchmark Benefit that was Substituted: Source:

. 7 Base Benchmark Diabetes Education

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

Duplication: Preventative Services: Diabetes Education under Essential Health Benefit 9.

Base Benchmark Benefit that was Substituted: Source: Base Benchmark

Eye Glasses for Children

Page 22 of 27 TN No. 13-0009 Approval Date: 03/17/2014. Effective Date: 01/01/2014

West Virginia ABP5-22 Supersedes: New

Alternative Benefit Plan

SOACSE TRAE ARA BARTLET

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

Remove Duplication: Medicaid State Plan EPSDT under Essential Health Benefit 10. Base Benchmark Benefit that was Substituted: Source: Base Benchmark Dental Check-up for Children ase Wenchmar Remove

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

Duplication: Medicaid State Plan EPSDT under Essential Health Benefit 10,

Page 23 of 27 TN No. 13-0009 Approval Date: 03/17/2014 Effective Date: 01/01/2014

West Virginia ABP5-23 Supersedes: New

sS Alternative Benefit Plan

TORE MANTA

Other Base Benchmark Benefits Not Covered Collapse All [7]

Base Benchmark Benefit not Included in the Alternative Source: Benefit Plan: Base Benchmark

Well Baby Care

Remove

»

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

‘The ABP population is for the new adult group, ages 19-64. As such "Well Baby Care" is for ages 0-6, therefore, would not apply to this population.

Base Benchmark Benefit not Included in the Alternative Source: Benefit Plan: Base Benchmark

Well Child Care

!

Remove

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

The ABP population is for the new adult group, ages 19-64. As such "Well Child Care" is for ages 6-17, therefore, would not apply to this population.

Add

Page 24 of 27 TN No. 13-0009 Approval Date: 03/17/2014 Effective Date: 01/01/2014 West Virginia ABP5-24 Supersedes: New

Alternative Benefit Plan

KX] Other 1937 Covered Benefits that are not Essential Health Benefits Collapse All [7] Other 1937 Benefit Provided: Source: r : 7 Section 1937 Coverage Option Benchmark Benefit Family Planning Services and Supplies Package

Authorization:

. Provider Qualifications:

Medicaid State Plan

Amount Limit:

Duration Limit:

(None None Scope Limit: (None Other: Other 1937 Benefit Provided: Source: 7 7 " Section 1937 Coverage Option Benchmark Benefit Preventative Services: Nutritional Education Remove Package Authorization: Provider Qualifications: Medicaid State Plan Amount Limit: Duration Limit: None Scope Limit: Other: Other 1937 Benefit Provided: Source: 7 - Section 1937 Coverage Option Benchmark Benefit [Tobacco Cessation Counseling for Pregnant Women Package

Authorization:

Provider Qualifications:

Medicaid State Plan

Amount Limit:

Duration Limit:

‘None

Scope Limit:

Other:

L

TN No. 13-0009 West Virginia Supersedes: New

Approval Date: 03/17/2014 ABPS-25

Page 25 of 27

Effective Date: 01/01/2014

Ccms Alternative Benefit Plan

CURSES TOR ARAE ADE MRT BENET

Remove

[eno | ;

Page 26 of 27 TN No. 13-0009 Approval Date: 03/17/2014 Effective Date: 01/01/2014

West Virginia ABP5-26 Supersedes: New

Ss

OER INES

Alternative Benefit Plan

oO Additional Covered Benefits (This category of benefits is not applicable to the adult group under Collapse All [1] section 1902(a)(10)(A)(i)(VILD) of the Act.)

Pp ‘isclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a

valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 5 hours per response, including the time to review instructions, search existing data Tesources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

V.20130814

TN No. 13-0009 West Virginia Supersedes: New

Page 27 of 27

Approval Date: 03/17/2014 Effective Date: 01/01/2014

ABPS5-27

Alternative Benefit Plan

OMB Control Number: 0938-1148 OMB Expiration date: 10/31/2014 ee ABP7

Attachment 3.1-L [ |

EPSDT Assurances +

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

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

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

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

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

@ Through an Alternative Benefit Plan.

C Through an Alternative Benefit Plan with additional benefits to ensure EPSDT services as defined in 1905(r). Other Information regarding how ESPDT benefits will be provided to participants under 21 years of age (optional):

Prescription Drug Coverage Assurances

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

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

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

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

Other Benefit Assurances

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

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

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

Page 1 of 2 TN No. 13-0009 Approval Date: 03/17/2014 Effective Date: 01/01/2014 West Virginia ABP7-1 Supersedes: New

CMS Alternative Benefit Plan

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

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

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

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

The state/territory assures, in accordance with 45 CFR 156.1 15(aX(4) and 45 CFR 147.130, that it will provide as Essential Health Benefits a broad range of preventive services including: “A” and “B” services recommended by the United States Preventive Services Task Force, Advisory Committee for Immunization Practices (ACIP) recommended vaccines; preventive care and screening for infants, children and adults recommended by HRSA's Bright Futures program/project; and additional preventive services for women recommended by the Institute of Medicine (IOM).

PRA Disclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 5 hours per response, including the time to review instructions, search existing data Tesources, gather the data needed, and complete and review the information collection. If you have comments conceming the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

V.20130807

Page 2 of 2 TN No. 13-0009 Approval Date: 03/17/2014 Effective Date: 01/01/2014 West Virginia ABP7-2 Supersedes: New

Alternative Benefit Plan

OMB Control Number: 0938-1148 OMB Expiration date: 10/31/2014 Provide detail on the type of delivery system(s) the state/territory will use for the Alternative Benefit Plan's benchmark benefit package or benchmark-equivalent benefit package, including any variation by the participants’ geographic area.

Attachment 3.1-L [_ |

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

(J Managed care. Fee-for-service. (7 Other service delivery system.

Fee-For-Service Options

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

@ Traditional state-managed fee-for-service

C Services managed under an administrative services organization (ASO) arrangement

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

The Medicaid Program provides healthcare benefits to approximately three hundred fifty thousand (350,000) people, on a monthly

basis, in fifty-five (55) counties using a network of twenty-four thousand (24,000) active providers. The MMIS processes nineteen million and a half (19,500,000) claims annually, including pharmacy claims. Ninety two and a half percent (92.5%) of claims are received electronically, of which, forty-seven percent (47%) were pharmacy. One hundred eighty-eight thousand ( 188,000) [Medicaid members (families with dependent children, low-income children and pregnant women) are enrolled in three (3) HMOs or in the Bureau’s Primary Care Case Management program, the Physician Assured Access System (PAAS). The Medicaid program pays for certain carved-out services for HMO recipients, specifically pharmacy and behavioral health services. The Medicaid MMIS

also processes claims for three (3) waiver programs and several State-funded eligibility programs, including Children with Special Health Care needs (CSHCN).

On January 1, 2014 West Virginia expanded its Medicaid program in accordance with the rules established by the Affordable Care

Act at 42 §CFR 435.119 to include non-pregnant, childless adults with income at or below 133% of the fed

leral poverty level. The new adult group receives all ABP benefits through a fee for service delivery system with WV Medicaid paying qualified providers for services.

Additional Information: Fee-For-Service (Optional)

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

Page 1 of 2 TN No. 13-0009 Approval Date: 03/17/2014 Effective Date: 01/01/2014

West Virginia ABP8-1 Supersedes: New

Alternative Benefit Plan

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 5 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of

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

V.20130718

TN No. 13-0009 West Virginia Supersedes: New

Page 2 of 2 Approval Date: 03/17/2014 Effective Date: 01/01/2014

ABP8-2

Alternative Benefit Plan

OMB Control Number: 0938-1148 Attachment 3.1-L [| OMB Expiration date: 10/31/2014

The state/territory provides the Alternative Benefit Plan through the payment of employer sponsored insurance for participants

with such coverage, with additional benefits and services provided through a Benchmark or Benchmark-Equivalent Benefit INo Package.

The state/territory otherwise provides for payment of premiums.

Yes

Provide a description including the population covered, the amount of premium assistance by population, required contributions, cost-effectiveness test requirements, and benefits information.

The state assures that ESI coverage is established in sections 3.2 and 4.22(h) of the state’s approved Medicaid state plan. The beneficiary will receive a benefit package that includes a wrap of benefits around the employer sponsored insurance plan that equals the benefit package to which the beneficiary is entitled. The beneficiary will not be responsible for payment of premiums or other cost sharing that exceeds nominal levels as established at 42 CFR part 447 subpart A.

Other Information Regarding Employer Sponsored Insurance or Payment of Premiums:

PRA Disclosur ny According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 5 hours per response, including the time to review instructions, search existing data Tesources, 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 Bo

ulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. Page 1 of 1 TN No. 13-0009 Approval Date: 03/17/2014 Effective Date: 01/01/2014 West Virginia

ABP9-1 Supersedes: New

CMS Alternative Benefit Plan

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

Attachment 3.1-L [|

Economy and Efficiency of Plans The state/territory assures that Altemative Benefit Plan coverage is provided in accordance with Federal upper payment limit

requirements and other economy and efficiency principles that would otherwise be applicable to the services or delivery system through which the coverage and benefits are obtained.

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

‘Compliance with the Law

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

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

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

P isclosur mi According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 5 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. Ifyou have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

V.20130807

Page 1 of 1 TN NO. 13-0009 Approval Date: 03/17/2014 Effective Date: 01/01/2014 West Virginia ABP10-1 Supersedes: New

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Table of Contents State Name: West Virginia State Plan Amendment (SPA) #: 13-0014-M M 1 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Superseding Pages Notice 4) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 150 S. Independence Mall West Suite 216, The Public Ledger Building Philadelphia, Pennsylvania 19106-3499 CMS CENTERS FOR MEDICARE & ,'viEDICAID SERVICES Region Ill/Division of Medicaid and Children's Health Operations SWIFT #121120134026 OEC 1 3 2013. Nancy V. Atkins, MSN, RNC, NP Commissioner Bureau for Medical Services 350 Capitol Street, Room 251 Charleston, West Virginia 25301-3706 Dear Commissioner Atkins: Enclosed is an approved copy of West Virginia's State Plan Amendment (SPA) 13-0014-MMI, which was submitted to the Centers for Medicare & Medicaid Services (CMS) on November 22, 2013. West Virginia (WV) SPA 13-0014-MM1 incorporates the MAGI-Based Eligibility Group SPA into West Virginia's State Plan in accordance with the Affordable Care Act. The effective date of this SPA is January I, 2014. Enclosed is a copy of the CMS 179 and the new State Plan pages to be incorporated within a separate section at the back of West Virginia's approved State Plan: • S 14, Pages S 14-1 through S 14-5 • S25, Pages S25-1 through S25-3 • S28, Pages S28-1 through S28-2 • S30, Pages S30-1 through S30-5 • S32, Pages S32-l through S32-2 • S33, Page S33-l • S50, Page S50-1 • S51, Page S51-1 • S52, Page S52-l • S53, Pages S53-l through S53-2 • S54, Page S54-1 • S55, Page S55-l • S57, Page S57-l • S59, Page S59-l In addition, enclosed is a summary of State Plan pages which are superseded by SPA 13-0014-MM1, which should also be incorporated into a separate section in the front of the State Plan: • Superseding Pages ofState Plan Material, 13-0014-MMI

Page 2- Nancy V. Atkins, MSN, RNC, NP Notwithstanding any other provisions of the West Virginia Medicaid State Plan, the financial eligibility methodologies described in WV SPA 13-00 14-MM will apply to all MAGI-based eligibility groups covered under West Virginia's Medicaid State Plan. The MAGI financial methodologies set forth in 42 CFR §435.603 apply to everyone except those individuals described at 42 CFR §435.603(j) for whom MAGI-based methods do not apply. This SPA supersedes the current financial eligibility provisions of the Medicaid State Plan only with respect to the MAGI- based eligibility groups. Congratulations to you and your staff for your hard work and strong collaboration. If you have any questions, please contact Margaret Kosherzenko at 215-861-4288 or by email at Margaret.K.osherzenkol@.cms. hhs.gov. Sincerely, Enclosures cc: Alva Page, BMS (b) (1) (A), (b) (b) (1) (b) (1) (A), (b) (b) (1) (A), (b) (b) (1) (A), (b) (b) (1) (A), (b) (b) (1) /S/

WV.0538.ROO.OO- Jan 01, 2014 Page 1 of2 Medicaid State Plan Eligibility: Sununary Pagl' (CMS 179) Staterrerritory name: West Virginia Transmittal Number: Please ellter 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-13-0014 Proposed Effective Date 01/01/2014 (mmldd/yyyy) Federal Statute/Regulation Citation ACA Federal Budget Impact Federal Fiscal Year First Year 2014 Second Year 2015 Subject of Amendment MAGI-Based Eligibility Groups Governor's Office Review $ 443375000.00 $447625000.00 Governor's office reported no comment Comments of Governor's office received Describe: No reply received within 45 days of submittal Other, as specified Describe: Not Required. Signature of State Agency Official Submitted By: Last Revision Date: Submit Date: Sarah Young Dec 10,2013 Nov 22,2013 Amount http:/1157.199.113.99/MMDL/faces/protected/mac/cO 1/print/Pri... 12/11/2013

WV.0538.ROO.OO- Jan 01, 2014 Page 2 of2 http:/1157.199.113.99/MMDL/faces/protected/mac/cO 1/print/Pri... 12/1112013

SUPERSEDING PAGES OF STATE PLAN MATERIAL TRANSMITTAL NUMBER: STATE: 13- 0014 - MM West Virginia Pages or sections of pages being superseded by S14 I S25 , S28 , S30 , S51 , S52 , S53 , and S54 , and related pages or sections of pages being deleted as obsolete State Plan Section Complete Pages Removed Partial Pages Removed Page 1 Page 2 , A. 2 . b Page 3 Page 2 , A. 2 . c Page 3a Page 2a , A. 3 Page 4 Page 5 , A. 10 Page 4a Page 9c , 8.1 for Attachment 2 . 2-A Page 12 caretaker relatives & Page 13 pregnant women Page 13a Page 20 , 8 . 14 Page 14 Page 23c , 8 . 19 Page 14a Page 25 , c. 4 Page 21 Page 23 Supplement 1 to Attachment 2 . 2-A Page 1 Page 3b Page 1 , A. 2 . a (i) and Page lla (iii) Page 19 Page 6 related to AFDC Page 19a recipients , pregnant Attachment 2 . 6-A Page 19b women , infants , and Page 21 children Page 7 1 1. a ( 1) and (2) Page 12 , C.l. e(2) Page 18 , C.5 . e Page 25 , 1l.a(3) Supplement 1 to Attachment 2.6-A Pages 1- 4 Supplement 1A to Attachment 2.6-A Page 1 Supplement 2 to Attachment 2.6- A Pages 1- 5 1

Page 1, #1 Page 1 , #2 r elated Supplement Ba to Attachment 2.6-A to categorica l ly needy AFDC-related f amilies , p r e gnant women & children Supplement Bb to Attachment 2 . 6-A Page 1 Supplement 12 to Attachment 2 . 6-A Page 1 2

Medicaid Eligibility AFDC Income Standards Enter the AFDC Standards below. All states must enter: MAGI-equivalent AFDC Payment Standard in Effect As of May I, 1988 and AFDC Payment Standard in Effect As of July 16. 1996 Entry of other.standards is optional. I MAGI-equivalent AFDC Payment Standard in Effect As of May 1, 1988 lQcom.e. Standard Entry- Dollar·Amm,tnt -Automatic Increase Option The standard is as follows: (e' Statewide standard (' Standard varies by region (' Standard varies by I ivi ng. arrangement (' Standard varies in some other way Enter the statewide standard Household size Standard($) + 171 + 2 236 + 3 293 + 4 365 + 5 422 + 6 484 + 7 541 + 8 567 Additional incremental amount (' Yes (e No X Increment amou nt $ ._I _ _ _ _, X X X X X X X The dollar amounts increase automatically each year (' Yes (e' No AFDC Payment Standard in Effect As of July 16, 1996 0\-18 Control Number O<J38-I 148 0\:IB Expiration date: I 0!3 1 /2014 Sl4 Sl3a I I Transmittal Number: 13-0014-MM 1 Approval Date: December 13, 2013 Effective Date: January 1, 2014

Medicaid Eligibility Income Standard Entry - Dollar Amount - Automatic Increase Option The standard is as fo llows: (.' Statewide standard (' Standard varies by region (' Standard varies by living arrangement (' Standard varies in some other way Enter the statewide standard Additional incremental amount Household size Standard($) (' Yes (.' No + I 149 X Increment amount $ !_ _____ __] + 2 201 X + 3 253 X + 4 312 X + 5 360 X + 6 413 X + 7 462 X + 8 477 X The dollar amounts increase automatically each year (' Yes (.' No ~GJ .. eq.-ivalent AFDC ~ayment Standard in Effe. ~t As of July 16, 1996 >. ••• • ' . ;... In~ome Standard Entry -':Dollar Amount -Automatic Increase Option The standard is as follows: (.' Statewide standard (' Standard varies by region (' Standard varies by living arrangement (' Standard varies in some other way JEnter the statewide standard Sl3a ~ S13a PallC 2 or :;

Medicaid Eligibility Additional incremental amount Household size Standard($) (Yes (e No + I 186 X Increment amount s! + ::: 251 X + 3 316 X + 4 388 X + 5 449 X + 6 515 X + 7 577 X + 8 605 X The dollar amounts increase automatically each year ( Yes (e No AFDC Need Standard in Effect As ofJuly 16, 1996 :ln¢ome Sta.ndard Entry - Dollar Amount - Automatic Increase Option The standard is as fo llmvs: l- Statewide standard ( Standard varies by region ( Standard varies by living arrangement ( Standard varies in some other way Enter the statewide standard Household size Standard ($) +I X Additional incremental amount ( Yes (e No Increment amount $1 The dollar amounts increase automatically each year ( Yes (e No I S13a Transmittal Number: 13-0014-MM1 Approval Date: December 13, 2013 Effective Date: January 1, 2014

Medicaid Eligibility Otv1B Controll\umber0938-1148 Ol\'18 Expiration elate: I 0!31 I 2014 Elig_i~illty Groups - Mandatory Coverage Parents and Other Caretaker Relatives 42 CFR 435.110 1902(a)( IO)(A}(i)(l) 1931(b) and (d) S25 ~ Parents and Other Caretaker Relatives- Parents and other caretaker relatives of dependent children with household income at or below a standard established by the state. 0 The state attests that it operates this eligibility group in accordance with the following provisions: ~ Individuals qualifying under this eligibility group must meet the following criteria: ~ Are parents or other caretaker relatives (defined at 42 CFR 435.4). including pregnant women. of dependent children (defined at 42 CFR 435.4) under age 18. Spouses of parents and other caretaker relatives are also included. The state elects the following options: This eligibi lity group includes individuals who are parents or other caretakers of children who are 18 years old. 0 provided the children are full-time students in a secondary school or the equivalent level of vocational or technical training. IZ] Options relating to the de-tinition of caretaker relative (select any that apply): O The delinition of caretaker relative includes the domestic partner of the parent or other caretaker relative. even after the partnership is terminated. Definition of domestic partner: IZJ The definition of caretaker relative includes other relatives of the child based on blood (including those of half-blood). adoption or marriage. Description of other relatives: Transmittal Number: 13-0014-MM1 Assumes primary responsibility tor the child's care, in a place established as the relative's home. A specified caretaker relative is defined below. -Natural or adoptive parents. - Blood relative: Those of half-blood. brothers or sisters. grandparents. great- grandparents, great-great grandparents. great-great-great grandparents, uncles or aunts, great-uncles or aunts. great-great uncles or aunts. nephews or nieces. first cousins. first cousins once removed: - Legal step-parent. step-brother or step-sister, step-grandparents, step-great- grandparents, step-great-great grandparents, step-great-great-great grandparents, step-uncles or aunts. step-great-uncles or aunts, step-great-great uncles or aunts, step-nephews or nieces, step-first cousins. step-f-irst cousins once removed: -The specified relationship exists even though the marriage terminated in death or divorce. t\·1ust not be the new spouses of step-relatives. Approvar uate: uecemuer I.J, ..::u I.J cuectrve uate: .~anuary 1, ..::u 1 q Pa!!.e I ofJ

Medicaid Eligibility D The definition of caretaker relative includes any adult with whom the child is living and who assumes primal)' responsibility for the dependent child's care. lXI Options relating to the definition of dependent child (select the one that applies): The state elects to eliminate the requirement that a dependent child must be deprived of parental support or (.' care by reason of the death, physical or mental incapacity. or absence fi·om the home or unemployment ufat least one parent. (' The child must be deprived of parental support or care. but a less restrictive standard is used to measure unemployment of the parent (select the one that applies): ~ Have household income at or below the standard established by the state. ~ MAGI-based income methodologies are used in calculating household income. Please refer as necessary to S I 0 MAGI- Based Income Methodologies, completed by the state. ~ Income standard used for this group ~ Minimum income standard The minimum income standard used for this group is the state's AFDC: payment standard in dtect as of May I, 1988, converted to MAGI-equivalent amounts by household size. The standard is described inS 14 AFDC Income Standards. 0 The state certifies that it has submitted and received approval t(x its converted May I, 1988 AFDC payment standard. An attachment is submitted. ~ Maximum income standard The state certifies that it has submitted and received approval for its converted income standard(s) f(x parents and 0 other caretaker relatives to MAGI-equivalent standards and the determination of the maximum income standard to be used for parents and other caretaker relatives under this eligibility group. An attachment is submitted. The state's maximum income standard lor this eligibility group is: (' The state's effective income level for section 1931 families under the Medicaid state plan as of J\.·larch 2:1, 20 I 0. converted to a MAGI-equivalent percent of FPL or amounts by household size. {e The state's effective income level for section 1931 families under the Medicaid state plan as of December 31 , 2013. converted to a MAGI-equivalent percent of FPL or amounts by household size. The state's effective income level for any population of parents/caretaker relatives under a l'vledicaid 1115 (' demonstration as of March '23. '20 I 0. converted to a MAGI-equivalent percent of FPL or amounts by household size. The state's effective income level for any population of parents/caretaker relatives under a Medicaid II 15 (' demonstration as of December 31 , 2013, converted to a MAGI-equivalent percent of FPL or amounb by household size. Enter the amount of the maximum income standard:

Medicaid Eligibility (' A percentage of the federal poverty level: D% (. The state's AFDC payment standard in effect as of July 16, 19%, converted to a MAGI-equivalent standard. The standard is described inS 14 AFDC Income Standards. The state's AFDC payment standard in effect as of July 16. 1996. increased by no more than the percentage (' increase in the Consumer Price Index for urban consumers (CPI-LI) since such date, converted to a I\1AGI- equivalent standard. The standard is described in S 14 A FDC Income Standards. (' The state's T ANF payment standard, converted to a MAGI-equivalent standard. The standard is described in S 14 AFDC Income Standards. (' Other dollar amount ~ Income standard chosen: Indicate the state's income standard used for this eligibility group: (' The minimum income standard (. The maximum income standard The state's AFDC payment standard in effect as of July 16. 1996. increased by no more than the percentage (' increase in the Consumer Price Index for urban consumers (CPI-U) since such date. The standard is described in S I 4 A FDC I nco me Standards. (' Another income standard in-between the minimum and maximum standards allowed ~ There is no resource test for this eligibility group. ~ Presumptive Eligibility The state covers individuals under this group when determined presumptively eligible by a qualified entity. The state assures it also covers individuals under the Pregnant Women (42 CFR 435.116) and/or Infants and Children under Age 19 ( 42 CFR 435.118) eligibility groups when determined presumptively eligible. (' Yes (. No PRA Disclosure Statement According to the Paperwork Reduction Act of 1995. no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this infomHttion collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response. including the time to review instructions. search existing data resources, gather the data needed. and complete and review the information collection. I fyou have comments concerning the uccuracy 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 2 I 244- I 850. Transmittal Number: 13-0014-MM1 Approval Date: December 13, 2013 Effective Date: January 1, 2014 Page J of3

Medicaid Eligibility Oiv1B Control Number 0938-1148 OMB Expiration date: I 0!3 1120 14 Eligibility Groups - Mandatory Coverage Pregnant Women 828 42 CFR 435.116 1902(a)(IO)lA)li)(lll) and (IV) 1902(a)( IO)(A)(ii)(l), (IV) and (IX) 1931(b) and (d) 1920 ~ Pregnant Women- Women who are pregnant or post-partum, with household income at or below a standard established by the state. 0 The state attests that it operates this eligibility group in accordance with the following provisions: ~ Individuals qualifying under this eligibility group must be pregnant or post-partum, as defined in 42 CFR 435.4. Pregnant women in the last trimester of their pregnancy without dependent children are eligible for full benef-its under this group in accordance with section 1931 of the Act, if they meet the income standard for state plan Parents <1nd Other Caretaker Relatives at 42 CFR 435.110. (' Yes (e No ~MAGI-based income methodologies are used in calculating household income. Please reler as necessary to S 10 :VlAGI-Based Income Methodologies. completed by the state. ~ Income standard used for this group ~Minimum income standard (Once entered and approved by CMS. the minimum income standard cannot be changed.) The state had an income standard higher than 133% FPL established as of December 19, 1989 for determining eligibility for pregnant women, or as of July I. 1989. had authorizing legislation to do so. (e Yes (' No Enter the amount of the minimum income standard (no higher than 185% FPL):~ % FPL ~ l'vlaximum income standard The state certifies that it has submitted and received approval for its converted income standard(s) for pregnant 0 women to MAGI-equivalent standards and the determination of the maximum income standard to be used for pregnant women under this eligibility group. An attachment is submitted. The state's maximum income standard for this eligibility group is: The state's highest effective income level for coverage of pregnant women under sections 1931 (low-income tam il ies), 1902(a)( I O)l A)( i ){Ill) (qualified pregnant women), 1902( a)( I O)(A )( i ){IV) (mandatory poverty level- (' related pregnant women). 1902(a )(I 0 J( A)( ii )(I X) (optional poverty level-related pregnant women). 1902(<1 )(I 0) (A )(ii)( I) (pregnant women "vho meet AFDC financial eligibility criteria) and 1902(a)( I O)(A )(ii)(IV) (institutionalized pregnant women) in effect under the l'vledicaid state plan as ofrvtarch 23.2010. converted to a MAG !-equivalent percent of FPL. Transmittal Number: 13-0014-MM1 Approval Date: December 13, 2013 Effective Date: January 1, 2014 Pat.:e I or~

Medicaid Eligibility The state's highest effective income level for coverage of pregnant women under sections I <>31 (low-income families), 1902(a)( IO)tA)(i)(lll) (qualified pregnant women), 1902(a)( IO)tA)(i)(IV) (mandatory poverty level- ( related pregnant women). 1902(a)( I O)(A)(ii)( IX) (optional poverty level-related pregnant \Nomen). 1902(a)( I 0) (A)(ii)(l) (pregnant women who meet AFDC financial eligibility criteria) and 1902ta)( IO)(A)(ii)(IV) (institutionalized pregnant women) in effect under the Medicaid state plan as of December 3 1. 2013. converted to a MAGI-equivalent percent of FPL. (' The state's effective income level for any population of pregnant women under a i'vlcdicaid I 115 demonstration as of March 23. 20 I 0. converted to a rvtAGI-equivalent percent of FPL. The state's effective income level for any population of pregnant women under a rv1edicaid 1115 demonstration as r of December 31. 2013. converted to a l'vtAGI-equivalent percent of FPL. \e 185% FPL ~ Income standard chosen Indicate the state's income standard used for this eligibility group: (' The minimum income standard (' The maximum income standard {e Another income standard in-between the minimum and maximum standards allovvcd. The amount of the income standard for this eligibility group is:~ % FPL ~There is no resource test for this eligibility group. ~ Benefits for individuals in this eligibility group consist of the following: {e All pregnant women eligible under this group receive full Medicaid coverage under this state plan. I (' Pregnant women whose income exceeds the income limit specitied below t(Jr full coverage of pregnant women receive only pregnancy-related services. ~ - Presumptive Eligibility The state covers ambulatory prenatal care for individuals under this group when determined presumptively eligible by a qualified entity. (' Yes \e 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 OMH control number. The valid OMB control number for this infom1ation collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response. including the time to review instructions. search existing data resources, gather the data needed. and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions f(x improving this limn. please write to: CMS. 7500 Security Boulevard. Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, l'v1aryland ~ 1244-1850. Transmittal Number: 13-0014-MM 1 Approval Date: December 13, 2013 Effective Date: January 1, 2014 Page 2 of 2

Medicaid Eligibility OMB Controll\umber 0938-1148 0\:IB Expiration date: I 0!31120 14 Eligibility Groups - Mandatory Coverage lnf3nts and Children under Age 19 42CFR435.118 1902(a)( IO)(A}(i)(lll), (IV), (VI) and (VII) 1902(a)( IO)(A)(ii)(IV) and (IX) 1931(b}and(d) S30 ~ Infants and Children under Age 19- Infants and children under age 19 with household income at or below standards established by the state based on age group. 0 The state attests that it operates this eligibility group in accordance with the f()llowing provisions: ~ Children quali(ying under this eligibility group must meet the following criteria: ~ Are under age 19 ~ Have household income at or below the standard established by the state. ~ MAGI-based income methodologies are used in calculating household income. Please refer as necessary to S 10 MAGI- Based Income Methodologies, completed by the state. ~ Income standard used for infants under age one ~ Minimum income standard The state had an income standard higher than 133% FPL established as of December 19, 1989 for determining eligibility for infants under age one. or as of July I. 1989. had authorizing legislation to do so. l- Yes (' No Enter the amount of the minimum income standard (no higher than 185% FPL):J150 -~] 0'o FPI. ~ Maximum income standard The state certifies that it has submitted and received approval lor its converted income standard(sl lor infants 0 under age one to MAGI-equivalent standards and the determination of the maximum income standard to be used for infants under age one. An attachment is submitted. The state's maximum income standard for this age group is: The state's highest effective income level for coverage of infants under age one under sections 1931 (low-income fam i I ies ). 1902(a )( I 0 )(A)( i )( 111) (qualified children). 1902(a )(I O)(A )( i )(IV) (mandatory poverty level-related (' infants). 1902(a)( IO)(A)(ii)(IX) (optional poverty level-related infants) and 1902(a)( IO)(A)(ii)(IV) (institutionalized children). in effect under the Medicaid state plan as of March 23. 20 I 0. converted to a 1\:fAGI- equivalent percent of FPL. Transmittal Number: 13-0014-MM 1 Approval Date: December 13, 2013 Effective Date: January 1, 2014

Medicaid Eligibility The state's highest effective income level tor coverage of infants under age one under sections 1931 (low-income families), 1902{a)(IO)(A)(i)(lll) (qualified children). 1902(a)( IO)(A)(i)(IV) (mandatory poverty level-related (' infants), 1902(a)( I 0)( A)( ii)( IX) (optional poverty level-related infants) and 1902(a)( I 0 )(A)( ii )(IV) (institutionalized children), in effect under the rvtedicaid state plan as of December 31 . 2013. converted to a MAGI-equivalent percent of FPL. (' The state's effective income level for any population of infants under age one under a Medicaid 1115 demonstration as of March 23. 20 I 0. converted to a l'v1AG !-equivalent percent of FPL. (' The state's effective income level for any population of infants under age one under a l'vledicaid 1115 demonstration as of December 31. 20 I 3. converted to a MAGI-equivalent percent of FPL \e 185% FPL ~ Income standard chosen The state's income standard used for infants under age one is: (' The maximum income standard If not chosen as the maximum income standard. the state's highest effective income level for coverage of infants under age one under sections 193 I (low-income families). 1902(a)( I O)(A )(i )(Ill) (qualified children), 1902(a)( I 0) \e <A)<i)(IV) {mandatory poverty level-related infants), 1902(a)( IO)(A)(ii)(IX) (optional poverty level-related infants) and 1902(a){ I 0 )(.'\ ){ii)( IV) (institutionalized children), in effect under the ~'ledicaid state plan as of March 23. 20 I 0. converted to a MAGI-equivalent percent of FPL. If higher than the highest effective income level for this age group under the state plan as of !\·larch 23. 20 I 0. and if not chosen as the maximum income standard. the state's highest effective income level hx coverage of infants (' under age one under sections I 93 I (low-income families}, 1902( a)( I O)(A )( i )(Ill) (qual itied children), 1902(a)( I 0) (A)(i)(IV) (mandatory poverty level-related infants). 1902(a)( IO)(A)(ii)(IX) (optional poverty level-related infants) and 1902(a)( IO)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of December 3 L 2013. converted to a MAGI-equivalent percent of FPL... (' If higher than the highest etfective income level tor this age group under the state plan as of March 23. 20 I 0. and if not chosen as the maximum income standard, the state's effective income level t(lr any population of infants under age one under a Medicaid 1115 demonstration as of March 23, 20 I 0, converted to a l'vlAGI-equivalent percent of FPL. If higher than the highest effective income level for this age group under the state plan as of f\..·Iarch 23, 20 I 0, and (' if not chosen as the maximum income standard, the state's effective income level for any population of infants under age one under a Medicaid 1115 demonstration as of December 31, 2013, converted to a 1\:IAGI-equivalent percent of FPL. (' Another income standard in-between the minimum and maximum standards allowed, provided it is higher than the effective income standard tor this age group in the state plan as of March 23, 20 I 0. The amount of the income standard for infants under one is: ~ % FPL ~ Income standard for children age one through age tive. inclusive ~ Minimum income standard Transmittal Number: 13-0014-MM1 Approval Date: December 13, 2013 Effective Date: January 1, 2014 Page 2 o f~

Medicaid Eligibility The minimum income standard used for this age group is 133% FPL. ~ Maximum income standard The state certifies that it has submitted and received approval for its conve11ed income standard(s) tor children [{) age one through tive to MAGI-equivalent standards and the determination of the maximum income standard to be used for children age one through five. An attachment is submitted. The state's maximum income standard tor children age one through five is: The state's highest effective income level for coverage of children age one through five under sections 1931 (low- (. income t~unilies). 1902(a)(I0)(A)(i)(III) (qualified children), 1902(a)(IO)(A)(i)(VI) (mandatory poverty level- related children age one through five). and 1902(a)( I O)(A )(ii )(IV) (institutionalized children). in eflect under the Medicaid state plan as of March 23, 20 I 0, converted to a MAGI-equivalent percent of FPL. The state's highest effective income level for coverage of children age one through five under sections 1931 (low- (' income families). 1902(a)( I O)(A)(i )(Ill) (qualified children). 1902(a)( I O)(A )(i )(VI) (mandatory poverty level- related children age one through five), and 1902( a)( I O)(A )(ii )(IV) (institutionalized children), in effect under the Medicaid state plan as of December 3 1. 2013. converted to a MAGI-equivalent percent of FPL. (' The state's effective income level for any population of children age one through tive under a Medicaid 111 5 demonstration as of March 23, 2010. converted to a MAGI-equivalent percent of FPL. (' The state's effective income level for any population of children age one through tive under a l'vledicaid 111 5 demonstration as of December 31. 2013. converted to a MAGI-equivalent percent of FPL. Enter the amount of the maximum income standard: EJ ~'o FPL ~ Income standard chosen The state's income standard used tor children age one through five is: \e The maximum income standard If not chosen as the maximum income standard. the state's highest effective income level for coverage of children age one through five under sections 1931 (low-income families). 1902(a)( I O)(A)( i)(lll) (qualified children), (' 1902(a)(10)(A)(i)(VI) (mandatory poverty level-related children age one through live). and 1902(a)( IO)(A)(ii) (IV) (institutionalized children). in effect under the Medicaid state plan as of March 23. 20 I 0. converted to a 1\:IAGI-equivalent percent of FPL. If higher than the highest effective income level tor this age group under the state plan as of March 23, 20 I 0, and if not chosen as the maximum income standard, the state's highest effective income level for coverage of children (' age one through tive under sections 1931 (low-income families), 1902(a)( I O)(A )(i)(lll) (qualified children). 1902(a)( I 0 )(A )(i)(VI) (mandatory poverty level-related children age one through five). and 1902(a)( I 0)( A)( ii) (IV) (institutionalized children). in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent ofFPL. Transmittal Number: 13-0014-MM1 Approval Date: December 13,2013 Effective Date: January 1, 2014

Medicaid Eligibility If higher than the highest effective income level for this age group under the state plan as of lVI arch 23, 20 I 0, and if not chosen as the maximum income standard, the state's effective income level for any population of children r age one through five under a Medicaid 1115 demonstration as of l\·1arch 23. 20 I 0. converted to a MAGI- equivalent percent of FPL. If higher than the highest etTective income level tor this age group under the state plan as of March 23, 20 I 0, and r if not chosen as the maximum income standard, the state's effective income level for any population of children age one through live under a Medicaid 1115 demonstration as of December 31. 2013. converted to a MAGI- equivalent percent of FPL. (' Another income standard in-between the minimum and maximum standards allowed, provided it is higher than the effective income standard for this age group in the state plan as of March 23, 20 I 0. ~ Income standard for children age six through age eighteen, inclusive ~ Minimum income standard The minimum income standard used for this age group is l.B% FPL. ~ Maximum income standard The state certifies that it has submitted and received approval tor its converted income standard(s) for children age IZJ six through eighteen to MAGI-equivalent standards and the determination of the maximum income standard to be used for children age six through age eighteen. An attachment is submitted. The state's maximum income standard for children age six through eighteen is: The state's highest effective income level for coverage of children age six through eighteen under sections 1931 (' (low-income families). 1902(a)(10)(A)(i)(lll) (qualified children). 1902(a)(l0)(A)(i)(VII) (mandatory poverty level-related children age six through eighteen) and 1902(a)( I O)(A )( ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of March 23. 20 I 0. converted to a MAGI-equivalent percent of FPL. The state's highest effective income level for coverage of children age six through eighteen under sections 1931 (' (low-income families), 1902(a)( IO){A)(i)(lll) (qualified children). 1902(a)( IO)(A){i)(VII) (mandatory poverty level-related children age six through eighteen) and 1902(a)( I 0)( A)( ii)( IV) (institutionalized children). in effect under the Medicaid state plan as of December 31. 2013. convet1ed to a MAGI-equivalent percent of FPL. (' The state's effective income level for any population of children age six through eighteen under a l'vledicaid I 115 demonstration as of March 23, 20 I 0. converted to a MAG !-equivalent percent of FPL. (' The state's etTective income level for any population of children age six through eighteen under a l'vledicaid 1115 demonstration as of December 31. 2013. converted to a MAGI-equivalent percent of FPL. (e' 133% FPL ~ Income standard chosen The state's income standard used for children age six through eighteen is: Transmtttal Number: 13-0014- ect1ve Date: January 1, 2014 Page 4 of~

Medicaid Eligibility (e' The maximum income standard If not chosen as the maximum income standard. the state's highest effective income level for coverage of children age six through eighteen under sections 193 I (low-income fiun ilies ). 1902(a )(I O)(A )( i l( Ill) (qual itied children). (' 1902(a)( IO)(A)(i)(VII) (mandatory poverty level-related children age six through eighteen) and 1902(a)( IO)(A) (ii)(IV) (institutionalized children). in effect under the Medicaid state plan as of March 23. 20 I 0. converted to a MAGI-equivalent percent ofFPL. If higher than the highest effective income level for this age group under the state plan as of March 23. 20 I 0. and if not chosen as the maximum income standard. the state's highest effective income level for coverage of children (' age six through eighteen under sections 1931 (low-income families), 1902(a)( I 0)( A)( i ){Ill) (qualified children), 1902(a)( I O)(A )(i)( VII) (mandatory poverty level-related children age six through eighteen) and 1902(a)( I 0)( A) ( ii)(IV) (institutionalized children). in etfect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. If higher than the highest effective income level t\Jr this age group under the state plan as of March 23. 20 I 0. and (' if not chosen as the maximum income standard. the state's effective income level for any population of children age six through eighteen under a Medicaid 111 5 demonstration as of March 23. 20 I 0. converted to a MAGI- equivalent percent of FPL. If higher than the highest effective income level for this age group under the state plan as of !\'larch 23, 20 I 0, and (' if not chosen as the maximum income standard, the state's effective income level fi.Jr any population of children age six through e·ighteen under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI- equivalent percent of FPL. (' Another income standard in-between the minimum and maximum standards allowed, provided it is higher than the effective income standard for this age group in the state plan as of March 23, 20 I 0. ~ There is no resource test for this eligibility group. ~ Presumptive Eligibility The state covers children when determined presumptively eligible by a qualilied entity. (' Yes (e' 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 tor this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions. search existing data resources. gather the data needed, and complete and review the information collection. I fyou have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS. 7500 Security Boulevard. Attn: PRA Reports Clearance Officer. Mail Stop C4-26-05. Baltimore. Maryland 21244 -1850. Transmittal Number: 13-0014-MM 1 Approval Date: December 13, 2013 Effective Date: January 1. 2014 l'a!.!.C 5 of:'

Medicaid Eligibility 0\-lB Contmll\umhcr 01J:;8-II '-18 Of\-IB Expiration date: I 0!.11 '20 I-I Eligibility Groups - Mandatory Coverage Adult Group 1902(a)( I 0)(:-\ )(i)(V III) 42 CFR 435.119 The state covers the Adult Group as described at 42 CFR 435.119. \e Yes { No S32 ~ Adult Group- Non-pregnant individuals age 19 through 64, not otherwise mandatori ly eligible. with income at or below I :no,;, FPL. [{] The state attests that it operate~ this eligibility group in accordance with the ti:JIIowing provisions: ~ Individuals qualifying under this eligibility group must meet the li.1llowing criteria: ~ Have attained age 19 but not age 65. ~ Are not pregnant. ~ Are not entitled to or enrol led lor Part A orB Medicare benefits. ~ Are not otherwise eligible for and enrolled ti.1r mandatory coverage under the state plan in accordanco.: • with 42 CFR 435, subpart B. Note: In 209(b) states. individuals receiving SSI or deemed to be receiving SSI who do not qualify ti.1r mandator~· l'v1edicaid eligibility due to nwre restrictive requirements may qualify fi.1r this eligibility gmup if otherwise o.:ligiblc. ~ Have household income at or below 133% FPL. ~ l'viAGI-based income methodologies are used in calculming houselwld income. Please refer as necessary to S I 0 MAGI-Based Income 1\:lethodologies. completed by the state. ~There is no resource test ti.1r this eligibility group. Parents or other caretaker relatives living with a child under the age specified he low are not covered unless the t:hild is ~receiving benefits under Medicaid. CHIP or through the Exchange. or otherwise enrolled in minimum essential coverage, as defined in 42 CFR 435.4. \e Under age 19, or { A higher age of children. if any. covered under 42 CFR 435.222 on 1\:larch 23. 20 I 0: ~ Presumptive Eligibility The state wvers individuals under this group when determined presumptively eli~ible by a qualified ..:ntity. The >lat.: assures it also covers individuals under the Pregnant Women (42 CFR 435.116) and!or Infants and Children under Age 19 (42 CFR 435.118) eligibility groups when determined presumptively eligible. C Yes r. No PRA Disclosure Statement Transmittal Number: 13-0014-MM1 Approval Date: December 13, 2013 Effective Date: January 1, 2014 Pa!!e I of2

Medicaid Eligibility According to the Paperwork Reduction Act of 1995. no persons are required to respond to a collection of in formation unless it displays a valid OMB control number. The valid Oi\'IB control number lor this information collection is 0938- 1 148. The time required to complete this inl<.mnation collection is estimated to average 40 hours per response. including the time to review instructions. search existing data resources, gather the data needed. and complete and review the information collection. If you have comments concerning. the accuracy of the time estimate(s) or suggestions f(.)r improving this form. please write to: CMS. 7.500 Security Boulevard. Attn: PRA Reports Ckarancc Officer, Mail Stop C4-26-05, Baltimore, tv1aryland 21244-18.50. Transmittal Number: 13-0014-MM1 Approval Date: December 13, 2013 Effective Date: January 1, 2014

Medicaid Eligibility IEJigibility Groups - Mandatory Coverage For19,er Foster c:ue Children 42 CFR 435.150 1902(a)( IO)(A)(i)(IX) O!'v1B Comrol Number 0938-1148 Ol\:IB Expiration date: I 0/.1 I i20 14 S33 ~ ~'ormer Foster Care Children- Individuals under the age of~6. not otherwise mandatorily eligible, vvho were on 1\:ledi~:aid and tn foster care when they turned age 18 or aged out of foster care. 0 The state attests that it operates this eligibility group under the following provisions: ~ Individuals qualifying under this eligibility group must meet the following criteria: ~ Are under age 26. ~ Are not otherwise eligible fi.x and enrolled for mandatory covernge under the state plan. except that eligibility under • this group takes precedence over eligibility under the Adult Group. Were in foster care under the responsibility of the state or Tribe and were enrolled in Medicaid under the state's state ~plan or I I 15 demonstration when they turned 18 or at the time of aging out of that state's or Tribe's foster care program. The state elects to cover children who were in foster ~:are and on rvtedicaid in illlY state at the time they turned 18 or aged out of the foster care system. ('Yes \e No The state covers individuals under this group when determined presumptively eligible by a qual ilied entity. The state assures it also covers individuals under the Pregnant Women (42 CFR 435. 1 16) and/or Infants and Children under Age 19 142 CFR 435.118) eligibility groups when determined presumptively eligible. \ 'l' es \e No PRA D is_£.1 OS!!J:s;. .S!.ll.~!ll~J11 According to the Papenvork 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 c01lection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response. including the time to review instructions. search existing data resources, gather the data needed. and complete and review the information collection. If you have comments concerning the accuracy or the time estimate(s) or suggestions for improving this lorm. please write to: Cl'viS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4 - ~6 - 05, Baltimore, tv1aryland ~I ~44 - 1850. Transmittal Number: 13-0014-MM1 Approval Date: December 13, 2013 Effective Date: January 1, 2014 i>ae.: I of I

Medicaid Eligibility E;J,igibi,lity Groups - Options for Coverage ~dividq.als .abov~ 133% FPL 1902(a)( I 0 )(A)( ii)( XX) 1902(hh) 42 CFR 435.218 0\·18 Control Number 0938-1148 Ol\:IB Expiration date: 10!31 /2014 sso Individuals abov~ 133"/o FPL- The state elects to cover individuals under 65. not otherwise mandatorily or optionally eligible. with income above 133% FPL and at or below a standard established by the state and in accordance with provisions described at 42 CFR 435.218. r Yes (i No . .PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to revie>v instructions, search e:\isting 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: crviS, 7500 Security Boulevard, Attn: PRA Reports Clearance Otticer. Mail Stop C4-26-05. Baltimore. Maryland 21244- 1850. Transmittal Number: 13-0014-MM1 Approval Date: December 13, 2013 Effective Date: January 1, 2014 Pa!!c I of I

Medicaid Eligibility Eligi~-Uity Groups - Optio:ns for Coverage Optiomd Coverage of Parents and Other Caretaker Relatives 42 CFR 435.220 1902(a)( 1 0)( A )(ii)( I) OMB Control Number 0938-1148 0!\:IB Expiration date: I 0/31 /2014 S5l Optional Coverage of Parents and Other Caretaker Relatives- The state elects to cover individuals qualif-)·ing as parents or other caretaker relatives who are not mandatorily eligible and who have income at or below a standard established by the state and in accordance with provisions described at 42 CFR 435.220. r Yes r. 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 01\:IB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources. gather the data needed. and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C 4-26-05. Baltimore. Maryland 21244-1850. Transmittal Number: 13-0014-MM 1 Approval Date: December 13, 2013 Effective Date: January 1, 2014 Page I or I

Medicaid Eligibility 0\18 Controll\umber 09)8-1148 OMB Expiration date: I 0!31 i20 I '-1 Eligibility Gr.o:ups - Options for Coverage Children with Non IV-E Adoption Assistance 42 CFR 435.227 1902(a)( I 0)( A)( ii)( VIII) Children with Non IV-E Adoption Assistance- The state elects to cover children with special needs for whom there is a non IV-E adoption assistance agreement in effect with a state. who were eligible for l'vledicaid. or who had income at or belmv a standard established by the state and in accordance with provisions described at 42 C:FR 435.227. (e' Yes (' No IZJ The state attests that it operates this eligibility group in accordance with the following provisions: ~ Individuals qualifying under this eligibility group must meet the following criteria: ~ The state adoption agency has determined that they cannot be placed without Medicaid coverage because of special needs for medical or rehabilitative care; ~ Are under the following age (see the Guidance for restrictions on the selection of an age): (e' Under age 21 (' Under age 20 (' Under age 19 (' Under age 18 ~ MAGI-based income methodologies are used in calculating household income. Please refer as necessary to S I 0 rv!AGI- Based Income 1\:lethodologies. completed by the state. The state covered this eligibil ity group in the Medicaid state plan as of December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23.2010 or December 31.2013. (e' Yes (' No The state also covered this eligibility group in the Medicaid state plan as of l\·1arch 23. 20 I 0. (e' Yes (' No S53 ~ Individuals qualify under this eligibility group if they were eligible under the state's approved state plan prior to • the execution of the adoption agreement. The state used an income standard or disregnrded all income for this eligibility group either in the 1\:Jedicaid state plan as of :\:larch 23, 20 I 0 or December 31, 2013, or under a Medicaid 1115 Demonstration as of l'vlarch 23. 20 I 0 or December 31. 2013. \e Yes (' No ~ Income standard used for this eligibility group ~ Minimum income standard The minimum income standard for this eligibility group is the AFDC payment standard in effect as of July 16. 1996. not conve11ed to MAGI-equivalent. This standard is described in S 14 A FDC Income Standards. ~ Maximum income standard Transmittal Number: 13-0014-MM1 Approval Date: December 13, 2013 Effective Date: January 1, 2014 Page I of2

Medicaid Eligibility No income test was used (all income was disregarded) for this eligibility group either in the l'v1edicaid state plan as of March 23, 20 I 0 or December 31, 2013, or under a l'v1edicaid II 15 Demonstration as of !\:larch 23, 20 I 0 or December 31, 2013. \e Yes (' No ~ No income test was used (all income was disregarded) for this eligibility group under (check all that apply): fZl The Medicaid state plan as of March 23. 20 I 0. fZ] The rvledicaid state plan as of December 31. 2013. 0 A Medicaid 1115 Demonstration as of March 23. 20 I 0. 0 A Medicaid 1115 Demonstration as of December 31. 2013. The state's maximum standard for this eligibility group is no income test (all income is disregarded). ~ Income standard chosen Individuals qualify under this eligibility group under the following income standard. which must be higher than the minimum for this child's age: This eligibility group does not use an income test (all income is disregarded). ~ There is no resource test for this eligibility group. PRA Di~&losur_~_StatenKIJJ 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 Ol'vlB control number for this information collection is 0938-1 148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources. gather the data needed. and complete and review the information collection. I fyou have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore. Maryland 21244-1850. Transmittal Number: 13-0014-MM1 Approval Date: December 13, 2013 Effective Date: January 1, 2014

Medicaid Eligibility El~gibility Groups - Options for Coverage Optional Targeted Low Income Children 1902(a)( I 0)( A )(ii)(XIV) 42 CFR 435.229 and 435.4 1905(u)(2)(B) OMB Control Number 0938-1148 OMB Expiration date: I 0/3 112014 S54 Optional Targeted Low Income Children- The state elects to cover uninsured children who meet the definition of optional targeted low income children at 42 CFR 435.4. who have household income at or below a standard established by the slate and in accordance with provisions described at 42 CFR 435.229. (' Yes (.' No PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a val.id OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed. and complete and review the information collection. I fyou have comments concerning the accuracy of the time estimate(s) or suggestions for impr,oving this 1onn. please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05. Baltimore. l'vlaryland 21244-1850. Transmittal Number: 13-0014-MM1 Approval Date: December 13, 2013 Effective Date: January 1, 2014 Page I of I

Medicaid Eligibility Eligibility Groups.- Options for Coverage Individuals with Tuberculosis 1902(a)( I 0)( A )(ii)(XII) 1902(z) OMB Control Number 0938-1148 OMB Expiration date: IO!J 1/2014 S55 Individuals with Tuberculosis- The state elects to cover individuals infected with tuberculosis "vho have income at or below a standard established by the state, limited to tuberculosis-related services. (' Yes r. No PRA Disclosure Statement According to the Pape1work 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 Ol'v1B control number f(x this information collection is 0938-1148. The time required to wmplete this information collection is estimated to average 40 hours per response. including the time to review instructions. search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS. 7500 Security Boulevard. Attn: PRA Reports Clearance Ollicer. Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. Transmittal Number: 13-0014-MM1 Approval Date: December 13, 2013 Effective Date: January 1, 2014

Medicaid Eligibility Eligibility Groups - Options for Coverage Independent Foster Care Adolescents 42 CFR 435.226 1902(a)( I O)(A )(ii}(XVII) OMB Control !\umber 09)8-1148 OivtB Expiration date: I 0/31 12014 857 Independent Fo~ ter Care Adolest~ents- The state elects to cover individuals under an age specified by the state, less than age 21, who were in state-sponsored f'oster care on their 18th birthday and who meet the income standard established by the state and in accordance with the provisions described at 42 CFR 435.226. (' Yes l- No eRA Disclo s ur~_.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 orv1B control number t~x this int~1nnation collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions. search existing data resources. gather the ?ata needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions tor improving this form, please write to: CMS. 7500 Security Boulevard. Attn: PRA Reports Clearance Otlicer. Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. Transmittal Number: 13-0014-MM 1 Approval Date: December 13, 2013 Effective Date: January 1, 2014 Pac.e I of I

Medicaid Eligibility Eligibility Groups - Options for Coverage Individuals Eligible for Family Planning Services 1902(a)( I 0)( A)( ii)( XX I l 42 CFR 435.214 OMB Controll\umber ()()38-1148 Oi\:IB Expirati\)n date: I 0/31 !20 14 S59 Individuals Eligible for Family Planning Services- The state elects to cover individuals who are not pregnant. and have household income at or below a standard established by the state. whose coverage is limited to family planning and related services and in accordance with provisions described at 42 CFR 435.214. (' Yes (. No PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of in formation unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including. the time to review instructions. search existing data resources_ gather the data needed, and complete and review the information collection. If you have comments concerning. the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard. Attn: PRA Reports Clearance Officer. Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. Transmittal Number: 13-0014-MM 1 Approval Date: December 13, 2013 Effective Date: January 1, 2014 Pae.c I of I

Table of Contents State Name: West Virginia State Plan Amendment (SPA)#: 13-0015-MM2 This file contains the following documents in the order listed: 1) Approval Letter 2) Additional Companion Letter 3) CMS 179 Form/Summary Form (with 179-like data) 4) Superseding Pages Notice 5) Approved SPA Pages 6) Additional Attachments that are part of the State Plan

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 150 S. Independence Mall West Suite 216, The Public Ledger Building Philadelphia, Pennsylvania 19106-3499 CMS CENTERS FOR MEDICARE & MEDICA ID SERVICES Region Ill/Division of Medicaid and Children's Health Operations SWIFT #012420144022 ,FEB 12 2014' Nancy V. Atkins, MSN, RNC, NP Commissioner Bureau for Medical Services 350 Capitol Street, Room 251 Charleston, West Virginia 25301-3706 Dear Commissioner Atkins: Enclosed is an approved copy of West Virginia's (WV) State Plan Amendment (SPA) WV 13- 0015-MM2, which was submitted to the Centers for Medicare & Medicaid Services (CMS) on November 22, 2013. WV SPA 13-0015-MM2 incorporates the MAGI-based eligibility process requirements, including the single streamlined application, into West Virginia's Medicaid State Plan in accordance with the Affordable Care Act. The effective date of this SPA is October 1, 2013. The approval of WV SPA 13-0015-MM2 includes full approval of the State's alternative paper application used to apply for multiple human service programs. The State is also using an interim alternative single streamlined online application and by March 31, 2014 will implement a revised alternative single streamlined online application that addresses CMS's concerns outlined in the companion letter issued with this SPA approval. Enclosed is a copy of the following S94 State Plan pages and attachments to be incorporated within a separate section at the end of West Virginia's approved State Plan: • S94, pages S94-1 , S94-2 • Attachment 1 -State of West Virginia alternative multi-benefit paper application • Attachment 2 - Statement of use with respect to the alternative single, streamlined online application In addition, enclosed is a summary of State Plan pages which are superseded by WV SPA 13- 0015-MM2, which should also be incorporated into a separate section in the front of the State Plan. • Superseding Pages of State Plan Material, 13-00 15-MM2

Page 2 - Ms. Nancy V. Atkins, RN, MSN, NP-BC The CMS appreciates the significant amount of work your staff dedicated to preparing this State Plan Amendment. We continue to be available to provide technical assistance. If you have any questions about your application, please contact Dena Green blum at 410-786-8684 or Dena.Greenblum@cms.hhs.gov. If you have any questions about this letter or need any additional information, please contact Margaret Kosherzenko at 215-861-4288 or Margaret. KoshcrzenkoW>cms.hhs.gov. Enclosures (b) (1) (A), (b) (b) (1) (A), (b) (b) (1) (A), (b) (b) (1) (A), (b) /S/

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 150 S. Independence Mall West Suite 216, The Public Ledger Building Philadelphia, Pennsylvania 19106-3499 CENTERS FOR MEDICARE & MEOI(.AIO SERVICES Region Ill/Division of Medicaid and Children's Health Operations SWIFT #012420144022 FEB 1 2 2014 Nancy V. Atkins, MSN, RNC, NP Commissioner Bureau for Medical Services 350 Capitol Street, Room 251 Charleston, West Virginia 25301-3706 Dear Commissioner Atkins: Dear Ms. Atkins: This letter is being sent as a companion to the Centers for Medicare & Medicaid Services (CMS) approval of State Plan Amendment (SPA) 13-0015-MM2, which was submitted to CMS on November 22, 2013. Our review of this submission included a review of West Virginia's alternative single streamlined online application. Through March 31, 2014 the State is using an interim alternative single streamlined online application. This interim online application will need to be revised to reflect the following changes. Necessary changes: Date by which changes will be completed: The addition of language to clarify that SSNs are optional for March 31, 2014 non-applicants. Clarification of income types countable under MAGI for March 31,2014 Medicaid and CHIP determinations. Please submit the revised alternative single, streamlined online application to CMS for review no later than March 10, 2014 to ensure approval by March 31,2014. We continue to be available to provide technical assistance.

Page 2- Ms. Nancy V. Atkins, RN, MSN, NP-BC If you have any questions about your application, please contact Dena Greenblum at Dena.Greenblum(W,cms.hhs.gov or 410-786-8684. If you have any questions about this letter or need any additional information, please contact Margaret Kosherzenko at 215-861-4288 or Margaret.Kosherzenko@cms. hhs. gov. (b) (1) (A), (b) (b) (1) (A), (b) (b) (1) (A), (b) (b) (1) (A), (b) /S/

WV.0539.ROO.OO- Oct 01, 2013 Page 1 of2 Medicaid State Plan Eligibility: Summary Page (CMS J 79) State/Territory name: West Virginia Transmittal Number: Please enter tile Transmittal Number (TN) in tile format ST-YY-0000 where ST= tile state abbreviation, YY =tile last two digits of tile submission year, and 0000 =a four digit number wit II leading zeros. Tile dashes must also be entered. WV-13-0015 Proposed ~ffectiv!_Date 10/01/2013 (mm/ dd/ yyyy) Federal Stat!Jte/Regulation Citation Federal Budget Impact Federal Fiscal Year First Year 2014 Second Year 2015 Subject of Amendment Eligibility Process Governor's Office Review $0.00 $0.00 Governor's office reported no comment Comments of Governor's office received Describe: No reply received within 45 days of submittal '! Other, as specified Describe: Not Required. Signature of State Agency Official Submitted By: Last Revision Date: Submit Date: Sarah Young Feb 10,2014 Nov 22,2013 Amount http:/1157.199.113.99/MMDL/faces/protected/mac/cOl/print/Pri ... 02/11/2014

WV.0539.ROO.OO- Oct 01, 2013 Page 2 of2 http:/1157.199 .113.99/MMDL/faces/protected/mac/cO 1/print/Pri... 02111/2014

SUPERSEDING PAGES OF STATE PLAN MATERIAL TRANSMITTAL NUMBER: STATE: I3-00I5 MM2 West Virginia PAGE NUMBER OF THE PLAN SECTION OR PAGE NUMBER OF THE SUPERSEDED PLAN SECTION ATTACHMENT: OR ATTACHMENT (If Applicable): . Section 2, Page I 0, section 2.I (a), TN 94-I5 S94- Eligibility Process Effective date: July I, I994, Approved: June 30, 1995 Section 2, Page II a, section 2.I (d), TN 9I-I3 Effective date: October I, I99I, Approved: January I, I992

Medicaid Eligibility OMB Control Number 0938-1148 OMB date: 10/3112014 [{] The state meets all the requirements of 42 CFR 435, Subpart J for processing applications, determining and verifying eligibility, and furnishing Medicaid. Application Processing Indicate which application the agency uses for individuals applying for coverage who may be eligible based on the applicable modified adjusted gross income standard. IZJ The single, streamlined application for all insurance affordability programs, developed by the Secretary in accordance with section 1413(b)(l)(A) of the Affordable Care Act An alternative single, streamlined application developed by the state in accordance with section 14 13(b)( I )(B) of the IZJ Affordable Care Act and approved by the Secretary, which may be no more burdensome than the streamlined application developed by the Secretary. An alternative application used to apply for multiple human service programs approved by the Secretary, provided that the IZJ agency makes readily available the single or alternative application used only for insurance affordability programs to individuals seeking assistance only through such programs. Indicate which application the agency uses for individuals applying for coverage who may be eligible on a basis other than the applicable modified adjusted gross income standard: The single, streamlined application developed by the Secretary or one of the alternate forms developed by the state and IZJ approved by the Secretary, and supplemental forms to collect additional information needed to determine eligibility on such other basis, submitted to the Secretary. D An application designed specifically to determine eligibility on a basis other than the applicable MAGI standard which minimizes the burden on applicants, submitted to the Secretary. The agency's procedures permit an individual, or authorized person acting on behalf of the individual, to submit an application via the internet website described in 42 CFR 435.1200(f), by telephone, via mail, and in person. The agency also accepts applications by other electronic means: r. Yes (' No TN No: 13-0015-MM2 West Virginia Approval Date: 02/12/2014 894-1 Page I of2 Effective Date: 10/01/2013

Medicaid Eligibility Indicate the other electronic means below: Name of Method Description Paper application may be sent via Facsimile .·········~ . The agency has procedures to take applications, assist applicants and perform initial processing of applications for the eligibility IZJ groups listed below at locations other than those used for the receipt and processing of applications for the title IV -A program, including Federally-qualified health centers and disproportionate share hospitals. Parents and Other Caretaker Relatives Pregnant Women Infants and Children under Age 19 Redetermination Pr'Jcessing Ill Redeterminations of eligibility for individuals whose financial eligibility is based on the applicable modified adjusted gross income standard are performed as follows, consistent with 42 CFR 435.916: 00 Once every 12 months OO Without requiring information from the individual if able to do so based on reliable information contained in the individual's • account or other more current information available to the agency If the agency cannot determine eligibility solely on the basis of the information available to it, or otherwise needs additional 00 information to complete the redetermination, it provides the individual with a pre-populated renewal form containing the information already available. OO Redeterminations of eligibility for individuals whose financial eligibility is not based on the applicable modified adjusted gross income standard are performed, consistent with 42 CFR 435.916 (check all that apply): ~ Once every 12 months 1:81 Once every 6 months D Other, more often than once every 12 months Coordination of Eligibility and Enrollment The state meets all the requirements of 42 CFR 435, Subpart M relative to coordination of eligibility and enrollment between [{] Medicaid, CHIP, Exchanges and other insurance affordability programs. The single state agency has entered into agreements with the Exchange and with other agencies administering insurance affordability programs. PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN No: 13-0015-MM2 West Virginia Approval Date: 02/12/2014 894-2 Page 2 of2 Effective Date: 10/01/2013

USE OF THE ALTERNATIVE SINGLE STREAMLINED APPLICATION D Paper Application 00 Online Application TRANSMITTAL NUMBER: STATE: WV 13-0015 MM West Virginia . Through March 31, 2014, the state is using an interim online alternative single streamlined application. After March 31, 2014, the state will use a revised online alternative single streamlined application, which will address the issues outlined in the CMS letter concerning the state's application. The revised application will be incorporated by reference. into the state plan.

WEST V IRGINIA if~ ~.ft/J Resources WEST VIRGINIA DEPARTMENT OF HEALTH AND HUMAN RESOURCES APPLICATION FOR BENEFITS The application will be considered if it contains a minimum of the Name, Address, and Signature below. The amount of SNAP benefits will be determined from the date of application. The amount of cash assistance will be determined from the date eligibility requirements are met, including signing the Personal Responsibility Contract (PRC), Self-Sufficiency Plan (SSP), and participating in orientation. You may appoint someone outside your household to act for your household to make an application and to be interviewed. This person should know your household's situation well enough to give any information needed to determine your eligibility and will include information from your tax returns. You are still responsible for the information that anyone acting as your authorized representative gives, including any information that may be incorrect. If you want to appoint someone for this, write his/her name and address here. For health coverage only, complete Appendix C. You may receive SNAP benefits within 7 calendar days if: your SNAP household has less than $150 in monthly gross income and liquid resources such as cash, checking or savings accounts are less than or equal to $100; or your rent/mortgage and utilities are more than your household's combined monthly income and liquid resources; or a member of your household is a migrant or seasonal farm worker. 1. How much money do the members of your household have in cash or a bank account? $ ~-------------- 2. What is the total amount of income you expect your household to receive this month? $ ------------------ 3. What is your current monthly rent/mortgage payment? $ Utilities _$;:;__ ______ _ 4. Is anyone in your household a migrant or seasonal farm worker? D Yes D No If yes, answer these questions: Did all of your household income stop recently? 0 Yes 0 No Does anyone in your household expect to receive income from a new source this .month? 0 Yes How 0 No Have you or anyone in your household received or do you expect to receive SNAP benefits from any other state this month? D Yes Where D No Your re TN No: 13-0015-MM2 West Virginia Page 1 of 17 Approval Date: 02/12/2014 Application for Benefits- 1 Effective Date: 10/01/2013

Date of birth Sex Marital Status Relationship I Buy/cook to you food In school Y/N Full time student Y/N **If Hispanic, Latino, ethnicity (OPTIONAL- check all that apply.) 0 Mexican 0 Mexican American 0 Chicano/a 0 Puerto Rican 0 Cuban 0 Other--------- **Race (OPTIONAL - check all that apply.) 0 White 0 American Indian or 0 Black or African American Alaska Native TN No: 13-0015-MM2 West Virginia 0 Asian Indian 0 Chinese 0 Filipino 0 Japanese 0 Korean 0 Vietnamese 0 Other Asian 0 Native Hawaiian Page 2 of 17 Approval Date: 02/12/2014 Application for Benefits- 2 0 Guamanian or Chamorro 0 Samoan 0 Other Pacific Islander 0 Other bathing, dressing, daily chores, Effective Date: 10/01/2013

Date of birth Sex Marital Status Relationship to you In I Last school grade YIN attended **If Hispanic, Latino, ethnicity (OPTIONAL- check all that apply.) 0 Mexican 0 Mexican American 0 Chicano/a 0 Puerto Rican 0 Cuban 0 Other--------- **Race (OPTIONAL- check all that apply.) 0 White 0 American Indian or 0 Black or African American Alaska Native 0 Asian Indian 0 Chinese 0 Filipino 0 Japanese 0 Korean 0 Vietnamese 0 Other Asian 0 Native Hawaiian 0 Guamanian or Chamorro 0 Samoan 0 Other Pacific Islander 0 Other * ~er SIJ.IAP, You may leave this blank for anyone not in the assistance request. We need this if you are applying for benefits and have an SSN or alien registration number for health coverage. Providing your SSN can be helpful even if you are not applying since it can speed up the application process. **Not required. This information is voluntary. Your benefits will not be affected if you do not answer the race and/or ethnicity questions above. Giving us this information will help ensure program benefits are distributed without regard to race, color, or national origin. Do you plan to file a federal income tax return NEXT YEAR? If yes, please answer questions a- c. D No I a. D No I b. 0 No I c. DYes No I Is this individual applying for health coverage? DYes 0 No I Are you pregnant? If yes, how many babies are expected during this pregnancy? ____ _ TN No: 13-0015-MM2 West Virginia Page 3 of 17 Approval Date: 02/12/2014 Application for Benefits- 3 filer Effective Date: 10/01/2013

Date of birth Sex Marital Status Relationship I Buy/cook to you food - If Hispanic, Latino, ethnicity (OPTIONAL- check all that apply.) D Mexican D Mexican American D Chicano/a D Puerto Rican D Cuban **Race (OPTIONAL- check all that apply.) D White D American Indian or D Black or African American Alaska Native D Asian Indian D Chinese D Filipino D Japanese D Korean In school YIN D Other _________ _ D Vietnamese D Other Asian D Native Hawaiian D Guamanian or Chamorro D Samoan D Other Pacific Islander D Other Full time student YIN * for SNAP, you may leave this blank for anyone not in the assistance request. We need this if you are applying for benefits and have an SSN or alien registration number for health coverage. Providing your SSN can be helpful even if you are not applying since it can speed up the application process. **Not required. This information is voluntary. Your benefits will not be affected if you do not answer the race and/or ethnicity questions above. Giving us this information will help ensure program benefits are distributed without regard to race, color, or national origin. income tax return NEXT YEAR? If yes, please answer questions a- c. Will you file jointly with a spouse? If yes, name of spouse: b. Will you claim any dependents on your tax return? If yes, list name of dependents: DYes D No c. Will you be claimed as a dependent on someone's tax return? ·If yes, list name of tax How are vou related to filer DYes D No I Is this individual applying for health l"'n\/<>r<>n<>? are expected during this pregnancy? ____ _ I health condition that causes limitations in activities (like bathing, the age of 19, and are you the main person taking care of this Were you an SSI recipient in the past but not receiving SSI now? If yes, date SSI ended: DYes D No I Are you an American Indian or Alaska Native? If yes, complete Appendix B. TN No: 13-0015-MM2 West Virginia Page 4 of 17 Approval Date: 02/12/2014 Application for Benefits- 4 , daily chores, Effective Date: 10/01/2013

Date of birth Sex Marital Status Relationship to you n school YIN **If Hispanic, Latino, ethnicity (OPTIONAL- check all that apply.) D Mexican D Mexican American D Chicano/a D Puerto Rican D Cuban D Other---------- **Race (OPTIONAL - check all that apply.) D White D American Indian or D Black or African American Alaska Native D Asian Indian D Chinese D Filipino D Japanese D Korean D Vietnamese D Other Asian D Native Hawaiian D Guamanian or Chamorro D Samoan D Other Pacific Islander D Other * For Sll>IAP, you may leave this blank for anyone not in the assistance request. We need this if you are applying for benefits and have an SSN or alien registration number for health coverage. Providing your SSN can be helpful even if you are not applying since it can speed up the application process. **Not required. This information is voluntary. Your benefits will not be affected if you do not answer the race and/or ethnicity questions above. Giving us this information will help ensure program benefits are distributed without regard to race, color, or national origin. Do you plan to file a federal income tax return NEXT YEAR? If yes, please answer questions a- c. DYes 0 No I a. Will you file jointly with a spouse? If yes, name of spouse: 0 Yes 0 No I b. Will you claim any dependents on your tax return? If yes, list name of dependents: 0 Yes 0 No I c. Will you be claimed as a dependent on someone's tax return? ns in activities (like bathing, dressing, daily chores, 0 Yes 0 No I Were you in foster care in West Virginia at age 18 or older? 0 Yes 0 No I Were you an SSI recipient in the past but not receiving SSI now? If yes, date SSI ended: 0 No I Are you an American Indian or Alaska Native? If yes, complete Appendix B. For additional household members, make copies of this page. TN No: 13-0015-MM2 West Virginia Page 5 of 17 Approval Date: 02/12/2014 Application for Benefits- 5 Effective Date: 10/01/2013

D Yes D No D Yes D No D Yes D No D Yes D No D Yes D No D Yes D No D Yes D No 3 I Is anyone on strike? 4 I Is anyone disabled? 2 I Have vou or anv member of vour household been convicted of buvina or sellina SNAP benefits over $500 after September 22, 3 I Have you or any member of your household been convicted of a felony under Federal or State law for possession, use or distribution of a controlled substance (felony drug conviction) after August 22, 1996? 4 I Have you or any member of your household been convicted of fraudulently receiving duplicate September 22, 1996? any State after 5 I Are you or any member of your household hiding or running from the law to avoid prosecution, being taken into custody or to jail for a felony crime or attempted felony crime, or violation of parole or probation? 6 I Have you or any member of your household been convicted of trading SNAP benefits for guns, ammunitions, or explosive September 22, 1996? If you answered "YES" to any of the above questions, please explain here. some 1ntormat1on is required. Vehicles are excluded If you have an expense that you do not report and/or provide proof of, you will not receive the deduction for the expense. YES I NO I VALUE Owner Model Year Value Amount Owed Vehicles I I I Model -- Year Value Amount Owed Value Amount Home Owed Do you own property Value I I I Amount other than your home? Owed I Model Year Value Amount Mobile Home I I Owed Page 6 of 17 TN No: 13-0015-MM2 Approval Date: 02/12/2014 Effective Date: 10/01/2013 West Virginia Application for Benefits- 6

. Checkina Account(s) Savinas Account(s) Money Market Account Credit Union Cash on Hand Christmas Club Stocks Bonds/Savings Bonds Certificates of Deposit Trust Funds IRA/Keogh Profit Sharina Escrow Account/Home Sale Life Insurance Policy No: Face Value: Cash Value: Funeral/Burial Funds Burial Plots Livestock Mineral Rights Business Equipment Model Year Value Amount Owed I Farm/Tractor Model Year Value Amount Owed ! Eauipment i Camper/Trailer Model Year Value Amount Owed I ATV, UTVor3 I Wheeler Model Year Value Amount Owed · Boat Model Year Value Amount Owed I Personal Collection Other Are any of the assets listed not available to the owner due to joint ownership, court proceedings/orders, etc? YES __ NO __ If "Yes," which assets and why?----------------------------------· Are any of the assets listed set aside for burial? YES NO If "Yes," which assets? TN No: 13-0015-MM2 West Virginia Page 7 of 17 Approval Date: 02/12/2014 Application for Benefits- 7 Effective Date: 10/01/2013

or given away property or any other asset, including vehicles or life insurance or established a 0 Yes 0 No Does anyone in your household receive any income from employment? D Yes D No If yes, list all gross income before deductions (such as full or part-time employment, self-employment, baby-sitting, odd jobs, days work, roomer/boarder payments, etc.) NAME NAME OF EMPLOYER (Include address and phone number) RATE OF PAY NUMBER OF HOURS WORKED AMOUNT PER PAY PERIOD HOW OFTEN RECEIVED In the past year, did any household member: 0 Change jobs 0 Stop working 0 Start working fewer hours 0 None of these Name Does this person receive this TN No: 13-0015-MM2 West Virginia Type of Name of Business income regularly? Monthly Income Received Page 8 of 17 Approval Date: 02/12/2014 Application for Benefits- 8 List Business Expenses and Amounts Effective Date: 10/01/2013

If anyone in your household receives, applied for or was denied any benefit listed below, place a check in the box next to the benefit. 0 Alimony 0 Child Support o Unemployment Benefits o Education Grants or Loans o Railroad Retirement 0 Veteran's Pension/Benefit o Union Benefits o Disability/Sick, Maternity Benefits 0 Worker's Compensation 0 Pension or Retirement 0 Black Lung Benefits o Money from friends or relatives 0 Military Allotment 0 Money from Rental Income 0 Temporary Cash Assistance o Mineral Rights o Lump Sum Cash Amounts 0 Social Security o SSI o Student Income 0 Adoption Assistance o Rent or Utility Supplement o Foster Care Payments o Interest Dividends from Stocks, Bonds, Savings or Other Investments If you checked yes to receiving, applying for or being denied any benefits, fill in below. NAME I TYPE OF BENEFIT APPLIED CLAIM NUMBER RECEIVED AMOUNT Yes I No Page 9 of 17 TN No: 13-0015-MM2 West Virginia Approval Date: 02/12/2014 Application for Benefits- 9 Effective Date: 10/01/2013

Does any household member pay legally obligated child support to a NON-HOUSEHOLD member? eludes current oavments. arrearaaes. health insurance, alimony, student loan interest or rl~vr.~rl'! PERSON WHO PAYS TYPE OF PAYMENT MONTHS PAID IN LAST 3MONTHS LEGALLY OBLIGATED AMOUNT Payment Amount AMOUNT ACTUALLY PAID How Often SNAP- Do you or any household members pay medical expenses for any person age 60 or over, or any person receiving disability benefits? o Yes 0 No If ves. check the aoorooriate box and list the mnnthlv 0 Dentures/Glasses/Hearing Aids $ 0 Hospital $ 0 Attendant Care $ 0 Transportation Costs 0 Nursing $ $ Is anyone in your household paying for any of the following? Check all those paid and answer the questions. -v EXPENSES Rent TN No: 13-0015-MM2 West Virginia AMOUNT Who pays? ,J EXPENSES Page 10 of 17 Approval Date: 02/12/2014 Application for Benefits- 10 AMOUNT Who Pays? Effective Date: 10/01/2013

Mortgage Sewer Electric Garbage Gas Wood/Coal Oil Property Tax Telephone Homeowner's Insurance Land Contract Other ~ -- Is heat included in your rent? D Yes D No If heat is not included in the rent, what is your source of heat? Do you pay for air conditioning/heating? D Yes D No Did your household receive LIEAP or does your household expect to receive LIEAP? DYes D No D Yes D No D Yes D No $ D Yes D No .,,/.,rvnn<> who lives in your home is 65 years of age or older, or is disabled or temporarily - - D Yes· D No 5 D Yes D No 6 D Yes D No 7 D Yes D No 8 D Yes D No 9 TN No: 13-0015-MM2 West Virginia Are you without food? Are you in need of shelter, clothing, and/or household supplies/furnishings due to a fire or some other man-made or natural disaster? Are you in need of emergency child care? If yes, what is the reason for the emergency? Are you in need of emergency transportation? If yes, what is your destination a Are you in need of emergency medical care? If yes, what is your medical emergency? Page 11 of 17 Approval Date: 02/12/2014 Application for Benefits- 11 need? Effective Date: 10/01/2013

anyone enrolled 1n health coverage now from the following: If yes, check the type of coverage and write the person(s) name(s) next to the coverage they have. 0 Medicaid: 0 Employer Insurance:--------------- 0 CHIP: 0 Name of Health Insurance: ____________ _ 0 Medicare: 0 Policy Number:-------=----=-------- 0 TRICARE (don't check if you have direct care or Is this COBRA coverage? 0 Yes 0 No Line of Duty): Is this a retiree health plan? 0 Yes 0 No 0 VA Health Care Programs: 0 Other: 0 Peace Corps: Name of Health Insurance: __________ _ health coverage Policy Number: ----------------=- Is this a limited-benefit plan (like a school accident policy)? . 0 Yes 0 No yes even if the coverage is from someone's ndix A. Is this a state n? o Yes c No If you want to register to vote, you can complete a voter registration form at www.sos.wv.gov. The U.S. Department of Agriculture prohibits discrimination against its customers, employees, and applicants for employment on the basis of race, color, national origin, age, disability, sex, gender identity, religion, reprisal, and where applicable, political beliefs, marital status, familial or parental status, sexual orientation, or all or part of an individual's income is derived from any public assistance program, or protected genetic information in employment or in any program or activity conducted or funded by the Department. (Not all prohibited bases will apply to all programs and/or employment activities.) If you wish to file a Civil Rights program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, found online at http://www.ascr.usda.gov/complaint filing cust.html, or at any USDA office, or call (866) 632-9992 to request the form. You may also write a letter containing all of the information requested in the form. Send your completed complaint form or letter to us by mail at U. S. Department of Agriculture, Director, Office of Adjudication, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, by fax (202) 690-7442 or email at program. intake@usda.gov. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339; or (800) 845-6136 (Spanish). For any other information dealing with Supplemental Nutrition Assistance program (SNAP) issues, persons should either contact the USDA SNAP Hotline Number at (800) 221-5689, which is also in Spanish or call the State lnformation/Hotline Number at (800) 642-8589. USDA is an equal opportunity provider and employer. I understand that DHHR will obtain income and TN No: 13-0015-MM2 West Virginia information from the ~H<>+<>rn Page 12 of 17 Approval Date: 02/12/2014 Application for Benefits- 12 Alien Verification and and U.S. Effective Date: 10/01 /2013

Citizenship and Immigration Services (USCIS) about each member of my group. This information will be obtained by the use of the SSN of each applicant/recipient. IMPORTANT INFORMATION ABOUT SNAP (Continued) I understand if I or any member of my household: a. Is found guilty in a federal, state, or local court of trading SNAP benefits for firearms, ammunition, explosives, or controlled substances; is a convicted felon, for possession, use or distribution of a controlled substance(s); or is found guilty of trafficking $500 or more in SNAP benefits, the guilty party will be permanently disqualified from participating in the SNAP Program. b. Makes a false statement or misrepresentation of identity and/or residence or receive duplicate benefits at the same time, the responsible party will be disqualified from the SNAP program for 10 years. c. Is found guilty of using or receiving benefits in a transaction involving the sale of a controlled substance, you will not be eligible for benefits for two years for the first offense and permanently for the second offense. I understand if I am found (by court action or an administrative disqualification hearing) to have committed an act of intentional program violation, I will not receive SNAP benefits as follows: First Offense- one year; Second Offense- two years; Third Offense- permanently. In addition, I will have to repay any benefits received for which I was not eligible. I also understand that any person who obtains benefits from the DHHR by means of a willfully false statement, impersonation, misrepresentation, or any other fraudulent device can be charged with fraud. Upon a conviction, punishment may be a fine up to $5,000 and/or sentence of 5 years in jail. Federal penalties m(lyjnclude a maximum fine of $250,000 and a jail sentence of up to 20 years. I sertify ~:Jnaer penalty of perj~:Jry, by si!,Jnin!:J my name below, that I am a Unites States Citizen or alien in la•Nf~:JI immi!:jration stat~:Js . This Eleslaration of sitizenship or alien stat~:Js is a sonaition of eli!,Jibility for IJIN WORKS, Health Covera!:Je, ana Sfl.IAP. I certify by signing my name below, under penalty of perjury, that I have correctly listed the citizenship or alien status of the individuals applying for benefits on this application. This declaration of United States Citizenship or alien in lawful immigration status if a condition of eligibility for WV WORKS, Health Coverage, and SNAP. Any household member for whom citizenship is not declared is not eligible to receive benefits. However, his income and assets will be considered available to the remaining members of the household. I understand that it is a criminal violation of federal and state law to provide false or misleading information for the purpose of receiving benefits to which I am not entitled. I understand it is my responsibility to provide complete and truthful information. Applicant's Signature Worker's Signature (Worker Who Interviewed Client) TN No: 13-0015-MM2 West Virginia Date Date Page 13 of 17 Approval Date: 02/12/2014 Application for Benefits- 13 Co-Applicant's Signature (WV WORKS only) Date Effective Date: 10/01/2013

APPENDIX A Health Coverage from Employment You DON'T need to answer these questions unless someone in the household is eligible for health coverage from a job. Attach a copy of this page for each job that offers coverage. Tell us about the job that offers coverage. EMPLOYEE Information 1. Employee name (First, Middle, Last) EMPLOYER Information 4. Employee Social Security number 13. Are you currently eligible for coverage offered by this employer, or will you become eligible in the next 3 months? D Yes (continue) 13a. If you're in a waiting or probationary period, when can you enroll in coverage? (mm/dd/yyyy) List the name of anyone else who is eligible for coverage from this job. Name: Name: Name: D No (Stop here and go to Step 5 in the application). Tell us about the health plan offered by this employer. ~~~~:r~;;i~~~~~~~;~,f~:;~ ·, ·~ , ·{~,~ ·· • ,~. ·· ~··~~i~r£EI ~m~loye~ (qqn't in¢Jl!de . . t~~ employee would pay if he/she me mc~tl!l1J.O dJJICOIJntfotanlffOiba)seo c~!M!~Pn nrt~,nrl:l,mc tarid.<JIIcflnotr~eive anyother diseounts based 16. What change will the employer make for the new plan year (if known)? D Employer won't offer health coverage. D Employer will start offering health coverage to employees or change the premium for the lowest-cost plan available only to the employee that meets the minimum value standard.* (Premium should reflect the discount for wellness programs. See question 15.) a. How much would the employee have to pay in premiums for this plan? $ b. How often? D Weekly D Every 2 weeks D Twice a month D Quarterly D Yearly Date of change (mm/dd/yyyy): _____ _ TN No: 13-0015-MM2 West Virginia Page 14 of 17 Approval Date: 02/12/2014 Application for Benefits- 14 Effective Date: 10/01/2013

iieaitiL Ai,Hunttan K11<~ \,.~'I -.::i# Resources EMPLOYER COVERAGE TOOL Use this tool to help answer questions in Appendix A about any employer health coverage that you're eligible for (even if it's from another person's job, like a parent or spouse). The information in the numbered boxes below match the boxes on Appendix A. For example, the answer to question 14 on this page should match question 14 on Appendix A. Write your name and social Security number in boxes 1 and 2 and ask the employer to fill out the rest of the form. Complete one tool for each employer that offers health coverage. EMPLOYEE Information 1. Employee name (First, Middle, Last) 4. Employee Social Security number 13. Are you currently eligible for coverage offered by this employer, or will you become eligible in the next 3 months? 0 Yes (continue) If you're in a waiting or probationary period, when can you enroll in coverage? (mm/dd/yyyy) (Continue) 0 No (Stop and return this form to employee) Tell us about the health plan offered by this employer. 14; 15; . . the emplpy~~ (don't · that tl)e ~iQployee tob,acc:o c:es~;(iti(m programs, a~~f dld not lfthe · If you don't KllOW, 16. What change will the employer make for the new plan year (if known)? 0 Employer won't offer health coverage. 0 Employer will start offering health coverage to employees or change the premium for the lowest-cost plan available only to the employee that meets the minimum value standard.* (Premium should reflect the discount for wellness programs. See question 15.) a. How much would the employee have to pay in premiums for this plan? $ =-:-:---=-- b. How often? 0 Weekly 0 Every 2 weeks 0 Twice a month 0 Quarterly 0 Yearly Date of change (mm/dd/yyyy): An employer-sponsored health plan meets the "minimum value standard" if the plan's share of the total allowed benefit costs covered by the plan is no less than 60 percent of such costs (Section 368©(2)©(ii) of the Internal Revenue code of 1986). New 10/13 TN No: 13-0015-MM2 West Virginia Page 15 of 17 Approval Date: 02/12/2014 Application for Benefits· 15 Effective Date: 10/01/2013

APPENDIX B American Indian or Alaska Native Family Member (AI/AN) Complete this appendix if you or a family member are American Indian or Alaska Native. Submit this with your Application for Health Coverage & Help Paying Costs. Tell us about your American Indian or Alaska Native family member(s). American Indians and Alaska Natives can get services from the Indian Health Services, tribal health programs, or urban Indian health programs. They also may not have to pay cost sharing and may be special monthly enrollment periods. Answer the following questions to make sure your family gets the most help possible. NOTE: If you have more people to include, make a copy of this page and attach. 1. 2. 3. Name (First name, Middle name, Last name) Member of a federally recognized tribe? Has this person ever gotten a service from the Indian Health Service, a tribal health program or urban Indian Health program, or through a referral from one of these programs? 4. Certain money received may not be counted for Medicaid or the Children's Health Insurance Program (CHIP). List any income (amount and how often) reported on your application that includes money from these sources: • Per capita payments from a tribe that come from natural resources, usage • • rights, leases or royalties. Payments from natural resources, farming, ranching, fishing, leases or royalties from land designated as Indian trust land by the Department of Interior (including reservations and former reservations). Money from selling things that have cultural significance. TN No: 13-0015-MM2 West Virginia AI/AN PERSON 1 AllAN PERSON 2 First Last DYes If yes, tribe name DNo DYes DNo Middle If no, is this person eligible to get services from the Indian Health Service, tribal. health programs, or urban Indian Health programs, or through a referral from one of these programs? D Yes D No $ How often: Page 16 of 17 Approval Date: 02/12/2014 Application for Benefits- 16 First Last DYes If yes, tribe name DNo DYes DNo Middle If no, is this person eligible to get services from the Indian Health Service, tribal health programs or urban Indian Health programs, or through a referral from one of these programs? D Yes D No $ _ _ _ How often? New 10/13 Effective Date: 10/01/2013

APPENDIX C Assistance with Completing this Application. You can choose an authorized representative. You can give a trusted person permission to talk about this application with us, see your information, and act for you on matters related to this application, including getting information about your application and signing your application on your behalf. This person is called an "authorized representative." If you ever need to change your authorized representative, contact your local DHHR office. If you're a legally appointed representative for someone on this application, submit proof with the application. 1. Name of authorized representative (First name, Middle name, Last name) 2. Address 3. Apartment or suite number 4. City 5. State 6. Zip code 7. Phone number 8. Organization name ID number (if applicable) By signing, you allow this person to sign your application, get official information about this application, and act for ou on all future matters with this a enc . 10. Your signature 11 . Date (mm/dd/yyyy) For certified application counselors, navigators, agents, and brokers only. Complete this section if you're a certified application counselor, navigator, agent or broker filling out this application for someone else. 1. Application start date (mm/dd/yyyy) 2. First name, Middle name, Last name & Suffix 3. Organization name TN No: 13-0015-MM2 West Virginia Page 17 of 17 Approval Date: 02/12/2014 Application for Benefits- 17 ID number (if applicable) New 10/13 Effective Date: 10/01/2013 SIGN

Table of Contents State Name: West Virginia State Plan Amendment (SPA)#: 13-0019-MM6 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Superseding Pages Notice 4) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVlCES Centers for Medicare & Medicaid Services 150 S. Independence Mall West Suite 216, The Public Ledger Building Philadelphia, Pennsylvania 19106-3499 -- CENTERS FOR MEDICARE & MEDICAID SERVICES Region Ill/Division of Medicaid and Children's Health Operations SWIFT #012420144027 MAR 0 7 2014 Ms. Nancy V. Atkins, RN, MSN, NP-BC Commissioner Bureau for Medical Services Department ofHealth and Human Resources 350 Capitol Street, Room 251 Charleston, WV 25301-3706 Dear Commissioner Atkins: The Centers for Medicare & Medicaid Services (CMS) has completed its review of West Virginia's State Plan Amendment (SPA) 13-0019-MM6. SPA13-0019-MM6 identifies the non- fmancial eligibility requirements for both citizens and eligible non-citizens and incorporates them into West Virginia's State Plan in accordance with the Social Security Act and regulations at Title 42, Part 435 of the Code of Federal Regulations. The effective date of this SPA is October 1, 2013. Enclosed is a copy of the CMS Summary Page (CMS-179 form), the approved State Plan pages for S89; and the Superseding Pages ofState Plan Material, which should also be incorporated into a separate section in the front ofWest Virginia's State Plan. We appreciate the cooperation and effort provided by your staff throughout this process. If you have further questions about this SPA, please contact Margaret Kosherzenko of my staff at 215- 861 -4288 or by email at Margaret.Kosherzenko@cms.hhs.gov. Enclosures (b) (1) (A), (b) (b) (1) (A), (b) (b) (1) (A), (b) (b) (1) (A), (b) (b) (1) (A), (b) (b) (1) (A), (b) /S/

WV.0572.ROO.OO- Oct 01, 2013 Page 1 of2 Medicaid State Plan Eligibilit)': Summary Page (CMS 179) State!Territory name: West Virginia Transmittal Number: Please enter the Transmittal Number (TN) in tlteformat ST- YY-0000 where ST= the stale abbreviation, YY = tlte last IIIIo digits of the submission year, and 0000 =a four digit mtmber with leading zeros. The dashes must also be elllered. WV-13-0019 Proposed Effective Date 10/01/2013 rnun / dd/ yyyy) Federal Statute/Regulation Citation ACA Federal Budget Impact Federal Fiscal Year First Year 20 14 Second Year 2015 Subject of Amendment Citizenship and Immigration Status Governor's Office Review $ 113756.00 $ 117598.00 Governor's office reported no comment Comments of Governor's office received Describe: No reply received within 45 days of submittal Other, as specified Describe: Not Required. Signature of State Agency Official Submitted By: Last Revision Date: Submit Date: Sarah Young Mar6,2014 Dec 9, 2013 Amount (b) (1) (A), (b) (b) (1) (A), (b) (b) (1) (A), (b)

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SUPERSEDING PAGES OF STATE PLAN MATERIAL TRANSMITTAL NUMBER: 13-0019-MM PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: S89 Non-Financial Eligibility- Citizenship and Non-citizen Eligibility STATE: West Virgi nia PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable): Attachment 2.6-A: Page 2, Item 3, subparagraphs (a)-(g), TN-97-07 Page 2a- Entire page, TN 97-07 Page 3, Item 3, subparagraphs (d) and (e), TN 94-1 5

Medicaid Eligibility OMB Control Number0938-ll48 OMB Expiration dare· 10/31/2014 Non-Financial Eligibility Citizenship and Non-Citizen Eligibility l902(a}(46)(8) 8 U .. C. 1611 , 1612, 1613, and 1641 1903(v}(2},(3) and (4) 42 CFR 435.4 42 CFR 435.406 42 CFR 435.956 Citizenship and Non-Citizen Eligibility S89 The state provides Medicaid to citizens and nationals of the United tates and certain non-citizens consistent with requirement of 42 [{] CFR 435.406, including during a reasonable opportunity period pending veri lication of their citizenship, national status or satisfactmy immigration status. ~ The tate provides Medicaid eligibility to otherwise eligible individuals: (!] Who arc citizens or nationals of the United States; and Who are quaiitied non-citizen as defined in section 43 1 of the Personal Rt.'Spon:;ibil ity 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. §I 6 I 2(b)) and is not prohibited by ection 403 of PRWORA (8 U.S.C. § 16 13); and Who have declared themselves to be citizens or nationals of the United States, or an individual having satisfacwry ~ immigration status. during a reasonable opportunity period pending verification of their citizenship, nationality or • atisfaetory immigration status consistent with requirements of I 903(x). I I 37(d}, 1902(ee) of the SSA and 42 CFR 435.406. and 956. The reasonable opportunity period hegins 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 rt:solve any incon ·istcncit:s or obtain any necessary documentation, or the agency needs more time to complete the vt:rification process. r. Yes ("' No The agency begins to furnish benefits to otherwise eligible individuals during the reasonable opportunity period on a dare earlier than the dare the notice is received by the individual. (. Yes ("' No The date bene tits are furn ishcd is: ("' The date of application containing the declaration of citizenship or immigration status. (.The date the reasonable opportunity notice is Sl!nt. ("' Other date. as described: TN No. 13-0019-MMS West Virginia Approval Date: 03107/2014 589-1 Page 1 of3 Effective Date: 10/1/2013

Medicaid Eligibility The state provides Medicaid coverage to all Qualified Non-Citizens whose eligibility is not prohibited by section 403 of PRWORA (8 U.S.C. *1613). { Yes (i" No Indicate which requirements apply: The state requires Lawful Permanent Residents to have 40 qualil)rtng work quarters under Title II of the Social Security Act. { Yes (i" No The state limits eligibility to 7 years tor certain non-citizens. (i" Yes { No Check all that apply: [g] Non-citizens admitted to the U.S. as a refugee under section 207 of the INA cg] Non-citizens granted a ·ylum under section 208 of the INA cg] on-~.:itizens whose deportation is withheld under section 243(h) or 24l(b)(3) of the INA [g] Non-citizens granted status as a Cuban-Haitian Entrant, as defined in section SO I(e) of the Refugee Education Assistance Act of 1980 cgj on-citizens admttted to the U.S. as Amerasian The state elects the option to provide Medicaid coverage to otherwise eligible individuals under 21 and pregnant women. lawfully residing in the United States, as provided in section 1903(v)(4) of the Act. (i" Yes { No C8J Pregnant women ~ Individuals under age 21 : { Individuals under age 21 { Individuals under age 20 (i" Individuals under age 19 An individual is considered to be lawfully residing in the United States if he or she is lawfully present and otherwise meets the [!] eligibility requirements in the state plan. [!] An individual is considered to be lawfully pre~ent in the United State~ if he or she: !.Is a qualiiied non-citizen as detined in& U. S.C. 164l(b) and (c); 2. Is a nun-citizen in a valid nuninnnignmt status, as deli ned in 8 U.S.C. 1101 (a)( 1 5) or otherwise under the immigration laws (as detined in 8 U.S.C. IIOI(a)(l 7)); 3. Is a non-citizen who has been paroled into the United States in accordance with 8 U.S.C. 11 82(d)(S) for less than 1 year, except for an individual paroled for prosecution, for dcfen·ed inspection or pending removal proceedings: 4. Is a non-citizen who belongs to one of the fo llowing da~scs : TN No. 13.Q019-MM6 West Virginia Approval Date: 03/07/2014 589-2 Page 2 of 3 Effective Date: 10/1/2013

Medicaid Eligibility [!: Grant<.,-d temporary resident status in accordance with 8 U.S.C. 1160 or 1255a, respectively; [:!: Granted Temporary Protected Status (TPS) in accordance with 8 U.S.C. * 1254a, and individuals with pending applications for TPS who have been gn111ted employment authorization; ~ Granted employment authorization under 8 CF R 274a. l 2(c); [!: Family Unity beneticiaries in accordance with section 30 1 of Pub. L. 101-649, as amended; (!j Under Defe1Ted Enforced Departure (DED) in accordance with a decision made by the President; ~ Granted Deferred Action status; (!j Granted an administrative stay of removal under 8 CFR 24 1; ~ Beneticiary uf approved visa petition who has a pending application tor adjustment of statu ; 5. Is an individual with a pending application lor 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 - ~ Has been granted employment authorization; or [!] Is under the age of 14 and has had an application pending tor at least 180 days; 6. Has been granted withholding of removal under the Convention Against Torture; 7. Is a chi ld who has a pending application for Special Immigrant Juvenile status as described in X U .S.C. II 0 I (a)(27)(J}; S. ls lawfully presem 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 ofTrafticking and Violence Protection Act of 2000, Pub. L. I 06-386, as amended (22 U.S.C. 7 1 05(b)); 10. Exception: An individual with deferred action under the Department of Homeland Security's dcfeJTCd action for the childhood arrivals process, as described in the ecretary 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 ( I) through (9} of this definition. 0 Other The state as ures that it provides limited Medicaid services for treatment of an emergency medical condition, not related to an organ transplant procedure, as defined in 1903( v)(3} of the SSA and implemented at 42 CFR 440.255, to the following lZJ individuals who meet all Medicaid eligibili ty requirements, except documentation of citizenship or satisfactory immigration status ancVor pre ent an SSN: ~ Qualified non-citizens ubjeclto the 5 year waiting period described in 8 U.S.C. 161 3; Non-qualified non-citizens, unless covered as a lawfu lly residing child or pregnant woman by the state under the option in [!] accordance with 1903(v)(4) and implemented at435.406(b}. PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons arc required to respond to a collection of infom1ation un lcs 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 averdge 40 hours per response, including the time to review instructions, search existing data resources, gather the clara needed. and complete and review the information collection. If you have comments concerning the accuracy of the t1me estimate(s) or suggestions tor improving this form. please write to: C MS. 7500 Security Boulevard, Attn: PRA Reports Clearance Officer. Mail Stop C4-26-05. Baltimore, Maryland 2 1244- 1850. TN No. 13-0019-MMG West Virginia Approval Date: 03107/2014 S89-3 Page 3 of 3 Effective Date: 10/1/2013

Table of Contents State Name: West Virginia State Plan Amendment (SPA)#: 13-0020-MM7 This file contains the following documents in the order listed: 1) Approval Letter 2) CIVJS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages 4) Additional Attachment that is part of the State Plan

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 150 S. Independence Mall West Suite 216, The Public Ledger Building Philadelphia, Pennsylvania 19106-3499 CENTERS FOR MEDICARE & MEDICAID SERVICES Region III/Division of Medicaid and Children's Health Operations SWIFT #011620144030 NAR 18 2014 Ms. Nancy V. Atkins, RN, MSN, NP-BC Commissioner Bureau for Medical Services Department ofHealth and Human Resources 350 Capitol Street, Room 251 Charleston, WV 25301-3706 Dear Commissioner Atkins: The Centers for Medicare & Medicaid Services (CMS) has ·completed its review of West Virginia's State Plan Amendment (SPA) 13-0020-MM7. SPA13-0020-MM7 proposes that one or more qualified hospitals determine presumptive eligibility under 42 Code of Federal Regulations §435.1100 and West Virginia provides Medicaid coverage for individuals determined presumptively eligible. This SPA is acceptable. Therefore, we are approving SPA 13-0020-MM7 with an effective date of January 1, 2014. Enclosed is a copy ofthe CMS Summary Page (CMS-179 form) and the approved State Plan pages for S21 . We appreciate the cooperation and effort provided by your staffthroughout this process. If you have further questions about this SPA, please contact Margaret Kosherzenko of my staff at 215- 861-4288 or by email at Margaret.Kosherzenko@cms.hhs.gov. Enclosures I C

WV.0726.ROO.OO- Jan 01,2014 Page I of2 Medicaid State Plan Eligibility: Summar~' Pa!!,e (CMS 179) Statefferritory name: West Virginia Transmittal Number: Please enter the Transmittal Number (TN) in the format ST- YY-0000 wltere ST= the state abbreviatio11, YY =the last two digits of tfre submission year, and 0000 =a four digit number with leading zeros. The dashes nw.~t al.to be entered. WV-13-0020 Proposed Eff-:_ctivc Date 01101/2014 (mmldd/ yyyyJ Federal Statute/Regulation Cit.ation ACA Federal Budget Impact Federal Fiscal Year First Year 2014 Second Year 20 IS Subject of Amendment Hospital-based Presumptive Eligibility Governor's Office Review $0.00 $0.00 Governor's office reported no comment Comments of Governor's office received Describe: No reply received within 45 days of submittal ,; Other, as specified Describe: Not required. Signature of State Agency Official Submitted By: Last Revision Date: Submit Date: Sarah Young Mar 7, 2014 Jan 6, 2014 Amount http://157.199.113.99/MMDL/faces/protected/mac/cOl/print/Pri... 03/12/2014

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Page 1 of 3 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Presumptive Eligibility by Hospitals S21 42 CFR 435.1110 One or more qualified hospitals are determining presumptive eligibility under 42 CFR 435.1110, and the state is providing Medicaid coverage for individuals determined presumptively eligible under this provision. Yes No The state attests that presumptive eligibility by hospitals is administered in accordance with the following provisions: ✔ A qualified hospital is a hospital that: ■ Participates as a provider under the Medicaid state plan or a Medicaid 1115 Demonstration, notifies the Medicaid agency of its election to make presumptive eligibility determinations and agrees to make presumptive eligibility determinations consistent with state policies and procedures. ■ Has not been disqualified by the Medicaid agency for failure to make presumptive eligibility determinations in accordance with applicable state policies and procedures or for failure to meet any standards that may have been established by the Medicaid agency. ■ Assists individuals in completing and submitting the full application and understanding any documentation requirements. Yes No The eligibility groups or populations for which hospitals determine eligibility presumptively are: ■ Pregnant Women ■ Infants and Children under Age 19 ■ Parents and Other Caretaker Relatives ■ Adult Group, if covered by the state ■ Individuals above 133% FPL under Age 65, if covered by the state ■ Individuals Eligible for Family Planning Services, if covered by the state ■ Former Foster Care Children ■ Certain Individuals Needing Treatment for Breast or Cervical Cancer, if covered by the state ■ Other Family/Adult groups: Eligibility groups for individuals age 65 and over Eligibility groups for individuals who are blind Eligibility groups for individuals with disabilities Other Medicaid state plan eligibility groups Demonstration populations covered under section 1115 The state establishes standards for qualified hospitals making presumptive eligibility determinations. TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 S21-1 Effective Date: 01/01/2014

Page 2 of 3 Medicaid Eligibility Yes No Select one or both: The state has standards that relate to the proportion of individuals determined presumptively eligible who submit a regular application, as described at 42 CFR 435.907, before the end of the presumptive eligibility period. Description of standards: 75% of individuals who are determined presumptively eligible must submit a regular application prior to the end of the presumptive eligibility period. The state has standards that relate to the proportion of individuals who are determined eligible for Medicaid based on the submission of an application before the end of the presumptive eligibility period. Description of standards: 50% of individuals who are determined presumptively eligible and have submitted a regular application prior to the end of the presumptive eligibility period must be determined eligible for Medicaid. The presumptive period begins on the date the determination is made. ■ The end date of the presumptive period is the earlier of: ■ The date the eligibility determination for regular Medicaid is made, if an application for Medicaid is filed by the last day of the month following the month in which the determination of presumptive eligibility is made; or The last day of the month following the month in which the determination of presumptive eligibility is made, if no application for Medicaid is filed by that date. Periods of presumptive eligibility are limited as follows: ■ No more than one period within a calendar year. No more than one period within two calendar years. No more than one period within a twelve-month period, starting with the effective date of the initial presumptive eligibility period. Other reasonable limitation: Name of limitation Description + HBPE Period No more than one period within a twelve-month period, starting with the effective date of the initial presumptive eligibility period. West Virginia will rely on patient attestation for verifications. x + Pregnancy Pregnant women may have more than one period in 12 months in the following scenarios: -The patient has two pregnancies in a 12 month period -The patient has one pregnancy and later in the same 12 month period requests a non-pregnancy PE determination -The patient had a non-pregnancy PE determination and then later in the 12 month period becomes pregnant x TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 S21-2 Effective Date: 01/01/2014

Page 3 of 3 Medicaid Eligibility The state requires that a written application be signed by the applicant, parent or representative, as appropriate. Yes No The presumptive eligibility determination is based on the following factors: ■ The individual’s categorical or non-financial eligibility for the group for which the individual’s presumptive eligibility is being determined (e.g., based on age, pregnancy status, status as a parent/caretaker relative, disability, or other requirements specified in the Medicaid state plan or a Medicaid 1115 demonstration for that group) ■ Household income must not exceed the applicable income standard for the group for which the individual's presumptive eligibility is being determined, if an income standard is applicable for this group. ■ State residency Citizenship, status as a national, or satisfactory immigration status The state assures that it has communicated the requirements for qualified hospitals, and has provided adequate training to the hospitals. A copy of the training materials has been included. ✔ An attachment is submitted. PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 S21-3 Effective Date: 01/01/2014

HOSPITAL-BASED PRESUMPTIVE ELIGIBILITY: AUTHORIZED HOSPITAL EMPLOYEE TRAINING State of West Virginia Bureau for Medical Services

Authorized Hospital Employee Training March 2014 TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 Hospital-Based Presumptive Eligibility:Authorized Hospital EmployeeTraining-1 Effective Date: 01/01/2014

2 Table of Contents 1. Introduction

1.1 Rule Overview

1.2 Impact on Hospitals

1.3 Hospital Employee Role Overview 2. Privacy and Security 3. Process for Making a Presumptive Eligibility Determination 3.1 When to use Hospital-Based Presumptive Eligibility (HBPE) 3.2 Desktop Manual 3.3 Steps for Making a Determination 3.4 Example Scenario 3.5 AHE Dashboard and System Administrator Functionality 4. Full Medicaid Application 5. Performance Measures 6. Corrective Action 7. Test

TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 Hospital-Based Presumptive Eligibility:Authorized Hospital EmployeeTraining-2 Effective Date: 01/01/2014

3 Introduction 1.1 Rule Overview Hospital Based Presumptive Eligibility (HBPE)

• The Affordable Care Act (ACA) added section 1902(a)(47)(B) of the Social Security Act (SSA) to give hospitals the option, as of January 1, 2014, to determine presumptive eligibility for certain Medicaid coverage groups. • A qualified hospital may elect to make presumptive eligibility determinations for populations whose eligibility is determined using the Modified Adjusted Gross Income (MAGI) methodology. • Determinations are made based on preliminary information, and according to policies and procedures established by the state Medicaid agency. TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 Hospital-Based Presumptive Eligibility:Authorized Hospital EmployeeTraining-3 Effective Date: 01/01/2014

4 Introduction 1.1 Rule Overview (continued) Hospital Based Presumptive Eligibility (HBPE)

• Patients may have no more than one Presumptive Eligibility (PE) determination within a 12- month period, starting with the effective date of the initial PE period. West Virginia will rely on patient attestation for verifications in the absence of an automated system that can verify the applicant’s past use of PE. • Pregnant women may have more than one period in 12 months in the following scenarios: o The patient has two pregnancies in a 12-month period. o The patient has one pregnancy and later in the same 12-month period requests a non- pregnancy PE determination. o The patient had a non-pregnancy PE determination and then later in the 12-month period becomes pregnant. TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 Hospital-Based Presumptive Eligibility:Authorized Hospital EmployeeTraining-4 Effective Date: 01/01/2014

5 Introduction 1.2 Impact on Hospitals If a hospital elects to participate in the HBPE program, the hospital is:

• Able to bill WV Medicaid for services provided during bill for services provided during the HBPE period (for PE patients), which will reduce the number of charity care cases hospitals must cover.

• Required to adhere to the BMS policies and procedures that govern the program.

TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 Hospital-Based Presumptive Eligibility:Authorized Hospital EmployeeTraining-5 Effective Date: 01/01/2014

6 Introduction 1.3 Hospital Employee Role Overview As an Authorized Hospital Employee (AHE), you : • Must participate in this training and pass the test to achieve certification. • Must complete and submit the User Agreement with WV inROADS prior to conducting PE determinations. • Must assist the Presumptively Eligible (PE) patient in submitting their full Medicaid application. o While a full Medicaid application is strongly encouraged, it cannot be required to complete a presumptive eligibility (PE) determination. • Are encouraged to transfer any and all necessary patient intake information the hospital gathered in the registration process if it is available (such as name, address, SSN, phone number) into the patient’s HBPE questionnaire. o AHEs should also confirm all information with the patient or an individual reasonably expected to know and ask the patient if the information is correct, modifying incorrect or incomplete questions.

TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 Hospital-Based Presumptive Eligibility:Authorized Hospital EmployeeTraining-6 Effective Date: 01/01/2014

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2. Privacy and Security All patient information gathered for the PE determination and full Medicaid application must be kept confidential by the AHE and any other hospital employee who has access to the information. This includes not providing information to their employer, unless he/she has written permission from the Bureau for Medical Services to access this information. AHEs must:

1. Treat all available data as confidential information. 2. Keep passwords secured and confidential, i.e., passwords cannot be shared with co-workers or other individuals. 3. Access the online computer system using his/her own ID and password. 4. Not access or request any information that is not necessary for making PE determinations or submitting the full Medicaid application. 5. Not leave WV inROADS open unless it is secured to the extent that no one else will be able to access, use, or view the data. 6. Not disclose confidential information even after the termination of employment or the business relationship, unless specifically waived in writing by the Bureau.

TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 Hospital-Based Presumptive Eligibility:Authorized Hospital EmployeeTraining-7 Effective Date: 01/01/2014

8 Process for Making a Presumptive Eligibility Determination 3.1 When to use HBPE HBPE should be offered to individuals who are not already enrolled in Medicaid, may be eligible for Medicaid, and are West Virginia Residents, AND are a member of one or more of the following groups:

• Children under Age 19 • Pregnant Women • Adults between ages 19 and 64 • Former West Virginia Foster Care Children under age 26 • Certain Individuals Needing Treatment for Breast or Cervical Cancer • Incarcerated Individuals With Hospital Stays Exceeding 24 Hours

TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 Hospital-Based Presumptive Eligibility:Authorized Hospital EmployeeTraining-8 Effective Date: 01/01/2014

9 Process for Making a Presumptive Eligibility Determination 3.1 When to use HBPE Using the WV inROADS system you will be able to: • Submit the HBPE questionnaire on behalf of the patient. • Review the responses to each question and make the PE determination for the patient. • Provide a determination notice to the patient immediately after the determination is made.

If the patient is presumed eligible, WV inROADS will provide you with the option to continue on to the full Medicaid application.

Note: The State will track how many individuals who were presumed eligible went on to complete the full Medicaid SLA.

TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 Hospital-Based Presumptive Eligibility:Authorized Hospital EmployeeTraining-9 Effective Date: 01/01/2014

10 Process for Making a Presumptive Eligibility Determination 3.2 Desktop Manual

The Desktop Manual will be available for the hospital administrator and AHE to review at any time. For detailed step-by-step documentation, please download the desktop manual: http://www.dhhr.wv.gov/bms.

TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 Hospital-Based Presumptive Eligibility:Authorized Hospital EmployeeTraining-10 Effective Date: 01/01/2014

11 Process for Making a Presumptive Eligibility Determination 3.4 Steps for Making a Determination (Page 1)

TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 Hospital-Based Presumptive Eligibility:Authorized Hospital EmployeeTraining-11 Effective Date: 01/01/2014

12 Process for Making a Presumptive Eligibility Determination 3.4 Steps for Making a Determination (Page 2)

TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 Hospital-Based Presumptive Eligibility:Authorized Hospital EmployeeTraining-12 Effective Date: 01/01/2014

13 Process for Making a Presumptive Eligibility Determination 3.4 Steps for Making a Determination (Page 3)

TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 Hospital-Based Presumptive Eligibility:Authorized Hospital EmployeeTraining-13 Effective Date: 01/01/2014

14 Process for Making a Presumptive Eligibility Determination 3.4 Steps for Making a Determination (Complete)

TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 Hospital-Based Presumptive Eligibility:Authorized Hospital EmployeeTraining-14 Effective Date: 01/01/2014

15 Process for Making a Presumptive Eligibility Determination 3.4 Steps for Making a Determination Select TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 Hospital-Based Presumptive Eligibility:Authorized Hospital EmployeeTraining-15 Effective Date: 01/01/2014

16 Process for Making a Presumptive Eligibility Determination 3.4 Steps for Making a Determination TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 Hospital-Based Presumptive Eligibility:Authorized Hospital EmployeeTraining-16 Effective Date: 01/01/2014

17 Process for Making a Presumptive Eligibility Determination 3.4 Steps for Making a Determination TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 Hospital-Based Presumptive Eligibility:Authorized Hospital EmployeeTraining-17 Effective Date: 01/01/2014

18 Process for Making a Presumptive Eligibility Determination 3.4 Steps for Making a Determination TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 Hospital-Based Presumptive Eligibility:Authorized Hospital EmployeeTraining-18 Effective Date: 01/01/2014

19 Process for Making a Presumptive Eligibility Determination 3.4 Steps for Making a Determination Note the required fields that you must collect from the patient TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 Hospital-Based Presumptive Eligibility:Authorized Hospital EmployeeTraining-19 Effective Date: 01/01/2014

20 Process for Making a Presumptive Eligibility Determination 3.4 Steps for Making a Determination TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 Hospital-Based Presumptive Eligibility:Authorized Hospital EmployeeTraining-20 Effective Date: 01/01/2014

21 Process for Making a Presumptive Eligibility Determination 3.4 Steps for Making a Determination TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 Hospital-Based Presumptive Eligibility:Authorized Hospital EmployeeTraining-21 Effective Date: 01/01/2014

22 Process for Making a Presumptive Eligibility Determination 3.4 Steps for Making a Determination TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 Hospital-Based Presumptive Eligibility:Authorized Hospital EmployeeTraining-22 Effective Date: 01/01/2014

23 Process for Making a Presumptive Eligibility Determination 3.4 Steps for Making a Determination TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 Hospital-Based Presumptive Eligibility:Authorized Hospital EmployeeTraining-23 Effective Date: 01/01/2014

24 Process for Making a Presumptive Eligibility Determination 3.4 Steps for Making a Determination Print temporary medical card TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 Hospital-Based Presumptive Eligibility:Authorized Hospital EmployeeTraining-24 Effective Date: 01/01/2014

25 Process for Making a Presumptive Eligibility Determination 3.4 Steps for Making a Determination PE can end due to the case time period ending or the patient applying to Medicaid. TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 Hospital-Based Presumptive Eligibility:Authorized Hospital EmployeeTraining-25 Effective Date: 01/01/2014

26 Process for Making a Presumptive Eligibility Determination 3.4 Steps for Making a Determination Proceed to full application TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 Hospital-Based Presumptive Eligibility:Authorized Hospital EmployeeTraining-26 Effective Date: 01/01/2014

27 Process for Making a Presumptive Eligibility Determination 3.4 Steps for Making a Determination Error: This person has previously passed PE TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 Hospital-Based Presumptive Eligibility:Authorized Hospital EmployeeTraining-27 Effective Date: 01/01/2014

28 Process for Making a Presumptive Eligibility Determination 3.4 Steps for Making a Determination Print for ineligibility determination notifications TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 Hospital-Based Presumptive Eligibility:Authorized Hospital EmployeeTraining-28 Effective Date: 01/01/2014

29 Process for Making a Presumptive Eligibility Determination 3.4 Example Scenarios Example Scenario I: The patient is incapacitated and there is no authorized representative present.

Solution: If a patient is incapacitated but is accompanied by someone who has reasonable knowledge of the patient’s status, that person can answer the questions needed to make a HBPE determination and the patient can still receive a HBPE determination. However, to complete the full Medicaid application, either the patient or an authorized representative must be available to answer the more detailed questions on the full application. If neither the patient nor an authorized representative is available, the AHE must save the case and schedule a follow-up with the patient (if possible) to complete the full Medicaid application.

TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 Hospital-Based Presumptive Eligibility:Authorized Hospital EmployeeTraining-29 Effective Date: 01/01/2014

30 Process for Making a Presumptive Eligibility Determination 3.4 Example Scenarios Example Scenario II: The patient or authorized representative is unable to complete the full Medicaid application in real time and does not respond to AHE’s follow up.

Solution: If the patient has been determined eligible for HBPE but is unable or unwilling to complete the full Medicaid application in real time, it is the AHE’s responsibility to set up a time to follow up with that patient. Should the AHE be unsuccessful in connecting with the patient at the designated follow-up time but discovers the patient was able to complete the full Medicaid application on their own, the AHE will need to notify the hospital and the process is ended. However, if the patient has not completed the full Medicaid application on their own, the AHE must again follow up with the patient in an attempt to assist them in filling out the application, noting that the case will expire on the designated date. TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 Hospital-Based Presumptive Eligibility:Authorized Hospital EmployeeTraining-30 Effective Date: 01/01/2014

31 Process for Making a Presumptive Eligibility Determination 3.4 Example Scenarios Example Scenario III: The patient completes their PE determination at Hospital A but is transferred to Hospital B for further treatment. Who is responsible for completing the full Medicaid application?

Solution: In this case, Hospital A should include the patient’s temporary card in the paperwork transfer to Hospital B. Additionally, Hospital A should communicate to Hospital B that the patient will need to complete their full application. Following up with the patient is Hospital A’s responsibility. The responsibility of the PE patient does not leave the hospital when the patient leaves. Should Hospital B complete the full Medicaid application with the patient, it would be credited to Hospital A. TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 Hospital-Based Presumptive Eligibility:Authorized Hospital EmployeeTraining-31 Effective Date: 01/01/2014

32 Process for Making a Presumptive Eligibility Determination 3.5 AHE Dashboard and System Administrator Functionality Worker Dashboard Worker Dashboard Learn More About: helpful links TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 Hospital-Based Presumptive Eligibility:Authorized Hospital EmployeeTraining-32 Effective Date: 01/01/2014

33 Process for Making a Presumptive Eligibility Determination 3.5 AHE Dashboard and System Administrator Functionality Application Search: Example Outcome Application Search: Example Outcome TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 Hospital-Based Presumptive Eligibility:Authorized Hospital EmployeeTraining-33 Effective Date: 01/01/2014

34 Process for Making a Presumptive Eligibility Determination 3.5 AHE Dashboard and System Administrator Functionality How many applications are saved and set to expire in the next 5 days? TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 Hospital-Based Presumptive Eligibility:Authorized Hospital EmployeeTraining-34 Effective Date: 01/01/2014

35 Process for Making a Presumptive Eligibility Determination 3.5 AHE Dashboard and System Administrator Functionality Applications set to expire TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 Hospital-Based Presumptive Eligibility:Authorized Hospital EmployeeTraining-35 Effective Date: 01/01/2014

36 Process for Making a Presumptive Eligibility Determination 3.5 AHE Dashboard and System Administrator Functionality TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 Hospital-Based Presumptive Eligibility:Authorized Hospital EmployeeTraining-36 Effective Date: 01/01/2014

37 Process for Making a Presumptive Eligibility Determination 3.5 AHE Dashboard and System Administrator Functionality TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 Hospital-Based Presumptive Eligibility:Authorized Hospital EmployeeTraining-37 Effective Date: 01/01/2014

38 Process for Making a Presumptive Eligibility Determination 3.5 AHE Dashboard and System Administrator Functionality For system administrators: Create New User For system administrators: Create New User TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 Hospital-Based Presumptive Eligibility:Authorized Hospital EmployeeTraining-38 Effective Date: 01/01/2014

39 Process for Making a Presumptive Eligibility Determination 3.5 AHE Dashboard and System Administrator Functionality For system administrators: Create New User For system administrators: Create New User TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 Hospital-Based Presumptive Eligibility:Authorized Hospital EmployeeTraining-39 Effective Date: 01/01/2014

40 Process for Making a Presumptive Eligibility Determination 3.5 AHE Dashboard and System Administrator Functionality For system administrators: Create New User For system administrators: Create New User TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 Hospital-Based Presumptive Eligibility:Authorized Hospital EmployeeTraining-40 Effective Date: 01/01/2014

41 Process for Making a Presumptive Eligibility Determination 3.5 AHE Dashboard and System Administrator Functionality TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 Hospital-Based Presumptive Eligibility:Authorized Hospital EmployeeTraining-41 Effective Date: 01/01/2014

Break Next: Full Medicaid Application Process TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 Hospital-Based Presumptive Eligibility:Authorized Hospital EmployeeTraining-42 Effective Date: 01/01/2014

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4. Full Medicaid Application • AHEs are not required to assist patients in completing any other applications except for the Medicaid Stream-Lined Application. • If patients ask AHEs about applying to other programs, the AHEs may point the patients to their local DHHR office or WV inROADS (https://www.wvinroads.org). TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 Hospital-Based Presumptive Eligibility:Authorized Hospital EmployeeTraining-43 Effective Date: 01/01/2014

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4. Full Medicaid Application Program Selection TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 Hospital-Based Presumptive Eligibility:Authorized Hospital EmployeeTraining-44 Effective Date: 01/01/2014

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4. Full Medicaid Application Privacy Practice TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 Hospital-Based Presumptive Eligibility:Authorized Hospital EmployeeTraining-45 Effective Date: 01/01/2014

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4. Full Medicaid Application Application Details TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 Hospital-Based Presumptive Eligibility:Authorized Hospital EmployeeTraining-46 Effective Date: 01/01/2014

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4. Full Medicaid Application Contact Information – Authorized Representative TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 Hospital-Based Presumptive Eligibility:Authorized Hospital EmployeeTraining-47 Effective Date: 01/01/2014

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4. Full Medicaid Application Contact Information – Authorized Representative TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 Hospital-Based Presumptive Eligibility:Authorized Hospital EmployeeTraining-48 Effective Date: 01/01/2014

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4. Full Medicaid Application Additional Contact Information - optional TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 Hospital-Based Presumptive Eligibility:Authorized Hospital EmployeeTraining-49 Effective Date: 01/01/2014

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4. Full Medicaid Application Registration Information TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 Hospital-Based Presumptive Eligibility:Authorized Hospital EmployeeTraining-50 Effective Date: 01/01/2014

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4. Full Medicaid Application Registration Summary TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 Hospital-Based Presumptive Eligibility:Authorized Hospital EmployeeTraining-51 Effective Date: 01/01/2014

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4. Full Medicaid Application Household Member Details TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 Hospital-Based Presumptive Eligibility:Authorized Hospital EmployeeTraining-52 Effective Date: 01/01/2014

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4. Full Medicaid Application Pregnancy TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 Hospital-Based Presumptive Eligibility:Authorized Hospital EmployeeTraining-53 Effective Date: 01/01/2014

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4. Full Medicaid Application Household Relationships TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 Hospital-Based Presumptive Eligibility:Authorized Hospital EmployeeTraining-54 Effective Date: 01/01/2014

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4. Full Medicaid Application Household Members Questions (applicant) TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 Hospital-Based Presumptive Eligibility:Authorized Hospital EmployeeTraining-55 Effective Date: 01/01/2014

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4. Full Medicaid Application School Enrollment (applicant) TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 Hospital-Based Presumptive Eligibility:Authorized Hospital EmployeeTraining-56 Effective Date: 01/01/2014

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4. Full Medicaid Application Household Members Summary TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 Hospital-Based Presumptive Eligibility:Authorized Hospital EmployeeTraining-57 Effective Date: 01/01/2014

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4. Full Medicaid Application Tax Filing Question TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 Hospital-Based Presumptive Eligibility:Authorized Hospital EmployeeTraining-58 Effective Date: 01/01/2014

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4. Full Medicaid Application Tax Filing Details TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 Hospital-Based Presumptive Eligibility:Authorized Hospital EmployeeTraining-59 Effective Date: 01/01/2014

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4. Full Medicaid Application Tax Filing Summary TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 Hospital-Based Presumptive Eligibility:Authorized Hospital EmployeeTraining-60 Effective Date: 01/01/2014

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4. Full Medicaid Application Insurance Questions TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 Hospital-Based Presumptive Eligibility:Authorized Hospital EmployeeTraining-61 Effective Date: 01/01/2014

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4. Full Medicaid Application Healthcare Coverage Details TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 Hospital-Based Presumptive Eligibility:Authorized Hospital EmployeeTraining-62 Effective Date: 01/01/2014

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4. Full Medicaid Application Healthcare Coverage Selections TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 Hospital-Based Presumptive Eligibility:Authorized Hospital EmployeeTraining-63 Effective Date: 01/01/2014

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4. Full Medicaid Application Lost Health Insurance Details TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 Hospital-Based Presumptive Eligibility:Authorized Hospital EmployeeTraining-64 Effective Date: 01/01/2014

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4. Full Medicaid Application Insurance Summary TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 Hospital-Based Presumptive Eligibility:Authorized Hospital EmployeeTraining-65 Effective Date: 01/01/2014

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4. Full Medicaid Application Job Income Questions TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 Hospital-Based Presumptive Eligibility:Authorized Hospital EmployeeTraining-66 Effective Date: 01/01/2014

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4. Full Medicaid Application Employment Details TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 Hospital-Based Presumptive Eligibility:Authorized Hospital EmployeeTraining-67 Effective Date: 01/01/2014

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4. Full Medicaid Application Self-Employment Type Selections TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 Hospital-Based Presumptive Eligibility:Authorized Hospital EmployeeTraining-68 Effective Date: 01/01/2014

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4. Full Medicaid Application Self-Employment Details TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 Hospital-Based Presumptive Eligibility:Authorized Hospital EmployeeTraining-69 Effective Date: 01/01/2014

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4. Full Medicaid Application Job Income Summary TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 Hospital-Based Presumptive Eligibility:Authorized Hospital EmployeeTraining-70 Effective Date: 01/01/2014

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4. Full Medicaid Application Other Income Questions TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 Hospital-Based Presumptive Eligibility:Authorized Hospital EmployeeTraining-71 Effective Date: 01/01/2014

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4. Full Medicaid Application Other Income Type Selection TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 Hospital-Based Presumptive Eligibility:Authorized Hospital EmployeeTraining-72 Effective Date: 01/01/2014

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4. Full Medicaid Application Other Income Details TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 Hospital-Based Presumptive Eligibility:Authorized Hospital EmployeeTraining-73 Effective Date: 01/01/2014

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4. Full Medicaid Application Other Income Summary TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 Hospital-Based Presumptive Eligibility:Authorized Hospital EmployeeTraining-74 Effective Date: 01/01/2014

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4. Full Medicaid Application Other Bills Question TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 Hospital-Based Presumptive Eligibility:Authorized Hospital EmployeeTraining-75 Effective Date: 01/01/2014

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4. Full Medicaid Application Deduction Type Selections TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 Hospital-Based Presumptive Eligibility:Authorized Hospital EmployeeTraining-76 Effective Date: 01/01/2014

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4. Full Medicaid Application Deduction Details TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 Hospital-Based Presumptive Eligibility:Authorized Hospital EmployeeTraining-77 Effective Date: 01/01/2014

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4. Full Medicaid Application Other Bills Summary TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 Hospital-Based Presumptive Eligibility:Authorized Hospital EmployeeTraining-78 Effective Date: 01/01/2014

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4. Full Medicaid Application Yearly Income Question TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 Hospital-Based Presumptive Eligibility:Authorized Hospital EmployeeTraining-79 Effective Date: 01/01/2014

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4. Full Medicaid Application Yearly Income Details TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 Hospital-Based Presumptive Eligibility:Authorized Hospital EmployeeTraining-80 Effective Date: 01/01/2014

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4. Full Medicaid Application Health Coverage from Employment Details TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 Hospital-Based Presumptive Eligibility:Authorized Hospital EmployeeTraining-81 Effective Date: 01/01/2014

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4. Full Medicaid Application AI/AN Details TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 Hospital-Based Presumptive Eligibility:Authorized Hospital EmployeeTraining-82 Effective Date: 01/01/2014

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4. Full Medicaid Application Additional Information Summary TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 Hospital-Based Presumptive Eligibility:Authorized Hospital EmployeeTraining-83 Effective Date: 01/01/2014

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4. Full Medicaid Application Application Submission TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 Hospital-Based Presumptive Eligibility:Authorized Hospital EmployeeTraining-84 Effective Date: 01/01/2014

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4. Full Medicaid Application Next Steps Overview – send to FFM TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 Hospital-Based Presumptive Eligibility:Authorized Hospital EmployeeTraining-85 Effective Date: 01/01/2014

Break Next: • Performance Measures • Corrective Action • Test TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 Hospital-Based Presumptive Eligibility:Authorized Hospital EmployeeTraining-86 Effective Date: 01/01/2014

87 5. Performance Measures BMS will be tracking each hospital’s performance as dictated by the following measurements:

1. 75% of patients who have been approved for HBPE have followed up and filled out the full Medicaid application prior to their designated case expiration date. 2. 50% of patients found eligible for HBPE and who have completed the full Medicaid application were found eligible for full Medicaid benefits. • Reports will be delivered quarterly to each hospital o These reports will provide data at the hospital level and at the individual AHE level. o These reports will allow the Bureau and the hospital to evaluate whether performance issues are hospital-wide or specific to an individual AHE. TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 Hospital-Based Presumptive Eligibility:Authorized Hospital EmployeeTraining-87 Effective Date: 01/01/2014

88 6. Corrective Action If a hospital has missed their performance standards: • They will have the opportunity to re-train and make a good faith effort to improve their performance. • They will have one full quarter to recover their performance.

If a hospital missed a performance goal in Quarter 1, the corrective action plan would proceed according to the following process: TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 Hospital-Based Presumptive Eligibility:Authorized Hospital EmployeeTraining-88 Effective Date: 01/01/2014

89 6. Corrective Action TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 Hospital-Based Presumptive Eligibility:Authorized Hospital EmployeeTraining-89 Effective Date: 01/01/2014

90 7. Test 1. Which groups of individuals who reside in WV may be eligible for PE? a. Children under age 19 b. Pregnant women c. Individuals aged 19 to 64 d. Former West Virginia foster care children under age 26 e. Certain individuals needing treatment for breast or cervical cancer f. Incarcerated Individuals With Hospital Stays Exceeding 24 Hours g. All of the above

TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 Hospital-Based Presumptive Eligibility:Authorized Hospital EmployeeTraining-90 Effective Date: 01/01/2014

91 7. Test 2. You are required to assist PE patients with their full Medicaid applications. a. True b. False TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 Hospital-Based Presumptive Eligibility:Authorized Hospital EmployeeTraining-91 Effective Date: 01/01/2014

92 7. Test 3. Can I log in with another AHE’s username and password to help them complete their patient applications? a. Yes, I can log in with their information anytime b. Yes, I can log in with their information, but only if I have express permission from them to do so c. No, but I can help them with their case load by using the WV inROADS dashboard to search for their patient and working the case through my account d. No, it is never acceptable to help with their cases TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 Hospital-Based Presumptive Eligibility:Authorized Hospital EmployeeTraining-92 Effective Date: 01/01/2014

93 7. Test 4. The same patient who was denied PE last week is trying to apply again using different information. What negative determination notification would you select? a. Your income exceeds the applicable income standard b. You have had a PE period previously in the past 12 months c. You are not a United States Citizen d. Administrative Denial (with a written explanation) e. None of these

TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 Hospital-Based Presumptive Eligibility:Authorized Hospital EmployeeTraining-93 Effective Date: 01/01/2014

94 7. Test 5. If a patient is transferred to your hospital and shows you their temporary medical card, you can assist them with their full Medicaid Application. a. True b. False

TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 Hospital-Based Presumptive Eligibility:Authorized Hospital EmployeeTraining-94 Effective Date: 01/01/2014

95 7. Test 6. You are speaking with a pregnant patient. After you enter her information into WV inROADS, the error reading “An individual with this SSN has been approved for presumptive eligibility in the last 12 months. Please evaluate accordingly.” appears. How do you proceed? a. Tell the patient that she can not be determined PE at this time due to the system alerting you that she has had it in the past 12 months b. Save and close the program c. Proceed with the PE determination because a patient can have two PE determinations in a 12-month period if one of them is for pregnancy d. None of the above

TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 Hospital-Based Presumptive Eligibility:Authorized Hospital EmployeeTraining-95 Effective Date: 01/01/2014

96 7. Test 7. BMS will be able to track hospital performance according to documented performance measures but will not be able to track individual AHE performance. a. True b. False

TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 Hospital-Based Presumptive Eligibility:Authorized Hospital EmployeeTraining-96 Effective Date: 01/01/2014

97 7. Test 8. If a hospital fails to meet one of the performance measures and is able to improve their performance after following the Corrective Action process, they will not be removed from the HBPE program. 8. True 9. False TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 Hospital-Based Presumptive Eligibility:Authorized Hospital EmployeeTraining-97 Effective Date: 01/01/2014

98 7. Test 9. What are you required to do after assisting a PE patient in completing and submitting their full Medicaid application? a. Help the patient apply for SNAP b. The process is complete c. Help the patient apply for Medicare

TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 Hospital-Based Presumptive Eligibility:Authorized Hospital EmployeeTraining-98 Effective Date: 01/01/2014

99 7. Test 10. When is the best time to assist a PE patient with their full Medicaid application? a. Between 6 p.m. and 10 p.m. b. Right after completing the HBPE questionnaire in WV inROADS c. Right After the patient is done being treated d. Two weeks after the patient visits the hospital e. On the patient’s birthday TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 Hospital-Based Presumptive Eligibility:Authorized Hospital EmployeeTraining-99 Effective Date: 01/01/2014

100 7. Test 11. Once you have made a PE determination for a patient, what is the next step? a. Print either the temporary medical card or the ineligibility determination notification and give it to the patient b. Begin filling out their Medicaid application without giving them any printed PDFs from WV inROADS c. Talk to them about other healthcare programs they can apply for d. None of these TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 Hospital-Based Presumptive Eligibility:Authorized Hospital EmployeeTraining-100 Effective Date: 01/01/2014

101 7. Test 12. If a PE patient has received their temporary medical card but refuses or is unable to complete the full Medicaid application immediately after their PE determination, what should you do? a. Attempt to schedule a follow-up b. Explain all the ways the patient can complete their full Medicaid application c. Fill out as much of the Medicaid application for the patient as possible without the patient’s consent d. A and B e. A and C f. A, B and C TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 Hospital-Based Presumptive Eligibility:Authorized Hospital EmployeeTraining-101 Effective Date: 01/01/2014

102 7. Test 13. If a patient indicates that they are currently receiving treatment for breast or cervical cancer, what is the next step after the patient has received their PE determination? a. Assist the patient in completing their full Medicaid application b. The process is complete at this point c. Save and close the application d. Using the tool in the AHE’s dashboard, offer to help the patient find a convenient screening facility to them, and then assist them with their full Medicaid application e. None of the above TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 Hospital-Based Presumptive Eligibility:Authorized Hospital EmployeeTraining-102 Effective Date: 01/01/2014

103 7. Test 14. Can an emergency room patient who is traveling in West Virginia on vacation receive hospital based presumptive eligibility? a. Yes b. No TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 Hospital-Based Presumptive Eligibility:Authorized Hospital EmployeeTraining-103 Effective Date: 01/01/2014

HOSPITAL-BASED PRESUMPTIVE ELIGIBILITY: AUTHORIZED HOSPITAL EMPLOYEE TRAINING State of West Virginia Bureau for Medical Services Thank you! TN No. 13-0020-MM7 West Virginia Approval Date: 03/18/2014 Hospital-Based Presumptive Eligibility:Authorized Hospital EmployeeTraining-104 Effective Date: 01/01/2014

Table of Contents State Name: West Virginia State Plan Amendment (SPA) #: 14-0007 This file contains the following documents in the order listed:

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

/S/

/S/ Francis McCullough Associate Regional Administrator

Cems, Medicaid Premiums and Cost Sharing

State Name: {West Virginia | ‘Transmittal Number: wv - 14 - 0007

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

1916 1916A 42 CFR 447.50 through 447.57 (excluding 447.55)

The state charges cost sharing (deductibles, co-insurance or co-payments) to individuals covered under Medicaid. Yes

The state assures that it administers cost sharing in accordance with sections 1916 and 1916A of the Social Security Act and 42 CFR 447.50 through 447.57.

General Provisions

{Z] The cost sharing amounts established by the state for services are always less than the amount the agency pays for the service,

[J No provider may deny services to an eligible individual on account of the individual's inability to pay cost sharing, except as elected by the state in accordance with 42 CFR 447.52(e)(1).

‘The process used by the state to inform providers whether cost sharing for a specific item or service may be imposed ona beneficiary and whether the provider may require the beneficiary to pay the cost sharing charge, as a condition for receiving the item or service, is (check all that apply):

‘The state includes an indicator in the Medicaid Management Information System (MMIS)

‘The state includes an indicator in the Eligibility and Enrollment System

The state includes an indicator in the Eligibility Verification System

[7] The state includes an indicator on the Medicaid card, which the beneficiary presents to the provider {7] Other process

fi] Contracts with managed care organizations (MCOs) provide that any cost-sharing charges the MCO imposes on Medicaid

enrollees are in accordance with the cost sharing specified in the state plan and the requirements set forth in 42 CFR 447.50 through 447.57.

Cost Sharing for Non-Emergency Services Provided in a Hospital Emergency Department The state imposes cost sharing for non-emergency services provided in a hospital emergency department. Yes

The state ensures that before providing non-emergency services and imposing cost sharing for such services, that the hospitals providing care:

fi) Conduct an appropriate medical screening under 42 CFR 489.24, subpart G to determine that the individual does not need emergency services;

[i] Inform the individual of the amount of his or her cost sharing obligation for non-emergency services provided in the emergency department;

fi] Provide the individual with the name and location of an available and accessible alternative non-emergency services provider;

Page | of 3

Transmittal Number 14-0007 Approval Date: September 18, 2015 Effective Date: January 1, 2014 West Virginia

ORLA THEE RRC TEENS

Medicaid Premiums and Cost Sharing

{&] Determine that the alternative provider can provide services to the individual in a timely manner with the imposition of a lesser cost sharing amount or no cost sharing if the individual is otherwise exempt from cost

sharing: and Provide a referral to coordinate scheduling for treatment by the alternative provider.

The state assures that it has a process in place to identify hospital emergency department services as non-emergency for purposes of imposing cost sharing. This process does not limit a hospital's obligations for screening and stabilizing treatment of an emergency medical condition under section 1867 of the Act; or modify any obligations under either state or federal standards relating to the application of a prudent-layperson standard for payment or coverage of emergency medical services by any managed care organization.

The process for identifying emergency department services as non-emergency for purposes of imposing cost sharing is:

Hospitals will provide an appropriate medical screening evaluation on the individual to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations. If it is determined that it is not a condition that requires emergency treatment, ithe hospital will assist the recipient in locating a non-emergency services provider including determining whether the alternative provider can provide services to the individual in a timely manner. If the recipient decides to be treated at the lemergency department for the non-emergency condition they will be informed at that time of the co-payment they will be

charged.

Cost Sharing for Drugs

The state charges cost sharing for drugs. Yes

The state has established differential cost sharing for preferred and non-preferred drugs. All drugs will be considered preferred drugs. Beneficiary and Public Notice Requirements

Consistent with 42 CFR 447.57, the state makes available a public schedule describing current cost sharing, requirements in a manner that ensures that affected applicants, beneficiaries and providers are likely to have access to the notice, Prior to submitting a SPA which establishes or substantially modifies existing cost sharing amounts or policies, the state provides the public with advance notice of the SPA, specifying the amount of cost sharing and who is subject to the charges, and provides reasonable opportunity for stakeholder comment. Documentation demonstrating that the notice requirements have been met are submitted with the SPA. The state also provides opportunity for additional public notice if cost sharing is substantially modified during the SPA approval process.

Other Relevant Information

| fe)

3

Transmittal Number 14-0007 Approvai Date: September 18, 2015 West Virginia .

Page 2 of 3

Effective Date: January 1, 2014

Cems Medicaid Premiums and Cost Sharing

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 contro! number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of

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

V.20140415

Page 3 of 3

Transmittal Number 14-0007 Approval Date: September 18, 2015 , Effective Date: January 1, 2014 West Virginia

AOE MEER A SORENSEN

Medicaid Premiums and Cost Sharing

State Name: [West Virginia

Transmittal Number: WV -

1916 1916A 42 CFR 447.52 through 54

14 - 0007

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

The state charges cost sharing to all categorically needy (Mandatory Coverage and Options for Coverage) individuals.

Services or Items with the Same Cost Sharing Amount for All Incomes

Service or Item

Amount

Explanation

Prescribed drugs

0.50

Prescribed drugs

1.00

; | Prescribed drugs

2.00

eg] Prescribed drugs

3.00

8.00

If the State's payment is $5.01 to $10.00 the Co-pay is $.50

if the State's payment is $10.01 to $25.00 the Co-pay is $1.00

If the State's payment is $25.01 to $50.00 the Co-pay is $2.00

If the State's payment is $50.01 and above the Co-pay is $3.00

If after an appropriate medical evaluation it is determined that it is not a condition that requires emergency treatment and the member still opts to be treated at the ER, the member will be required to pay the $8 co-pay.

Services or Items with Cost Sharing Amounts that Vary by Income

Remoye Service Service or Item:|Inpatient Hospital (Acute Care) Oh ponds: Indicate the income ranges by which the cost sharing amount for this service or item varies. Incomes | Incomes Less Dollars or Greater than |than or Equal to} Amount |Percentage| Unit Explanation hi 10.00% of 50.00% of FPL 0.00) . $0.00 per admission. WV will reduce a Lee IFPL, s Entire Stay provider's reimbursement by $0.00. 5450.01% of —|100.00% of 35.00 $35.00 per admission. WV will reduce a ens EPL EPL s provider's reimbursement by $35.00. Service or Item;{Office Visit

Indicate the income ranges by which the cost sharing amount for this service or item varies.

Explanation

Incomes | Incomes Less Dollars or Greater than |than or Equal to] Amount |{Percentage| Unit - 40.00% of — |50.00% of FPL 0.00 ai FPL 6

For providers of CPT Codes 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, and 99215 WV will reduce a provider's reimbursement by $0.00.

Transmittal Number 14-0007

West Virginia

Approval Date: September 18, 2015

Page | of 2

Effective Date: January 1, 2014

Medicaid Premiums and Cost Sharing

Incomes Less Dollars or than or Equal to} Amount |Percentage| Unit 100.00% of 2.00 FPL a i Visit

Explanation

For providers of CPT Codes 99201, 99202, '99203,.99204, 99205, 99212, 99213, 99214, and 99215 WV will reduce a provider's

reimbursement by $2.00.

Service or ltemAny outpatient surgical services excluding emergency rooms

a

Indicate the incom

e ranges by whic

h the cost sharing amount for this service or item varies.

or ite

Incomes Incomes Less Dollars or Greater than |than or Equal to] Amount {Percentage Unit Explanation 10.00% of 50.00% of FPL 0.00) Any outpatient surgical services rendered in a EPL physician's office, Ambulatory Surgical s ‘Other (Center or Outpatient Hospital excluding lemergency services, WV will reduce a provider's reimbursement by $0.00 50.01% of —|100.00% of 2.00 Any outpatient surgical services rendered in FPL FPL. physician's office, Ambulatory Surgical i$ Center or Outpatient Hospital excluding lemergency services, WV will reduce a

provider's reimbursement by $2.00

Exempt {ndividuals

the following question:

exempt individuals.

Cost Sharing for Non-preferved Drugs Charged to Otherwise Exempt individuals

Ifthe state charges cost sharing for non-preferred drugs (entered above), answer the following question:

The state charges cost sharing for non-preferred drugs to otherwise exempt individuals.

Cost Sharing for Non-emergency Services Provided in the Hospital Emergency Department Charged to Otherwise

If the state charges cost sharing for non-emergency services provided in the hospital emergency department (entered above), answer

The state charges cost sharing for non-emergency services provided in the hospital emergency department to otherwise

No

PRA Disclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

Transmittal Number 14-0007

West Virginia

Approval Date: September 18, 2015

V.20140415

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Effective Date: January 1, 2014

Cems Medicaid Premiums and Cost Sharing

State Name:|West Virginia | OMB Control Number: 0938-1148 Transmittal Number: 14 - - 0007 Expiration date: 10/31/2014

1916 1916A 42 CFR 447.52 through 54

‘The state charges cost sharing to all medically needy individuals.

The cost sharing charged to medically needy individuals is the same as that charged to categorically needy individuals. | Yes

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance

Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. V.20140415

Page | of |

Transmittal Number 14-0007 Approval Date: September 18, 2015 Effective Date: January 1, 2014 West Virginia

Medicaid Premiums and Cost Sharing

Sie he aGican ktecneD ERIC

| OMB Control Number: 0938-1148

State Name:| West Virginia Expiration date: 10/31/2014

Transmittal Number: WV - 14 - 0007

1916

1916A

42 CFR 447.52 through 54

‘The state targets cost sharing to a specific group or groups of individuals. Yes Population Name (optional): | _|

Eligibility Group(s) Included: | Adult Expansion Group (100.01-133% FPL); Transitional Medicaid (Phase I 100.01-No Limit FPL) ‘(Phase If 100.01-185% FPL); Extended Medicaid (100.01-No Limit FPL); Former WV Foster Children (100.01-No Limit FPL); Working disabled individuals (M-WIN)(100.01-250% FPL); Medically Needy (spenddown) for aged, blind and disabled (SSI-Related)(100.01-No Limit FPL); Medically Needy (spenddown) for specified relatives (AFDC-Retated)(100.01-No Limit FPL)

4FPL| TO Incomes Less than or Equal to [|

Incomes Greater than Dollars or Service Amount _ [Percentage Unit -___ Explanation iNon-Emergency Use of 8.00 If after an appropriate medical evaluation it is

determined that it is not a condition that requires emergency treatment and the member still opts to be treated at the ER, the member will be required to pay the $8 co- _i|P2Y-

$75.00 per admission. WV will reduce a provider's reimbursement by $75.00. The laverage inpatient cost for SFY is $5,042.00 For providers of CPT Codes 99201, 99202, 199203, 99204, 99205, 99212, 99213, 99214, and 99215 WV will reduce a provider's reimbursement by $4.00. The average office visit reimbursement is $52.22.

Any outpatient surgical services rendered in a physician's office, Ambulatory Surgical (Center or Outpatient Hospital excluding lemergency services, WV will reduce a provider's reimbursement by $4.00

‘4Emergency Department - Hospital Only

s

‘Inpatient Hospital (Acute Care) 75.00)

Office Visit 4.00

E A

4] Any outpatient surgical services 4.00 excluding emergency room

Ess es

The state permits providers to require individuals fo pay cost sharing as a condition for receiving items or services, subject to the conditions specified at 42 CFR 447.52(e)(1). This is only permitted for non-exempt individuals with family income above} Yes 100% FPL, Providers may require payment of cost sharing as a condition for receiving all items or services listed above. Yes Page | of 2

Transmittal Number 14-0007 Approval Date: September 18, 2015 Effective Date: January 1, 2014

West Virginia

CEmMsS. Medicaid Premiums and Cost Sharing

Cost Sharing for Non-preferred Drugs Charged to Otherwise Exempt Individuals

If the state targets cost sharing for non-preferred drugs to specific groups of individuals (entered above), answer the following question:

The state charges cost sharing for non-preferred drugs to otherwise exempt individuals. No

Cost Sharing for Non-emergency Services Provided in the Hospital Emergency Department Charged to Otherwise Exempt Individuals

If the state charges cost sharing for non-emergency services provided in the hospital emergency department to specific individuals (entered above), answer the following question:

The state charges cost sharing for non-emergency services provided in the hospital emergency department to otherwise

fi No exempt individuals.

PRA Disclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, scarch 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.20140415

Page 2 of 2

Transmittal Number 14-0007 Approval Date: September 18, 2015 Effective Date: January 1, 2014 West Virginia

(RAS Medicaid Premiums and Cost Sharing

State Name:|West Virginia | OMB Control Number: 0938-1148 14

Transmittal Number: 1007 Expiration date: 10/31/2014

42 CFR 447.56 1916 1916A

‘The state administers cost sharing in accordance with the limitations described at 42 CFR 447.56, and 1916(a)(2) and (j) and 1916A(b) of the Social Security Act, as follows:

OA ions Groups of individuals - Mandatory Exemptions ‘The state may not impose cost sharing upon the following groups of individuals:

{@] Individuals ages | and older, and under age 18 eligible under the Infants and Children under Age 18 eligibility group (42 CFR 435.118).

[i] Infants under age | eligible under the Infants and Children under Age 18 eligibility group (42 CFR 435.118), whose income does not exceed the higher of:

[i] 133% FPL; and

(&] 1f applicable, the percent FPL described in section 1902(1)(2)(A)(iv) of the Act, up to 185 percent. Disabled or blind individuals under age 18 eligible for the following eligibility groups:

SSI Beneficiaries (42 CFR 435.120). ,

[@] Blind and Disabled Individuals in 209(b) States (42 CFR 435.121).

Individuals Receiving Mandatory State Supplements (42 CFR 435.130).

Children for whom child welfare services are made available under Part B of title LV of the Act on the basis of being a child in foster care and individuals receiving benefits under Part E of that title, without regard to age.

[i] Disabled children eligible for Medicaid under the Family Opportunity Act (1902(a)(10)(A)Gi)(XIX) and 1902(cc) of the Act).

Pregnant women, during pregnancy and through the postpartum period which begins on the last day of pregnancy and extends through the end of the month in which the 60-day period following termination of pregnancy ends, except for cost sharing for services specified in the state plan as not pregnancy-related.

Any individual whose medical assistance for services furnished in an institution is reduced by amounts reflecting available income other than required for personal needs.

An individual receiving hospice care, as defined in section 1905(o) of the Act.

{&] Indians who are currently receiving or have ever received an item or service furnished by an Indian health care provider or through referral under contract health services.

Individuals who are receiving Medicaid because of the state's election to extend coverage to the Certain Individuals Needing, Treatment for Breast or Cervical Cancer eligibility group (42 CFR 435.213).

Page | of 5

Transmittal Number 14-0007 Approval Date: September 18, 2015 Effective Date: January 1, 2014 West Virginia

i

_oRMiS Medicaid Premiums and Cost Sharing

Groups of Individuals - Optional Exemptions

The state may elect to exempt the following groups of individuals from cost sharing:

The state elects to exempt individuals under age 19, 20 or 21, or any reasonable category of individuals 18 years of age Yes or over.

Indicate below the age of the exemption: ( Under age 19 C Under age 20 @ Under age 21

(Other reasonable category

The state elects to exempt individuals whose medical assistance for services furnished in a home and community-based No setting is reduced by amounts reflecting available income other than required for personal needs.

Services - Mandatory Exemptions The state may not impose cost sharing for the following services: [ai] Emergency services as defined at section 1932(b)(2) of the Act and 42 CFR 438.114(a).

[i] Family planning services and supplies described in section 1905(a)(4)(C) of the Act, including contraceptives and

Pharmaceuticals for which the state claims or could claim federal match at the enhanced rate under section 1903(a)(5) of the Act for family planning services and supplies.

Preventive services, at a minimum the services specified at 42 CFR 457.520, provided to children under 18 years of age

regardless of family income, which reflect the well-baby and well child care and immunizations in the Bright Futures guidelines issued by the American Academy of Pediatrics.

[&] Pregnancy-related services, including those defined at 42 CFR 440.210(a)(2) and 440.250(p), and counseling and drugs for

cessation of tobacco use. All services provided to pregnant women will be considered pregnancy-related, except those services specificially identified in the state plan as not being related to pregnancy.

Provider-preventable services as defined'in 42 CFR 447.26(b). Enforceability of Exemptions

The procedures for implementing and enforcing the exemptions from cost sharing contained in 42 CFR 447.56 are (check all that apply):

To identify that American Indians/Alaskan Natives (AI/AN) are currently receiving or have ever received an item or service

furnished by an Indian health care provider or through referral under contract health services in accordance with 42 CFR 447,56(a)(1)(x), the state uses the following procedures:

{] The state accepts self-attestation

[7] The state runs periodic claims reviews

[7] The state obtains an Active or Previous User Letter or other Indian Health Services (IHS) document

{([) The Eligibility and Enrollment and MMIS systems flag exempt recipients

Page 2 of 5

Transmittal Number 14-0007 Approval Date: September 18, 2015 Effective Date: January 1, 2014 West Virginia

Medicaid Premiums and Cost Sharing

enyaTED A ectenuee A eocHSMCE

[7] Other procedure

Additional description of procedures used is provided below (optional):

(The state utilizes the single streamlined application for self-attestation purposes.

To identify all other individuals exempt from cost sharing, the state uses the following procedures (check all that apply): {] The MMIS system flags recipients who are exempt The Eligibility and Enrollment System flags recipients who are exempt [7] The Medicaid card indicates if beneficiary is exempt The Eligibility Verification System notifies providers when a beneficiary is exempt (7) Other procedure

Additional description of procedures used is provided below (optional):

Payments to Providers

‘The state reduces the payment it makes to a provider by the amount of a beneficiary's cost sharing obligation, regardless of whether the provider has collected the payment or waived the cost sharing, except as provided under 42 CFR 447.56(c).

[Payments naped Care Or izations The state contracts with ane or more managed care organizations to deliver services under Medicaid. Yes

The state calculates its payments to managed care organizations to include cost sharing established under the state plan for beneficiaries not exempt from cost sharing, regardless of whether the organization imposes the cost sharing on its recipient members or the cost sharing is collected.

Ageregate Limits

Medicaid premiums and cost sharing incurred by all individuals in the Medicaid household do not exceed an aggregate limit of 5 percent of the family's income applied on a quarterly or monthly basis.

[&] The percentage of family income used for the aggregate limit is:

Page 3 of 5

Transmittal Number 14-0007 Approval Date: September 18, 2015 Effective Date: January 1, 2014

West Virginia

_ RAS Medicaid Premiums and Cost Sharing

@ 5%

C 4%

C 3%

C 2%

C 1%

( Other: [Jv

[i] The state calculates family income for the purpose of the aggregate limit on the following basis:

@ Quarterly

C Monthly

The state has a process to track each family's incurred premiums and cost sharing through a mechanism that does not

Yes rely on beneficiary documentation,

Describe the mechanism by which the state tracks each family's incurred premiums and cost sharing (check all that apply):

BX] As claims are submitted for dates of services within the family's current monthly or quarterly cap period, the state applies the incurred cost sharing for that service to the family's aggregate limit. Once the family reaches the aggregate limit, based on incurred cost sharing and any applicable premiums, the state notifies the family and providers that the family has reached their aggregate limit for the current monthly or quarterly cap period, and are no longer subject to premiums or cost sharing.

i] Managed care organization(s) track each family's incurred cost sharing, as follows:

‘As claims are submitted for dates of services within the family's current monthly or quarterly cap period, the iManaged Care Organization applies the incurred cost sharing for that service to the family's aggregate limit. Once the family reaches the aggregate limit, based on incurred cost sharing and any applicable premiums, the Managed Care Organization notifies the family and providers that the family has reached their aggregate limit for ithe current monthly or quarterly cap period, and are no longer subject to premiums or cost sharing.

7] Other process:

fi] Describe how the state informs beneficiaries and providers of the beneficiaries’ aggregate family limit and notifies beneficiaries and providers when a beneficiary has incurred premiums and cost sharing up to the aggregate family limit and individual family members are no longer subject to premiums or cost sharing for the remainder of the family's current monthly or quarterly cap period:

(On a monthly basis, the MMIS system will automatically generate a co-pay (cost sharing) letter for those beneficiaries who have reached the quarterly aggregate limit/cap during that month. This letter will only be generated when the family has met their cap/ageregate limit for the quarter. The letter will have the head of household, members of the case, and claim details for the month being reported for each individuals member in the household. Also, the letter will include the total co-pays for each household member with medical and pharmacy co-pays separated.

The state has a documented appeals process for families that believe they have incurred premiums or cost sharing over

the aggregate limit for the current monthly or quarterly cap period. Yes | Describe the appeals process used: L |w.va. Code Section 9-2-6(13)(14) allows a beneficiary to request an appeal pertaining to public assistance. [fa | Page 4 of 5 Transmittal Number. 14-0007 Approval Date: September 18, 2015 Effective Date: January 1, 2014

West Virginia

_CRAS Medicaid Premiums and Cost Sharing

beneficiary was charged a co-pay and, in fact, reimbursed a provider for that co-pay the member may request an appeal that the co-pay was improperly applied to them.

Describe the process used to reimburse beneficiaries and/or providers if the family is identified as paying over the aggregate limit for the month/quarter:

{if a member was inappropriately charged a co-pay and reimbursed a provider that co-pay, BMS will notify the provider of ithe miscalculation, reimburse the provider the difference in payment amount and request the provider to reimburse the member,

iif a member was inappropriately charged a co-pay and did not reimburse a provider the amount, BMS will notify the provider of the miscaiculation and reimburse the provider the difference in payment amount.

Describe the process for beneficiaries to request a reassessment of their family aggregate limit if they have a change in circumstances or if they are being terminated for failure to pay a premium:

When the family reports a change in circumstances, the eligibility system recalculates the applicable FPL% and passes this information to the claims system and member's file.

The state imposes additional aggregate limits, consistent with 42 CFR 447.56(£)(5). [ No

PRA Disclosure Statement . According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

V.20140415

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Transmittal Number 14-0007 Approval Date: September 18, 2015 Effective Date: January 1, 2014 West Virginia

Table of Contents State Name: West Virginia State Plan Amendment (SPA) #: 16‐0007 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 150 S. Independence Mall West Suite 216, The Public Ledger Building Philadelphia, Pennsylvania 19106-3499 Region III/Division of Medicaid and Children’s Health Operations SWIFT #022120174060 0D\ Cynthia Beane, MSW, LCSW Acting Commissioner Bureau for Medical Services 350 Capitol Street, Room 251 Charleston, West Virginia 25301-3706 Re: Approval of Health Home State Plan Amendment WV SPA 16-0007 Dear Acting Commissioner Beane: The Centers for Medicare & Medicaid Services (CMS), has completed its review of West Virginia State Plan Amendment (SPA) Transmittal Number 16-0007, Statewide Bipolar and at risk of Hepatitis B & C. This SPA implements Health Homes as authorized under Section 2703 of the Patient Protection and Affordable Care Act (1945 of the Social Security Act). Individuals eligible to receive Health Home services include Medicaid members with bipolar disorder who are at risk for Hepatitis Type B and/or Type C (HH-BD/H). The Health Home model is person-centered, primary care-based, behavioral health integrated, and case-managed by an interdisciplinary team. We approve West Virginia State Plan Amendment (SPA) Transmittal No. 16-007 on May 4, 201 with an effective date of April 1, 2017. Enclosed is a copy of the approved pages for incorporation into the West Virginia State plan. In accordance with the statutory provisions at Section 1945 (c) (1) of the Social Security Act, for payments made to health home providers under this amendment, during the first eight fiscal quarters that the SPA is in effect, April 1, 2017 through March 31, 2019, the federal medical assistance percentage (FMAP) rate applicable to such payments shall be equal to 90 percent. The FMAP rate for payments made to health home providers will return to the state's published FMAP rate March 31, 2019. The Form CMS-64 has a designated category of service Line 43 for states to report health home services expenditures for enrollees with chronic conditions. Please share with your staff my appreciation for their time and effort throughout this process. If you have any questions regarding this Health Home State Plan Amendment, please contact Dan Belnap at (215)861-4273 or Dan.Belnap@cms.hhs.gov. Sincerely, Francis 7McCullough Associate Regional Administrator Enclosures cc: Ryan Sims, Bureau for Medical Services Sabrina Tillman Boyd, CMS /S/

5/4/2017 Medicaid State Plan Print View 1/21 CMS-10434 OMB 0938-1188 Approval Notice DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-14-26 Baltimore, Maryland 21244-1850 Date: 05/04/2017 Head of Agency: Cynthia Beane Title/Dept : Acting Commissioner, WV Medicaid Address 1: 350 Capitol street, Room 251 Address 2: City : Charleston State: WV Zip: 25301 MACPro Package ID: WV2017MH0001O SPA ID: WV-16-0007 Subject WV SPA 16-0007 Dear Cynthia Beane This is an informal communication that will be followed with an official communication to the State's Medicaid Director. The Centers for Medicare and Medicaid Services (CMS) is pleased to inform you that we are recommending approval for your request for WV State Plan Amendment Reviewable Unit Effective Date Health Homes Intro 4/1/2017 Health Homes Population and Enrollment Criteria 4/1/2017 Health Homes Geographic Limitations 4/1/2017 Health Homes Services 4/1/2017 Health Homes Providers 4/1/2017 Health Homes Service Delivery Systems 4/1/2017 Health Homes Payment Methodologies 4/1/2017 Health Homes Monitoring, Quality Measurement and Evaluation 4/1/2017 For payments made to Health Homes providers under this new Health Homes Program submission package a medical assistance percentage (FMAP) rate of 90% applies to such payments for the period 4/1/2017 to 3/31/2019. Sincerely, Alissa DeBoy (Name) Deputy Director, DEHPG (title) WV 16-0007 Superseded SPA: N/A Effective Date: April 1, 2017 CMS Approval: May 4, 2017

5/4/2017 Medicaid State Plan Print View 2/21 Approval Documentation Name Date Created Type No items available Package Information Package ID WV2017MH0001O Program Name Statewide Bipolar and at risk of Hep B & C SPA ID WV-16-0007 Version Number 3 Submitted By Richard Ernest Package Disposition Submission Type Official State WV Region Philadelphia, PA Package Status Approved Submission Date 2/8/2017 Approval Date 5/4/2017 11:46 AM EDT Submission - Summary MEDICAID - Health Homes - Statewide Bipolar and at risk of Hep B & C - WV - 2017 Not Started In Progress Complete Package Header Package ID WV2017MH0001O Submission Type Official - Review 1 Approval Date 5/4/2017 Superseded SPA ID N/A SPA ID WV-16-0007 Initial Submission Date 2/8/2017 Effective Date N/A State Information State/Territory Name West Virginia Medicaid Agency Name WV Bureau for Medical Services Submission Component State Plan Amendment Medicaid CHIP Submission Type Official Submission Package Draft Submission Package Allow this official package to be viewable by other states? Yes No Key Contacts Name Title Phone Number Email Address Name Title Phone Number Email Address Becker, MD, James Medical Director (304)558-1700 james.b.becker@wv.gov Ernest, Richard Program Manager, Health Homes (304)558-1700 richard.d.ernest@wv.gov Young, Sarah Acting Deputy Commissioner (304)558-1700 sarah.k.young@wv.gov WV 16-0007 Superseded SPA: N/A Effective Date: April 1, 2017 CMS Approval: May 4, 2017

5/4/2017 Medicaid State Plan Print View 3/21 SPA ID and Effective Date SPA ID WV-16-0007 Reviewable Unit Proposed Effective Date Health Homes Intro 4/1/2017 Health Homes Population and Enrollment Criteria 4/1/2017 Health Homes Geographic Limitations 4/1/2017 Health Homes Services 4/1/2017 Health Homes Providers 4/1/2017 Health Homes Service Delivery Systems 4/1/2017 Health Homes Payment Methodologies 4/1/2017 Health Homes Monitoring, Quality Measurement and Evaluation 4/1/2017 Executive Summary Summary Description Including Goals and Objectives West Virginia's State Plan Amendment (SPA) is health delivery model targeted for the treatment of Medicaid members with bipolar disorder who are at risk for Hepatitis Type B and/or Type C (HH-BD/H). The Health Home model is person-centered, primary care- based, behavioral health integrated, and case-managed by an interdisciplinary team. Goals of this Health Home SPA include improving the health care experience, improving the health of populations, reducing per capita costs of health care, and promoting the integration of behavioral health into primary care. Objectives include a reduction in emergency department use, hospital admissions and re-admissions, health care costs, reliance on long-term care facilities, and improving the health care experience, quality and outcomes for the individual and providers. Dependency Description Description of any dependencies between this submission package and any other submission package undergoing review Disaster-Related Submission This submission is related to a disaster Yes No Federal Budget Impact and Statute/Regulation Citation Federal Budget Impact Federal Fiscal Year Amount First 2017 $777,546.00 Second 2018 $1,542,240.00 Federal Statute / Regulation Citation Affordable Care Act, Section 2703, Section 1945 Governor's Office Review No comment Comments received No response within 45 days Other WV 16-0007 Superseded SPA: N/A Effective Date: April 1, 2017 CMS Approval: May 4, 2017

5/4/2017 Medicaid State Plan Print View 4/21 Authorized Submitter The following information will be provided by the system once the package is submitted to CMS. Name of Authorized Submitter Richard Ernest Title None Phone number 3045581700 Email address richard.d.ernestjr@wv.gov Authorized Submitter's Signature Richard Ernest I hereby certify that I am authorized to submit this package on behalf of the Medicaid Agency. Submission - Public Comment MEDICAID - Health Homes - Statewide Bipolar and at risk of Hep B & C - WV - 2017 Not Started In Progress Complete Package Header Package ID WV2017MH0001O Submission Type Official - Review 1 Approval Date 5/4/2017 Superseded SPA ID N/A SPA ID WV-16-0007 Initial Submission Date 2/8/2017 Effective Date N/A Name of Health Homes Program Statewide Bipolar and at risk of Hep B & C Indicate whether public comment was solicited with respect to this submission. Public notice was not required and comment was not solicited Public notice was not required, but comment was solicited Public notice was required and comment was solicited Indicate how the public notice was issued and public comment was solicited Newspaper Announcement Name of Paper Date of Publication Locations covered Charleston Daily Mail 11/29/2016 Central West Virginia Charleston Gazette 11/29/2016 Central West Virginia Dominion Post 11/29/2016 North Central West Virginia Huntington Herald Dispatch 11/29/2016 Western West Virginia News Register 11/29/2016 Northern West Virginia Register Herald 11/29/2016 Souther West Virginia Wheeling Intelegencer 11/29/2016 Northern West Virginia 1-7 of 7 Publication in state's administrative record, in accordance with the administrative procedures requirements Date of Publication Dec 2, 2016 Email to Electronic Mailing List or Similar Mechanism Date of Email or other electronic notification Jan 27, 2017 Description of Letters and application will be sent to Behavioral Health WV 16-0007 Superseded SPA: N/A Effective Date: April 1, 2017 CMS Approval: May 4, 2017

5/4/2017 Medicaid State Plan Print View 5/21 mailing list, in particular parties and organizations included, and, if not email, description of similar mechanism used Providers listed in Care Connection; Providers listed in C3; Notification letter WVHA; WVSMA; Primary Care Physician/Family Health Practice: Home Health and Hospice Agencies; Advanced Nurse Practioners (WV Nursing Association); PT/OT; and Pharmacy Association. Website Notice Select the type of website Website of the State Medicaid Agency or Responsible Agency Date of Posting Nov 21, 2016 Website URL http://www.dhhr.wv.gov/bms/public%20notices/pages/d efault.aspx Website for State Regulations Other Public Hearing or Meeting Date of meeting 2/2/2017 Time of meeting 1:00 PM Location of meeting Beckley, WV Communication Method Web Conferencing Capability Used Public Forum Used Other similar process for public input that afforded interested parties the opportunity to learn about the contents of the Demonstration application and to comment on its contents. Name of process Description of process Publis meeting Meeting held to present that Health Homes Program, open to the public. Date of meeting 2/3/2017 Time of meeting 1:00 PM Location of meeting Charleston, WV Communication Method Web Conferencing Capability Used Public Forum Used Other similar process for public input that afforded interested parties the opportunity to learn about the contents of the Demonstration application and to comment on its contents. Name of process Description of process Public meeting Meeting held to present that Health Homes Program, open to the public. Date of meeting 1/31/2017 Time of meeting 1:00 PM Location of meeting Morgantown, WV Communication Method Web Conferencing Capability Used Public Forum Used Other similar process for public input that afforded interested parties the opportunity to learn about the contents of the Demonstration application and to comment on its contents. WV 16-0007 Superseded SPA: N/A Effective Date: April 1, 2017 CMS Approval: May 4, 2017

5/4/2017 Medicaid State Plan Print View 6/21 Name of process Description of process Public meeting Meeting held to present that Health Homes Program, open to the public. Other method Name of method Date Description Public Notices posted at County DHHR offices 11/22/2016 Attached public notice was posted in common area at all county DHHR offices Webinar 1/25/2017 Conducted a webinar to present information on the program, review provider application, review member letter, review SPA, provider standards, and other general design and overview. Upload copies of public notices and other documents used Name Date Created Type 16-007 Health Home Bipolar-Hepatitis 2/8/2017 3:06 PM EST WVHealthHomesProviderLetterFinalapproved 2/8/2017 3:06 PM EST Upload with this application a written summary of public comments received (optional) Name Date Created Type No items available Indicate the key issues raised during the public comment period (optional) Access Quality Cost Payment methodology Eligibility Benefits Service delivery Other issue Submission - Tribal Input MEDICAID - Health Homes - Statewide Bipolar and at risk of Hep B & C - WV - 2017 Not Started In Progress Complete Package Header Package ID WV2017MH0001O Submission Type Official - Review 1 Approval Date 5/4/2017 Superseded SPA ID N/A SPA ID WV-16-0007 Initial Submission Date 2/8/2017 Effective Date N/A Name of Health Homes Program Statewide Bipolar and at risk of Hep B & C WV 16-0007 Superseded SPA: N/A Effective Date: April 1, 2017 CMS Approval: May 4, 2017

5/4/2017 Medicaid State Plan Print View 7/21 One or more Indian health programs or Urban Indian Organizations furnish health care services in this state Yes No Submission - SAMHSA Consultation MEDICAID - Health Homes - Statewide Bipolar and at risk of Hep B & C - WV - 2017 Not Started In Progress Complete Package Header Package ID WV2017MH0001O Submission Type Official - Review 1 Approval Date 5/4/2017 Superseded SPA ID N/A SPA ID WV-16-0007 Initial Submission Date 2/8/2017 Effective Date N/A Name of Health Homes Program Statewide Bipolar and at risk of Hep B & C The State provides assurance that it has consulted and coordinated with the Substance Abuse and Mental Health Services Administration (SAMHSA) in addressing issues regarding the prevention and treatment of mental illness and substance abuse among eligible individuals with chronic conditions. Date of consultation 12/8/2016 Health Homes Intro MEDICAID - Health Homes - Statewide Bipolar and at risk of Hep B & C - WV - 2017 Not Started In Progress Complete Package Header Package ID WV2017MH0001O Submission Type Official - Review 1 Approval Date 5/4/2017 Superseded SPA ID N/A SPA ID WV-16-0007 Initial Submission Date 2/8/2017 Effective Date 4/1/2017 Program Authority 1945 of the Social Security Act The state elects to implement the Health Homes state plan option under Section 1945 of the Social Security Act. Name of Health Homes Program Statewide Bipolar and at risk of Hep B & C Executive Summary Provide an executive summary of this Health Homes program including the goals and objectives of the program, the population, providers, services and service delivery model used West Virginia's State Plan Amendment (SPA) is health delivery model targeted for the treatment of Medicaid members with bipolar disorder who are at risk for Hepatitis Type B and/or Type C (HH-BD/H). The Health Home model is person-centered, primary care-based, behavioral health integrated, and case-managed by an interdisciplinary team. Regardless of the Health Homes Programs that a member may qualify for based on diagnosis, they will be allowed to be enrolled in one (1) Health Home at a time Goals of this Health Home SPA include improving the health care experience, improving the health of populations, reducing per capita costs of health care, and promoting the integration of behavioral health into primary care. Objectives include a reduction in emergency department use, hospital admissions and re-admissions, health care costs, reliance on long-term care facilities, and improving the health care experience, quality and outcomes for the individual and providers. WV 16-0007 Superseded SPA: N/A Effective Date: April 1, 2017 CMS Approval: May 4, 2017

5/4/2017 Medicaid State Plan Print View 8/21 General Assurances The state provides assurance that eligible individuals will be given a free choice of Health Homes providers. The states provides assurance that it will not prevent individuals who are dually eligible for Medicare and Medicaid from receiving Health Homes services. The state provides assurance that hospitals participating under the state plan or a waiver of such plan will be instructed to establish procedures for referring eligible individuals with chronic conditions who seek or need treatment in a hospital emergency department to designated Health Homes providers. The state provides assurance that FMAP for Health Homes services shall be 90% for the first eight fiscal quarters from the effective date of the SPA. After the first eight quarters, expenditures will be claimed at the regular matching rate. The state provides assurance that it will have the systems in place so that only one 8-quarter period of enhanced FMAP for each health homes enrollee will be claimed. The state provides assurance that there will be no duplication of services and payment for similar services provided under other Medicaid authorities. Health Homes Population and Enrollment Criteria MEDICAID - Health Homes - Statewide Bipolar and at risk of Hep B & C - WV - 2017 Not Started In Progress Complete Package Header Package ID WV2017MH0001O Submission Type Official - Review 1 Approval Date 5/4/2017 Superseded SPA ID N/A SPA ID WV-16-0007 Initial Submission Date 2/8/2017 Effective Date 4/1/2017 Categories of Individuals and Populations Provided Health Homes Services The state will make Health Homes services available to the following categories of Medicaid participants Categorically Needy (Mandatory and Options for Coverage) Eligibility Groups Medically Needy Eligibility Groups Mandatory Medically Needy Medically Needy Pregnant Women Medically Needy Children under Age 18 Optional Medically Needy (select the groups included in the population) Families and Adults Medically Needy Children Age 18 through 20 Medically Needy Parents and Other Caretaker Relatives Aged, Blind and Disabled Medically Needy Aged, Blind or Disabled Medically Needy Blind or Disabled Individuals Eligible in 1973 Population Criteria The state elects to offer Health Homes services to individuals with Two or more chronic conditions One chronic condition and the risk of developing another Specify the conditions included Mental Health Condition Substance Use Disorder Asthma Diabetes Heart Disease BMI over 25 Other (specify) Name Description WV 16-0007 Superseded SPA: N/A Effective Date: April 1, 2017 CMS Approval: May 4, 2017

5/4/2017 Medicaid State Plan Print View 9/21 Name Description Bipolar Disorder N/a Hepatitis Type B and/or Type C n/a Specify the criteria for at risk of developing another chronic condition Evidence published indicates that individuals with Bipolar Disorder represent a patient population at high risk for: statistically high mortality rates compared to the general medical population; developing comorbid medical diseases because of lifestyle; substance abuse; having Hepatitis Type B and/or C. These individuals have a pattern of poor treatment compliance. Prescription psychotropic medication costs for individuals with Bipolar Disorder in West Virginia average over $30,000 per year, per individual. If the individual concurrently suffers from Hepatitis Type C and is receiving the most current treatment, yearly prescription medical costs can easily exceed $100,000 per individual before other medications or other health care costs are considered. For the reasons noted, targeted treatment of this population meets the needs of West Virginians and is highly aligned with the three main goals to: improve the experience of care, improve the health of our population, and to reduce per capita health care costs. One serious and persistent mental health condition Enrollment of Participants Participation in a Health Homes is voluntary. Indicate the method the state will use to enroll eligible Medicaid individuals into a Health Home Opt-In to Health Homes provider Referral and assignment to Health Homes provider with opt-out Other (describe) Describe the process used Claims based information for automatic assignment based on prior relationship with Health Home provider or, in the absence of relationship, Health Home that is geographically closest to patient. Patient notification completed by mail and by health home for options including opting out. The state provides assurance that it will clearly communicate the individual's right to opt out of the Health Homes benefit or to change Health Homes providers at any time and agrees to submit to CMS a copy of any letter or communication used to inform the individuals of the Health Homes benefit and their rights to choose or change Health Homes providers or to elect not to receive the benefit Name Date Created Type HEALTH HOME 02_BiPolar_ MEMBER LETTER HH ASSIGNMENT 2016_FinalApproved 2/8/2017 2:38 PM EST Health Homes Geographic Limitations MEDICAID - Health Homes - Statewide Bipolar and at risk of Hep B & C - WV - 2017 Not Started In Progress Complete Package Header Package ID WV2017MH0001O Submission Type Official - Review 1 Approval Date 5/4/2017 Superseded SPA ID N/A SPA ID WV-16-0007 Initial Submission Date 2/8/2017 Effective Date 4/1/2017 Health Homes services will be available statewide Health Homes services will be limited to the following geographic areas Health Homes services will be provided in a geographic phased-in approach Health Homes Services MEDICAID - Health Homes - Statewide Bipolar and at risk of Hep B & C - WV - 2017 Not Started In Progress Complete Package Header WV 16-0007 Superseded SPA: N/A Effective Date: April 1, 2017 CMS Approval: May 4, 2017

5/4/2017 Medicaid State Plan Print View 10/21 g Package ID WV2017MH0001O Submission Type Official - Review 1 Approval Date 5/4/2017 Superseded SPA ID N/A SPA ID WV-16-0007 Initial Submission Date 2/8/2017 Effective Date 4/1/2017 Service Definitions Provide the state's definitions of the following Health Homes services and the specific activities performed under each service Comprehensive Care Management Definition Comprehensive Care Management is the development, implementation, and ongoing reassessment of a comprehensive individualized patient-centered care plan for each member. The care plan design will be developed with input from the interdisciplinary team of providers on the basis of information obtained from a comprehensive risk assessment that identifies the member’s needs in areas including: medical, mental health, substance abuse/misuse, and social services. The comprehensive risk assessment will also include mental health and substance abuse screenings using standardized tools. HH Providers will be required to update the clinical/medical/social data received during an assessment at least every four months. The individualized care plan will include integrated services to meet the member’s behavioral health, rehabilitative, long term care, and social service needs, as indicated. The care plan will be developed with input from the interdisciplinary team of providers; identify the primary care physician, other health and behavioral health care providers, Care Manager, and other health team providers directly involved in the individual’s care; and also identify community networks and supports needed for comprehensive quality health care. The Care Manager is a member of the team and responsible for the maintenance of the care plan document and ensures the client receives a copy of the initial care plan and any time that changes are made. Goals and timeframes for improving the member’s health, overall health care status and identified interventions will be included in the care plan, as well as schedules for plan assessment and update. Comprehensive care management will assure that the member or legal health representative is an active team member in the care plan’s development, implementation and assessment and is informed and in agreement with plan components. Member’s family and other recognized supports will be involved in the member’s care as requested by the member. Describe how Health Information Technology will be used to link this service in a comprehensive approach across the care continuum Penetration of HIT adoption in WV is variable at the current time, although a growing number of providers are adopting EHR’s in response to the federal incentive program and BMS has partnered with the WV Regional Extension Center to further promote the use of HIT within the Medicaid provider community. Providers will be expected to demonstrate a commitment to the use of HIT by all members of the Health Home team, as part of the application to serve as a Health Home. At minimum, a certified EHR is required at the primary care site; the EHR is expected to document the elements of an individual care plan for each Health Home member. The use of HIT is also encouraged in the identification of individuals who are at highest risk and in need of more intense care management services; this will be done through analysis of population level reports of member characteristics and utilization patterns. This may also be done through electronic responses to a health risk assessment tool. To facilitate communication about care coordination and care management activities, various systems are being explored; however, none is expected to be in place prior to SPA implementation. As the use of HIT and the implementation of a statewide health information exchange evolve, it is anticipated that the use of HIT to support all of the health homes services will also evolve. Scope of service The service can be provided by the following provider types Behavioral Health Professionals or Specialists Description Initial assessment and care plan development will be conducted in a face to face encounter. Follow-up services may be provided in either a face to face encounter, telephonically, or via telehealth modalities. Nurse Practitioner Nurse Care Coordinators Description Under the supervision of the primary care physician or advanced nurse practitioner, the nurse care coordinator supervises and facilitates the coordination of health care to the member. Initial assessment and care plan development will be conducted in a face to face encounter. Follow-up services may be provided in either a face to face encounter, telephonically, or via telehealth modalities. Nurses Description Under the supervision of the primary care physician or advanced nurse practitioner, the nurse care coordinator supervises and facilitates the coordination of health care to the member. Initial assessment and care plan development will be conducted in a face to face encounter. Follow-up services may be provided in either a face to face encounter, telephonically, or via telehealth modalities. Medical Specialists Physicians Description Initial assessment and care plan development will be conducted in a face to face encounter. Follow-up services may be provided in either a face to face encounter, telephonically, or via telehealth modalities. WV 16-0007 Superseded SPA: N/A Effective Date: April 1, 2017 CMS Approval: May 4, 2017

5/4/2017 Medicaid State Plan Print View 11/21 Physician's Assistants Pharmacists Social Workers Description Eligible as behavioral health specialist. Initial assessment and care plan development will be conducted in a face to face encounter. Follow-up services may be provided in either a face to face encounter, telephonically, or via telehealth modalities.. Doctors of Chiropractic Licensed Complementary and alternative Medicine Practitioners Dieticians Nutritionists Other (specify) Care Coordination Definition Care Coordination is the delivery of comprehensive, multidisciplinary care to a member that links all involved resources by maintaining and disseminating current, relevant health and care plan data. Care coordination manages resource linkages, referrals, coordination and follow-up to plan-identified resources. Activities include, but are not limited to: appointment scheduling, conducting referrals and follow-up monitoring, participating in facility discharge processes and communicating with other providers and members/family members. Describe how Health Information Technology will be used to link this service in a comprehensive approach across the care continuum Each Health Home provider will be encouraged to use the HIT resources they have available through their internal EHRs to track referrals and generate reminders for follow up. Where there are available electronic linkages with partner hospitals and their EHRs, the Health Home providers will be encouraged to maximize the use of these linkages to share bi-directional information. West Virginia is just starting its gradual roll-out of a state-wide HIE. As the state HIE is implemented, all Health Home providers will be encouraged to fully participate, as is feasible, to utilize the HIE to share information with members of their referral network. Health Home providers will also be encouraged to implement a patient portal to communicate with patients/ family members. Health Home providers will be encouraged to utilize their EHRs and/ or patient portals to link to health information and resources applicable to the member’s condition. Member educational materials will be generated electronically to allow for customization and appropriateness to the member’s condition, literacy level, and cultural preferences, where feasible. Scope of service The service can be provided by the following provider types Behavioral Health Professionals or Specialists Description Services may be provided in either a face to face encounter, telephonically, or via telehealth modalities. Nurse Practitioner Nurse Care Coordinators Description Services may be provided in either a face to face encounter, telephonically, or via telehealth modalities. Nurses Description Services may be provided in either a face to face encounter, telephonically, or via telehealth modalities. Medical Specialists Physicians Description Services may be provided in either a face to face encounter, telephonically, or via telehealth modalities. Physician's Assistants Pharmacists Social Workers Description Services may be provided in either a face to face encounter, telephonically, or via telehealth modalities. Doctors of Chiropractic Licensed Complementary and alternative Medicine Practitioners Dieticians Nutritionists WV 16-0007 Superseded SPA: N/A Effective Date: April 1, 2017 CMS Approval: May 4, 2017

5/4/2017 Medicaid State Plan Print View 12/21 Other (specify) Health Promotion Definition Health Promotion includes the provision of: health education specific to a member’s health and behavioral health; development of self-management plans effectively emphasizing the importance of immunizations and preventive screenings; understanding and management of prescribed medications; supporting improvement of social networks; and providing healthy lifestyle interventions. Areas of focus include but are not limited to: substance use and smoking prevention and cessation, nutritional counseling, weight management, and increasing physical activity. Health promotion services assist members to participate in the development and implementation of their care plan and emphasize person-centered empowerment to facilitate self-management of chronic health conditions through informed awareness. Describe how Health Information Technology will be used to link this service in a comprehensive approach across the care continuum Each Health Home provider will be encouraged to use the HIT resources they have available through their internal EHRs to track referrals and generate reminders for follow up. Where there are available electronic linkages with partner hospitals and their EHRs, the Health Home providers will be encouraged to maximize the use of these linkages to share bi-directional information. West Virginia is just starting its gradual roll-out of a state-wide HIE. As the state HIE is implemented, all Health Home providers will be encouraged to fully participate, as is feasible, to utilize the HIE to share information with members of their referral network. Health Home providers will also be encouraged to implement a patient portal to communicate with patients/ family members. Health Home providers will be encouraged to utilize their EHRs and/ or patient portals to link to health information and resources applicable to the member’s condition. Member educational materials will be generated electronically to allow for customization and appropriateness to the member’s condition, literacy level, and cultural preferences, where feasible. Scope of service The service can be provided by the following provider types Behavioral Health Professionals or Specialists Description Services may be provided in either a face to face encounter, telephonically, or via telehealth modalities. Nurse Practitioner Nurse Care Coordinators Description Services may be provided in either a face to face encounter, telephonically, or via telehealth modalities. Nurses Description Services may be provided in either a face to face encounter, telephonically, or via telehealth modalities. Medical Specialists Description Services may be provided in either a face to face encounter, telephonically, or via telehealth modalities. Physicians Description Services may be provided in either a face to face encounter, telephonically, or via telehealth modalities. Physician's Assistants Description Services may be provided in either a face to face encounter, telephonically, or via telehealth modalities. Pharmacists Description Services may be provided in either a face to face encounter, telephonically, or via telehealth modalities. Social Workers Description Services may be provided in either a face to face encounter, telephonically, or via telehealth modalities. Doctors of Chiropractic Description Services may be provided in either a face to face encounter, telephonically, or via telehealth modalities. Licensed Complementary and alternative Medicine Practitioners Description Services may be provided in either a face to face encounter, telephonically, or via telehealth modalities. Dieticians Description Services may be provided in either a face to face encounter, telephonically, or via telehealth modalities. Nutritionists Description Services may be provided in either a face to face encounter, telephonically, or via telehealth modalities. Other (specify) WV 16-0007 Superseded SPA: N/A Effective Date: April 1, 2017 CMS Approval: May 4, 2017

5/4/2017 Medicaid State Plan Print View 13/21 Provider Type Description Care Coordinator; Others Services may be provided in either a face to face encounter, telephonically, or via telehealth modalities. Comprehensive Transitional Care from Inpatient to Other Settings (including appropriate follow-up) Definition Comprehensive Transitional Care is care coordination services designed to prevent avoidable emergency department visits, admissions, and readmission after discharge from an inpatient facility. For each enrollee transferred from one caregiver or site of care to another, the health home team ensures proper and timely follow-up care and safe, coordinated transitions, including reconciliation of medications. The transition could include any inpatient care to home and community based services and supports. This is accomplished through formal relationships and communication systems with health facilities including emergency departments, hospitals, long-term care facilities, residential/rehabilitation settings, as well as with other providers and community-based services. Describe how Health Information Technology will be used to link this service in a comprehensive approach across the care continuum Health Home providers will be encouraged to develop partnerships that maximize the use of HIT across various caregivers and care settings. The provider will be encouraged to use HIT when available to communicate with health facilities and to facilitate interdisciplinary collaboration among all care team members. Providers will be encouraged to share information through the statewide HIE once that capability becomes available. Providers will also be encouraged to provide enrollees with web-based access to their records that can follow the enrollees as they transition to different care settings. To facilitate post-hospital follow-up, BMS will be exploring a means of communication to health homes about enrollees who have been admitted to a hospital. QIO will provide via its web-based system a notification to the assigned Health Home when a non-MCO member has had a request for medical or psychiatric hospitalization made/authorized. The MCOs will be encouraged to provide like information to the Health Homes for their members served by a Health Home. Scope of service The service can be provided by the following provider types Behavioral Health Professionals or Specialists Description Services may be provided in either a face to face encounter, telephonically, or via telehealth modalities. Nurse Practitioner Nurse Care Coordinators Description Services may be provided in either a face to face encounter, telephonically, or via telehealth modalities. Nurses Description Services may be provided in either a face to face encounter, telephonically, or via telehealth modalities. Medical Specialists Physicians Description Services may be provided in either a face to face encounter, telephonically, or via telehealth modalities. Physician's Assistants Pharmacists Social Workers Doctors of Chiropractic Licensed Complementary and alternative Medicine Practitioners Dieticians Nutritionists Other (specify) Individual and Family Support (which includes authorized representatives) Definition Individual and Family Support Services include service provision and resource identification that assist members to attain their highest level of health and functioning. Peer supports, support groups, and self-care programs can be utilized by providers to increase members’ and support members’ knowledge about the member’s diseases, promote member’s engagement and self-management capabilities, while assisting the member to adhere to their care plan. A primary focus of individual and family supports will be strengthened through increased health literacy. This effort will include communicated information that is language, literacy, and culturally appropriate, and designed to improve the member’s ability to self-manage their health and participate in the ongoing care planning. Describe how Health Information Technology will be used to link this service in a comprehensive approach across the care continuum Health Home providers will be encouraged to utilize their EHRs and/or patient portals to link to health information and resources applicable to the member’s condition. The use of a patient portal or PHR is encouraged to proivde for patient/ family interaction with the care team and for development and monitoring of WV 16-0007 Superseded SPA: N/A Effective Date: April 1, 2017 CMS Approval: May 4, 2017

5/4/2017 Medicaid State Plan Print View 14/21 shared care plans. Member educational materials will be generated electronically to allow for customization and appropriateness to the member’s condition, literacy level, and cultural preferences, where feasible. Scope of service The service can be provided by the following provider types Behavioral Health Professionals or Specialists Description Services may be provided in either a face to face encounter, telephonically, or via telehealth modalities. Nurse Practitioner Nurse Care Coordinators Nurses Description Services may be provided in either a face to face encounter, telephonically, or via telehealth modalities. Medical Specialists Physicians Description Services may be provided in either a face to face encounter, telephonically, or via telehealth modalities. Physician's Assistants Pharmacists Social Workers Doctors of Chiropractic Licensed Complementary and alternative Medicine Practitioners Dieticians Nutritionists Other (specify) Referral to Community and Social Support Services Definition Referral to Community and Social Support Services includes the identification of available community resources, active management of referrals, access to care, including long term services and supports, engagement with other community and social supports, coordination of services and follow-up. This may include but not limited to, Alcoholics Anonymous and/or Narcotics Anonymous. The Community and Social Support Services network includes development of policies, procedures and accountabilities (through contractual agreements, where applicable) which clearly define the roles and responsibilities of the participants in order to support effective collaboration between the health home and community-based resources, and the member. The member’s care plan will include community-based and other social support services that address and respond to the member’s needs and preferences, and contribute to achieving the care plan goals. Describe how Health Information Technology will be used to link this service in a comprehensive approach across the care continuum Health Home providers will be encouraged to utilize HIT as feasible to initiate, manage and follow up on community based and other social services referrals. Scope of service The service can be provided by the following provider types Behavioral Health Professionals or Specialists Description Services may be provided in either a face to face encounter, telephonically, or via telehealth modalities. Nurse Practitioner Nurse Care Coordinators Description Services may be provided in either a face to face encounter, telephonically, or via telehealth modalities. Nurses Description Services may be provided in either a face to face encounter, telephonically, or via telehealth modalities. Medical Specialists Description WV 16-0007 Superseded SPA: N/A Effective Date: April 1, 2017 CMS Approval: May 4, 2017

5/4/2017 Medicaid State Plan Print View 15/21 Services may be provided in either a face to face encounter, telephonically, or via telehealth modalities. Physicians Description Services may be provided in either a face to face encounter, telephonically, or via telehealth modalities. Physician's Assistants Description Services may be provided in either a face to face encounter, telephonically, or via telehealth modalities. Pharmacists Description Services may be provided in either a face to face encounter, telephonically, or via telehealth modalities. Social Workers Description Services may be provided in either a face to face encounter, telephonically, or via telehealth modalities. Doctors of Chiropractic Description Services may be provided in either a face to face encounter, telephonically, or via telehealth modalities. Licensed Complementary and alternative Medicine Practitioners Description Services may be provided in either a face to face encounter, telephonically, or via telehealth modalities. Dieticians Description Services may be provided in either a face to face encounter, telephonically, or via telehealth modalities. Nutritionists Description Services may be provided in either a face to face encounter, telephonically, or via telehealth modalities. Other (specify) Provider Type Description Care Coordinator; Others Services may be provided in either a face to face encounter, telephonically, or via telehealth modalities. Health Homes Patient Flow Describe the patient flow through the state's Health Homes system. Submit with the state plan amendment flow-charts of the typical process a Health Homes individual would encounter The admission continuing stay criteria for Tier 1 will be: Medicaid Eligibility and documented diagnosis of a Bipolar Disorder that are determined to be at risk for becoming infected with or currently have Hepatitis B and/or C. The criteria for Tier 2 will be: at least one of the core health home services has been provided during the previous quarter and documented in the member’s medical record. There has been marked deterioration in behavioral stability demonstrated via an appropriate screening tool and or marked deterioration of medical stability or a change in the complexity of the medical issues identified requiring daily co-ordination. Name Date Created Type HH2FlowChartShort10.14.16 2/8/2017 2:40 PM EST Health Homes Providers MEDICAID - Health Homes - Statewide Bipolar and at risk of Hep B & C - WV - 2017 Not Started In Progress Complete Package Header Package ID WV2017MH0001O Submission Type Official - Review 1 Approval Date 5/4/2017 Superseded SPA ID N/A SPA ID WV-16-0007 Initial Submission Date 2/8/2017 Effective Date 4/1/2017 WV 16-0007 Superseded SPA: N/A Effective Date: April 1, 2017 CMS Approval: May 4, 2017

5/4/2017 Medicaid State Plan Print View 16/21 Types of Health Homes Providers Designated Providers Indicate the Health Homes Designated Providers the state includes in its program and the provider qualifications and standards Physicians Describe the Provider Qualifications and Standards WV Medicaid enrolled licensed health care practitioner Clinical Practices or Clinical Group Practices Describe the Provider Qualifications and Standards WV Medicaid enrolled licensed health care practitioner or group Rural Health Clinics Describe the Provider Qualifications and Standards WV Medicaid enrolled licensed rural health clinic Community Health Centers Describe the Provider Qualifications and Standards WV Medicaid enrolled licensed community health center Community Mental Health Centers Describe the Provider Qualifications and Standards WV Medicaid enrolled licensed community mental health center Home Health Agencies Case Management Agencies Community/Behavioral Health Agencies Describe the Provider Qualifications and Standards WV Medicaid enrolled licensed community or behavioral health agency Federally Qualified Health Centers (FQHC) Describe the Provider Qualifications and Standards WV Medicaid enrolled licensed federally qualified health centers Other (Specify) Teams of Health Care Professionals Health Teams Provider Infrastructure Describe the infrastructure of provider arrangements for Health Home Services West Virginia's provider infrastructure will include a designated primary care physician or advanced practice nurse practitioner, working with multidisciplinary teams in a variety of possible settings: primary care and solo medical practices; comprehensive community behavioral health centers with a primary care service base; providers who serve special populations; academic medical centers; other entities meeting established qualifications. Supports for Health Homes Providers Describe the methods by which the state will support providers of Health Homes services in addressing the following components 1. Provide quality-driven, cost-effective, culturally appropriate, and person- and family- centered Health Homes services 2. Coordinate and provide access to high quality health care services informed by evidence-based clinical practice guidelines 3. Coordinate and provide access to preventive and health promotion services, including prevention of mental illness and substance use disorders 4. Coordinate and provide access to mental health and substance abuse services 5. Coordinate and provide access to comprehensive care management, care coordination, and transitional care across settings. Transitional care includes appropriate follow-up from inpatient to other settings, such as participation in discharge planning and facilitating transfer from a pediatric to an adult system of health care 6. Coordinate and provide access to chronic disease management, including self-management support to individuals and their families 7. Coordinate and provide access to individual and family supports, including referral to community, social support, and recovery services 8. Coordinate and provide access to long-term care supports and services 9. Develop a person-centered care plan for each individual that coordinates and integrates all of his or her clinical and non-clinical health-care related needs and services 10. Demonstrate a capacity to use health information technology to link services, facilitate communication among team members and between the health team and individual and family caregivers, and provide feedback to practices, as feasible and appropriate WV 16-0007 Superseded SPA: N/A Effective Date: April 1, 2017 CMS Approval: May 4, 2017

5/4/2017 Medicaid State Plan Print View 17/21 11. Establish a continuous quality improvement program, and collect and report on data that permits an evaluation of increased coordination of care and chronic disease management on individual-level clinical outcomes, experience of care outcomes, and quality of care outcomes at the population level Description The State will provide support to providers using a variety of media. Specific programs will be developed and determined based on feedback from providers and identification of needs. This will include face to face training on the requirements and expectations of the SPA, including outreach, assessment, documentation, invoicing, and reporting. Scenarios will be used to illustrate the expectations for care coordination and other health home services. A website has been set up to provide additional information about the SPA and will include access to recorded training webcasts as well as provider manual and FAQ's.Providers will have a specific Quality Improvement Organization (QIO) trainer consultant assigned to their agency in which they may request training and/or technical assistance. The Quality Improvement Organization (QIO) trainer consultant will be on the provider’s site at least one time every twelve months providing training based upon the findings of a record review and certification audit. The findings of these reviews will be analyzed to determine a training plan for all Health Home Providers. The State will provide support to providers using a variety of media. This will include face to face training on health home requirements and expectations for all providers prior to the effective date of the SPA, including outreach, assessment, documentation, invoicing and reporting. A learning community of health home participants will be set up to allow for regular sharing of experiences among health homes providers and teams. Qualitative information about program implementation will be collected through this community. and Lessons learned will be harvested through the health home learning community. Other Health Homes Provider Standards The state's requirements and expectations for Health Homes providers are as follows 1. Health home providers must enroll or be enrolled in the WV Medicaid program and agree to comply with all Medicaid program requirements. 2. Care coordination and the other five health home services, as identified by CMS, will be provided to all health home enrollees by an interdisciplinary team of providers. As described in the Provider Infrastructure section above, each health home will define its multidisciplinary team in a manner that assures capacity to provide or arrange for the six defined health home services. However, at minimum, each team shall include a primary care provider (physician or advanced practice nurse), a licensed behavioral health specialist, a registered nurse, and a care manager (who could be the nurse or the behavioral health specialist for persons with SMI). Each team shall include an individual who is designated as a care coordinator but who may also fill other roles. The care manager leads the health home team and is accountable for assuring that patient needs are identified and that an integrated care plan is developed and coordinated for each enrollee and is carried out by assuring access to medical and behavioral health care services and community social supports as defined in the care plan. Additional members of the health home team may include physicians, physicians’ assistants, nurses, nurse practitioners, pharmacists, social workers, mental health workers, health educators, community health workers, and others, dependent on the delivery model of the health home. Specific qualifications for the required team member roles are as follows: • Provider---MD, DO, or Advanced Practice Nurse licensed in the state of WV; • Behavioral Health Specialist ---Masters prepared individual licensed in the state of WV in counseling, psychology, or social work; • Nurse---Registered Nurse licensed in the state of WV; • Care Manager---Registered Nurse or licensed Behavioral Health Specialist. Completed an internal credentialing process through a provider designation as a health home; • Care Coordinator---Licensed Registered Nurse or Bachelor’s Degree in a social science with some applicable patient care or counseling experience. Completed an internal credentialing process through a provider designation as a health home The health home provider must identify the means for care plan documentation, communication, and integration across the various service delivery components of the health home. Health home providers can either directly provide or subcontract for the provision of health home services. The health home provider remains responsible for all health home program requirements, including services performed by the subcontractor. The health home provider is required to describe the methods and processes for providing the health home services. Where contractual relationships are to be used, the health home provider must demonstrate that formal written agreements are in place at the time health home services are initiated. 3. Health home providers are expected to establish a medical neighborhood of local community providers that will serve as referral providers for various medical, behavioral health, and facility services, and as applicable to managed care, the medical neighborhood must include providers that are part of the contracted network of the managed care entity. At minimum, each health home must either include provision of behavioral health services or must establish a formal partnership with a behavioral health entity in order to assure appropriate access to a range of behavioral health services for all of its health home enrollees. Services will be available 24 hours a day/7 days a week. Hospitals that are part of a health home neighborhood must have procedures in place for referring any eligible individual with chronic conditions who seek or need treatment in a hospital emergency department to a health home or other facility based settings to ensure coordination of all aspects of transitional care for current and eligible recipients. Documentation describing the medical neighborhood and hospitals’ referral commitment must be provided. 4. Health home providers must demonstrate their ability to perform each of the following functional requirements. This includes documentation of the processes used to perform these functions and the methods used to assure service delivery takes place in the described manner. • Provide quality-driven, cost-effective, culturally appropriate, and person- and family-centered health home services. • Coordinate and provide access to high-quality health care services informed by evidence-based clinical practice guidelines. • Coordinate and provide access to preventive and health promotion services, including the promotion of mental and emotional well-being and the prevention of substance abuse. • Coordinate and provide access to mental health and substance abuse services. • Coordinate and provide access to comprehensive care management, care coordination, and transitional care across settings. • Coordinate and provide access to chronic disease management, including self-management support to individuals and their families. • Coordinate and provide access to individual and family supports, including referral to community, social support, and recovery services. • Coordinate and provide access to long-term care supports and services. • Develop a person-centered care plan for each individual that coordinates and integrates all of his or her clinical and non-clinical health-care related needs and services. • Demonstrate a capacity to use health information technology to link services, facilitate communication among team members and between the health team and individual and family caregivers, and provide feedback to practices, as feasible and appropriate. • Establish a continuous quality improvement program, and collect and report on data that permits an evaluation of increased coordination of care and chronic disease management on individual-level clinical outcomes, experience of care outcomes, and quality of care outcomes at the population level. 5. The health home provider must use an electronic health record system that qualifies under the Meaningful Use provisions of the HITECH Act, and which allows the patient’s health information and plan of care to be accessible to the interdisciplinary team of providers. Providers may also access the The West Virginia Health Information Network (WVHIN), which is an interactive network. 6. As a condition of being a designated provider, the health home must agree not to refuse enrollment of eligible potential health home enrollee referred by Bureau for Medical Services (BMS). 7. As a condition of being a designated provider, the health home is subject to all audit and monitoring systems currently in place for Bureau for Medical Services programs. Documentation of health home services for enrollees is subject to audit by a Bureau for Medical Services contractor. In addition, the provider understands that BMS will monitor outcome measures and the provider is subject to discontinuation of designation as a health home if measures are not reported as required, or if anticipated outcomes are not achieved. 8. Health Home provider qualifications will initially be assessed and approved by the DHHR Bureau for Medical Services. Once a provider gains Health Home provider status, the provider record in the State’s MMIS will include this designation. Subsequent Health Home provider recertification, conducted by QIO, will WV 16-0007 Superseded SPA: N/A Effective Date: April 1, 2017 CMS Approval: May 4, 2017

5/4/2017 Medicaid State Plan Print View 18/21 occur within thirteen months of the Health Home designation anniversaries. The QIO is under contract with the Bureau for Medical Services to provide utilization management for certain Medicaid-covered services, including prior approval for inpatient hospital admission. Name Date Created Type No items available Health Homes Service Delivery Systems MEDICAID - Health Homes - Statewide Bipolar and at risk of Hep B & C - WV - 2017 Not Started In Progress Complete Package Header Package ID WV2017MH0001O Submission Type Official - Review 1 Approval Date 5/4/2017 Superseded SPA ID N/A SPA ID WV-16-0007 Initial Submission Date 2/8/2017 Effective Date 4/1/2017 Identify the service delivery system(s) that will be used for individuals receiving Health Homes services Fee for Service PCCM Risk Based Managed Care Other Service Delivery System Health Homes Payment Methodologies MEDICAID - Health Homes - Statewide Bipolar and at risk of Hep B & C - WV - 2017 Not Started In Progress Complete Package Header Package ID WV2017MH0001O Submission Type Official - Review 1 Approval Date 5/4/2017 Superseded SPA ID N/A SPA ID WV-16-0007 Initial Submission Date 2/8/2017 Effective Date 4/1/2017 Payment Methodology The State's Health Homes payment methodology will contain the following features Fee for Service Individual Rates Per Service Per Member, Per Month Rates Fee for Service Rates based on Severity of each individual's chronic conditions Capabilities of the team of health care professionals, designated provider, or health team Other Describe below WV 16-0007 Superseded SPA: N/A Effective Date: April 1, 2017 CMS Approval: May 4, 2017

5/4/2017 Medicaid State Plan Print View 19/21 Payment methodology described below Comprehensive Methodology Included in the Plan Incentive Payment Reimbursement Describe any variations in payment based on provider qualifications, individual care needs, or the intensity of the services provided Payment methodology described below PCCM (description included in Service Delivery section) Risk Based Managed Care (description included in Service Delivery section) Alternative models of payment, other than Fee for Service or PMPM payments (describe below) Agency Rates Describe the rates used FFS Rates included in plan Comprehensive methodology included in plan The agency rates are set as of the following date and are effective for services provided on or after that date Rate Development Provide a comprehensive description in the SPA of the manner in which rates were set 1. In the SPA please provide the cost data and assumptions that were used to develop each of the rates 2. Please identify the reimbursable unit(s) of service 3. Please describe the minimum level of activities that the state agency requires for providers to receive payment per the defined unit 4. Please describe the state's standards and process required for service documentation, and 5. Please describe in the SPA the procedures for reviewing and rebasing the rates, including the frequency with which the state will review the rates, and the factors that will be reviewed by the state in order to understand if the rates are economic and efficient and sufficient to ensure quality services. Comprehensive Description Reimbursement will only be made for health home services not covered by any other available Medicaid reimbursement options. The criteria required for receiving a monthly PMPM reimbursement is: a) The member meets health home eligibility criteria and is so flagged in the MMIS; b) The member is enrolled as a health home member with the health home provider billing for the service reimbursement; c) At least one of the core health home services has been provided during the previous month and documented in the member's medical record. By submitting the basic or intense health home service code for reimbursement, the provider is attesting to the fact that at least one of the six health home services has been provided during the month. The following steps are used to determine the rates: 1 . The State will use West Virginia wage specific data obtained from the Bureau for Labor Statistics (BLS) for each Health Home designated multidisciplinary team professional. 2. Salary will be adjusted for fringe benefits and assigned at a rate of 40 percent of the average BLS annualized salary for each wage classification. 3. The fringe adjusted annual salary is converted to an hourly rate per wage classification assuming 2,080 work hours. 4. The hourly rate for each wage classification is adjusted for each multidisciplinary team member's level of participation in the health home team for each payment by dividing the team members assigned level of participation by the total assigned monthly participation for the health home team. 5. The monthly health home team level of participation assigned to services is two hours PMPM and Health home participation levels will vary based on each targeted health home condition. 6. The PMPM rate will equal the sum of hourly rates for each health home multidisciplinary team member that has been adjusted for fringe benefits and participation level. Payment for Health Home services under the State Plan will not duplicate payments made to public agencies or private entities under other program authorities for the same purpose. Medicaid will be the payer of last resort. Unless specifically notes otherwise in the plan, the state developed rate is the same for both governmental and private providers. Providers will be reimbursed at the lesser of the provider's usual and customary billed charge or the Bureau for Medical Services (Bureau) fee schedule. Rates will be published on the Bureau's website at: www.dhhr.wv.gov/bms. The agency's fee schedule rate was set as of July 1, 2014, the start date of WV 1st Health Home program, and is effective for services provided on or after that date. All rates are published on the agency's website. Two Level System: Payment will be made on a per member per month (PMPM) basis for each health home enrollee. Basic and Intensive Health Home Services comprise the two-level system. Health Home Service Level I: The basic Level I health home service code is intended to cover the provision of all of the six health home services, as determined to be appropriate to meet the member needs. At the time of enrollment, the Health Homes requests prior authorization of the Level I service for each enrollee through a web- based prior authorization system managed by QIO. Both at initial enrollment and at the time of each service request, the QIO verifies the person's Medicaid eligibility. Payment will be made based on the presence of the Health Home attribute in the member's MMIS record, the member's Medicaid eligibility during the service month, a prior authorization in the MMIS including the service month and the submission for payment through the MMIS of the service code for Health Home Services: Level I. The benefit package for all Health Home enrollees includes eligibility for services covered by the basic health home code. WV 16-0007 Superseded SPA: N/A Effective Date: April 1, 2017 CMS Approval: May 4, 2017

5/4/2017 Medicaid State Plan Print View 20/21 Health Home Service Level II: A second health home level of service, Level II, is available for those health home enrollees determined to require more intense service for a period. Health Homes request prior authorization of the Level II intensive service through the same web-based prior authorization system managed by QIO. At the time of a request for Level II service, QIO will conduct verification of the HH member's Medicaid eligibility. Each Medicaid member whom qualifies for Level II Health Home service will receive a one-month authorization. Authorization is based on clinical information presented by the Health Home provider, including hospitalizations, ER utilization, assessment scores, and clinical judgment documenting a deterioration of the enrollee's condition and crisis situation requiring stabilization. Payment will be made based on the presence of the Health Home attribute in the member's MMIS record, the member's Medicaid eligibility during the service month, a prior authorization in the MMIS including the service month and the submission for payment through the MMIS of the service code for Health Home Services: Level II. Assurances The State provides assurance that it will ensure non-duplication of payment for services similar to Health Homes services that are offered/covered under a different statutory authority, such as 1915(c) waivers or targeted case management. Describe below how non- duplication of payment will be achieved There will be a contractual agreement with Health Home Providers and other providers, such as waiver services providers and targeted case management providers, regarding non-duplication of similar benefits. In addition, Bureau for Medical Services does periodic retrospective reviews for these services. The State meets the requirements of 42 CFR Part 447, Subpart A, and sections 1902(a)(4), 1902(a)(6), 1902(a)(30)(A), and 1903 with respect to non- payment for provider-preventable conditions. The State provides assurance that all governmental and private providers are reimbursed according to the same rate schedule, unless otherwise described above. The State provides assurance that it shall reimburse providers directly, except when there are employment or contractual arrangements consistent with section 1902(a)(32). Health Homes Monitoring, Quality Measurement and Evaluation MEDICAID - Health Homes - Statewide Bipolar and at risk of Hep B & C - WV - 2017 Not Started In Progress Complete Package Header Package ID WV2017MH0001O Submission Type Official - Review 1 Approval Date 5/4/2017 Superseded SPA ID N/A SPA ID WV-16-0007 Initial Submission Date 2/8/2017 Effective Date 4/1/2017 Monitoring Describe the state's methodology for calculating cost saving (and report cost savings annually in Quality Measure Report). Include savings that result from improved coordination of care and chronic disease management achieved through the Health Homes Program, including data sources and measurement specifications, as well as any savings associated with dual eligibles, and if Medicare data was available to the state to utilize in arriving at its cost-savings estimates Data Source: MMIS Measurement Specifications: Compare total cost of care for health home members to costs of care for similar cohorts not enrolled with a HH. Calculations will exclude claims for high cost outliers more than three standard deviations from the mean annual cost and will include incremental HH reimbursement. HH member costs will also be compared pre- and post- HH implementation. Describe how the state will use health information technology in providing Health Homes services and to improve service delivery and coordination across the care continuum (including the use of wireless patient technology to improve coordination and management of care and patient adherence to recommendations made by their provider) West Virginia currently has several HIT initiatives in place and underway that will support the provision of health home services and improvement of care coordination across the care continuum. • The state is in the process of implementing a statewide health information exchange that will facilitate the sharing of information across various care delivery settings. All health home providers will be expected to participate in the HIE as it is implemented across the state. The HIE will be used to capture meaningful use measures and several of these are incorporated into the information that will be used to monitor and evaluate health home services. Until the HIE is fully in place in the state, each health home provider will also be expected to use their EHR to generate a Continuity of Care Document (CCD) that can be shared with other providers in order to facilitate transitions in care and care coordination across care settings. • A pharmacy data warehouse is in place that will provide for monitoring of patient adherence to prescribed drug regimens as well as appropriate use of pharmaceutical agents. • A data warehouse/decision support system has been implemented to capture MMIS claims data as well clinical data that will flows through the HIE. This data warehouse will be the primary source of evaluation information for the health homes initiative. • A web-based vendor system will be used for documentation of medically necessary services and authorization information. • Information on hepatitis will be shared with the West Virginia Bureau for Public Health: the Office of Epidemiology and Prevention Services maintains a data base of information regarding incidence of hepatitis in the State. Quality Measurement and Evaluation WV 16-0007 Superseded SPA: N/A Effective Date: April 1, 2017 CMS Approval: May 4, 2017

5/4/2017 Medicaid State Plan Print View 21/21 The state provides assurance that all Health Homes providers report to the state on all applicable quality measures as a condition of receiving payment from the state The state provides assurance that it will identify measureable goals for its Health Homes model and intervention and also identify quality measures related to each goal to measure its success in achieving the goals The state provides assurance that it will report to CMS information submitted by Health Homes providers to inform evaluations, as well as Reports to Congress as described in Section 2703(b) of the Affordable Care Act and as described by CMS The state provides assurance that it will track avoidable hospital readmissions and report annually in the Quality Measures report 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 0938-1188. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. This view was generated on 5/4/2017 1:57 PM EDT WV 16-0007 Superseded SPA: N/A Effective Date: April 1, 2017 CMS Approval: May 4, 2017

Table of Contents State Name: West Virginia State Plan Amendment (SPA) #: 16‐0008 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 150 S. Independence Mall West Suite 216, The Public Ledger Building Philadelphia, Pennsylvania 19106-3499 Region III/Division of Medicaid and Children’s HealthOperations SWIFT # 022120174054 0D\ Cynthia Beane, MSW, LCSW Acting Commissioner Bureau for Medical Services 350 Capitol Street, Room 251 Charleston, West Virginia 25301-3706 Re: Approval of Health Home State Plan Amendment WV SPA 16-0008 Dear Acting Commissioner Beane: The Centers for Medicare & Medicaid Services (CMS), has completed its review of West Virginia State Plan Amendment (SPA) Transmittal Number 16-0008, Pre-Diabetes, Diabetes, Obesity, at Risk for Anxiety and/or Depression. This SPA implements Health Homes as authorized under Section 2703 of the Patient Protection and Affordable Care Act (1945 of the Social Security Act). Individuals eligible to receive Health Home services include Medicaid members with Pre Diabetes, Diabetes, and/or Obesity who are at risk of Anxiety and/or Depression. The Health Homes model is person-centered, primary care-based, behavioral health integrated, and case-managed by an interdisciplinary team. We approve West Virginia State Plan Amendment (SPA) Transmittal No. 16-0008 on May 4, 2017 with an effective date of April 1, 2017. Enclosed is a copy of the approved pages for incorporation into the West Virginia State plan. In accordance with the statutory provisions at Section 1945 (c) (1) of the Social Security Act, for payments made to health home providers under this amendment, during the first eight fiscal quarters that the SPA is in effect, April 1, 2017 through March 31, 2019, the federal medical assistance percentage (FMAP) rate applicable to such payments shall be equal to 90 percent. The FMAP rate for payments made to health home providers will return to the state's published FMAP rate March 31, 2019. The Form CMS-64 has a designated category of service Line 43 for states to report health home services expenditures for enrollees with chronic conditions.

Francis 7McCullough Associate Regional Administrator Enclosures cc: Ryan Sims, Bureau for Medical Services Sabrina Tillman Boyd, CMS 3OHDVHVKDUHZLWK\RXUVWDIIP\DSSUHFLDWLRQIRUWKHLUWLPHDQGHIIRUWWKURXJKRXWWKLVSURFHVV,I\RXKDYH DQ\TXHVWLRQVUHJDUGLQJWKLV+HDOWK+RPH6WDWH3ODQ$PHQGPHQWSOHDVHFRQWDFW'DQ%HOQDSDW   RU'DQ%HOQDS#FPVKKVJRY 6LQFHUHO\ /S/

5/4/2017 Medicaid State Plan Print View 1/21 CMS-10434 OMB 0938-1188 Approval Notice DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-14-26 Baltimore, Maryland 21244-1850 Date: 05/04/2017 Head of Agency: Cynthia Beane Title/Dept : Acting Commissioner, WV Medicaid Address 1: 350 Capitol street, Room 251 Address 2: City : Charleston State: WV Zip: 25301 MACPro Package ID: WV2016MH0003O SPA ID: WV-16-0008 Subject WV 16-0008 Dear Cynthia Beane This is an informal communication that will be followed with an official communication to the State's Medicaid Director. The Centers for Medicare and Medicaid Services (CMS) is pleased to inform you that we are recommending approval for your request for WV SPA 16-0008 Reviewable Unit Effective Date Health Homes Intro 4/1/2017 Health Homes Population and Enrollment Criteria 4/1/2017 Health Homes Geographic Limitations 4/1/2017 Health Homes Services 4/1/2017 Health Homes Providers 4/1/2017 Health Homes Service Delivery Systems 4/1/2017 Health Homes Payment Methodologies 4/1/2017 Health Homes Monitoring, Quality Measurement and Evaluation 4/1/2017 For payments made to Health Homes providers under this new Health Homes Program submission package a medical assistance percentage (FMAP) rate of 90% applies to such payments for the period 4/1/2017 to 3/31/2019. Sincerely, Alissa DeBoy (Name) Deputy Director, DEHPG WV 16-0008 Superseded SPA: N/A Effective Date: April 1, 2017 CMS Approval: May 4, 2017

5/4/2017 Medicaid State Plan Print View 2/21 Approval Documentation Name Date Created Type No items available Package Information Package ID WV2016MH0003O Program Name Pre-Diabetes, Diabetes, Obesity, at Risk for Anxiety and/or Depression SPA ID WV-16-0008 Version Number 3 Submitted By Richard Ernest Package Disposition Submission Type Official State WV Region Philadelphia, PA Package Status Approved Submission Date 2/8/2017 Approval Date 5/4/2017 11:47 AM EDT Submission - Summary MEDICAID - Health Homes - Pre-Diabetes, Diabetes, Obesity, at Risk for Anxiety and/or Depression - WV - 2016 Not Started In Progress Complete Package Header Package ID WV2016MH0003O Submission Type Official - Review 1 Approval Date 5/4/2017 Superseded SPA ID N/A SPA ID WV-16-0008 Initial Submission Date 2/8/2017 Effective Date N/A State Information State/Territory Name West Virginia Medicaid Agency Name WV Bureau for Medical Services Submission Component State Plan Amendment Medicaid CHIP Submission Type Official Submission Package Draft Submission Package Allow this official package to be viewable by other states? Yes No Key Contacts Name Title Phone Number Email Address Name Title Phone Number Email Address Becker, MD, James Medical Director (304)558-1700 james.b.becker@wv.gov Ernest, Richard Program Manager, Health Homes (304)558-1700 richard.d.ernest@wv.gov Young, Sarah Acting Deputy Commissioner (304)558-1700 sarah.k.young@wv.gov WV 16-0008 Superseded SPA: N/A Effective Date: April 1, 2017 CMS Approval: May 4, 2017

5/4/2017 Medicaid State Plan Print View 3/21 SPA ID and Effective Date SPA ID WV-16-0008 Reviewable Unit Proposed Effective Date Health Homes Intro 4/1/2017 Health Homes Population and Enrollment Criteria 4/1/2017 Health Homes Geographic Limitations 4/1/2017 Health Homes Services 4/1/2017 Health Homes Providers 4/1/2017 Health Homes Service Delivery Systems 4/1/2017 Health Homes Payment Methodologies 4/1/2017 Health Homes Monitoring, Quality Measurement and Evaluation 4/1/2017 Executive Summary Summary Description Including Goals and Objectives West Virginia’s State Plan Amendment (SPA) is health delivery model targeted for the treatment of members with Pre Diabetes, Diabetes , and/or Obesity who are at risk of Anxiety and/or Depression. The Health Homes model is person-centered, primary care- based, behavioral health integrated, and case-managed by an interdisciplinary team. Goals of this Health Home SPA include improving the health care experience, improving the health of populations, reducing per capita costs of health care, and promoting the integration of behavioral health into primary care. Objectives include a reduction in emergency department use, hospital admissions and re-admissions, health care costs, reliance on long-term care facilities, and improving the health care experience, quality and outcomes for the individual and providers. Dependency Description Description of any dependencies between this submission package and any other submission package undergoing review Disaster-Related Submission This submission is related to a disaster Yes No Federal Budget Impact and Statute/Regulation Citation Federal Budget Impact Federal Fiscal Year Amount First 2017 $1,471,784.00 Second 2018 $2,919,240.00 Federal Statute / Regulation Citation Affordable Care Act, Section 2703, Section 1945 Governor's Office Review No comment Comments received No response within 45 days Other WV 16-0008 Superseded SPA: N/A Effective Date: April 1, 2017 CMS Approval: May 4, 2017

5/4/2017 Medicaid State Plan Print View 4/21 Authorized Submitter The following information will be provided by the system once the package is submitted to CMS. Name of Authorized Submitter Richard Ernest Title None Phone number 3045581700 Email address richard.d.ernestjr@wv.gov Authorized Submitter's Signature Richard Ernest I hereby certify that I am authorized to submit this package on behalf of the Medicaid Agency. Submission - Public Comment MEDICAID - Health Homes - Pre-Diabetes, Diabetes, Obesity, at Risk for Anxiety and/or Depression - WV - 2016 Not Started In Progress Complete Package Header Package ID WV2016MH0003O Submission Type Official - Review 1 Approval Date 5/4/2017 Superseded SPA ID N/A SPA ID WV-16-0008 Initial Submission Date 2/8/2017 Effective Date N/A Name of Health Homes Program Pre-Diabetes, Diabetes, Obesity, at Risk for Anxiety and/or Depression Indicate whether public comment was solicited with respect to this submission. Public notice was not required and comment was not solicited Public notice was not required, but comment was solicited Public notice was required and comment was solicited Indicate how the public notice was issued and public comment was solicited Newspaper Announcement Name of Paper Date of Publication Locations covered Charleston Dailey Mail 11/29/2016 Central West Virginia Charleston Gazette 11/29/2016 Central West Virginia Dominion Post 11/26/2016 North Central West Virginia Huntington Herald Dispatch 11/24/2016 Western West Virginia;Southeast Ohio,Eastern Kentucky News Register 11/25/2016 Northern West Virginia Register Herald 11/28/2016 Southern West Virginia Wheeling Intelligencer 11/25/2016 Northern West Virginia 1-7 of 7 Publication in state's administrative record, in accordance with the administrative procedures requirements Date of Publication Dec 2, 2016 Email to Electronic Mailing List or Similar Mechanism Date of Email or other electronic notification Jan 27, 2017 Description of Letters and application sent to Behavioral Health WV 16-0008 Superseded SPA: N/A Effective Date: April 1, 2017 CMS Approval: May 4, 2017

5/4/2017 Medicaid State Plan Print View 5/21 mailing list, in particular parties and organizations included, and, if not email, description of similar mechanism used Providers listed in QIO system; Notification letter WVHA; WVSMA; Primary Care Physician/Family Health Practice: Home Health and Hospice Agencies; Advanced Nurse Practioners (WV Nursing Association); PT/OT; and Pharmacy Association. Provider letter uploaded to documents Website Notice Select the type of website Website of the State Medicaid Agency or Responsible Agency Date of Posting Nov 21, 2016 Website URL http://www.dhhr.wv.gov/bms/Public%20Notices/Pages/ default.aspx Website for State Regulations Other Public Hearing or Meeting Date of meeting 2/2/2017 Time of meeting 1:00 PM Location of meeting Beckley, WV Communication Method Web Conferencing Capability Used Public Forum Used Other similar process for public input that afforded interested parties the opportunity to learn about the contents of the Demonstration application and to comment on its contents. Name of process Description of process Public Meeting Notice will be posted and a public meeting will be held in the county DHHR office. Date of meeting 2/3/2017 Time of meeting 1:00 PM Location of meeting Charleston, WV Communication Method Web Conferencing Capability Used Public Forum Used Other similar process for public input that afforded interested parties the opportunity to learn about the contents of the Demonstration application and to comment on its contents. Name of process Description of process Public Meeting Notice will be posted and a public meeting will be held in the county DHHR office. Date of meeting 1/31/2017 Time of meeting 1:00 PM Location of meeting Morgantown Communication Method Web Conferencing Capability Used Public Forum Used Other similar process for public input that afforded interested parties the opportunity to learn about the contents of the Demonstration application and to comment on its contents. WV 16-0008 Superseded SPA: N/A Effective Date: April 1, 2017 CMS Approval: May 4, 2017

5/4/2017 Medicaid State Plan Print View 6/21 Name of process Description of process Public Meetings Notice will be posted and a Public meeting will be held at the county DHHR office Other method Name of method Date Description Public Notice Posted at County DHHR offices 11/22/2016 Attached Public Notice was posted in a common area at county DHHR offices Webinar 1/25/2017 Conduct webinar to present introduction information on the program, review provider application, review member letter, review SPA, provider standards, and other general program design and overview. Upload copies of public notices and other documents used Name Date Created Type 16-008 Health Home Diabetes-Depression-Anxiety Public Notice 12/28/2016 2:27 PM EST WVHealthHomesProviderLetterFinalapproved 1/20/2017 12:31 PM EST Upload with this application a written summary of public comments received (optional) Name Date Created Type No items available Indicate the key issues raised during the public comment period (optional) Access Quality Cost Payment methodology Eligibility Benefits Service delivery Other issue Submission - Tribal Input MEDICAID - Health Homes - Pre-Diabetes, Diabetes, Obesity, at Risk for Anxiety and/or Depression - WV - 2016 Not Started In Progress Complete Package Header Package ID WV2016MH0003O Submission Type Official - Review 1 Approval Date 5/4/2017 Superseded SPA ID N/A SPA ID WV-16-0008 Initial Submission Date 2/8/2017 Effective Date N/A Name of Health Homes Program Pre-Diabetes, Diabetes, Obesity, at Risk for Anxiety and/or Depression WV16-0008 Superseded SPA: N/A Effective Date: April 1, 2017 CMS Approval: May 4, 2017

5/4/2017 Medicaid State Plan Print View 7/21 One or more Indian health programs or Urban Indian Organizations furnish health care services in this state Yes No Submission - SAMHSA Consultation MEDICAID - Health Homes - Pre-Diabetes, Diabetes, Obesity, at Risk for Anxiety and/or Depression - WV - 2016 Not Started In Progress Complete Package Header Package ID WV2016MH0003O Submission Type Official - Review 1 Approval Date 5/4/2017 Superseded SPA ID N/A SPA ID WV-16-0008 Initial Submission Date 2/8/2017 Effective Date N/A Name of Health Homes Program Pre-Diabetes, Diabetes, Obesity, at Risk for Anxiety and/or Depression The State provides assurance that it has consulted and coordinated with the Substance Abuse and Mental Health Services Administration (SAMHSA) in addressing issues regarding the prevention and treatment of mental illness and substance abuse among eligible individuals with chronic conditions. Date of consultation 12/8/2016 Health Homes Intro MEDICAID - Health Homes - Pre-Diabetes, Diabetes, Obesity, at Risk for Anxiety and/or Depression - WV - 2016 Not Started In Progress Complete Package Header Package ID WV2016MH0003O Submission Type Official - Review 1 Approval Date 5/4/2017 Superseded SPA ID N/A SPA ID WV-16-0008 Initial Submission Date 2/8/2017 Effective Date 4/1/2017 Program Authority 1945 of the Social Security Act The state elects to implement the Health Homes state plan option under Section 1945 of the Social Security Act. Name of Health Homes Program Pre-Diabetes, Diabetes, Obesity, at Risk for Anxiety and/or Depression Executive Summary Provide an executive summary of this Health Homes program including the goals and objectives of the program, the population, providers, services and service delivery model used West Virginia’s State Plan Amendment (SPA) is health delivery model targeted for the treatment of members with Pre Diabetes, Diabetes, and Obesity who are at risk of Anxiety and/or Depression The Health Home model is person-centered, primary care-based, behavioral health integrated, and case-managed by an interdisciplinary team.Regardless of the Health Homes Programs that a member may qualify for based on diagnosis, they will be allowed to be enrolled in one (1) Health Home at a time. Goals of this Health Home SPA include improving the health care experience, improving the health of populations, reducing per capita costs of health care, and promoting the integration of behavioral health into primary care. Objectives include a reduction in emergency department use, hospital admissions and re- admissions, health care costs, reliance on long-term care facilities, and improving the health care experience, quality and outcomes for the individual and providers. WV 16-0008 Superseded SPA: N/A Effective Date: April 1, 2017 CMS Approval: May 4, 2017

5/4/2017 Medicaid State Plan Print View 8/21 General Assurances The state provides assurance that eligible individuals will be given a free choice of Health Homes providers. The states provides assurance that it will not prevent individuals who are dually eligible for Medicare and Medicaid from receiving Health Homes services. The state provides assurance that hospitals participating under the state plan or a waiver of such plan will be instructed to establish procedures for referring eligible individuals with chronic conditions who seek or need treatment in a hospital emergency department to designated Health Homes providers. The state provides assurance that FMAP for Health Homes services shall be 90% for the first eight fiscal quarters from the effective date of the SPA. After the first eight quarters, expenditures will be claimed at the regular matching rate. The state provides assurance that it will have the systems in place so that only one 8-quarter period of enhanced FMAP for each health homes enrollee will be claimed. The state provides assurance that there will be no duplication of services and payment for similar services provided under other Medicaid authorities. Health Homes Population and Enrollment Criteria MEDICAID - Health Homes - Pre-Diabetes, Diabetes, Obesity, at Risk for Anxiety and/or Depression - WV - 2016 Not Started In Progress Complete Package Header Package ID WV2016MH0003O Submission Type Official - Review 1 Approval Date 5/4/2017 Superseded SPA ID N/A SPA ID WV-16-0008 Initial Submission Date 2/8/2017 Effective Date 4/1/2017 Categories of Individuals and Populations Provided Health Homes Services The state will make Health Homes services available to the following categories of Medicaid participants Categorically Needy (Mandatory and Options for Coverage) Eligibility Groups Medically Needy Eligibility Groups Mandatory Medically Needy Medically Needy Pregnant Women Medically Needy Children under Age 18 Optional Medically Needy (select the groups included in the population) Families and Adults Medically Needy Children Age 18 through 20 Medically Needy Parents and Other Caretaker Relatives Aged, Blind and Disabled Medically Needy Aged, Blind or Disabled Medically Needy Blind or Disabled Individuals Eligible in 1973 Population Criteria The state elects to offer Health Homes services to individuals with Two or more chronic conditions One chronic condition and the risk of developing another Specify the conditions included Mental Health Condition Substance Use Disorder Asthma Diabetes Heart Disease BMI over 25 Other (specify) WV 16-0008 Superseded SPA: N/A Effective Date: April 1, 2017 CMS Approval: May 4, 2017

5/4/2017 Medicaid State Plan Print View 9/21 Name Description Pre-Diabetes n/a Anxiety and/or Depression n/a Specify the criteria for at risk of developing another chronic condition Evidence published indicates that individuals with Pre-Diabetes, Diabetes, and Obesity represent a patient population at high risk for: anxiety; depression; statistically high mortality rates compared to the general medical population; developing comorbid medical diseases because of lifestyle; substance abuse; and/or other related physical and mental health diagnosis. These individuals have a pattern of poor treatment compliance. The diagnosis of Diabetes increases the members risk of developing many other serious health problems to include: Skin complications including wound healing; eye complications and deteriorating vision; neuropathy; foot complications to include numbness, burning, stinging and weakness; Ketoacidosis; kidney disease to include kidney disease; high blood pressure, stroke and/or other cardiovascular diseases; Hyperosmolar Hyperglycemic Nonketotic Syndrome (HNNS); gastroparesis; along with having effects on pregnancy and members overall mental health. Prescription medication costs for individuals with Pre Diabetes, Diabetes, Obesity, in West Virginia average approximately $3,000 per year, per individual. If the individual concurrently suffers from anxiety and/or depression and is receiving the most current treatment, yearly prescription medical costs can be significantly higher. For example, about 25% of West Virginia’s antipsychotics, antidepressants, and/or antianxiety medications are attributed to this patient population. Overall medical cost for this patient population can easily exceed $30,000 per individual, per year. An estimated 10% of the total West Virginia Medicaid population is diagnosed within these target diagnosis. However, there is reason to believe that Diabetes is severely underdiagnosed in West Virginia due to members not receiving routine health care, and the average person is estimated to have diabetes 5 years, or more, before they are diagnosed. For the reasons noted, targeted treatment of this population meets the needs of West Virginians and is highly aligned with the three main goals to: improve the experience of care, improve the health of our population, and to reduce per capita health care costs. One serious and persistent mental health condition Enrollment of Participants Participation in a Health Homes is voluntary. Indicate the method the state will use to enroll eligible Medicaid individuals into a Health Home Opt-In to Health Homes provider Referral and assignment to Health Homes provider with opt-out Other (describe) Describe the process used Claims based information for automatic assignment based on prior relationship with Health Home provider or, in the absence of relationship, Health Home that is geographically closest to patient. Patient notification completed by mail and by health home for options including opting out. The state provides assurance that it will clearly communicate the individual's right to opt out of the Health Homes benefit or to change Health Homes providers at any time and agrees to submit to CMS a copy of any letter or communication used to inform the individuals of the Health Homes benefit and their rights to choose or change Health Homes providers or to elect not to receive the benefit Name Date Created Type N Date T WV HH 03 _Diabetes_ MEMBER LETTER HH ASSIGNMENT 2016_Approved 1/20/2017 2:43 PM EST Health Homes Geographic Limitations MEDICAID - Health Homes - Pre-Diabetes, Diabetes, Obesity, at Risk for Anxiety and/or Depression - WV - 2016 Not Started In Progress Complete Package Header Package ID WV2016MH0003O Submission Type Official - Review 1 SPA ID WV-16-0008 Initial Submission Date 2/8/2017 WV 16-0008 Superseded SPA: N/A Effective Date: April 1, 2017 CMS Approval: May 4, 2017

5/4/2017 Medicaid State Plan Print View 10/21 Approval Date 5/4/2017 Superseded SPA ID N/A Effective Date 4/1/2017 Health Homes services will be available statewide Health Homes services will be limited to the following geographic areas Health Homes services will be provided in a geographic phased-in approach Specify the geographic limitations of the program By county By region By city/municipality Other geographic area Specify which counties 1. Boone 2. Cabell 3. Fayette 4. Kanawha 5. Lincoln 6. Logan 7. McDowell 8. Mason 9. Mercer 10. Mingo 11. Putnam 12. Raleigh 13. Wayne 14. Wyoming Health Homes Services MEDICAID - Health Homes - Pre-Diabetes, Diabetes, Obesity, at Risk for Anxiety and/or Depression - WV - 2016 Not Started In Progress Complete Package Header Package ID WV2016MH0003O Submission Type Official - Review 1 Approval Date 5/4/2017 Superseded SPA ID N/A SPA ID WV-16-0008 Initial Submission Date 2/8/2017 Effective Date 4/1/2017 Service Definitions Provide the state's definitions of the following Health Homes services and the specific activities performed under each service Comprehensive Care Management Definition Comprehensive Care Management is the development, implementation, and ongoing reassessment of a comprehensive individualized patient-centered care plan for each member. The care plan design will be developed with input from the interdisciplinary team of providers on the basis of information obtained from a comprehensive risk assessment that identifies the member’s needs in areas including: medical, mental health, substance abuse/misuse, and social services. The comprehensive risk assessment will also include mental health and substance abuse screenings using standardized tools. HH Providers will be required to update the clinical/medical/social data received during an assessment at least every four months. The individualized care plan will include integrated services to meet the member’s behavioral health, rehabilitative, long term care, and social service needs, as indicated. The care plan will be developed with input from the interdisciplinary team of providers; identify the primary care physician, other health and behavioral health care providers, Care Manager, and other health team providers directly involved in the individual’s care; and also identify community networks and supports needed for comprehensive quality health care. The Care Manager is a member of the team and responsible for the maintenance of the care plan document and ensures the client receives a copy of the initial care plan and any time that changes are made. Goals and timeframes for improving the member’s health, overall health care status and identified interventions will be included in the care plan, as well as schedules for plan assessment and update. Comprehensive care management will assure that the member or legal health representative is an active team member in the care plan’s development, implementation and assessment and is informed and in agreement with plan components. Member’s family and other recognized supports will be involved in the member’s care as requested by the member. Describe how Health Information Technology will be used to link this service in a comprehensive approach across the care continuum Penetration of HIT adoption in WV is variable at the current time, although a growing number of providers are adopting EHR’s in response to the federal incentive program and BMS has partnered with the WV Regional Extension Center to further promote the use of HIT within the Medicaid provider community. Providers will be expected to demonstrate a commitment to the use of HIT by all members of the Health Home team, as part of the application to serve as a Health Home. At minimum, a certified EHR is required at the primary care site; the EHR is expected to document the elements of an individual care plan for each Health Home member. The use of HIT is also encouraged in the identification of individuals who are at highest risk and in need of more intense care WV 16-0008 Superseded SPA: N/A Effective Date: April 1, 2017 CMS Approval: May 4, 2017

5/4/2017 Medicaid State Plan Print View 11/21 management services; this will be done through analysis of population level reports of member characteristics and utilization patterns. This may also be done through electronic responses to a health risk assessment tool. To facilitate communication about care coordination and care management activities, various systems are being explored; however, none is expected to be in place prior to SPA implementation. As the use of HIT and the implementation of a statewide health information exchange evolve, it is anticipated that the use of HIT to support all of the health homes services will also evolve. Scope of service The service can be provided by the following provider types Behavioral Health Professionals or Specialists Description Initial assessment and care plan development will be conducted in a face to face encounter. Follow up services may be provided in either a face to face encounter, telephonically, or via telehealth modalities. Nurse Practitioner Nurse Care Coordinators Description Under the supervision of the primary care physician or advanced nurse practitioner, the nurse care coordinator supervises and facilitates the coordination of health care to the member. Initial assessment and care plan development will be conducted in a face to face encounter. Follow up services may be provided in either a face to face encounter, telephonically, or via telehealth modalities. Nurses Description Under the supervision of the primary care physician or advanced nurse practitioner, the nurse care coordinator supervises and facilitates the coordination of health care to the member. Initial assessment and care plan development will be conducted in a face to face encounter. Follow up services may be provided in either a face to face encounter, telephonically, or via telehealth modalities. Medical Specialists Physicians Description Initial assessment and care plan development will be conducted in a face to face encounter. Follow up services may be provided in either a face to face encounter, telephonically, or via telehealth modalities. Physician's Assistants Pharmacists Social Workers Description Eligible as behavioral health specialist. Initial assessment and care plan development will be conducted in a face to face encounter. Follow up services may be provided in either a face to face encounter, telephonically, or via telehealth modalities. Doctors of Chiropractic Licensed Complementary and alternative Medicine Practitioners Dieticians Nutritionists Other (specify) Care Coordination Definition Care Coordination is the delivery of comprehensive, multidisciplinary care to a member that links all involved resources by maintaining and disseminating current, relevant health and care plan data. Care coordination manages resource linkages, referrals, coordination and follow-up to plan-identified resources. Activities include, but are not limited to: appointment scheduling, conducting referrals and follow-up monitoring, participating in facility discharge processes and communicating with other providers and members/family members. Describe how Health Information Technology will be used to link this service in a comprehensive approach across the care continuum Each Health Home provider will be encouraged to use the HIT resources they have available through their internal EHRs to track referrals and generate reminders for follow up. Where there are available electronic linkages with partner hospitals and their EHRs, the Health Home providers will be encouraged to maximize the use of these linkages to share bi-directional information. West Virginia is just starting its gradual roll-out of a state-wide HIE. As the state HIE is implemented, all Health Home providers will be encouraged to fully participate, as is feasible, to utilize the HIE to share information with members of their referral network. Health Home providers will also be encouraged to implement a patient portal to communicate with patients/ family members. Health Home providers will be encouraged to utilize their EHRs and/ or patient portals to link to health information and resources applicable to the member’s condition. Member educational materials will be generated electronically to allow for customization and appropriateness to the member’s condition, literacy level, and cultural preferences, where feasible. WV 16-0008 Superseded SPA: N/A Effective Date: April 1, 2017 CMS Approval: May 4, 2017

5/4/2017 Medicaid State Plan Print View 12/21 Scope of service The service can be provided by the following provider types Behavioral Health Professionals or Specialists Description Services may be provided in either a face to face encounter, telephonically, or via telehealth modalities. Nurse Practitioner Nurse Care Coordinators Description Services may be provided in either a face to face encounter, telephonically, or via telehealth modalities. Nurses Description Services may be provided in either a face to face encounter, telephonically, or via telehealth modalities. Medical Specialists Physicians Description Services may be provided in either a face to face encounter, telephonically, or via telehealth modalities. Physician's Assistants Pharmacists Social Workers Description Services may be provided in either a face to face encounter, telephonically, or via telehealth modalities. Doctors of Chiropractic Licensed Complementary and alternative Medicine Practitioners Dieticians Nutritionists Other (specify) Health Promotion Definition Health Promotion includes the provision of: health education specific to a member’s health and behavioral health; development of self-management plans effectively emphasizing the importance of immunizations and preventive screenings; understanding and management of prescribed medications; supporting improvement of social networks; and providing healthy lifestyle interventions. Areas of focus include but are not limited to, substance use and smoking prevention and cessation, nutritional counseling, weight management, and increasing physical activity. Health promotion services assist members to participate in the development and implementation of their care plan and emphasize person-centered empowerment to facilitate self-management of chronic health conditions through informed awareness. Describe how Health Information Technology will be used to link this service in a comprehensive approach across the care continuum Each Health Home provider will be encouraged to use the HIT resources they have available through their internal EHRs to track referrals and generate reminders for follow up. Where there are available electronic linkages with partner hospitals and their EHRs, the Health Home providers will be encouraged to maximize the use of these linkages to share bi-directional information. West Virginia is just starting its gradual roll-out of a state-wide HIE. As the state HIE is implemented, all Health Home providers will be encouraged to fully participate, as is feasible, to utilize the HIE to share information with members of their referral network. Health Home providers will also be encouraged to implement a patient portal to communicate with patients/ family members. Health Home providers will be encouraged to utilize their EHRs and/ or patient portals to link to health information and resources applicable to the member’s condition. Member educational materials will be generated electronically to allow for customization and appropriateness to the member’s condition, literacy level, and cultural preferences, where feasible. Scope of service The service can be provided by the following provider types Behavioral Health Professionals or Specialists Description Services may be provided in either a face to face encounter, telephonically, or via telehealth modalities. Nurse Practitioner Nurse Care Coordinators Description Services may be provided in either a face to face encounter, telephonically, or via telehealth modalities. Nurses Description WV 16-0008 Superseded SPA: N/A Effective Date: April 1, 2017 CMS Approval: May 4, 2017

5/4/2017 Medicaid State Plan Print View 13/21 Services may be provided in either a face to face encounter, telephonically, or via telehealth modalities. Medical Specialists Description Services may be provided in either a face to face encounter, telephonically, or via telehealth modalities. Physicians Description Services may be provided in either a face to face encounter, telephonically, or via telehealth modalities. Physician's Assistants Description Services may be provided in either a face to face encounter, telephonically, or via telehealth modalities. Pharmacists Description Services may be provided in either a face to face encounter, telephonically, or via telehealth modalities. Social Workers Description Services may be provided in either a face to face encounter, telephonically, or via telehealth modalities. Doctors of Chiropractic Description Services may be provided in either a face to face encounter, telephonically, or via telehealth modalities. Licensed Complementary and alternative Medicine Practitioners Description Services may be provided in either a face to face encounter, telephonically, or via telehealth modalities. Dieticians Description Services may be provided in either a face to face encounter, telephonically, or via telehealth modalities. Nutritionists Description Services may be provided in either a face to face encounter, telephonically, or via telehealth modalities. Other (specify) Provider Type Description Care Coordinator; Others Services may be provided in either a face to face encounter, telephonically, or via telehealth modalities. Comprehensive Transitional Care from Inpatient to Other Settings (including appropriate follow-up) Definition Comprehensive Transitional Care is care coordination services designed to prevent avoidable emergency department visits, admissions, and readmission after discharge from an inpatient facility. For each enrollee transferred from one caregiver or site of care to another, the health home team ensures proper and timely follow-up care and safe, coordinated transitions, including reconciliation of medications. The transition could include any inpatient care to home and community based services and supports. This is accomplished through formal relationships and communication systems with health facilities including emergency departments, hospitals, long-term care facilities, residential/rehabilitation settings, as well as with other providers and community-based services. Describe how Health Information Technology will be used to link this service in a comprehensive approach across the care continuum Health Home providers will be encouraged to develop partnerships that maximize the use of HIT across various caregivers and care settings. The provider will be encouraged to use HIT when available to communicate with health facilities and to facilitate interdisciplinary collaboration among all care team members. Providers will be encouraged to share information through the statewide HIE once that capability becomes available. Providers will also be encouraged to provide enrollees with web-based access to their records that can follow the enrollees as they transition to different care settings. To facilitate post-hospital follow-up, BMS will be exploring a means of communication to health homes about enrollees who have been admitted to a hospital. The QIO will provide via its web-based system a notification to the assigned Health Home when a non-MCO member has had a request for medical or psychiatric hospitalization made/authorized. The MCOs will be encouraged to provide like information to the Health Homes for their members served by a Health Home. Scope of service The service can be provided by the following provider types Behavioral Health Professionals or Specialists Description Services may be provided in either a face to face encounter, telephonically, or via telehealth modalities. Nurse Practitioner Nurse Care Coordinators Description WV 16-0008 Superseded SPA: N/A CMS Approval: May 4, 2017 Effective Date: April 1, 2017

5/4/2017 Medicaid State Plan Print View 14/21 Nurses Description Services may be provided in either a face to face encounter, telephonically, or via telehealth modalities. Medical Specialists Physicians Description Services may be provided in either a face to face encounter, telephonically, or via telehealth modalities. Physician's Assistants Pharmacists Social Workers Doctors of Chiropractic Licensed Complementary and alternative Medicine Practitioners Dieticians Nutritionists Other (specify) Individual and Family Support (which includes authorized representatives) Definition Individual and Family Support Services include service provision and resource identification that assist members to attain their highest level of health and functioning. Peer supports, support groups, and self-care programs can be utilized by providers to increase members’ and support members’ knowledge about the member’s diseases, promote member’s engagement and self-management capabilities, while assisting the member to adhere to their care plan. A primary focus of individual and family supports will be strengthened through increased health literacy. This effort will include communicated information that is language, literacy, and culturally appropriate, and designed to improve the member’s ability to self-manage their health and participate in the ongoing care planning. Describe how Health Information Technology will be used to link this service in a comprehensive approach across the care continuum Health Home providers will be encouraged to utilize their EHRs and/or patient portals to link to health information and resources applicable to the member’s condition. The use of a patient portal or PHR is encouraged to provide for patient/ family interaction with the care team and for development and monitoring of shared care plans. Member educational materials will be generated electronically to allow for customization and appropriateness to the member’s condition, literacy level, and cultural preferences, where feasible. Scope of service The service can be provided by the following provider types Behavioral Health Professionals or Specialists Description Services may be provided in either a face to face encounter, telephonically, or via telehealth modalities. Nurse Practitioner Nurse Care Coordinators Nurses Description Services may be provided in either a face to face encounter, telephonically, or via telehealth modalities. Medical Specialists Physicians Description Services may be provided in either a face to face encounter, telephonically, or via telehealth modalities. Physician's Assistants Pharmacists Social Workers Doctors of Chiropractic Licensed Complementary and alternative Medicine Practitioners Dieticians WV 16-0008 Superseded SPA: N/A Effective Date: April 1, 2017 CMS Approval: May 4, 2017

5/4/2017 Medicaid State Plan Print View 15/21 Nutritionists Other (specify) Referral to Community and Social Support Services Definition Referral to Community and Social Support Services includes the identification of available community resources, active management of referrals, access to care, including long term services and supports, engagement with other community and social supports, coordination of services and follow-up. This may include but not limited to, Alcoholics Anonymous and/or Narcotics Anonymous. The Community and Social Support Services network includes development of policies, procedures and accountabilities (through contractual agreements, where applicable) which clearly define the roles and responsibilities of the participants in order to support effective collaboration between the health home and community-based resources, and the member. The member’s care plan will include community-based and other social support services that address and respond to the member’s needs and preferences, and contribute to achieving the care plan goals. Describe how Health Information Technology will be used to link this service in a comprehensive approach across the care continuum Health Home providers will be encouraged to utilize HIT as feasible to initiate, manage and follow up on community based and other social services referrals. Scope of service The service can be provided by the following provider types Behavioral Health Professionals or Specialists Description Services may be provided in either a face to face encounter, telephonically, or via telehealth modalities. Nurse Practitioner Nurse Care Coordinators Description Services may be provided in either a face to face encounter, telephonically, or via telehealth modalities. Nurses Description Services may be provided in either a face to face encounter, telephonically, or via telehealth modalities. Medical Specialists Description Services may be provided in either a face to face encounter, telephonically, or via telehealth modalities. Physicians Description Services may be provided in either a face to face encounter, telephonically, or via telehealth modalities. Physician's Assistants Description Services may be provided in either a face to face encounter, telephonically, or via telehealth modalities. Pharmacists Description Services may be provided in either a face to face encounter, telephonically, or via telehealth modalities. Social Workers Description Services may be provided in either a face to face encounter, telephonically, or via telehealth modalities. Doctors of Chiropractic Description Services may be provided in either a face to face encounter, telephonically, or via telehealth modalities. Licensed Complementary and alternative Medicine Practitioners Description Services may be provided in either a face to face encounter, telephonically, or via telehealth modalities. Dieticians Description Services may be provided in either a face to face encounter, telephonically, or via telehealth modalities. Nutritionists Description Services may be provided in either a face to face encounter, telephonically, or via telehealth modalities. Other (specify) Provider Type Description WV 16-0008 Superseded SPA: N/A Effective Date: April 1, 2017 CMS Approval: May 4, 2017

5/4/2017 Medicaid State Plan Print View 16/21 Care Coordinator; Others Services may be provided in either a face to face encounter, telephonically, or via telehealth modalities. Health Homes Patient Flow Describe the patient flow through the state's Health Homes system. Submit with the state plan amendment flow-charts of the typical process a Health Homes individual would encounter The admission continuing stay criteria for Tier 1 will be: Medicaid Eligibility and documented diagnosis of a Bipolar Disorder that are determined to be at risk for becoming infected with or currently have Hepatitis B and/or C. Name Date Created Type HH3FlowChartShort10.14.16 12/21/2016 2:50 PM EST Health Homes Providers MEDICAID - Health Homes - Pre-Diabetes, Diabetes, Obesity, at Risk for Anxiety and/or Depression - WV - 2016 Not Started In Progress Complete Package Header Package ID WV2016MH0003O Submission Type Official - Review 1 Approval Date 5/4/2017 Superseded SPA ID N/A SPA ID WV-16-0008 Initial Submission Date 2/8/2017 Effective Date 4/1/2017 Types of Health Homes Providers Designated Providers Indicate the Health Homes Designated Providers the state includes in its program and the provider qualifications and standards Physicians Describe the Provider Qualifications and Standards WV Medicaid enrolled licensed health care practitioner Clinical Practices or Clinical Group Practices Describe the Provider Qualifications and Standards WV Medicaid enrolled licensed health care practitioner or group Rural Health Clinics Describe the Provider Qualifications and Standards WV Medicaid enrolled licensed rural health clinic Community Health Centers Describe the Provider Qualifications and Standards WV Medicaid enrolled licensed community health center Community Mental Health Centers Describe the Provider Qualifications and Standards WV Medicaid enrolled licensed community mental health center Home Health Agencies Case Management Agencies Community/Behavioral Health Agencies Describe the Provider Qualifications and Standards WV Medicaid enrolled licensed community or behavioral health agency Federally Qualified Health Centers (FQHC) Describe the Provider Qualifications and Standards WV Medicaid enrolled licensed federally qualified health centers WV 16-0008 Superseded SPA: N/A Effective Date: April 1, 2017 CMS Approval: May 4, 2017

5/4/2017 Medicaid State Plan Print View 17/21 Other (Specify) Teams of Health Care Professionals Health Teams Provider Infrastructure Describe the infrastructure of provider arrangements for Health Home Services West Virginia's provider infrastructure will include a designated primary care physician or advanced practice nurse practitioner, working with multidisciplinary teams in a variety of possible settings: primary care and solo medical practices; comprehensive community behavioral health centers with a primary care service base; providers who serve special populations; academic medical centers; other entities meeting established qualifications. Supports for Health Homes Providers Describe the methods by which the state will support providers of Health Homes services in addressing the following components 1. Provide quality-driven, cost-effective, culturally appropriate, and person- and family- centered Health Homes services 2. Coordinate and provide access to high quality health care services informed by evidence-based clinical practice guidelines 3. Coordinate and provide access to preventive and health promotion services, including prevention of mental illness and substance use disorders 4. Coordinate and provide access to mental health and substance abuse services 5. Coordinate and provide access to comprehensive care management, care coordination, and transitional care across settings. Transitional care includes appropriate follow-up from inpatient to other settings, such as participation in discharge planning and facilitating transfer from a pediatric to an adult system of health care 6. Coordinate and provide access to chronic disease management, including self-management support to individuals and their families 7. Coordinate and provide access to individual and family supports, including referral to community, social support, and recovery services 8. Coordinate and provide access to long-term care supports and services 9. Develop a person-centered care plan for each individual that coordinates and integrates all of his or her clinical and non-clinical health-care related needs and services 10. Demonstrate a capacity to use health information technology to link services, facilitate communication among team members and between the health team and individual and family caregivers, and provide feedback to practices, as feasible and appropriate 11. Establish a continuous quality improvement program, and collect and report on data that permits an evaluation of increased coordination of care and chronic disease management on individual-level clinical outcomes, experience of care outcomes, and quality of care outcomes at the population level Description The State will provide support to providers using a variety of media. Specific programs will be developed and determined based on feedback from providers and identification of needs. This will include face to face training on the requirements and expectations of the SPA, including outreach, assessment, documentation, invoicing, and reporting. Scenarios will be used to illustrate the expectations for care coordination and other health home services. A website has been set up to provide additional information about the SPA and will include access to recorded training webcasts as well as provider manual and FAQ's.Providers will have a specific QIO trainer consultant assigned to their agency in which they may request training and/or technical assistance. The QIO trainer consultant will be on the provider’s site at least one time every twelve months providing training based upon the findings of a record review and certification audit. The findings of these reviews will be analyzed to determine a training plan for all Health Home Providers. The State will provide support to providers using a variety of media. This will include face to face training on health home requirements and expectations for all providers prior to the effective date of the SPA, including outreach, assessment, documentation, invoicing and reporting. A learning community of health home participants will be set up to allow for regular sharing of experiences among health homes providers and teams. Qualitative information about program implementation will be collected through this community. and Lessons learned will be harvested through the health home learning community. Other Health Homes Provider Standards The state's requirements and expectations for Health Homes providers are as follows 1. Health home providers must enroll or be enrolled in the WV Medicaid program and agree to comply with all Medicaid program requirements. 2. Care coordination and the other five health home services, as identified by CMS, will be provided to all health home enrollees by an interdisciplinary team of providers. As described in the Provider Infrastructure section above, each health home will define its multidisciplinary team in a manner that assures capacity to provide or arrange for the six defined health home services. However, at minimum, each team shall include a primary care provider (physician or advanced practice nurse), a licensed behavioral health specialist, a registered nurse, and a care manager (who could be the nurse or the behavioral health specialist for persons with SMI). Each team shall include an individual who is designated as a care coordinator but who may also fill other roles. The care manager leads the health home team and is accountable for assuring that patient needs are identified and that an integrated care plan is developed and coordinated for each enrollee and is carried out by assuring access to medical and behavioral health care services and community social supports as defined in the care plan. Additional members of the health home team may include physicians, physicians’ assistants, nurses, nurse practitioners, pharmacists, social workers, mental health workers, health educators, community health workers, and others, dependent on the delivery model of the health home. Specific qualifications for the required team member roles are as follows: • Provider---MD, DO, or Advanced Practice Nurse licensed in the state of WV; • Behavioral Health Specialist ---Masters prepared individual licensed in the state of WV in counseling, psychology, or social work; • Nurse---Registered Nurse licensed in the state of WV; • Care Manager---Registered Nurse or licensed Behavioral Health Specialist. Completed an internal credentialing process through a provider designation as a health home; • Care Coordinator---Licensed Registered Nurse or Bachelor’s Degree in a social science with some applicable patient care or counseling experience.Completed an internal credentialing process through a provider designation as a health home. The health home provider must identify the means for care plan documentation, communication, and integration across the various service delivery components of the health home. Health home providers can either directly provide or subcontract for the provision of health home services. The health home provider remains responsible for all health home program requirements, including services performed by the subcontractor. The health home provider is required to describe the methods and processes for providing the health home services. Where contractual relationships are to be used, the health home provider must demonstrate that formal written agreements are in place at the time health home services are initiated. 3. Health home providers are expected to establish a medical neighborhood of local community providers that will serve as referral providers for various medical, behavioral health, and facility services, and as applicable to managed care, the medical neighborhood must include providers that are part of the WV 16-0008 Superseded SPA: N/A Effective Date: April 1, 2017 CMS Approval: May 4, 2017

5/4/2017 Medicaid State Plan Print View 18/21 contracted network of the managed care entity. At minimum, each health home must either include provision of behavioral health services or must establish a formal partnership with a behavioral health entity in order to assure appropriate access to a range of behavioral health services for all of its health home enrollees. Services will be available 24 hours a day/7 days a week. Hospitals that are part of a health home neighborhood must have procedures in place for referring any eligible individual with chronic conditions who seek or need treatment in a hospital emergency department to a health home or other facility based settings to ensure coordination of all aspects of transitional care for current and eligible recipients. Documentation describing the medical neighborhood and hospitals’ referral commitment must be provided. 4. Health home providers must demonstrate their ability to perform each of the following functional requirements. This includes documentation of the processes used to perform these functions and the methods used to assure service delivery takes place in the described manner. • Provide quality-driven, cost-effective, culturally appropriate, and person- and family-centered health home services. • Coordinate and provide access to high-quality health care services informed by evidence-based clinical practice guidelines. • Coordinate and provide access to preventive and health promotion services, including the promotion of mental and emotional well-being and the prevention of substance abuse. • Coordinate and provide access to mental health and substance abuse services. • Coordinate and provide access to comprehensive care management, care coordination, and transitional care across settings. • Coordinate and provide access to chronic disease management, including self-management support to individuals and their families. • Coordinate and provide access to individual and family supports, including referral to community, social support, and recovery services. • Coordinate and provide access to long-term care supports and services. • Develop a person-centered care plan for each individual that coordinates and integrates all of his or her clinical and non-clinical health-care related needs and services. • Demonstrate a capacity to use health information technology to link services, facilitate communication among team members and between the health team and individual and family caregivers, and provide feedback to practices, as feasible and appropriate. • Establish a continuous quality improvement program, and collect and report on data that permits an evaluation of increased coordination of care and chronic disease management on individual-level clinical outcomes, experience of care outcomes, and quality of care outcomes at the population level. 5. The health home provider must use an electronic health record system that qualifies under the Meaningful Use provisions of the HITECH Act, and which allows the patient’s health information and plan of care to be accessible to the interdisciplinary team of providers. Providers may also access the The West Virginia Health Information Network (WVHIN), which is an interactive network. 6. As a condition of being a designated provider, the health home must agree not to refuse enrollment of eligible potential health home enrollee referred by Bureau for Medical Services (BMS). 7. As a condition of being a designated provider, the health home is subject to all audit and monitoring systems currently in place for Bureau for Medical Services programs. Documentation of health home services for enrollees is subject to audit by a Bureau for Medical Services contractor. In addition, the provider understands that BMS will monitor outcome measures and the provider is subject to discontinuation of designation as a health home if measures are not reported as required, or if anticipated outcomes are not achieved. 8. Health Home provider qualifications will initially be assessed and approved by the DHHR Bureau for Medical Services. Once a provider gains Health Home provider status, the provider record in the State’s MMIS will include this designation. Subsequent Health Home provider recertification, conducted by QIO, will occur within thirteen months of the Health Home designation anniversaries. The QIO is under contract with the Bureau for Medical Services to provide utilization management for certain Medicaid-covered services, including prior approval for inpatient hospital admission. Name Date Created Type No items available Health Homes Service Delivery Systems MEDICAID - Health Homes - Pre-Diabetes, Diabetes, Obesity, at Risk for Anxiety and/or Depression - WV - 2016 Not Started In Progress Complete Package Header Package ID WV2016MH0003O Submission Type Official - Review 1 Approval Date 5/4/2017 Superseded SPA ID N/A SPA ID WV-16-0008 Initial Submission Date 2/8/2017 Effective Date 4/1/2017 Identify the service delivery system(s) that will be used for individuals receiving Health Homes services Fee for Service PCCM Risk Based Managed Care Other Service Delivery System Health Homes Payment Methodologies MEDICAID - Health Homes - Pre-Diabetes, Diabetes, Obesity, at Risk for Anxiety and/or Depression - WV - 2016 WV 16-0008 Superseded SPA: N/A Effective Date: April 1, 2017 CMS Approval: May 4, 2017

5/4/2017 Medicaid State Plan Print View 19/21 Package Header Package ID WV2016MH0003O Submission Type Official - Review 1 Approval Date 5/4/2017 Superseded SPA ID N/A SPA ID WV-16-0008 Initial Submission Date 2/8/2017 Effective Date 4/1/2017 Payment Methodology The State's Health Homes payment methodology will contain the following features Fee for Service Individual Rates Per Service Per Member, Per Month Rates Fee for Service Rates based on Severity of each individual's chronic conditions Capabilities of the team of health care professionals, designated provider, or health team Other Describe below described below Comprehensive Methodology Included in the Plan Incentive Payment Reimbursement Describe any variations in payment based on provider qualifications, individual care needs, or the intensity of the services provided Health Homes providers will be paid a flat rate per member, per month for indicated services. This rate will be the equivalent of the Tier One payment in the State's Pilot Heath Homes for individuals with bipolar disorder and risk of hepatitis b and/or c in 6 counties and Health Homes II for individuals with bipolar disorder and risk of hepatitis b and/or c in 49 counties. PCCM (description included in Service Delivery section) Risk Based Managed Care (description included in Service Delivery section) Alternative models of payment, other than Fee for Service or PMPM payments (describe below) Agency Rates Describe the rates used FFS Rates included in plan Comprehensive methodology included in plan The agency rates are set as of the following date and are effective for services provided on or after that date Rate Development Provide a comprehensive description in the SPA of the manner in which rates were set 1. In the SPA please provide the cost data and assumptions that were used to develop each of the rates 2. Please identify the reimbursable unit(s) of service 3. Please describe the minimum level of activities that the state agency requires for providers to receive payment per the defined unit 4. Please describe the state's standards and process required for service documentation, and 5. Please describe in the SPA the procedures for reviewing and rebasing the rates, including the frequency with which the state will review the rates, and the factors that will be reviewed by the state in order to understand if the rates are economic and efficient and sufficient to ensure quality services. Comprehensive Description Reimbursement will only be made for health home services not covered by any other available Medicaid reimbursement options. The criteria required for receiving a monthly PMPM reimbursement is: a) The member meets health home eligibility criteria and is so flagged in the MMIS; b) The member is enrolled as a health home member with the health home provider billing for the service reimbursement; WV 16-0008 Superseded SPA: N/A Effective Date: April 1, 2017 CMS Approval: May 4, 2017

5/4/2017 Medicaid State Plan Print View 20/21 c) At least one of the core health home services has been provided during the previous month and documented in the member's medical record. By submitting the basic or intense health home service code for reimbursement, the provider is attesting to the fact that at least one of the six health home services has been provided during the month. The following steps are used to determine the rates: I . The State will use West Virginia wage specific data obtained from the Bureau for Labor Statistics (BLS) for each Health Home designated multidisciplinary team professional. 2. Salary will be adjusted for fringe benefits and assigned at a rate of 40 percent of the average BLS annualized salary for each wage classification. 3. The fringe adjusted annual salary is converted to an hourly rate per wage classification assuming 2,080 work hours. 4. The hourly rate for each wage classification is adjusted for each multidisciplinary team member's level of participation in the health home team for payment by dividing the team members assigned level of participation by the total assigned monthly participation for the health home team. 5. The monthly health home team level of participation assigned is two hours PMPM for individuals with target diagnosis. Health home participation levels will vary based on each targeted health home condition. 6. The PMPM rate will equal the sum of hourly rates for each health home multidisciplinary team member that has been adjusted for fringe benefits and participation level. Payment for Health Home services under the State Plan will not duplicate payments made to public agencies or private entities under other program authorities for the same purpose. Medicaid will be the payer of last resort. Unless specifically notes otherwise in the plan, the state developed rate is the same for both governmental and private providers. Providers will be reimbursed at the lesser of the provider's usual and customary billed charge or the Bureau for Medical Services (Bureau) fee schedule. Rates will be published on the Bureau's website at: www.dhhr.wv.gov/bms. The agency's fee schedule rate was set as of July 1, 2014, the start date of WV 1st Health Home program, and is effective for services provided on or after that date. All rates are published on the agency's website. Payment will be made on a per member per month (PMPM) basis for each health home enrollee. The Health Home service code is intended to cover the provision of all of the six health home services, as determined to be appropriate to meet the member needs. At the time of enrollment, the Health Homes requests prior authorization of the service for each enrollee through a web-based prior authorization system managed by the contracted QIO. Both at initial enrollment and at the time of each service request, the QIO verifies the person's Medicaid eligibility. Payment will be made based on the presence of the Health Home attribute in the member's MMIS record, the member's Medicaid eligibility during the service month, a prior authorization in the MMIS including the service month and the submission for payment through the MMIS of the service code. The benefit package for all Health Home enrollees includes eligibility for services covered by the basic health home code. Assurances The State provides assurance that it will ensure non-duplication of payment for services similar to Health Homes services that are offered/covered under a different statutory authority, such as 1915(c) waivers or targeted case management. Describe below how non- duplication of payment will be achieved There will be a contractual agreement with Health Home Providers and other providers, such as waiver services providers and targeted case management providers, regarding non-duplication of similar benefits. In addition, Bureau for Medical Services does periodic retrospective reviews for these services. The State meets the requirements of 42 CFR Part 447, Subpart A, and sections 1902(a)(4), 1902(a)(6), 1902(a)(30)(A), and 1903 with respect to non- payment for provider-preventable conditions. The State provides assurance that all governmental and private providers are reimbursed according to the same rate schedule, unless otherwise described above. The State provides assurance that it shall reimburse providers directly, except when there are employment or contractual arrangements consistent with section 1902(a)(32). Health Homes Monitoring, Quality Measurement and Evaluation MEDICAID - Health Homes - Pre-Diabetes, Diabetes, Obesity, at Risk for Anxiety and/or Depression - WV - 2016 Not Started In Progress Complete Package Header Package ID WV2016MH0003O Submission Type Official - Review 1 Approval Date 5/4/2017 Superseded SPA ID N/A SPA ID WV-16-0008 Initial Submission Date 2/8/2017 Effective Date 4/1/2017 Monitoring Describe the state's methodology for calculating cost saving (and report cost savings annually in Quality Measure Report). Include savings that result from improved coordination of care and chronic disease management achieved through the Health Homes Program, including data sources and measurement specifications, as well as any savings associated with dual eligibles, and if Medicare data was available to the state to utilize in arriving at its cost-savings estimates Data Source: MMIS Measurement Specifications: Compare total cost of care for health home members to costs of care for similar cohorts not enrolled with a HH. Calculations will WV 16-0008 Superseded SPA: N/A Effective Date: April 1, 2017 CMS Approval: May 4, 2017

5/4/2017 Medicaid State Plan Print View 21/21 exclude claims for high cost outliers more than three standard deviations from the mean annual cost and will include incremental HH reimbursement. HH member costs will also be compared pre- and post- HH implementation. Describe how the state will use health information technology in providing Health Homes services and to improve service delivery and coordination across the care continuum (including the use of wireless patient technology to improve coordination and management of care and patient adherence to recommendations made by their provider) West Virginia currently has several HIT initiatives in place and underway that will support the provision of health home services and improvement of care coordination across the care continuum. • The state is in the process of implementing a statewide health information exchange that will facilitate the sharing of information across various care delivery settings. All health home providers will be expected to participate in the HIE as it is implemented across the state. The HIE will be used to capture meaningful use measures and several of these are incorporated into the information that will be used to monitor and evaluate health home services. Until the HIE is fully in place in the state, each health home provider will also be expected to use their EHR to generate a Continuity of Care Document (CCD) that can be shared with other providers in order to facilitate transitions in care and care coordination across care settings. • A pharmacy data warehouse is in place that will provide for monitoring of patient adherence to prescribed drug regimens as well as appropriate use of pharmaceutical agents. • A data warehouse/decision support system has been implemented to capture MMIS claims data as well clinical data that will flows through the HIE. This data warehouse will be the primary source of evaluation information for the health homes initiative. • A web-based vendor system will be used for documentation of medically necessary services and authorization information. • Information on hepatitis will be shared with the West Virginia Bureau for Public Health: the Office of Epidemiology and Prevention Services maintains a data base of information regarding incidence of hepatitis in the State. Quality Measurement and Evaluation The state provides assurance that all Health Homes providers report to the state on all applicable quality measures as a condition of receiving payment from the state The state provides assurance that it will identify measureable goals for its Health Homes model and intervention and also identify quality measures related to each goal to measure its success in achieving the goals The state provides assurance that it will report to CMS information submitted by Health Homes providers to inform evaluations, as well as Reports to Congress as described in Section 2703(b) of the Affordable Care Act and as described by CMS The state provides assurance that it will track avoidable hospital readmissions and report annually in the Quality Measures report 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 0938-1188. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. This view was generated on 5/4/2017 3:03 PM EDT WV 16-0008 Superseded SPA: N/A Effective Date: April 1, 2017 CMS Approval: May 4, 2017

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-26-12 Baltimore, Maryland 21244-1850 August 13, 2020 Cynthia Beane, MSW, LCSW Commissioner Bureau for Medical Services 350 Capitol Street, Room 251 Charleston, WV 25301-3706 Re: West Virginia State Plan Amendment (SPA) 20-0004 Dear Commissioner Beane: We have reviewed the proposed amendment to add section 7.4 Medicaid Disaster Relief for the COVID-19 National Emergency to your Medicaid state plan, as submitted under transmittal number (TN) 20-0004. This amendment proposes to implement temporary policies, which are different from those policies and procedures otherwise applied under your Medicaid state plan, during the period of the Presidential and Secretarial emergency declarations related to the COVID-19 outbreak (or any renewals thereof). On March 13, 2020, the President of the United States issued a proclamation that the COVID-19 outbreak in the United States constitutes a national emergency by the authorities vested in him by the Constitution and the laws of the United States, including sections 201 and 301 of the National Emergencies Act (50 U.S.C. 1601 et seq.), and consistent with section 1135 of the Social Security Act (Act). On March 13, 2020, pursuant to section 1135(b) of the Act, the Secretary of the United States Department of Health and Human Services invoked his authority to waive or modify certain requirements of titles XVIII, XIX, and XXI of the Act as a result of the consequences of the COVID-19 pandemic, to the extent necessary, as determined by the Centers for Medicare & Medicaid Services (CMS), to ensure that sufficient health care items and services are available to meet the needs of individuals enrolled in the respective programs and to ensure that health care providers that furnish such items and services in good faith, but are unable to comply with one or more of such requirements as a result of the COVID-19 pandemic, may be reimbursed for such items and services and exempted from sanctions for such noncompliance, absent any determination of fraud or abuse. This authority took effect as of 6PM Eastern Standard Time on March 15, 2020, with a retroactive effective date of March 1, 2020. The emergency period will terminate, and this state plan provision will no longer be in effect, upon termination of the public health emergency, including any extensions. Pursuant to section 1135(b)(5) of the Act, for the period of the public health emergency, CMS is modifying the requirement at 42 C.F.R. 430.20 that the state submit SPAs related to the COVID-19 public health emergency by the final day of the quarter, to obtain a SPA effective

GDWH GXULQJ the quarter, enabling SPAs submitted after the last day of the quarter to have an effective date in a previous quarter, but no earlier than the effective date of the public health emergency. The State of West Virginia also requested a waiver of public notice requirements applicable to the SPA submission process. Pursuant to section 1135(b)(1)(C) of the Act, CMS is waiving public notice requirements applicable to the SPA submission process. Public notice for SPAs is required under 42 C.F.R. §447.205 for changes in statewide methods and standards for setting Medicaid payment rates, 42 C.F.R. §447.57 for changes to premiums and cost sharing, and 42 C.F.R. §440.386 for changes to Alternative Benefit Plans (ABPs). Pursuant to section 1135(b)(1)(C) of the Act, CMS is approving the state’s request to waive these notice requirements otherwise applicable to SPA submissions. These waivers or modifications of the requirements related to SPA submission timelines and public notice apply only with respect to SPAs that meet the following criteria: (1) the SPA provides or increases beneficiary access to items and services related to COVID-19 (such as by waiving or eliminating cost sharing, increasing payment rates or amending ABPs to add services or providers); (2) the SPA does not restrict or limit payment or services or otherwise burden beneficiaries and providers; and (3) the SPA is temporary, with a specified sunset date that is not later than the last day of the declared COVID-19 public health emergency (or any extension thereof). We nonetheless encourage states to make all relevant information about the SPA available to the public so they are aware of the changes. We conducted our review of your submittal according to the statutory requirements at section 1902(a) of the Act and implementing regulations. This letter is to inform you that West Virginia’s Medicaid SPA Transmittal Number 20-0004 is approved effective March 1, 2020. Please note that the effective date for the new COVID-19 testing eligibility group described at section 1902(a)(10)(A)(ii)(XXIII) of the Act is March 18, 2020. )LQDOO\ WKH HIIHFWLYH GDWH IRU WHOHGHQWLVWU\ VFUHHQLQJ LV $SULO   Enclosed is a copy of the CMS-179 summary form and the approved state plan pages. Please contact Dan Belnap at 215-861-4273 or by email at Dan.Belnap@cms.hhs.gov if you have any questions about this approval. We appreciate the efforts of you and your staff in responding to the needs of the residents of the State of West Virginia and the health care community. Sincerely, Enclosures $OLVVD 0RRQH\ 'H%R\ 'LUHFWRU 'LVDEOHG DQG (OGHUO\ +HDOWK 3URJUDPV *URXS RQ EHKDOI RI $QQH 0DULH &RVWHOOR $FWLQJ 'LUHFWRU &HQWHU IRU 0HGLFDLG &+,3 6HUYLFHV Alissa M. Deboy -S Digitally signed by Alissa M. Deboy -S Date: 2020.08.13 08 38:18 -04'00'

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED HEALTH CARE FINANCING ADMINISTRATION OMB NO. 0938-0193 1. TRANSMITTAL NUMBER: 2. STATE: 2 0 - 0 0 4 3. SECURITY ACT (MEDICAID) TO: REGIONAL ADMINISTRATOR 4. PROPOSED EFFECTIVE DATE HEALTH CARE FINANCING ADM NISTRATION DEPARTMENT OF HEALTH AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL (Check One) NEW STATE PLAN AMENDMENT TO BE CONSIDERED AS NEW PLAN X AMENDMENT 6. FEDERAL STATUTE/REGULATION CITATION: 7. FEDERAL BUDGET IMPACT: a. FFY $ b. FFY $ 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: 9. 10. SUBJECT OF AMENDMENT: 11. GOVERNOR'S REV EW (Check One): X GOVERNOR'S OFFICE REPORTED NO COMMENT OTHER, AS SPECIF ED: COMMENTS OF GOVERNOR'S OFFICE ENCLOSED NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL 12. SIGNATURE OF STATE AGENCY OFFICIAL: 16 RETURN TO: 13. TYPED NAME: 14. TITLE: 15. DATE SUBMITTED: 17. DATE RECEIVED 18 DATE APPROVED 19. EFFECTIVE DATE OF APPROVED MATERIAL: 20 SIGNATURE OF REGIONAL OFFICIAL: 21. TYPED NAME: 22 TITLE 23. REMARKS: FORM HCFA-179 (07-92) INSTRUCTIONS ON BACK TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL FOR HEALTH CARE FINANCING ADMINISTRATION COMPLETE BLOCKS 6 THRU 10 F THIS IS AN AMENDMENT (Separate Transmittal for each amendment) FOR REGIONAL OFFICE USE ONLY PLAN APPROVED - ONE COPY ATTACHED West Virginia 03-01-2020 2019 2020 Unknown Unknown 42 U.S.C. §1396a(a)(13)(1997) Title XIX of the Social Security Act Section 7 - General Provisions 7.4 Medicaid Disaster Relief for COVID-19 National Emergency Medicaid Disasteer Relief for COVID-19 National Emergency Cynthia Beane Commissioner 26-May-20 Bureau for Medical Services 350 Capitol Street Room 251 Charleston West Virginia 25301 PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable). 0D\   0DUFK   $XJXVW   $OLVVD 0RRQH\ 'H%R\ 'LUHFWRU 'LVDEOHG DQG (OGHUO\ +HDOWK 3URJUDPV *URXS RQ EHKDOI RI $FWLQJ 'LUHFWRU &HQWHU IRU 0HGLFDLG &+,3 6HUYLFHV Alissa M. Deboy -S Digitally signed by Alissa M. Deboy - S Date 2020.08.13 08 39 22 -04'00'

Page 1 State/Territory: _West Virginia_ TN: ________________ Supersedes TN: ________________ Section 7 – General Provisions 7.4. Medicaid Disaster Relief for the COVID-19 National Emergency On March 13, 2020, the President of the United States issued a proclamation that the COVID-19 outbreak in the United States constitutes a national emergency by the authorities vested in him by the Constitution and the laws of the United States, including sections 201 and 301 of the National Emergencies Act (50 U.S.C. 1601 et seq.), and consistent with section 1135 of the Social Security Act (Act). On March 13, 2020, pursuant to section 1135(b) of the Act, the Secretary of the United States Department of Health and Human Services invoked his authority to waive or modify certain requirements of titles XVIII, XIX, and XXI of the Act as a result of the consequences COVID-19 pandemic, to the extent necessary, as determined by the Centers for Medicare & Medicaid Services (CMS), to ensure that sufficient health care items and services are available to meet the needs of individuals enrolled in the respective programs and to ensure that health care providers that furnish such items and services in good faith, but are unable to comply with one or more of such requirements as a result of the COVID-19 pandemic, may be reimbursed for such items and services and exempted from sanctions for such noncompliance, absent any determination of fraud or abuse. This authority took effect as of 6PM Eastern Standard Time on March 15, 2020, with a retroactive effective date of March 1, 2020. The emergency period will terminate, and waivers will no longer be available, upon termination of the public health emergency, including any extensions. The State Medicaid agency (agency) seeks to implement the policies and procedures described below, which are different than the policies and procedures otherwise applied under the Medicaid State Plan, during the period of the Presidential and Secretarial emergency declarations related to the COVID-19 outbreak (or any renewals thereof), or for any shorter period described below: Describe shorter period here. 1) The additional rate increase effective 3/1/20 for ambulance and dental codes will end 6/30/20 2) ICF Services are increased by $10 per day effective from 3/1/2020 through 6/30/20. 3) 20 percent for Behavioral Health and PRTF Services as of 3/1/2020 through 6/30/20. NOTE: States may not elect a period longer than the Presidential or Secretarial emergency declaration (or any renewal thereof). States may not propose changes on this template that restrict or limit payment, services, or eligibility, or otherwise burden beneficiaries and providers. Request for Waivers under Section 1135 __X__ The agency seeks the following under section 1135(b)(1)(C) and/or section 1135(b)(5) of the Act: a. __X__ SPA submission requirements – the agency requests modification of the requirement to submit the SPA by March 31, 2020, to obtain a SPA effective date during the first calendar quarter of 2020, pursuant to 42 CFR 430.20. b. __X__ Public notice requirements – the agency requests waiver of public notice requirements that would otherwise be applicable to this SPA submission. These requirements may include those specified in 42 CFR 440.386 (Alternative Benefit Plans), 42 CFR 447.57(c) (premiums and cost sharing), and 42 CFR 447.205 (public notice of changes in statewide methods and standards for setting payment rates). ϮϬͲϬϬϬϰ Approval Date: ƵŐƵƐƚ ϭϯ͕ ϮϬϮϬ Effective Date: DĂƌĐŚ ϭ͕ ϮϬϮϬ EĞǁ

Page 2 State/Territory: _West Virginia_ TN: ________________ Approval Date: ƵŐƵƐƚ ϭϯ͕ ϮϬϮϬ Supersedes TN: ________________ Effective Date: __________ c. __N/A_ Tribal consultation requirements – the agency requests modification of tribal consultation timelines specified in [insert name of State] Medicaid State Plan, as described below: Please describe the modifications to the timeline. Section A – Eligibility 1. __X___ The agency furnishes medical assistance to the following optional groups of individuals described in section 1902(a)(10)(A)(ii) or 1902(a)(10)(c) of the Act. This may include the new optional group described at section 1902(a)(10)(A)(ii)(XXIII) and 1902(ss) of the Act providing coverage for uninsured individuals. Include name of the optional eligibility group and applicable income and resource standard. The State elects to cover all uninsured individuals as defined under 1902(ss) of the Act pursuant to Section 1902(a)(10)(A)(ii)(XXIII) of the Act effective March 18, 2020. 2. _____ The agency furnishes medical assistance to the following populations of individuals described in section 1902(a)(10)(A)(ii)(XX) of the Act and 42 CFR 435.218: a. _____ All individuals who are described in section 1905(a)(10)(A)(ii)(XX) Income standard: _____________ -or-

b. _____ Individuals described in the following categorical populations in section 1905(a) of the Act: Income standard: _____________ 3. _____ The agency applies less restrictive financial methodologies to individuals excepted from financial methodologies based on modified adjusted gross income (MAGI) as follows. Less restrictive income methodologies: ϮϬͲϬϬϬϰ EĞǁ DĂƌĐŚ ϭ͕ ϮϬϮϬ

Page 3 State/Territory: _West Virginia_ TN: ________________ Approval Date: ƵŐƵƐƚ ϭϯ͕ ϮϬϮϬ Supersedes TN: ________________ Effective Date: __________ 4. __X__ The agency considers individuals who are evacuated from the State, who leave the State for medical reasons related to the disaster or public health emergency, or who are otherwise absent from the State due to the disaster or public health emergency and who intend to return to the State, to continue to be residents of the State under 42 CFR 435.403(j)(3). 5. __X___ The agency provides Medicaid coverage to the following individuals living in the State, who are non-residents: Individuals caring for a family member due to illness or quarantined due to illness or otherwise unable to return home and residing in the State. 6. _____ The agency provides for an extension of the reasonable opportunity period for non- citizens declaring to be in a satisfactory immigration status, if the non-citizen is making a good faith effort to resolve any inconsistences or obtain any necessary documentation, or the agency is unable to complete the verification process within the 90-day reasonable opportunity period due to the disaster or public health emergency. Section B – Enrollment 1. ____ The agency elects to allow hospitals to make presumptive eligibility determinations for the following additional State Plan populations, or for populations in an approved section 1115 demonstration, in accordance with section 1902(a)(47)(B) of the Act and 42 CFR 435.1110, provided that the agency has determined that the hospital is capable of making such determinations. Please describe the applicable eligibility groups/populations and any changes to reasonable limitations, performance standards or other factors. 2. _____ The agency designates itself as a qualified entity for purposes of making presumptive eligibility determinations described below in accordance with sections 1920, 1920A, 1920B, and 1920C of the Act and 42 CFR Part 435 Subpart L. Please describe any limitations related to the populations included or the number of allowable PE periods. 3. _____ The agency designates the following entities as qualified entities for purposes of making presumptive eligibility determinations or adds additional populations as described below in accordance with sections 1920, 1920A, 1920B, and 1920C of the Act and 42 CFR Part 435 Subpart L. Indicate if any designated entities are permitted to make presumptive eligibility determinations only for specified populations. Please describe the designated entities or additional populations and any limitations related to the specified populations or number of allowable PE periods. ϮϬͲϬϬϬϰ EĞǁ DĂƌĐŚ ϭ͕ ϮϬϮϬ

Page 4 State/Territory: _West Virginia_ TN: ________________ Approval Date: ƵŐƵƐƚ ϭϯ͕ ϮϬϮϬ Supersedes TN: ________________ Effective Date: __________ 4. _____ The agency adopts a total of _____ months (not to exceed 12 months) continuous eligibility for children under age enter age _____ (not to exceed age 19) regardless of changes in circumstances in accordance with section 1902(e)(12) of the Act and 42 CFR 435.926. 5. ____ The agency conducts redeterminations of eligibility for individuals excepted from MAGI- based financial methodologies under 42 CFR 435.603(j) once every _____ months (not to exceed 12 months) in accordance with 42 CFR 435.916(b). 6. ____ The agency uses the following simplified application(s) to support enrollment in affected areas or for affected individuals (a copy of the simplified application(s) has been submitted to CMS). a. ____ The agency uses a simplified paper application. b. ____ The agency uses a simplified online application. c. ____ The simplified paper or online application is made available for use in call-centers or other telephone applications in affected areas. Section C – Premiums and Cost Sharing 1. __X___ The agency suspends deductibles, copayments, coinsurance, and other cost sharing charges as follows: Please describe whether the State suspends all cost sharing or suspends only specified deductibles, copayments, coinsurance, or other cost sharing charges for specified items and services or for specified eligibility groups consistent with 42 CFR 447.52(d) or for specified income levels consistent with 42 CFR 447.52(g). Excluding non-COVID-19 pharmacy benefits, the State is suspending all cost sharing for individuals covered by Medicaid for the duration of the pandemic. The State will continue to charge cost sharing for drugs unrelated to the treatment of COVID-19. Individuals covered in the eligibility group authorized through section 1902(ss) group will not be subject to any cost sharing. 2. __X__ The agency suspends enrollment fees, premiums and similar charges for: a. __X__ All beneficiaries b. _____ The following eligibility groups or categorical populations: Please list the applicable eligibility groups or populations. ϮϬͲϬϬϬϰ EĞǁ DĂƌĐŚ ϭ͕ ϮϬϮϬ

Page 5 State/Territory: _West Virginia_ TN: ________________ Approval Date: ƵŐƵƐƚ ϭϯ͕ ϮϬϮϬ Supersedes TN: ________________ Effective Date: __________ 3. ____ The agency allows waiver of payment of the enrollment fee, premiums and similar charges for undue hardship. Please specify the standard(s) and/or criteria that the State will use to determine undue hardship. Section D – Benefits Benefits: 1. ____ The agency adds the following optional benefits in its State Plan (include service descriptions, provider qualifications, and limitations on amount, duration or scope of the benefit): 2. __X __ The agency makes the following adjustments to benefits currently covered in the State Plan: The State allows physicians and other licensed practitioners, in accordance with State law, to order Medicaid Home Health services as authorized in the COVID-19 Public Health Emergency Medicare interim final rule (CMS-1744-IFC). 3. __X__ The agency assures that newly added benefits or adjustments to benefits comply with all applicable statutory requirements, including the statewideness requirements found at 1902(a)(1), comparability requirements found at 1902(a)(10)(B), and free choice of provider requirements found at 1902(a)(23). 4. __X__ Application to Alternative Benefit Plans (ABP). The State adheres to all ABP provisions in 42 CFR Part 440, Subpart C. This section only applies to states that have an approved ABP(s). ƒǤ ̴̴X̴̴ Š‡ ƒ‰‡ › ƒ••—”‡• –Šƒ– –Š‡•‡ ‡™Ž› ƒ††‡† ƒ†Ȁ‘” ƒ†Œ—•–‡† „‡‡ˆ‹–• ™‹ŽŽ „‡ ƒ†‡ ƒ˜ƒ‹Žƒ„Ž‡ –‘ ‹†‹˜‹†—ƒŽ• ”‡ ‡‹˜‹‰ •‡”˜‹ ‡• —†‡” •Ǥ „Ǥ ̴̴̴̴̴ †‹˜‹†—ƒŽ• ”‡ ‡‹˜‹‰ •‡”˜‹ ‡• —†‡” • ™‹ŽŽ ‘– ”‡ ‡‹˜‡ –Š‡•‡ ‡™Ž› ƒ††‡† ƒ†Ȁ‘” ƒ†Œ—•–‡† „‡‡ˆ‹–•ǡ ‘” ™‹ŽŽ ‘Ž› ”‡ ‡‹˜‡ –Š‡ ˆ‘ŽŽ‘™‹‰ •—„•‡–ǣ Please describe. ϮϬͲϬϬϬϰ EĞǁ DĂƌĐŚ ϭ͕ ϮϬϮϬ

Page 6 State/Territory: _West Virginia_ TN: ________________ Approval Date: ƵŐƵƐƚ ϭϯ͕ ϮϬϮϬ Supersedes TN: ________________ Effective Date: __________ Telehealth: 5. _X___ The agency utilizes telehealth in the following manner, which may be different than outlined in the State’s approved State Plan: Please describe. FQHC and RHC Core Provider Services provided via telehealth for the duration of the federal PHE period are considered encounters. Non-core Provider services are paid as FFS at the rate in the Medicaid State Plan. The modification of a face-to-face encounter requirement for reimbursement for FQHCs and RHCs relative to covered services via telehealth provided by clinic providers. Drug Benefit: 6. _X___ The agency makes the following adjustments to the day supply or quantity limit for covered outpatient drugs. The agency should only make this modification if its current State Plan pages have limits on the amount of medication dispensed. Please describe the change in days or quantities that are allowed for the emergency period and for which drugs. Allow early refill and up to 90 day supply of non-controlled maintenance medications. 7. _____ Prior authorization for medications is expanded by automatic renewal without clinical review, or time/quantity extensions. 8. __ __ The agency makes the following payment adjustment to the professional dispensing fee when additional costs are incurred by the providers for delivery. States will need to supply documentation to justify the additional fees. Please describe the manner in which professional dispensing fees are adjusted. 9. _X___ The agency makes exceptions to their published Preferred Drug List if drug shortages occur. This would include options for covering a brand name drug product that is a multi-source drug if a generic drug option is not available. Section E – Payments Optional benefits described in Section D: 1. ____ Newly added benefits described in Section D are paid using the following methodology: ƒǤ ̴̴ ̴̴̴ —„Ž‹•Š‡† ˆ‡‡ • Š‡†—Ž‡• Effective date (enter date of change): _______ ϮϬͲϬϬϬϰ EĞǁ DĂƌĐŚ ϭ͕ ϮϬϮϬ

Page 7 State/Territory: _West Virginia_ TN: ________________ Approval Date: ƵŐƵƐƚ ϭϯ͕ ϮϬϮϬ Supersedes TN: ________________ Effective Date: __________ Location (list published location): „Ǥ ̴̴ ̴̴ –Š‡”ǣ Describe methodology here. 2. _X____ The agency increases payment rates for the following services: Please list all that apply. Nursing home services Intermediate Care Facility (ICF) services Behavioral health services Psychiatric Residential Treatment Facility (PRTF) services Ambulance Services* Dental Services* * The increases for ambulance and dental codes are in addition to the existing rates in effect as of 3/1/2020 and the increases that were already in process and implemented effective April 1, 2020. Ambulance was increased to 90 percent of the new Medicare rates effective April 1, 2020. Dentists received a 15 percent increase effective April 1, 2020. The additional rate increase effective 3/1/20 for ambulance and dental codes will end 6/30/20. a. _____ Payment increases are targeted based on the following criteria: Please describe criteria. b. Payments are increased through: ‹Ǥ ̴̴X̴̴̴  •—’’Ž‡‡–ƒŽ ’ƒ›‡– ‘” ƒ††Ǧ‘ ™‹–Š‹ ƒ’’Ž‹ ƒ„Ž‡ —’’‡” ’ƒ›‡– Ž‹‹–•ǣ Please describe. Nursing Home Services are increased by $20 per-patient-per-day for non- public facilities effective 3/1/20 through the end of the national emergency period. The $20 per-patient-per-day increase will be used to offset COVID related costs in a separate cost settlement process. The State will allow provider lost revenue amounts – not reimbursed to the Nursing Homes through the CARES Act Provider Relief payments – to be included in the separate COVID cost settlement process to reconcile the $20 per-patient-per- day payments. ϮϬͲϬϬϬϰ EĞǁ DĂƌĐŚ ϭ͕ ϮϬϮϬ

Page 8 State/Territory: _West Virginia_ TN: ________________ Approval Date: ƵŐƵƐƚ ϭϯ͕ ϮϬϮϬ Supersedes TN: ________________ Effective Date: __________ ICF Services are increased by $10 per day effective from 3/1/2020 through 6/30/20. ‹‹Ǥ ̴̴X̴̴̴  ‹ ”‡ƒ•‡ –‘ ”ƒ–‡• ƒ• †‡• ”‹„‡† „‡Ž‘™Ǥ Rates are increased: __X___ Uniformly by the following percentage: _20 percent for Behavioral Health and PRTF Services; 10 percent for Ambulance services; and 15 percent for Dental Services. These increases are effective as of 3/1/2020 through 6/30/20. _____ Through a modification to published fee schedules – Effective date (enter date of change): _____________ Location (list published location): _____________ _____ Up to the Medicare payments for equivalent services. _____ By the following factors: Please describe. Payment for services delivered via telehealth: 3. __X__ For the duration of the emergency, the State authorizes payments for telehealth services that: ƒǤ ̴X̴̴̴ ”‡ ‘– ‘–Š‡”™‹•‡ ’ƒ‹† —†‡” –Š‡ ‡†‹ ƒ‹† –ƒ–‡ ŽƒǢ „Ǥ ̴̴̴̴̴ ‹ˆˆ‡” ˆ”‘ ’ƒ›‡–• ˆ‘” –Š‡ •ƒ‡ •‡”˜‹ ‡• ™Š‡ ’”‘˜‹†‡† ˆƒ ‡ –‘ ˆƒ ‡Ǣ

Ǥ ̴X̴̴̴ ‹ˆˆ‡” ˆ”‘ —””‡– –ƒ–‡ Žƒ ’”‘˜‹•‹‘• ‰‘˜‡”‹‰ ”‡‹„—”•‡‡– ˆ‘” –‡Ž‡Š‡ƒŽ–ŠǢ Describe telehealth payment variation. (E.3.c) Allow for reimbursement for telephone visits at the same rate as telehealth video visits. (E.3.a) Effective April 1, 2020, all dental providers will be reimbursed at the FFS rate for teledentistry screening (D9995). This service will be provided to help identify and triage dental emergency services during the pandemic. Published fee schedules: https://dhhr.wv.gov/bms/fees/Pages/default.aspx ϮϬͲϬϬϬϰ EĞǁ DĂƌĐŚ ϭ͕ ϮϬϮϬ

Page 9 State/Territory: _West Virginia_ TN: ________________ Approval Date: ƵŐƵƐƚ ϭϯ͕ ϮϬϮϬ Supersedes TN: ________________ Effective Date: __________ †Ǥ ̴̴̴̴̴  Ž—†‡ ’ƒ›‡– ˆ‘” ƒ ‹ŽŽƒ”› ‘•–• ƒ••‘ ‹ƒ–‡† ™‹–Š –Š‡ †‡Ž‹˜‡”› ‘ˆ ‘˜‡”‡† •‡”˜‹ ‡• ˜‹ƒ –‡Ž‡Š‡ƒŽ–Šǡ ȋ‹ˆ ƒ’’Ž‹ ƒ„Ž‡Ȍǡ ƒ• ˆ‘ŽŽ‘™•ǣ ‹Ǥ ̴̴̴̴̴  ‹ŽŽƒ”› ‘•– ƒ••‘ ‹ƒ–‡† ™‹–Š –Š‡ ‘”‹‰‹ƒ–‹‰ •‹–‡ ˆ‘” –‡Ž‡Š‡ƒŽ–Š ‹• ‹ ‘”’‘”ƒ–‡† ‹–‘ ˆ‡‡Ǧˆ‘”Ǧ•‡”˜‹ ‡ ”ƒ–‡•Ǥ ‹‹Ǥ ̴̴̴̴̴  ‹ŽŽƒ”› ‘•– ƒ••‘ ‹ƒ–‡† ™‹–Š –Š‡ ‘”‹‰‹ƒ–‹‰ •‹–‡ ˆ‘” –‡Ž‡Š‡ƒŽ–Š ‹• •‡’ƒ”ƒ–‡Ž› ”‡‹„—”•‡† ƒ• ƒ ƒ†‹‹•–”ƒ–‹˜‡ ‘•– „› –Š‡ –ƒ–‡ ™Š‡ ƒ ‡†‹ ƒ‹† •‡”˜‹ ‡ ‹• †‡Ž‹˜‡”‡†Ǥ Other: 4. _X___ Other payment changes: Please describe. Payment for additional Bed-hold Days: Reimbursement for greater than six therapeutic, non-medical bed hold days per year will be permitted to allow nursing home settings to retain settings when members have the option to stay with their families during the pandemic period. The 6 day bed-hold limit is currently in the State Plan in Attachment 4.19 -D-1, VII. The 6-day bed-hold limit can be exceeded with prior authorization. BMS also requests the modification of State Plan Attachment 4.19-D, which establishes the provision for reimbursement of Intermediate Care Facilities. Members using ICF services often participate in day programs, which reduces the need for staffing in facilities while clients are in these programs. ICF rates account for this reduced staff time. ICF day programs are being suspended to prevent the spread of COVID-19, resulting in clients needing to stay within their facilities and increasing the cost for facilities to have adequate staff. The assumed participation time in the day programs are not built into ICF rates. The State seeks to modify the current ICF rate-setting methodology to provide an add-on to facility rates to compensate for the increased cost of staff time not accounted for in the current facility’s daily rates during the duration of the emergency. Long-term Acute Care Hospital Services not reimbursed under the state plan: A Medicaid Per Diem Cost amount will be calculated (including routine and ancillary costs) from Worksheets D1 and S3 from the Medicare Cost Report. The Medicare Per Diem cost will be adjusted for a cost coverage percentage (81.58 percent) = Adjusted Per Diem. Medicaid will reimburse providers the Adjusted Per Diem. Days Awaiting Placement: Inappropriate level of care days in inpatient hospitals (also called days awaiting placement) for members will be reimbursed at a rate of $238 per day when the member cannot be discharged to home or to another care setting, including but not limited to nursing home settings, due to a need for isolation or continued medical care; the rate reflects the level of ϮϬͲϬϬϬϰ EĞǁ DĂƌĐŚ ϭ͕ ϮϬϮϬ

Page 10 State/Territory: _West Virginia_ TN: ________________ Approval Date: ƵŐƵƐƚ ϭϯ͕ ϮϬϮϬ Supersedes TN: ________________ Effective Date: __________ care received and is lower than other inpatient hospital services in a manner consistent with 1861(v)(1)(G) of the Social Security Act. Section F – Post-Eligibility Treatment of Income ͳǤ ̴̴ ̴̴ Š‡ –ƒ–‡ ‡Ž‡ –• –‘ ‘†‹ˆ› –Š‡ „ƒ•‹ ’‡”•‘ƒŽ ‡‡†• ƒŽŽ‘™ƒ ‡ ˆ‘” ‹•–‹–—–‹‘ƒŽ‹œ‡† ‹†‹˜‹†—ƒŽ•Ǥ Š‡ „ƒ•‹ ’‡”•‘ƒŽ ‡‡†• ƒŽŽ‘™ƒ ‡ ‹• ‡“—ƒŽ –‘ ‘‡ ‘ˆ –Š‡ ˆ‘ŽŽ‘™‹‰ ƒ‘—–•ǣ ƒǤ ̴̴̴̴̴ Š‡ ‹†‹˜‹†—ƒŽǯ• –‘–ƒŽ ‹ ‘‡ „Ǥ ̴̴ ̴̴ ͵ͲͲ ’‡” ‡– ‘ˆ –Š‡  ˆ‡†‡”ƒŽ „‡‡ˆ‹– ”ƒ–‡

Ǥ ̴̴̴̴̴ –Š‡” ”‡ƒ•‘ƒ„Ž‡ ƒ‘—–ǣ ̴̴̴̴̴̴̴̴̴̴̴̴̴̴̴̴̴ ʹǤ ̴̴̴ ̴ Š‡ –ƒ–‡ ‡Ž‡ –• ƒ ‡™ ˜ƒ”‹ƒ ‡ –‘ –Š‡ „ƒ•‹ ’‡”•‘ƒŽ ‡‡†• ƒŽŽ‘™ƒ ‡Ǥ ȋ‘–‡ǣ Ž‡ –‹‘ ‘ˆ –Š‹• ‘’–‹‘ ‹• ‘– †‡’‡†‡– ‘ ƒ –ƒ–‡ ‡Ž‡ –‹‰ –Š‡ ‘’–‹‘ †‡• ”‹„‡† –Š‡ ‘’–‹‘ ‹ ǤͳǤ ƒ„‘˜‡ǤȌ The State protects amounts exceeding the basic personal needs allowance for individuals who have the following greater personal needs: Please describe the group or groups of individuals with greater needs and the amount(s) protected for each group or groups. Section G – Other Policies and Procedures Differing from Approved Medicaid State Plan /Additional Information PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148 (Expires 03/31/2021). The time required to complete this ϮϬͲϬϬϬϰ EĞǁ DĂƌĐŚ ϭ͕ ϮϬϮϬ

Page 11 State/Territory: _West Virginia_ TN: ________________ Approval Date: ƵŐƵƐƚ ϭϯ͕ ϮϬϮϬ Supersedes TN: ________________ Effective Date: __________ information collection is estimated to average 1 to 2 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. Your response is required to receive a waiver under Section 1135 of the Social Security Act. All responses are public and will be made available on the CMS web site. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. ***CMS Disclosure*** Please do not send applications, claims, payments, medical records or any documents containing sensitive information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information collection burden approved under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please contact the Centers for Medicaid & CHIP Services at 410-786-3870. ϮϬͲϬϬϬϰ EĞǁ DĂƌĐŚ ϭ͕ ϮϬϮϬ

Table of Contents State/Territory Name: :HVW 9LUJLQLD State Plan Amendment (SPA) #:  This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-26-12 Baltimore, Maryland 21244-1850

August 27, 2021

Cynthia Beane, MSW, LCSW Commissioner Bureau for Medical Services 350 Capitol Street, Room 251 Charleston, WV 25301-3706

Re: West Virginia State Plan Amendment (SPA) 21-0010

Dear Commissioner Beane:

We have reviewed the proposed amendment to add section 7.4 Medicaid Disaster Relief for the COVID-19 National Emergency to your Medicaid state plan, as submitted under transmittal number (TN) 21-0010. This amendment proposes to implement temporary policies, which are different from those policies and procedures otherwise applied under your Medicaid state plan, during the period of the Presidential and Secretarial emergency declarations related to the COVID-19 outbreak (or any renewals thereof).

On March 13, 2020, the President of the United States issued a proclamation that the COVID-19 outbreak in the United States constitutes a national emergency by the authorities vested in him by the Constitution and the laws of the United States, including sections 201 and 301 of the National Emergencies Act (50 U.S.C. 1601 et seq.), and consistent with section 1135 of the Social Security Act (Act). On March 13, 2020, pursuant to section 1135(b) of the Act, the Secretary of the United States Department of Health and Human Services invoked his authority to waive or modify certain requirements of titles XVIII, XIX, and XXI of the Act as a result of the consequences of the COVID-19 pandemic, to the extent necessary, as determined by the Centers for Medicare & Medicaid Services (CMS), to ensure that sufficient health care items and services are available to meet the needs of individuals enrolled in the respective programs and to ensure that health care providers that furnish such items and services in good faith, but are unable to comply with one or more of such requirements as a result of the COVID-19 pandemic, may be reimbursed for such items and services and exempted from sanctions for such noncompliance, absent any determination of fraud or abuse. This authority took effect as of 6PM Eastern Standard Time on March 15, 2020, with a retroactive effective date of March 1, 2020. The emergency period will terminate, and this state plan provision will no longer be in effect, upon termination of the public health emergency, including any extensions.

Pursuant to section 1135(b)(5) of the Act, for the period of the public health emergency, CMS is modifying the requirement at 42 C.F.R. 430.20 that the state submit SPAs related to the COVID- 19 public health emergency by the final day of the quarter, to obtain a SPA effective date during the quarter, enabling SPAs submitted after the last day of the quarter to have an effective date in a previous quarter, but no earlier than the effective date of the public health emergency. The State of West Virginia also requested a waiver of public notice requirements applicable to the SPA submission process. Pursuant to section 1135(b)(1)(C) of the Act, CMS is waiving public notice requirements applicable to the SPA submission process. Public notice for SPAs is required under 42 C.F.R. §447.205 for changes in statewide methods and standards for setting Medicaid payment rates, 42 C.F.R. §447.57 for changes to premiums and cost sharing, and 42 C.F.R. §440.386 for changes to Alternative Benefit Plans (ABPs). Pursuant to section 1135(b)(1)(C) of the Act, CMS is approving the state’s request to waive these notice requirements otherwise applicable to SPA submissions. These waivers of the requirements related to SPA submission timelines and public notice apply only with respect to SPAs that meet the following criteria: (1) the SPA provides or increases beneficiary access to items and services related to COVID-19 (such as by waiving or eliminating cost sharing, increasing payment rates or amending ABPs to add services or providers); (2) the SPA does not restrict or limit payment or services or otherwise burden beneficiaries and providers; and (3) the SPA is temporary, with a specified sunset date that is not later than the last day of the declared COVID-19 public health emergency (or any extension thereof). We nonetheless encourage states to make all relevant information about the SPA available to the public so they are aware of the changes. We conducted our review of your submittal according to the statutory requirements at section 1902(a) of the Act and implementing regulations. This letter is to inform you that West Virginia Medicaid SPA Transmittal Number 21-0010 is approved effective June 1, 2020. 7KLV 63$ LV LQ DGGLWLRQ WR DQG GRHV QRW VXSHUVHGH WKH 'LVDVWHU 5HOLHI 63$V DSSURYHG $XJXVW   :9   'HFHPEHU   :9   $SULO   :9   DQG 0D\  

:9  Enclosed is a copy of the CMS-179 summary form and the approved state plan pages. Please contact Dan Belnap at 215-861-4273 or by email at dan.belnap@cms.hhs.gov if you have any questions about this approval. We appreciate the efforts of you and your staff in responding to the needs of the residents of the State of West Virginia and the health care community. Sincerely, Alissa Mooney DeBoy On Behalf of Anne Marie Costello, Deputy Director Center for Medicaid and CHIP Services Enclosures Alissa M. Deboy -S Digitally signed by Alissa M. Deboy -S Date: 2021 08.27 07:59:34 -04'00'

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB No. 0938-0193

TRANSMITTAL AND NOTICE OF APPROVALOF | 2. STATE STATE PLAN MATERIAL 2_1_—o_ 9 1 0 |West Virginia

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

TO: REGIONAL ADMINISTRATOR 4. PROPOSED EFFECTIVE DATE CENTERS FOR MEDICARE & MEDICAID SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES June 1, 2020 5. TYPE OF PLAN MATERIAL (Check One) C0 NEw STATE PLAN [0 AMENDMENT TO BE CONSIDERED AS NEW PLAN [HM] AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate transmittal for each amendment) 6. FEDERAL STATUTE/REGULATION CITATION 7. FEDERAL BUDGET IMPACT Title 19 of the Social Security Act; Section 1135 of the Social Security Act a. FFY 2021 $ 0.00 b. FFY 2022 $ 0.00 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION Section 7 - General Provisions OR ATTACHMENT (If Applicable) 7.4 Medicaid Disaster Relief for COVID-19 National N/A Emergency

10. SUBJECT OF AMENDMENT Designates Local Health Departments as qualified entities for purposes of making presumptive eligibility determinations during the COVID-19 national emergency.

11. GOVERNOR'S REVIEW (Check One)

IB) GOVERNOR'S OFFICE REPORTED NO COMMENT O OTHER, AS SPECIFIED (J ComMENTS OF GOVERNOR'S OFFICE ENCLOSED [1 No REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL

12. SIGNATURE OF STATE AGENCY OFFICIAL 16. RETURN TO Cynthia Beane, MSW, LCSWatet"ratsrre ii tears “oneaeremow'sc | Bureau for Medical Services

13. TYPED NAME 350 Capitol Street Room 251 Cynthia Beane Charleston West Virginia 25301 14. TITLE

Commissioner, Bureau for Medical Services 15. DATE SUBMITTED

07/28/2021 FOR REGIONAL OFFICE USE ONLY 17. DATE RECEIVED 18. DATE APPROVED 07/28/2021 08/27/2021 PLAN APPROVED - ONE COPY ATTACHED 19. EFFECTIVE DATE OF APPROVED MATERIAL 20. SIGNATURE OF REGIONAL OFFICIAL 6/1/2020 Alissa M. Deboy - ditaty sqnedby Atssa Deboy s Date: 202498 27a on oo ogo 21. TYPED NAME 22. TITLE

Alissa Mooney DeBoy, On behalf of Anne Marie Costello | Deputy Director, Center for Medicaid & CHIP Services 23. REMARKS

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

Page 1 State/Territory: West Virginia

TN: 21-0010 Approval Date: 08/27/2021 Supersedes TN: New Effective Date: 06/1/2020 This SPA is in addition to, and does not supersede, the Disaster Relief SPAs approved August 13, 2020 (WV 20-0004), December 17, 2020 (WV 20-0006), April 8, 2021 (WV 21-0007), and May 7, 2021 (WV-21- 0005). Section 7 – General Provisions 7.4. Medicaid Disaster Relief for the COVID-19 National Emergency

On March 13, 2020, the President of the United States issued a proclamation that the COVID-19 outbreak in the United States constitutes a national emergency by the authorities vested in him by the Constitution and the laws of the United States, including sections 201 and 301 of the National Emergencies Act (50 U.S.C. 1601 et seq.), and consistent with section 1135 of the Social Security Act (Act). On March 13, 2020, pursuant to section 1135(b) of the Act, the Secretary of the United States Department of Health and Human Services invoked his authority to waive or modify certain requirements of Titles XVIII, XIX, and XXI of the Act as a result of the consequences COVID-19 pandemic, to the extent necessary, as determined by the Centers for Medicare & Medicaid Services (CMS), to ensure that sufficient health care items and services are available to meet the needs of individuals enrolled in the respective programs and to ensure that health care providers that furnish such items and services in good faith, but are unable to comply with one or more of such requirements as a result of the COVID-19 pandemic, may be reimbursed for such items and services and exempted from sanctions for such noncompliance, absent any determination of fraud or abuse. This authority took effect as of 6 PM Eastern Standard Time on March 15, 2020, with a retroactive effective date of March 1, 2020. The emergency period will terminate, and waivers will no longer be available, upon termination of the public health emergency, including any extensions.

The State Medicaid agency (agency) seeks to implement the policies and procedures described below, which are different than the policies and procedures otherwise applied under the Medicaid State Plan, during the period of the Presidential and Secretarial emergency declarations related to the COVID-19 outbreak (or any renewals thereof), or for any shorter period described below:

Describe shorter period here. N/A NOTE: States may not elect a period longer than the Presidential or Secretarial emergency declaration (or any renewal thereof). States may not propose changes on this template that restrict or limit payment, services, or eligibility, or otherwise burden beneficiaries and providers. Request for Waivers under Section 1135 __X__ The agency seeks the following under section 1135(b)(1)(C) and/or section 1135(b)(5) of the Act: a. __X__ SPA submission requirements – the agency requests modification of the requirement to submit the SPA by March 31, 2020, to obtain a SPA effective date during the first calendar quarter of 2020, pursuant to 42 CFR 430.20. b. __X__ Public notice requirements – the agency requests waiver of public notice requirements that would otherwise be applicable to this SPA submission. These requirements may include those specified in 42 CFR 440.386 (Alternative Benefit Plans),

Page 2 State/Territory: West Virginia

TN: 21-0010 Approval Date: 08/27/2021 Supersedes TN: New Effective Date: 06/1/2020 This SPA is in addition to, and does not supersede, the Disaster Relief SPAs approved August 13, 2020 (WV 20-0004), December 17, 2020 (WV 20-0006), April 8, 2021 (WV 21-0007), and May 7, 2021 (WV-21- 0005). 42 CFR 447.57(c) (premiums and cost sharing), and 42 CFR 447.205 (public notice of changes in statewide methods and standards for setting payment rates). c. _n/a_ Tribal consultation requirements – the agency requests modification of tribal consultation timelines specified in [insert name of State] Medicaid State Plan, as described below:

Section A – Eligibility 1. _____ The agency furnishes medical assistance to the following optional groups of individuals described in section 1902(a)(10)(A)(ii) or 1902(a)(10)(c) of the Act. This may include the new optional group described at section 1902(a)(10)(A)(ii)(XXIII) and 1902(ss) of the Act providing coverage for uninsured individuals.

2. _____ The agency furnishes medical assistance to the following populations of individuals described in section 1902(a)(10)(A)(ii)(XX) of the Act and 42 CFR 435.218:

a. _____ All individuals who are described in section 1905(a)(10)(A)(ii)(XX)

Income standard: _____________

-or-

b. _____ Individuals described in the following categorical populations in section 1905(a) of the Act:

Income standard: _____________

3. _____ The agency applies less restrictive financial methodologies to individuals excepted from financial methodologies based on modified adjusted gross income (MAGI) as follows.

Less restrictive income methodologies:

Page 3 State/Territory: West Virginia

TN: 21-0010 Approval Date: 08/27/2021 Supersedes TN: New Effective Date: 06/1/2020 This SPA is in addition to, and does not supersede, the Disaster Relief SPAs approved August 13, 2020 (WV 20-0004), December 17, 2020 (WV 20-0006), April 8, 2021 (WV 21-0007), and May 7, 2021 (WV-21- 0005).

Less restrictive resource methodologies:

4. _____ The agency considers individuals who are evacuated from the State, who leave the State for medical reasons related to the disaster or public health emergency, or who are otherwise absent from the State due to the disaster or public health emergency and who intend to return to the State, to continue to be residents of the State under 42 CFR 435.403(j)(3).

5. _____ The agency provides Medicaid coverage to the following individuals living in the State, who are non-residents:

6. _____ The agency provides for an extension of the reasonable opportunity period for non- citizens declaring to be in a satisfactory immigration status, if the non-citizen is making a good faith effort to resolve any inconsistences or obtain any necessary documentation, or the agency is unable to complete the verification process within the 90-day reasonable opportunity period due to the disaster or public health emergency. Section B – Enrollment 1. _____ The agency elects to allow hospitals to make presumptive eligibility determinations for the following additional State Plan populations, or for populations in an approved section 1115 demonstration, in accordance with section 1902(a)(47)(B) of the Act and 42 CFR 435.1110, provided that the agency has determined that the hospital is capable of making such determinations.

2. _____ The agency designates itself as a qualified entity for purposes of making presumptive eligibility determinations described below in accordance with sections 1920, 1920A, 1920B, and 1920C of the Act and 42 CFR Part 435 Subpart L.

Page 4 State/Territory: West Virginia

TN: 21-0010 Approval Date: 08/27/2021 Supersedes TN: New Effective Date: 06/1/2020 This SPA is in addition to, and does not supersede, the Disaster Relief SPAs approved August 13, 2020 (WV 20-0004), December 17, 2020 (WV 20-0006), April 8, 2021 (WV 21-0007), and May 7, 2021 (WV-21- 0005).

3. __X__ The agency designates the following entities as qualified entities for purposes of making presumptive eligibility determinations or adds additional populations as described below in accordance with sections 1920, 1920A, 1920B, and 1920C of the Act and 42 CFR Part 435 Subpart L. Indicate if any designated entities are permitted to make presumptive eligibility determinations only for specified populations.

Local Health Departments (LHDs) located in West Virginia as qualified entities to make presumptive eligibility determinations for the following 1902 (a) MAGI mandatory groups: 42 CFR 435.118: Infants and Children under Age 19, 42 CFR 435.116: Pregnant Women, 42 CFR 435.110: Parents and other Caretaker Relatives, 42 CFR 435.150: Former Foster Care Children, and 42 CFR 435.119: Adult Group.

Applicants are allowed only one PE determination per 12-month period starting with the effective date of the initial PE period or, if pregnant, one per pregnancy.

4. _____ The agency adopts a total of _____ months (not to exceed 12 months) continuous eligibility for children under age enter age _____ (not to exceed age 19) regardless of changes in circumstances in accordance with section 1902(e)(12) of the Act and 42 CFR 435.926.

5. _____ The agency conducts redeterminations of eligibility for individuals excepted from MAGI- based financial methodologies under 42 CFR 435.603(j) once every _____ months (not to exceed 12 months) in accordance with 42 CFR 435.916(b).

6. _____ The agency uses the following simplified application(s) to support enrollment in affected areas or for affected individuals (a copy of the simplified application(s) has been submitted to CMS). a. _____ The agency uses a simplified paper application. b. _____ The agency uses a simplified online application. c. _____ The simplified paper or online application is made available for use in call-centers or other telephone applications in affected areas. Section C – Premiums and Cost Sharing 1. ____ The agency suspends deductibles, copayments, coinsurance, and other cost sharing charges as follows:

Page 5 State/Territory: West Virginia

TN: 21-0010 Approval Date: 08/27/2021 Supersedes TN: New Effective Date: 06/1/2020 This SPA is in addition to, and does not supersede, the Disaster Relief SPAs approved August 13, 2020 (WV 20-0004), December 17, 2020 (WV 20-0006), April 8, 2021 (WV 21-0007), and May 7, 2021 (WV-21- 0005). 2. _____ The agency suspends enrollment fees, premiums and similar charges for: a. _____ All beneficiaries b. _____ The following eligibility groups or categorical populations:

3. _____ The agency allows waiver of payment of the enrollment fee, premiums and similar charges for undue hardship.

Section D – Benefits Benefits: 1. ____ The agency adds the following optional benefits in its State Plan (include service descriptions, provider qualifications, and limitations on amount, duration or scope of the benefit):

2. ____ The agency makes the following adjustments to benefits currently covered in the State Plan:

3. ____ The agency assures that newly added benefits or adjustments to benefits comply with all applicable statutory requirements, including the statewideness requirements found at 1902(a)(1), comparability requirements found at 1902(a)(10)(B), and free choice of provider requirements found at 1902(a)(23).

4. ____ Application to Alternative Benefit Plans (ABP). The State adheres to all ABP provisions in 42 CFR Part 440, Subpart C. This section only applies to states that have an approved ABP(s). a. ____ The agency assures that these newly added and/or adjusted benefits will be made available to individuals receiving services under ABPs. b. _____ Individuals receiving services under ABPs will not receive these newly added and/or adjusted benefits, or will only receive the following subset:

Page 6 State/Territory: West Virginia

TN: 21-0010 Approval Date: 08/27/2021 Supersedes TN: New Effective Date: 06/1/2020 This SPA is in addition to, and does not supersede, the Disaster Relief SPAs approved August 13, 2020 (WV 20-0004), December 17, 2020 (WV 20-0006), April 8, 2021 (WV 21-0007), and May 7, 2021 (WV-21- 0005).

Telehealth: 5. _____ The agency utilizes telehealth in the following manner, which may be different than outlined in the State’s approved State Plan:

Drug Benefit: 6. _____ The agency makes the following adjustments to the day supply or quantity limit for covered outpatient drugs. The agency should only make this modification if its current State Plan pages have limits on the amount of medication dispensed.

7. _____ Prior authorization for medications is expanded by automatic renewal without clinical review, or time/quantity extensions.

8. _____ The agency makes the following payment adjustment to the professional dispensing fee when additional costs are incurred by the providers for delivery. States will need to supply documentation to justify the additional fees.

9. _____ The agency makes exceptions to their published Preferred Drug List if drug shortages occur. This would include options for covering a brand name drug product that is a multi-source drug if a generic drug option is not available. Section E – Payments Optional benefits described in Section D: 1. ____ Newly added benefits described in Section D are paid using the following methodology:

a. ____ Published fee schedules

Page 7 State/Territory: West Virginia

TN: 21-0010 Approval Date: 08/27/2021 Supersedes TN: New Effective Date: 06/1/2020 This SPA is in addition to, and does not supersede, the Disaster Relief SPAs approved August 13, 2020 (WV 20-0004), December 17, 2020 (WV 20-0006), April 8, 2021 (WV 21-0007), and May 7, 2021 (WV-21- 0005). b. ______ Other:

Increases to State Plan payment methodologies: 2. ____ The agency increases payment rates for the following services:

a. ____ Payment increases are targeted based on the following criteria:

b. Payments are increased through: i. _____ A supplemental payment or add-on within applicable upper payment limits:

ii. _____ An increase to rates as described below.

Rates are increased:

_____ Uniformly by the following percentage: _____________

_____ Through a modification to published fee schedules –

Effective date (enter date of change): _____________

Location (list published location): _____________

____ Up to the Medicare payments for equivalent services.

____ By the following factors:

Page 8 State/Territory: West Virginia

TN: 21-0010 Approval Date: 08/27/2021 Supersedes TN: New Effective Date: 06/1/2020 This SPA is in addition to, and does not supersede, the Disaster Relief SPAs approved August 13, 2020 (WV 20-0004), December 17, 2020 (WV 20-0006), April 8, 2021 (WV 21-0007), and May 7, 2021 (WV-21- 0005). Payment for services delivered via telehealth: 3. _____ For the duration of the emergency, the State authorizes payments for telehealth services that: a. _____ Are not otherwise paid under the Medicaid State Plan; b. _____ Differ from payments for the same services when provided face to face; c. _____ Differ from current State Plan provisions governing reimbursement for telehealth;

d. _____ Include payment for ancillary costs associated with the delivery of covered services via telehealth, (if applicable), as follows: i. _____ Ancillary cost associated with the originating site for telehealth is incorporated into fee-for-service rates. ii. _____ Ancillary cost associated with the originating site for telehealth is separately reimbursed as an administrative cost by the State when a Medicaid service is delivered. Other: 4. ____ Other payment changes:

Section F – Post-Eligibility Treatment of Income 1. _____ The State elects to modify the basic personal needs allowance for institutionalized individuals. The basic personal needs allowance is equal to one of the following amounts: a. _____ The individual’s total income b. _____ 300 percent of the SSI federal benefit rate c. _____ Other reasonable amount: _________________ 2. _____ The State elects a new variance to the basic personal needs allowance. (Note: Election of this option is not dependent on a State electing the option described the option in F.1. above.)

Page 9 State/Territory: West Virginia

TN: 21-0010 Approval Date: 08/27/2021 Supersedes TN: New Effective Date: 06/1/2020 This SPA is in addition to, and does not supersede, the Disaster Relief SPAs approved August 13, 2020 (WV 20-0004), December 17, 2020 (WV 20-0006), April 8, 2021 (WV 21-0007), and May 7, 2021 (WV-21- 0005). The State protects amounts exceeding the basic personal needs allowance for individuals who have the following greater personal needs:

Section G – Other Policies and Procedures Differing from Approved Medicaid State Plan /Additional Information

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148 (Expires 03/31/2021). The time required to complete this information collection is estimated to average 1 to 2 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. Your response is required to receive a waiver under Section 1135 of the Social Security Act. All responses are public and will be made available on the CMS web site. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. ***CMS Disclosure*** Please do not send applications, claims, payments, medical records or any documents containing sensitive information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information collection burden approved under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please contact the Centers for Medicaid & CHIP Services at 410-786-3870.

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State/Territory Name: West Virginia State Plan Amendment (SPA) #: 22-0008 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 601 E. 12th St., Room 355 Kansas City, Missouri 64106 Medicaid and CHIP Operations Group

October 5, 2022

Cynthia Beane, MSW, LCSW Commissioner Bureau for Medical Services 350 Capitol Street, Room 251 Charleston, WV 25301-3706

Re: West Virginia State Plan Amendment (SPA) 22-0008

Dear Commissioner Beane:

The Centers for Medicare & Medicaid Services (CMS) reviewed your Medicaid State Plan Amendment (SPA) submitted under transmittal number (TN) 22-0008. This amendment proposes to update the state’s premium assistance program requirements.

We conducted our review of your submittal according to statutory requirements in Title XIX of the Social Security Act and implementing regulations. This letter is to inform you that West Virginia Medicaid SPA 22-0008 was approved on October 4, 2022 with an effective date of January 1, 2022.

CMS will continue to work with West Virginia on the implementation and operation of the premium assistance program.

If you have any questions, please contact Dan Belnap at 215-861-4273 or via email at Dan.Belnap@cms.hhs.gov.

Sincerely,

James G. Scott, Director Division of Program Operations

cc: Sarah Young

Riley Romeo

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

DEPARTMENT OF HEAL TH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES TO: CENTER DIRECTOR CENTERS FOR MEDICAID & CHIP SERVICES DEPARTMENT OF HEAL TH AND HUMAN SERVICES 1. TRANSMITTAL NUMBER 2. STATE 2 2 - 0 0 0 8 WV -- ---- -- 3. PROGRAM IDENTIFICATION: TITLE OF THE SOCIAL SECURITY ACT @ XIX Q XXI 4. PROPOSED EFFECTIVE DATE 01/01/2022 FORM APPROVED 0MB No. 0938--0193 5. FEDERAL STATUTE/REGULATION CITATION 6. FEDERAL BUDGET IMPACT (Amounts in WHOLE dollars) Section 1906 7. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT Section 4.22 page 70 Attachment 4.22-C pages 1-4 9. SUBJECT OF AMENDMENT Health Insurance Premium Payment Program 10. GOVERNOR'S REVIEW (Check One) ® GOVERNOR'S OFFICE REPORTED NO COMMENT 0 COMMENTS OF GOVERNOR'S OFFICE ENCLOSED 0 NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL li,; .!. : • .!. .!. li,; • !. :,,: • I ~ ... :,; Cynthia Beane 13. TITLE Commissioner, Bureau for Medical Services 14. DATE SUBMITTED 03/24/2022 a FFY 2022 $ 0 b. FFY 2023 $ 0 8. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable) Section 4.22 page 70 Attachment 4.22-C page 1 0 OTHER, AS SPECIFIED: 15. RETURN TO Bureau for Medical Services 350 Capitol Street Room 251 Charleston, West Virginia 25301 FOR CMS USE ONLY 16. DATE RECEIVED March 24, 2022 17. DATE APPROVED 10/04/2022 PLAN APPROVED - ONE COPY ATTACHED 18. EFFECTIVE DATE OF APPROVED MATERIAL January 1, 2022 20. TYPED NAME OF APPROVING OFFICIAL James G. Scott 22. REMARKS FORM CMS-179 (09/24) Director, Division of Program Operations Instructions on Back

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: West Virginia Attachment 4.22-C Page 1 TN No.: 22-008 Approval Date: Effective Date: Supersedes: 93-12 01/01/2022 PROPOSED SECTION 4 – GENERAL PROGRAM ADMINISTRATION Attachment 4.22-C State Method on Cost Effectiveness of Employer-Based Group Health Plans Citation 1906 of the Act Condition or Requirement Enrollment in the West Virginia Health Insurance Premium Payment (HIPP) program is voluntary. A) Cost Effectiveness Calculation: 1) Enrollment in a group health insurance plan shall be considered cost effective when the cost of paying the premiums, coinsurance, deductibles, benefits wrap, cost- sharing, and additional administrative costs is estimated to be less than the amount paid for an equivalent set of Medicaid services. a) When determining cost effectiveness of a group health insurance plan, the State shall consider the following information: i) The cost of the insurance premium, coinsurance, and deductible; ii) The scope of services covered under the insurance plan, exclusions to enrollment, and lifetime maximum benefits imposed; iii) The average anticipated Medicaid utilization: 1) By age, sex, and coverage group for persons covered under the insurance plan; and 2) Using a statewide average for the geographic component iv) The specific health-related circumstances of the persons covered under the insurance plan; and v) Annual administrative expenditures of an amount determined by the State per Medicaid recipient covered under the group health insurance plan. All relevant information is gathered and evaluated by the State’s third party liability (TPL) vendor. The TPL vendor determines HIPP eligibility, processes payments, and performs eligibility reviews utilizing the State’s cost effectiveness calculation described above. 2) If the Medicaid beneficiary who has access to a group health insurance plan is not deemed cost effective for enrollment in premium assistance and a family member has a high-cost condition and Medicaid coverage, the State will conduct a family-based cost effectiveness test to determine if it will be less expensive for the State to cover the cost of health insurance premiums and cost sharing for the entire family. B) Cost Effectiveness Review: 1) The State shall complete a cost effectiveness review: a) At least once every six (6) months for an employer-related group health insurance plan. 

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: West Virginia Attachment 4.22-C Page 2 TN No.: 22-0008 Approval Date: Effective Date: Supersedes: New 01/01/2022 2) The State shall perform a cost effectiveness re-determination if: a) A predetermined premium rate, deductible, or coinsurance increases; b) Any of the individuals covered under the group health plan lose full Medicaid eligibility; or c) There is a: i. Change in Medicaid eligibility; ii. Loss of employment when the insurance is through an employer; or iii. A decrease in the services covered under the policy. 3) Changes in enrollment a) A HIPP recipient, who is a Medicaid enrollee, shall report all changes concerning health insurance coverage to the recipient’s local DHHR representative within ten (10) business days of the change. b) Except as allowed in section four (4) below, if a Medicaid recipient who is a HIPP program participant fails to comply with paragraph (a) of this subsection, the department shall disenroll the HIPP program participating Medicaid enrollee, and any family member enrolled in the HIPP program directly through the individual if applicable, from the HIPP program. Individuals who remain eligible for Medicaid will receive medical assistance under the State Plan. 4) The department shall not disenroll an individual from HIPP program participation if the individual demonstrates to the department, within thirty (30) days of notice of HIPP program disenrollment, good cause for failing to comply with subsection three (3) of this section. 5) Good cause for failing to comply with subsection three (3) of this section shall exist if: a)There was a serious illness or death of the recipient, parent, guardian, or caretaker or a member of the recipient’s, parent’s, guardian’s, or caretaker’s family; b) There was a family emergency or natural disaster – for example, a fire, flood, tornado, or similar; c) The recipient, parent, guardian, or caretaker offers a good cause beyond the recipient’s, parent’s, guardian’s or caretaker’s control; or d) There was a failure to receive the department’s request for information or notification for a reason not attributable to the recipient, parent, guardian, or caretaker or lack of a forwarding address shall be attributable to the recipient, parent, guardian, or caretaker. C) Coverage of Non-Medicaid Family Members. 1) If determined to be cost effective, the department shall: a) Pay a HIPP program premium on behalf of a HIPP program participating family member who is not a Medicaid enrollee; and b) Not pay a deductible, coinsurance, or other cost-sharing obligation on behalf of a HIPP program-participating family member who is not a Medicaid enrollee. D) Beneficiary Protections: 1) Individuals enrolled in the State’s premium assistance program are afforded the same beneficiary protections provided to all other Medicaid enrollees. The beneficiary will not be responsible for payment of premiums or other cost sharing that exceeds nominal levels as established at 42 CFR part 447 subpart A. 

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: West Virginia Attachment 4.22-C Page 3 TN No.: 22-0008 Approval Date: Effective Date: Supersedes: New 01/01/2022 2) The State will provide a benefits wrap to all services and benefits available under the Medicaid State Plan that are not provided through the Employee Sponsored Insurance (ESI) plan. a) After providers submit an explanation of benefits to Medicaid showing that the services were not covered through the ESI, Medicaid will then pay primary for these Medicaid covered services. The State will inform beneficiaries how to obtain benefits through the benefits wrap. 3) The State will provide a cost-sharing wrap to any cost-sharing amounts that exceed the cost-sharing limits described in the State Plan. For the cost sharing wrap around: a) The State has implemented a provider enrollment strategy to enroll non- participating Medicaid providers. The State educates non-participating Medicaid providers on how to enroll in Medicaid for the specific (and sole) purpose of receiving payment from the State for cost sharing amounts that exceed the Medicaid permissible limits for the patient responsibility portion of the claim. b) The State will assist beneficiaries in choosing in-network providers of the health plan that are also Medicaid enrolled providers. c) The State will encourage HIPP program beneficiaries to access services from an ESI in-network provider that is also a Medicaid provider. The State will inform beneficiaries that if the beneficiary wants to seek care from a non-Medicaid provider, they should request their provider to contact Provider Enrollment for assistance with enrolling in Medicaid for the purposes of cost-sharing. The beneficiary can also request assistance from Member Services. Provider Enrollment can contact the provider to explain that the State will pay the total patient responsibility amount once the provider contracts to become a Medicaid provider. Medicaid will pay secondary on claims for services rendered by out-of-network providers, only if the ESI covers out-of-network providers. d) The State allows HIPP beneficiaries to obtain services from any provider in the Medicaid network for any Medicaid State Plan Service or Medicaid Waiver Service (if the beneficiary meets waiver criteria as applicable). 4) The State will provide pre-payment for the beneficiary portion of the premiums for a cost effective ESI directly to the policy holder using the following process: a) As the State is requiring the HIPP TPL contractor to prefund their bank account for reimbursements to policy holders. The contractor will follow the process of presenting a funding request to the State so that they are aware and agree with the premiums being reimbursed. Once approved, the contractor will fund their bank account and distribute reimbursements to the appropriate policy holder via direct deposit or paper check (whichever method is selected by the policy holder). b) In addition to the monthly check runs scheduled near the first of each month, another check run occurs on the fifteenth of each month to help ensure direct payment of premium payments to employers, ESI plans, and COBRA administrators and to help ensure payment for cases pended and released later in the month. 

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: West Virginia Attachment 4.22-C Page 4 TN No.: 22-0008 Approval Date: Effective Date: Supersedes: New 01/01/2022 c) Direct payments are scheduled for release two weeks prior to the official premium due dates to avoid late payments or interruptions in coverage. 

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State/Territory Name: West Virginia State Plan Amendment (SPA) #: 22-0020 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 601 E. 12th St., Room 355 Kansas City, Missouri 64106 Medicaid and CHIP Operations Group July 11, 2022 Cynthia Beane, MSW, LCSW Commissioner Bureau for Medical Services 350 Capitol Street, Room 251 Charleston, WV 25301-3706 Re: West Virginia State Plan Amendment (SPA) 22-0020 Dear Commissioner Beane: The Centers for Medicare & Medicaid Services (CMS) reviewed your Medicaid State Plan Amendment (SPA) submitted under transmittal number (TN) 22-0020. This amendment proposes to update third-party liability requirements. We conducted our review of your submittal according to statutory requirements in Title XIX of the Social Security Act and implementing regulations. This letter is to inform you that West Virginia Medicaid SPA 22-0020 was approved on July 11, 2022, with an effective date of April 1, 2022. If you have any questions, please contact Dan Belnap at 215-861-4273 or via email at Dan.Belnap@cms.hhs.gov. Sincerely, Nicole McKnight, Acting Director Division of Program Operations cc: Sarah Young Fred Lewis Britany Mullins Riley Romeo CENTERS FOR MEDICARE & MEDICAID SERVICES CENTER FOR MEDICAID & CHIP SERVICES

DEPARTMENT OF HEAL TH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES TO: CENTER DIRECTOR CENTERS FOR MEDICAID & CHIP SERVICES DEPARTMENT OF HEAL TH AND HUMAN SERVICES 1. TRANSMITTAL NUMBER 2. STATE 2 2 _ Q 0 2 0 WV -- - --- -- 3. PROGRAM IDENTIFICATION: TITLE OF THE SOCIAL SECURITY ACT (e) XIX 0 XXI 4. PROPOSED EFFECTIVE DATE April 1, 2022 FORM APPROVED 0 MB No. 0938-0193 5. FEDERAL STATUTE/REGULATION CITATION 6. FEDERAL BUDGET IMPACT (Amounts in WHOLE dollars) a FFY 2022 $ 0 Title XIX of the Social Security Act b. FFY 2023 $ 0 7. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT 8. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION Page 69a OR ATTACHMENT (If Applicable) Attachment 4.22-B page 1 Page 69a Attachment 4.22-B page 1 9. SUBJECT OF AMENDMENT This amendment proposes to update Third Party Liability requirements as authorized under the Bipartisan Budget Act (BSA) of 2018 (Pub. L. 115- 123) and the Medicaid Services Investment and Accountability Act (MSIAA) of 2019 (Pub. L. 116-16). 10. GOVERNOR'S REVIEW (Check One) ® GOVERNOR'S OFFICE REPORTED NO COMMENT O OTHER, AS SPECIFIED: 0 COMMENTS OF GOVERNOR'S OFFICE ENCLOSED 0 NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL 15. RETURN TO Bureau for Medical Services 350 Capitol Street Room 251 12. TYPED NAME Charleston West Virginia 25301 Cynthia Beane 13. TITLE Commissioner, WV Bureau for Medical Services 14. DATE SUBMITTED 06/28/2022 16. DATE RECEIVED June 28, 2022 FOR CMS USE ONLY 17. DATE APPROVED 07/11/2022 PLAN APPROVED· ONE COPY ATTACHED 18. EFFECTIVE DATE OF APPROVED MATERIAL April 1, 2022 20. TYPED NAME OF APPROVING OFFICIAL Nicole McKnight 22. REMARKS FORM CMS-179 (09/24} 19. SIGNATURE OF APPROVING OFFICIAL 21. TITLE OF APPROVING OFFICIAL Acting Director, Division of Program Operations Instructions on Back

TN No. 22-0020 Effective Date: April 1, 2022 Supersedes TN No. 87-04 Approval Date:__________ Revision: HCFA-PM-87-9 August 1987 Supplement to Attachment 4.22-B Page 1 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE / TERRITORY: West Virginia __________________________________________________________________________________ Requirements for Third Party Liability Payment of Claims West Virginia has established methods through which providers must screen for Third Party Liability (TPL) payments where TPL is known to exist, prior to submitting claims to Medicaid. The Third-Party Liability (TPL) Program is designed to function primarily as a cost avoidance system. West Virginia complies with the following TPL requirements: Social Security Act Section 1902 (a)(25)(E): Applying cost avoidance procedures to claims for prenatal services, including labor, delivery, and postpartum care services. Social Security Act Section 1902 (a)(25)(E): Making payment without regard to potential third-party liability for pediatric preventive services, unless the state has made a determination related to cost-effectiveness and access to care that warrants cost avoidance for up to 90 days. Social Security Act Section 1902 (a)(25)(F): Making payment for claims related to child support enforcement beneficiaries without regard to potential third-party liability, if payment has not been made by the third party within 100 days after the provider submitted a claim to the third party, except that West Virginia may make such payment within 30 days after such date if it determines doing so is cost effective and necessary to ensure access to care. Threshold Amounts for Purposes of Seeking Recovery from a Liable Third Party Pursuant to 42 C.F.R §433.139(f)(2). West Virginia will seek recovery unless the agency determines that the recovery will not be cost effective. The thresholds listed below will be used as a guideline to recover from liable third parties. Threshold Amounts and Timing for Purposes of Seeking Recoveries Pursuant to 42 C.F.R §433.139(f)(3). West Virginia will seek recovery unless the agency determines that the recovery will not be cost effective. A thresholds listed below will be used as a guideline to recover from liable third parties. Inpatient Hospital $500.00 Outpatient Hospital $200.00 Physician $100.00 Dentist $100.00 Laboratory/Radiology $200.00 Pharmacy $ 50.00 Home Health $100.00 Transportation

$100.00 Vision/Eyeglasses

$200.00 Durable Medical Equipment and Supplies $200.00 Therapist $200.00 July 11, 2022

Revision: Citation HCFA-PM-94-1 {MB) February 1994 42 CFR 433.139{b)(3)(ii)(A) 42 CFR 433.139{b){3){ii)(c) 42 CFR 433.139{f)(2) 42 CFR 433.139{f)(3) 42 CFR 447.20 TN No. 22-0020 Supersedes TN No. ~ 69a State/Territory: West Virginia X (c) Providers are required to bill liable third parties when services covered under the plan are furnished to an individual on whose behalf child support enforcement is being carried out by the State IV-D agency. (d) ATTACHMENT 4.22- B specifies the following: {l) The method used in determining a provider's compliance with the third-party billing requirements at §433.139{b )(3 )(ii)(C). (2) The threshold amount or other guideline used in determining whether to seek recovery of reimbursement from a liable third party, or the process by which the agency determines that seeking recovery of reimbursement would not be cost effective. (3) The dollar amount or time period the State uses to accumulate billings from a particular liable third party in making the decision to seek recovery of reimbursement. (e) The Medicaid agency ensures that the provider furnishing a service for which a third party is liable follows the restrictions specified in 42 CFR 447.20. Effective Date: April 1, 2022 Approval Date: July 11, 2022

Table of Contents State/Territory Name: West Virginia State Plan Amendment (SP A) #: 23-0001 This file contains the following docmnents in the order listed: 1) Approval Letter 2) Companion letter 3) Summary Form (with 179-like data) 4) Approved SPA Pages

Records Submission Packages - View All WV - Submission Package - WV2022MS0002O - (WV-23-0001) - Eligibility Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter RAI Transaction Logs News Related Actions DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services CAHPG 601 E. 12th St., Room 3S5 Kansas City, MO 64106 ctNlfllS IOR -'IIDICARl &MIOICAIO SIJIVIClS Center for Medicaid & CHIP Services December 19, 2024 Cynthia Beane Commissioner WV Bureau for Medical Services 350 Capitol Street, Room 251 Charleston, WV 25301 Re: Approval of State Plan Amendment WV-23-0001 Dear Commissioner Beane, On March 08, 2023, the Centers for Medicare & Medicaid Services (CMS) received West Virginia State Plan Amendment (SPA) WV-23-0001 to conduct Medicaid presumptive eligibility determinations. We approve West Virginia State Plan Amendment (SPA) WV-23-0001 with an effective date{s) of Reviewable Unit Optional Eligibility Groups Presumptive Eligibility Presumptive Eligibility for Children under Age 19 Parents and Other Caretaker Relatives• Presumptive Eligibility Presumptive Eligibility for Pregnant Women Adult Group -Presumptive Eligibility Former Foster Care Children - Presumptive Eligibility Individuals Needing Treatment for Breast or Cervical Cancer - Presumptive Eligibility Effective Date May 12, 2023 May 12. 2023 May 12, 2023 May 12, 2023 May 12, 2023 May 12, 2023 May 12, 2023 January 01, 2023 Please note that accompanying the approval of SPA 23-0001 is the enclosed companion letter regarding the need for West Virginia to make modifications to its on line PE application (on line portal ), provider training materials. and policy manual. West Virginia will provide dates for completion of outstanding changes within 60 days of approval of this SPA and will implement revised online PE, provider training materials, and policy manual addressing CMS concerns by the dates listed in the companion letter. Name Date Created WV-23-0001 companion letter signed 12/19/2024 10:24 AM EST If you have any questions regarding this amendment. please contact Nicole Guess at nicole.guess@cms.hhs.gov. Sincerely, Ruth A. Hughes Acting Director, Division of Program Operations Center for Medicaid & CHIP Services I CMS j_

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 601 E. 12th St., Room 355 MS Kansas City, Missouri 64106 CENTERS FOR MEOICARE & MEOICAIU SERVICES CENTER FOR MEDICAID & CHIP SERVICE5 Medicaid and CHIP Operations Group December 18, 2024 Cynthia Beane Commissioner WV Bureau for Medical Services 350 Capitol Street, Room 251 Charleston, WV 25301 Re: West Virginia State Plan Amendment (SPA) 23-0001 - Companion Letter Dear Commissioner Beane: This letter is being sent as a companion to the Centers for Medicare & Medicaid Services (CMS) approval of State Plan Amendment (SPA) WV 23-0001, which was submitted to CMS on March 8, 2023. Approval of SPA WV 23-0001 includes approval of the provider training materials, the online Presumptive Eligibility (PE) application, WV policy manual 400.8 Presumptive Eligibility Policy, and other materials used for the following PE groups: children under age 19, parents and other caretaker relatives, pregnant women, adults, former foster care children, and individuals needing treatment for breast or cervical cancer. This approval of all PE Reviewable Units (RU) will be effective as of May 12, 2023, except that the individuals needing treatment for breast or cervical cancer PE RU is effective as of January 1, 2023. Pending implementation of the changes described below, West Virigina will use an interim online PE application and provider training materials. The state will revise the online PE application, provider training materials, and policy manual as described below. Necessary Change Date by which the change will be completed: 1. Online PE Application and Provider Training Materials WV wi II remove "Other" and "Administrative reason" as denial reasons in the Job Aid, online PE application, and denial notices. The state will provide a date by which these changes will be made, along with screenshots and/or copies of all updated PE materials. 2. Online PE Application and Provider Training Materials WV will revise the Job Aid, online PE application, and denial notices to include the following denial reasons in PE: r <I.

Submission - Summary MEDICAID I Medicaid State Plan I Eligibility I WV2022MS0002O I WV-23-0001 Package Header Package ID WV2022MS00020 Submission Type Official Approval Date 12/19/2024 Superseded SPA 10 N/A Executive Summary SPA ID WV-23-0001 Initial Submission Date 3/8/2023 Effective Date N/A Summary Description Including West Virginia is adding Local Health Departments, Medicaid enrolled pharmacies and First Choice Services as qualified Goals and Objectives entities to conduct Medicaid presumptive eligibility determinations. Amendments were made to provide Medicaid coverage to Children Under Age 19, Pregnant Women, Parents/Caretaker Relatives, Adult Group, Breast and Cervical Cancer group, and Former Foster Children when determined presumptively eligible by additional qualified entities as identified. Federal Budget Impact and Statute/Regulation Citation Federal Budget Impact First Second Federal Fiscal Year 2023 2024 Federal Statute I Regulation Citation Sections 1920, 1920A, 19206, and 1920C of the Act and 42 CFR Part 435 Subpart L Supporting documentation of budget Impact is uploaded (optional). Amount $0 $0 Name Date Created No items available

Submission - Summary MEDICAID I Medicaid State Plan I Eligibility I WV2022MS0002O I WV-23-0001 Package Header Package ID WV2022MS0002O Submission Type Official Approval Date 12/19/2024 Superseded SPA 10 N/A Governor's Office Review 0 No comment O Comments received 0 No response within 45 days Q Other SPA ID WV-23-0001 Initial Submission Date 3/8/2023 Effective Date N/A PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory Informati on in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12): which sets forth the authori ty for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medi caid programs and Children's Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state's program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children's Health Insurance Program in efforts to boost program Integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally Identifying information obtained will be kept private to the extent of the law. According to the Paperwor1< Reduction Act of 1995, no persons are required to respond to a collection of Information unless It displays a valid 0MB control number. The valid OMS control number for this Information collect Ion Is 0938-1 188. The time required to complete this Information colleetlon Is estimated to range from 1 hour to 80 hours per response(see below). including the time to review instructions. search existing data resources, gather the data needed. and complete and review the information collection. If you have comments concerning the accuracy of the time estlmate(s) or suggestions for Improvi ng this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer. Mall Stop C.4-26-05. Baltimore, Maryland 21244-1850. This view was generated on 12/26/2024 11 :25 AM EST i i I . . I r I ' I

12/20/24, 10:38 AM WV - Submission Package - WV2022MS0002O - (WV-23-0001) - Eligibility Records Submission Packages • View All WV - Submission Package - WV2022MS0002O - {WV-23-0001) - Eligibility I VIEW PRINT PREVIEW I Summary Reviewable Units Versions Correspondence Log Analyst Notes Review Assessment Report Approval Letter RAI Transaction Logs News Related Actions <= All Reviewable Units ϝ.Former Foster Care Children. -.Presumptive .Eligibility Medicaid State Plan Eligibility Presumptive Eligibility View.compare.Doc Individuals Needing Treatment for Breast or Cervical Cancer - Presumptive Eligibility MEDICAID I Medicaid State Plan I Eligibility I WV2022MS00020 I WV-23-0001 .!;. Spell Check Instructions I f) Request System Help CMS-104340MB 0938-1188 Not Started In Progress Complete Package Header Package 10 WV2022MS00020 Submission Type Official SPA ID WV-23-0001 Initial Submission Date 3/8/2023 Effective Date 1/1/2023 Approval Date 12/19/2024 Superseded SPA 10 New User-Entered View Implementation Guide I VIEW All RESPONSES The state covers the individuals needing treatment for breast or cervi cal cancer group when determined presumptively eligible by a qualified entity. A. Presumptive Eligibility Period Collapse 1. The presumptive period begins on the date the determination is made. 2. The end date of the presumptive period Is the earlier of: a. The date the eligibility determination for regular Medicaid is made, if an application for Medicaid is filed by the last day of the month following the month in which the determination of presumptive eligibility Is made; or b. The last day of the month following the month in which the determination of presumptive eligibility is made. if no application for Medicaid is filed by that date. 3. Periods of presumptive eligibility are limited as follows: O a. No more than one period within a calendar year. b. No more than one period wi thin two calendar years. c. No more than one period within a six-month period, starting with the effective date of the initial presumptive eligibility period. C' d. No more than one period within a twelve-month period, starti ng with the effective date of the initial presumptive eligibility period. O e. Other reasonable limitation: Name of Limitation One PE period per CDC BCCEDP enrollment Description PE may be provided for each time the woman is screened under the Centers for Disease Control and Prevention (CDC) breast and cervical cancer early detection program https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1 iljGeHwXRmZtl2Llcjf-vAMo-BtAWp T gO6QfW7 sfytGJjTskhdvPqCEg8Oq39-... 1 /5 11 ii i . i. I i j -

12/20/24, 10:38 AM WV - Submission Package - WV2022MS0002O - (WV-23-0001) - Eligibility Name of Limitation B. Application for Presumptive Eligibility 0 1. The state uses a standardized screening process for determining presumptive eligi bility. Description (BCCEDP) and found to need treatment for breast or cervical cancer. Collapse D 2. The state uses the single streamli ned paper and/or online application for Medicaid and Presumptive Eligibility, approved by CMS. A copy of the single streamlined paper and/or online application with questions necessary for a PE determination highlighted or denoted is attached. 0 3. The state uses a separate paper application form for presumptive eligibility, approved by CMS. A copy of the application form is included. O 4. The state uses an on line portal or electronic screening tool for presumptive eligibility approved by CMS. Screenshots of the tool included. 5. Describe the presumptive eligibility screening process: Name CDC_Certiflcate_Oiagnosls_Medicai d_Referral_FForm BCC-1-Rev-8-17-23 2-Approved-CC- 8-8-23 Name WV SPA 23 0001 Presumptive Eligibility Application screenshots Date Create<! 10/6/2022 4:18 PM EDT I 9/26/2024 5:42 PM EDT Date Created 9/26/2024 5:42 PM EDT I Breast and Cervical Cancer Screening Providers (BC CSP): A woman is screened at a BC CSP si te. If diagnosed with breast or cervical cancer, she is given a CDC Certificate of Diagnosis and completes form DFA-BCC-1. If the woman Is determined presumptively eligible, the DFA-BCC-1 form Is forwarded by the CDC facility to the DHHR office in the county in which the applicant resides. The Worker enters the information in the eligibility system to issue a Medical ID card. Other entities: Authorized presumptive eligibility (PE) employees will gather data from the Indivi dual using the presumptive eligibil ity determination portion of the on-line system. The employee may obtain information relating to the individual such as name, address. phone number, and social security number from other facility personnel such as registrars; however, this information must be confirmed by the individual or another person with reasonable knowledge of the individual's needs status. The individual or another person with reasonable knowledge of the Individual's status seeking PE must attest to the information provided on the application. Authorized employees may not request any documentation or require verification of information provided. The authorized employee must make the final determination of whether or not the individual may be eligible for Medicaid. This decision is made based on the criteria in section 400.8.3 of the policy manual and the results of the on-line system. Once a fi nal decision is made by the authorized worker he/she will provide the patient with either a temporary Medicaid card or a document stating why he/she was not determined presumptively eligible. The Authorized Employee must assist the applicant or his authorized representative in completing the single streamlined application (SLA) for Medicaid and forward the application to the Department. C. Presumptive Eligibility Determination The presumptive eligibility determination is based on the following factors: 1. The individual must meet the categorical requirements of 42 CFR 435.213. D 2. State residency 0 3. Citizenship, status as a national, or satisfactory immigration status D. Qualified Entities Collapse Collapse 1. The state uses qualified entities, as defined in section 19208 of the Act, to determine eligibility presumptively for this eligibility group. These entities must be eligible to receive payment for services under the state's approved Medicaid state plan and determined by the state to be capable of determining presumptive eligibility for this group. 2. The types of entities used to determine presumptive eligibility for this eligibility group are: 0 a. Providers who conduct screenings for breast and cervical cancer under the state's Centers for Disease Control and Prevention's National Breast and Cervical Cancer Early Detection Program. 0 b. Other entity Type of entity Federally Qualified Health Centers Description Federally Qualified Health Centers (FQHC) receiving a grant under https:f/macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1 iljGeHwXRmZtl2Llcjf-vAMo-BtAWp T gO6QfW7 sfytGJjTskhdvPqCEg8Oq39-... 2/5 I. i - ! ! ! !. I 11 I!

12/20/24, 1 0: 38 AM WV - Submission Package - WV2022MS0002O - (WV-23-0001) - Eligibility Type of entity Comprehensive community mental health centers Free Clinics Rural Health Clinics (RH() Description Section 330 of the Public Health Service (PHS) Act; or, receiving funding from a grant under a contract with the recipient of a grant and meets the requirements to receive a grant under Section 330 of the PHS Act; or, Is not receiving a grant under Secti on 330 of the PHS Act but is determined by the Secretary of the Department of Health & Human Services (HHS) to meet the requirements for receiving such a grant (i.e., qualifies as a FQHC look-alike) based on the recommendati on of the Health Resources and Services Administration; or, was treated by the Secretary of the Department of HHS for purposes of Medicare Part B as a comprehensive Federally funded health center as of January 1, 1990; or is operating as an outpatient health program or facility of a tribe or tribal organization under the Indian Self­ Determination Act or as an urban Indian organization receiving funds under Tide v of the Indian Health Care Improvement Act as of October 1, 1991. Comprehensive community mental health centers as ldenOfled in west Virginia Code §27-2A-1. The Department of Health and Human Resources is authorized and directed to establish, maintain and operate comprehensive community mental health centers at locations within the state that are determined by the secretary in accordance with the state's comprehensive mental health plan. Free and Charitable Clinics are Silfety­ net health care organizations that utilize a volunteer/staff model to provide a range of medical, dental, pharmacy, vision and/or behavioral health services to economically disadvantaged individuals. Such clinics are 501 (c)(3) tax-exempt organizations, or operate as a program component or affiliate of a 501(c)(3) organization. Entities that otherwise meet the above definition, but charge a nominal/sliding fee to patients, may still be considered Free or Charitable Clinics provided essential services are delivered regardless of the patient's ability to pay. Free or charitable clinics restrict eligibility for their services to individuals who are uninsured, underinsured and/or have limited or no access to primary, specialty or prescription health care. Rural Health Clinics are defined In section 1861 (aa)(2) of the Social Security Act (the Act) as facilities that are engaged pri marily in provi ding services that are typically furnished in an outpatient clinic. RHC services are defined as: https:f/macpro.cms.gov/suiteitempo/records/item/lUBGxuxnAYNcw8V8rAi1 iljGeHwXRmZtl2Llcjf-vAMo-BtAWp T gO6QfW7 sfytGJjTskhdvPqCEg8Oq39-... 3/5 i. j - i I i I

12/20124, 1 0: 38 AM WV - Submission Package - WV2022MS0002O - (WV-23-0001) - Eligibility Type of entity Local Health Departments First Choice Services Description • Physician services; • Services and supplies furnished incident to a physician's services; • Nurse Practitioner {NP), Physician Assistants (PA), certified nurse midwife {CNM), clinical psychologist {CP), and clinical social worker (CSW) services; and • Services and supplies furnished incident to an NP. PA. CNM, CP. or CSW services. To be eligible for certification as a RHC, a clinic must be located in a non-urbanized area, as determined by the U.S. Census Bureau, and in an area designated or certified within the previous 4 years by the Secretary, Health and Human Services {HHS), in any one of the four types of shortage area designations that are accepted for RHC certification. RHCs can be either independent or provider-based. Independent RHCs are stand-alone or freestanding clinics and submit claims to a Medicare Administrative Contractor {A/B MAC). The statutory requirements for RHCs are found in section 1861(aa)<2) of the Act. Many of the regulations pertaining to RHCs can be found at 42 CFR 405.2400 Subpart X and following. and 42 CFR 491 Subpart A and following. West Virginia's 55 counties are served by 49 local boards of health charged with protecting the health and safety of the citizens of West Virginia. Local boards of health provide services through local health departments located in all 55 counties including communicable and reportable disease prevention and control. First Choice Services -ACA Navigators and HELP4WV Helpline Specialists First Choice Services operates several programs and helplines with the common goal of promoting well• being and facilitating access to behavioral health and social services. First Choice began as a collaborative effort among West Virginia's comprehensive behavioral health care centers. First Choice also operates the ACA Navigator program which Is funded by a grant from the Center for Medicare and Medicaid services. ACA Navigators provides free health coverage enrollment assistance to people who are uninsured. Certified Navigators help consumers enroll in qualified health plans through the Health Insurance Marketplace or, if eligible, Medicaid. HELP4WV offers a 24/7 call, chat, and text line that provides immediate help for any West Virginian struggling with an addiction or mental health https:f/macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1 iljGeHwXRmZtl2Llcjf-vAMo-BtAWp T gO6QfW7 sfytGJjTskhdvPqCEg8Oq39-... 4/5 i I j -

12/20124, 10:38 AM WV - Submission Package - WV2022MS0002O - (WV-23-0001) - Eligibility Type of entity Medicaid enrolled pharmacies Description issue. The helpline staff offers confidential support and resource referrals, including self-help groups, out-patient counseling, medication• assisted treatment, psychiatric care, emergency care, and residential treatment. Licensed pharmacists and pharmacy technicians employed by MediC<lid enrolled pharmacies. D 3, The state assures that it has communicated the requirements for entities, at 1920B of the Act, and has provided adequate training to the entities and organizations involved. 4. A copy of the training materials has been uploaded for review during the submission process, E. Additional Information (optional) Name SL_Presumptive Eligibility (PE) Worker - MR9.docx PP JobAid­ Presumptive_Eligibility _ Worker Date Created 9126/2024 5:44 PM EDT 9/26/2024 5:44 PM EDT Collapse PRA Disclosure Statement: Centers for Medicare & Medicaid SeNices (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of Improving the state application and federal review processes, improve federal program management of Medicaid programs and Children's Health Insurance Program. and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state's program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children·s Health Insurance Program In effons to boost program Integrity efforts. ,mprove performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid 0MB control number. The valid 0MB control number for this information collection is 0938--1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), including the time to review instructions, search existing data resources, gather the data needed, and complete and review the Information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Ann: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. https://macpro.cms.gov/suiteltempo/records/item/lUBGxuxnAYNcw8V8rAi1 iljGeHwXRmZtl2Llcjf-vAMo-BtAWp T gO6QfW7 sfytGJjTskhdvPqCEg8Oq39-... 5/5 j -

Records / Submission Packages - View All WV - Submission Package - WV2022MS0002O - (WV-23-0001) - Eligibility Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter RAI Transaction Logs Medicaid State Plan Eligibility Optional Eligibility Groups MEDICAID I Me<licaid State Plan I Eligibility I WV2022MS0002O I WV-23-0001 CMS• I 0434 0MB 0938-1188 Package Header Package 10 WV2022MS00-02O Submission Type Official Approval Date 12/19/2024 Superseded SPA ID New User-Entered A. Options for Coverage The state provides Medicaid to specified optional groups of individuals. Yes O No SPA 10 WV-23-00-01 Initial Submission Date 3/8/2023 Effective Date 5/12/2023 News Related Actions ... The optional eligibility groups covered in the state plan are (elections made in this screen may not be comprehensive during the transition period from the paper• based state plan to MACPro): Families and Adults Eligibility Group Name Optional Coverage of Parents and Other Caretaker Relatives Reasonable Classifications of Individuals under Age 21 Children with Non-lV-E Adoption Assistance Independent Foster Care Adolescents Optional Targeted Low Income Children Individuals above 133% FPL under Age 65 Individuals Needing Treatment for Breast or Cervical Cancer Individuals Eligible for Family Planning Services Individuals with Tuberculosis Individuals Electing COBRA Continuation Coverage Covered In State Plan Ⱥ □ Ⱥ D [!] C: [!] D [!] D Ⱥ D Ⱥ c:: [!] D Ⱥ D [!] Include RU In Package i) □ D D D D D D D D □ Included In Another Submission Package 0 0 0 0 0 0 0 0 0 0 Source Type & NEW NEW CONVERTED NEW NEW NEW NEW NEW NEW NEW

Aged, Blind and Disabled Eligibility Group Name Covered In State Plan Include RU In Package Included in Another Source Type 6 6 Submission Package Individuals Eligible for [!) but Not Receiving Cash Assistance D 0 NEW Individuals Eligible for [!] 0 Cash Except for □ □ NEW Institutionalization Individuals Receiving Home and Community• ͎ 0 Based Waiver Se,vices C □ NEW under Institutional Rules Optional State ͎ 0 Supplement □ □ NEW Beneficiaries Individuals in Institutions Eligible ନ C D 0 NEW under a Special Income L evel PACE Participants ͎ D D 0 NEW Individuals Receiving [!] C □ 0 NEW Hospice Children under Age 19 [!] C □ 0 NEW with a Disability Age and Disability• [!) □ □ 0 NEW Related Poverty Level Work Incentives ͎ □ □ 0 NEW Ticket to work Basic [!] C □ 0 NEW Ticket to work Medical ͎ C D 0 NEW Improvements Family Opportunity Act [!] 0 Children with a □ D NEW Disability Individuals Receiving State Plan Home and [!] □ □ 0 NEW Community-Based Services Individuals Receiving State Plan Home and Community-Based [!) D D 0 NEW Se,vices Who Are Otherwise Eligible for HCBS Waivers

Optional Eligibility Groups MEDICAID I Medicaid State Plan I Eligibility I WV2022MS0002O I WV-23-0001 Package Header Package ID WV2022MS0002O Submission Type Official Approval Date 12/19/2024 Superseded SPA 10 New User-Entered B. Medically Needy Options for Coverage SPA ID WV-23-0001 Initial Submission Date 3/8/2023 Effective Date S/12/2023 The state provides Medicaid to specified groups of individuals who are medically needy. O Yes O No The medically needy eligibility groups covered in the state plan are: 1 . Mandatory Medically Needy: Families and Adults Eligibility Group Name Medically Needy Pregnant women Medically Needy Children under Age 18 Aged, Blind and Disabled Eligibility Group Name Protected Medically Needy Individuals Who Were El igible in 1973 [!1 [!] 2. Optional Medically Needy: Families and Adults Eligibility Group Name Medically Needy Reasonable Ⱥ Classifications of Individuals under Age 21 Medically Needy Ⱥ Parents and Other Caretaker Relatives Aged, Blind and Disabled Eligibility Group Name Medically Needy Populations Based on [!] Age, Blindness or Disability Covered In State Plan C C Covered In State Plan Covered In State Plan C Covered In State Plan Include RU In Package 0 □ □ Include RU In Package 0 □ Include RU In Package 0 □ □ Include RU In Package 0 □ Included in Another Submission Package 0 0 Included in Another Submission Package 0 Included in Another Submission Package 0 0 Included in Another Submission Package 0 Source Type €) NEW NEW Source Type €> NEW Source Type €) NEW NEW Source Type €) NEW C: c::

Optional Eligibility Groups MEDICAID I Me<licaid State Plan I Eligibility I WV2022MS0002O I WV-23-0001 Package Header Package ID WV2022MS0002O Submission Type Official Approval Date 12/19/2024 Superseded SPA 10 New User-Entered C. Additional Information (optional) Eligibility Groups Deselected from Coverage SPA ID WV-23-0001 Initial Submission Date 3/8/2023 Effective Date S/12/2023 The following eligibility groups were previously covered in the source approved version of the state plan and deselected from coverage as part of this submission package: • N/A PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory Informati on in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12): which sets forth the authori ty for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes. improve federal program management of Medi caid programs and Children's Health Insurance Program. and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state's program. The information will be used 10 monitor and analyze performance metrics related to the Medicaid and Children's Health Insurance Program in efforts to boost program Integrity efforts. Improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally Identifying information obtained will be kept private to the extent of the law. According to the Paperwor1< Reduction Act of 1995, no persons are required to respond to a collection of Information unless it displays a valid 0MB control number. The valid 0MB control number for this Information collect Ion Is 0938· 1188. The time required to complete this Information colleetlon Is estimated to range from 1 hour to 80 hours per response(see below). including the time to review Instructions. search existing data resources. gather the data needed. and complete and review the informati on collection. If you have comments concerning the accuracy of the time estlmate(s) or suggestions for Improvi ng this form. please write to: CMS. 7500 Security Boulevard. Attn: PRA Reports Clearance Officer. Mall Stop C4•26-0S. Baltimore, Maryland 21244• 1850. This view was generated on 12/26/2024 11:27 AM EST i i I . . I ' I

Records / Submission Packages - Vif:N'I All WV - Submission Package - WV2022MS0002O - (WV-23-0001) - Eligibility Summary Reviewable Units Versions Correspondence Log Ana lyst Notes Approval Letter RAI Transaction Logs Medicaid State Plan Eligibility Eligibility and Enrollment Processes Presumptive Eligibility MEDICAID I Medicaid State Plan I Eligibility I WV2022MS0002O I WV-23·0001 CMS-I0434OMB 0938-1188 Package Header Package ID WV2022MS0002O Submission Type Official Approval Date 12/19/2024 Superseded SPA ID New User-Entered SPA ID WV-23·0001 Initial Submission Date 3/8/2023 Effective Date 5/12/2023 The state provides Medicaid services to individuals during a presumptive eligibility period following a determination by a qualified entity. Presumptive eligibility covered in the state plan includes: Eligibility Groups Eligibility Group Name Presumptive Eligibility for Children under Age 1 9 Parents and Other Caretaker Relatives • Presumptive Eligibility Presumptive Eligibility for Pregnant women Adult Group• Presumptive Eligibility Individuals above 133% FPL under Age 65 • Presumptive Eligibility Individuals Eligible for Fami ly Planning Services• Presumptive Eligibility Former Foster Care Children • Presumptive Eligibility Individuals Needing Treat ment for Breast or Cervical Cancer• Presumptive Eligibility Hospitals Eligibility Group Name Presumptive Eligibility by Hospitals Covered In State Plan C C C □ □ C C Covered In State Plan C Include RU In Package 0 C C C □ □ C C Include RU In PackageO □ Included in Another Submission Package 0 0 0 0 0 0 0 0 Included in Another Submission Package 0 News Related Actions .. Source Type 0 APPROVED APPROVED APPROVED APPROVED NEW NEW APPROVED APPROVED Source Type 0 CONVERTED C

Presumptive Eligibility MEDICAID I Medicaid State Plan I Eligibility I WV2022MS0002O I WV-23-0001 Package Header Package ID WV2022MS0002O Submission Type Official Approval Date 12/19/2024 Superseded SPA 10 New User-Entered Eligibility Groups Deselected from Coverage SPA ID WV-23·0001 Initial Submission Date 3/8/2023 Effective Date 5/12/2023 The following eligibility groups were previously covered in the source approved version of the state plan and deselected from coverage as part of this submission package: • NIA PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory Informati on in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authori ty for the subminal and collection of state plans and plan amendment informa!iOn in a format defined by CMS for the purpose of improving the state application and federal review processes. improve federal program management of Medi caid programs and Children's Health Insurance Program. and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state's program. The informati on will be used co monitor and analyze performance metrics related to the Medicaid and Children·s Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the ext em of the law. According to the Paperwor1< Reduction Act of 1995, no persons are required to respond to a colleetlon of Information unless It displays a valid OMS control number. The valid OMS control number for this information collection is 0938-1 188, The ti me required to complete chis information collection is estimated to range from 1 hour to 80 hours per response(see below). including the time to review instructions. search existing data resources, gather the data needed. and complete and review the informati on collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improvi ng this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. This view was generated on 12/26I2024 11:28AM EST i i i • - i ' I

12/20/24, 10:21 AM Records Submission Packages • View All WV - Submission Package - WV2022MS0002O - (WV-23-0001) - Eligibility WV - Submission Package - WV2022MS0002O - {WV-23-0001) - Eligibility I VIEW PRINT PREVIEW I Summary Reviewable Units Versions Correspondence Log Analyst Notes Review Assessment Report Approval Letter RAI Transaction Logs News Related Actions <= All Reviewable Units ϝ.Presumptive.Eligibility Pa rents .and .Other. Caretaker .Relatives •.Presumptive.Eligibility.--+ Medicaid State Plan Eligibility Presumptive Eligibility Presumptive Eligibility for Children under Age 1 9 MEDICAID I Medicaid State Plan I Eligibility I WV2022MS0002O I WV-23-0001 View.compare.Doc The state provides Medicaid coverage to children when determined presumptively eligi ble by a qualified entity. CMS-10434 0MB 0938-1188 Not Started Package Header Package ID WV2022MS0002O Submission Type Official Approval Date 12/19/2024 Superseded SPA 10 WV-15-0006 System-Derived In Progress Presumptive eligibility for children is determined under the following provisions: A. Presumptive Eligibility Income Standard .!, Spell Check Instructions I f) Request System Help Complete SPA ID WV-23-0001 Initial Submission Date 3/8/2023 Effective Date S/12/2023 View Implementation Guide VIEW ALL RESPONSES Collapse 1. The income standard for presumptive eligi bility is the standard used under the Infants and Children under Age 19 eligibility group (42 CFR 435.118), for that child's age. B. Presumptive Eligibility Age Limit Children under the following age may be determined presumptively eligible: C. Presumptive Eligibility Period 1. The presumptive period begins on the date the determination is made. 2. The end date of the presumptive period is the earlier of: Underage: 19 View approved version. of the .Infants and Children under. Age .1.9 Collapse Collapse 1. a. The date the eligi bility determination for regular Medicaid is made, if an application for Medicaid is filed by the last day of the month following the month in which the determination of presumptive eligibility is made; or 2. b. The last day of the month followi ng the month In which the determination of presumptive eligibility Is made, If no application for Medicaid Is flied by that date. 3. Periods of presumptive eligibility are limited as follows: a. No more than one period within a calendar year. O b. No more than one period within two calendar years. https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1 iljGeHwXRmZtl2Llcjf-vAMo-BtAWp T gO6QfW7 sfytGJjTskhdvPqCEg8Oq39-... 1 /4 i i 11 ii j -

12/20/24, 10:21 AM WV - Submission Package - WV2022MS0002O - (WV-23-0001) - Eligibility 0 c. No more than one period within a six-month period, starting with the effective date of the initial presumptive eligibility period. d. No more than one period within a twelve-month period, starting with the effective date of the initial presumptive eligibility period. () e. Other reasonable !imitation: D. Application for Presumptive Eligibility Collapse D 1. The state uses a standardized screening process for determining presumptive eligibility. 0 2. The state uses the single streamlined paper and/or online application for Medicaid and Presumptive Eligibility, approved by CMS. A copy of the single streamlined paper and/or online application with questions necessary for a PE determination highlighted or denoted is attached. 3. The state uses a separate paper applicati on fonm for presumptive eligibility, approved by CMS. A copy of the application form is included. D 4. The state uses an on line portal or electronic screening tool for presumptive eligibility approved by CMS. Screenshots of the tool included. Name Date Created WI/ SPA 23 0001 Presumptive Eligibility Application screenshots 9/26/2024 4:52 PM EDT S. Describe the presumptive eligibility screening process: Authorized presumptive eligibility (PE) employees will gather data from the individual using the presumptive eligibility determination portion of the on٫ine system. The employee may obtain information relating to the individual such as name, address, phone number, and social security number from other facility personnel such as registrars; however, this information must be confirmed by the individual or another person with reasonable knowledge of the individual's needs status. The indivi dual or another person with reasonable knowledge of the Individual's status seeking PE must attest to the information provided on the application. Authorized employees may not request any documentation or require verification of Information provided. Applicants are allowed only one PE period per 12-month period or, if pregnant. per pregnancy. In the absence of an automated system that can verify the applicant's past use of presumptive eligibili ty, the facility will rely on self-attestation. The authorized employee must make the final determination of whether or not the individual may be eligible for Medicaid. This decision is made based on the criteria in section 400.8.3 of the policy manual and the results of the on-line system. Once a final decision is made by the authorized worker he/she will provide the patient with either a temporary Medicaid card or a document stating why he/she was not determined presumptively eligible. The Authorized Employee must assist the applicant or his authorized representative In completing the single streamli ned application (SLA) for Medicaid and forward the application to the Department. E. Presumptive Eligibility Determination Collapse The presumptive eligibility determination is based on the following factors: 1. Household income must not exceed the applicable income standard for the child's age, described in Section A. a. A reasonable estimate of MAGI-based income is used to determine household income. O b. Gross income is used to determine household size. 0 2. State residency 0 3. Citi zenship, status as a national, or satisfactory immigration status F. Qualified Entities Collapse 1. The state uses qualified entities, as defined in section 1920A of the Act, to determine eligibility presumptively for this eligibility group. A quali0ed entity is an entity that is determined by the agency to be capable of making presumptive eligi bility determinations based on an individual's household income and other requirements. 2. The following qualified entitles are used to determine presumpt ive eligibility for this eligibility group: D Other entity the agency determines is capable of making presumptive eligibility determinations Name of entity First Choice Services Description First Choice Services -ACA Navigators and HELP4WV Helpline Specialists - First Choice Services operates several programs and helplines with the common goal of promoting well-being and facilitating access to behavioral health and social services. First Choice began as a collaborative effort among West Virginia's comprehensive behavioral health care centers. First Choice also operates the ACA Navigator program which is funded by a grant from the Center for Medicare and Medicaid Services. ACA Navigators provides free health coverage enrollment assistance to people who are uninsured. Certified Navigators help consumers enroll In qualified health plans through the Health Insurance Marketplace or, if eligible, Medicaid. HELP4WV offers a 24n call, chat, and text line that provides immediate help for any West Virginian struggling with an https:f/macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1 iljGeHwXRmZtl2Llcjf-vAMo-BtAWp T gO6QfW7 sfytGJjTskhdvPqCEg8Oq39-... 2/4 0 □ i I i i 0 I i I i i i i j -

12/20/24, 10:21 AM WV - Submission Package - WV2022MS0002O - (WV-23-0001) - Eligibility Name of entity Description Medicaid enrolled pharmacies local Health Departments Free Clinics Rural Health Clinics (RHC) Federally Qualified Health Centers addiction or mental health issue. The helpline staff offers confi dential support and resource referrals, including self­ help groups, out-patient counseling, medication-assisted treatment. psychiatric care, emergency care, and residential treatment. Licensed pharmacists and pharmacy technicians employed by Medicaid enrolled pharmacies West Virginia's 55 counties are served by 49 local boards of health charged with protecting the health and safety of the citizens of West Virginia. Local boards of health provide services through local health departments located in all 55 counties including communicable and reportable disease prevention and control. Free and Charitable Clinics are safety-net health care organizations that utilize a volunteer/staff model to provi de a range of medical, dental, pharmacy, vision and/or behavioral health services to economically disadvantaged Individuals. Such clinics are 501(c)(3) tax-exempt organizations, or operate as a program component or affiliate of a 501 (c)(3) organization. Entities that otherwise meet the above definition, but charge a nominal/sliding fee to patients, may still be considered Free or Charitable Clinics provided essential services are delivered regardless of the patient's ability to pay. Free or charitable clinics restrict eligibility for their services to individuals who are uninsured, underlnsured and/or have hmlted or no access to primary, specialty or prescription health care. Rural Health Clinics are defined in section 1861(aa)(2) of the Social Security Act (the Act) as facilities that are engaged primarily in providing services that are typically furnished In an outpatient clinic. RHC services are defined as: • Physician services; • Services and supplies furnished incident to a physician's services; • Nurse Prac!itioner (NP), Physician Assistants (PA), certified nurse midwife (CNM), clinical psychologist (CP), and clinical social worker (CSW) services; and • Services and supplies furnished Incident to an NP, PA, CNM, CP, or CSW services. To be eligible for certification as a RHC, a clinic must be located in a non-urbanized area, as determined by the U.S. Census Bureau, and in an area designated or certified within the previous 4 years by the Secretary, Health and Human Services (HHS), In any one of the four types of shortage area designations that are accepted for RHC certification. RHCs can be either independent or provider-based. Independent RHCs are stand-alone or freestanding clinics and submit claims to a Medicare Administrative Contractor (A/B MAC). The statutory requirements for RHCs are found In section 1861(aa)(2) of the Act. Many of the regulations pertaining to RHCs can be found at 42 CFR 405.2400 Subpart X and following, and 42 CFR 491 Subpart A and following, Federally Qualified Health Centers (FQHC) receiving a grant under Section 330 of the Public Health Service (PHS) Act; or, receiving funding from a grant under a contract with the recipient of a grant and meets the requirements to receive a grant under Section 330 of the PHS Act: or, is not receiving a grant under Section 330 of the PHS Act but is determined by the Secretary of the Department of Health & Human Services (HHS) to meet the requirements for receiving such a grant (i.e., qualifies as a FQHC look-alike) based on the recommendation of the Health Resources and Services Administration; or, was treated by the Secretary of the Department of HHS for purposes of Medicare Part Bas a comprehensive Federally funded health center as of January 1, 1990; or is operating as an outpatient health program or facility of a tribe or tribal organization under the Indian Self- https://macpro.cms.gov/suiteitempo/records/item/lUBGxuxnAYNcw8V8rAi1 iljGeHwXRmZtl2Llcjf-vAMo-BtAWp T gO6QfW7 sfytGJjTskhdvPqCEg8Oq39-... 3/4 i - - - ii i I j -

12/20124, 10:21 AM WV - Submission Package - WV2022MS0002O - (WV-23-0001) - Eligibility Name of entity Description Determination Act or as an urban Indian organization receiving funds under Title V of the Indian Health Care Improvement Act as of October 1, 1991. Comprehensive community mental health centers Comprehensive community mental health centers as Identified in West Virginia Code §27-2A-1. The Department of Health and Human Resources is authorized and directed to establish, maintain and operate comprehensive community mental health centers at locations within the state that are determined by the secretary in accordance with the state's comprehensive mental health plan. 0 3. The state assures that it has communicated the requirements for qualified entities, at 1920A(bJ(3J of the Act, and provided adequate training to the entities and organizations involved. A copy of the training materials has been included. 4. A copy of the training materials has been uploaded for review during the submission process. G. Additional Information (optional) Name PPjobAid- Presumptive_ Eligibility_ Worker SL_Presumptlve Eligibility (PE) Worker• MR9.docx Date Created 9126/2024 4:54 PM EDT 9/26/2024 4:56 PM EDT I Collapse PRA Disclosure Statement: Centers for Medicare & Medicaid SeNices (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of Improving the state application and federal review processes, improve federal program management of Medicaid programs and Children's Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state's program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children·s Health Insurance Program In efforcs to boost program Integrity efforts. improve performance and accountab,lll)' across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a vali d 0MB control number. The valid 0MB control number for this information collection is 0938--1188. The time required to compl ete this information collection is estimated to range from 1 hour to 80 hours per response (see below), including the time to review instructions, search existing data resources, gather the data needed, and complete and review the Information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Ann: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1 iljGeHwXRmZtl2Llcjf-vAMo-BtAWp T gO6QfW7 sfytGJjTskhdvPqCEg8Oq39-... 4/4 j -

(ɹHUMAN-PATH+ ɺHome QFELJAT "Eng,sh .l TestTT· PE•MRPFoundabon: I HelpCente< v SERVICES - • - 0 Presumptive Eligibility Personal Questions • Pe<sooal 1ntonnation Prefix Middle Name M<:ۂk>Name Suffix Social Security N""'1>er (SSN) Medical Identification Number Gender' 0 Male @.) Female First Name" Suffix Middle Name First Name· Freda last HarneR V..VSPA BiRh Date• 09/15/1970 MM DDIYYYY Conform SSH Has this person be<tn known by another name? ࢮ Yes O No Last Name• Print

(M)HUMAN..pATHt NHO'l1e Q FELJAT 0e,,gl,sh .I. Tes1TT·PE·AARPfoundatJon;;; I H"pC<!nte< v SERVICES - l!.' Presumptive Eligibility Personal Questions • Pe<sona1 fnformatk>n Prefix Middle Name M,c:dleName Suffix Social Security Number (SSN) Medical Identification Number Condo,... O Male ® Female Does this person Intend to remain tn lhis state? r,;> Yes QNo Fir,t Name• Freda Last Name· VWSPA Binh oa,e· 09/1511970 Ml,1/DD/VVVY Confirm SSN Has this person been known by another name? 0 Yes ® No Is this person currently cove,ed by Medicaid or CHIP?"' 0 Yes E] No

Mailing Address •Address is required for an application. If you do not have a permanent address, please give us an address where you can get your mail. Street Number Street Direction Street Name or PO Box• 350 Street Type Street Direction Street Oirect:on O Add Secondary Address Email Address test@mystateservlces.com Phone Number (30.:!) 352-1111 County" Ka,iawha Street 0,rect,on Apartment Number Apt.Number Ext State• West Virginia Cap.tel City• Charleston Phone Type Zip Code• 2530' Zip Ext. Ext ; ; ;

El Add Secondary Address Address Type" O Maifing O Temporary Secondary Address Street Address Street Number Street Type Street Type Street Direction Street Direction Email Address test@mystateservices com Phone Number {30ࠝ) 352-1111 State• Street Direction Street Directioࠜ Apartment Number Apt Number West Virginia Ext County* Co.inty Street Name or PO Box• Street Na-ne or PO Box City• Ct, Zip Code" Phone Type Primary Phone To assist your WV DoHS Agency Worker, please provide your preferred contact method(s). To request paperless option, please go to My Account • My Profile once your case is opened. Preferred Contact Method 1 Mail Ema Phore Interpreter Needed 0 Yes O No Preferred Contact Method 2 Preferred Spoken Language Eng' sn Zip Ext Ext E] : :

When "No" is selected, one or more reasons must be chosen. You must also select the check box to indicate that you verified the applicant is not covered by Medicaid or CHIP. Click the Submit Determination button to continue. 2.27 Printing Denial ' \fyAqff;'fl᚝᚞᚟ Notes: When a presumptive eligibility application is denied, you must print the eligibility notice, including the reason for the denial, and provide it to the applicant. To do this, click the My Agency's Recently Saved Draft Applications accordion. 2.28 Printing Denial Q,W'llaf#-ᚠ t.,ᚡ U:ltᚡ ... " ... 06.::a-ᚢᚣ C:a,:$du (6Ct,::::e, -- ᚥ- ᚦ ..,. .. 8io1illy ᚧ w ʉ s..c. Sir....- 0. ᚤ ON 0. ::..

.... 18

Notes: Click the radio button for the denied application in the Presumptive Eligibility Application sub-accordion. 2.29 Printing Denial ComRleting a PE Determination Notes: -- ᚨ ᚨ ᚩbotl Oig,,tM, St.lift (;,,(I ᚪeel $.t.tl $dKt C, $:LA 0.,, P.-... 0- D.!lf: Gitt 8Y t!) i'e'.ᚫ SN"tt.ecl CVᚬ.4 ᚭᚮ OS.:MC:: Click the View Application & Eligibility Notice button. 2.30 Printing Denial J Notes: -- .......... _,.__,.,, .. __...,,..... .... _, t .... , o.. .. ____ .__ŗ ,_ -­ ,,,,.. ... ... - Ó .... _ ..... ._ __ ., ... ... --,.- 19

A PDF of the selected application displays in a new browser window. Click the Scroll bar to scroll down to the second page to view the denial. 2.31 Printing Denial Completing a PE Determination Notes: ...... "_,..._Jilll'_,...Ǟǟ---­ :::i•--t.-do ... .....,._...,..._.._._ Q 'fWhM,_•-.""""'P"ᚯ•h .... U_... ;J Vo,,, ... IICl11_.,,,,,,.,.of_fllN,..,.,.r• □ '(o..,.,..,..,a,.w.-..ᚰᚱ ... ᚲᚳ ri "ᚴ-"ICl:•Wtcll .... ᚵ –....._..,.,...._ ... This page of the denial must be printed and provided to the customer. Click Next to continue. 20 ·-........ ,. ,......,,_ --·---­ ,,__,_Ÿa.-,-N ---...... ----bc ----

3. Printing Temporary Medical Card 3.1 Dashboard •O,,..ᚶ t.-4'11 .,...,.....,,.pq-- • Ut.ᚷ Ř_-......,.. ·--- . v .• -Ҿ Notes: The application is submitted and you are returned to the Dashboard. Now you need to print the applicant's Temporary Medical Card and complete a Full Medicaid Application. To do this, click the My Recently Saved Draft Applications accordion. 3.2 My Recently Submitted Applications Notes: I I M· iiiliE \..... _______ _ _ _ ........,) -ř "°'........ ᚸt,,d ᚹ Olllt °'' °"'" ) .. "rONI tt':1040 t •;cr:u cc.-,:".!'.19 :;.l".'?:1'9 «IX;.1- This is the Presumptive Eligibility Application that you just submitted. Notice that WV PATH started a Full Application for you. We'll come back to this in a bit. 21 Printing a Temporary Medical Card 'e>rc1:...Mfr¹-AAT.,_. • • • J I' .. '"' .I. My Account Printing a Temporary Medical Card , ___ ,_____u.4-,.._ - 0., 'lloll,- iao-. Ott,, to-t:-=,, :t?:-:--·; :,.--x:::i·: 11 ,,, lllD - WMS£

Click the radio button to select the Presumptive Eligibility Application you want to print. 3.3 View Application & Eligibility Notice P.r.ir.lting a if emQorarY. Medical Card Notes: ř-- 3 o..tit•lh«in- Ś• u,·1.1aar""° ś -..c o -- - 0.- .. ;.. .. —,˜™ At<a:lt(fl ᚺ-WI ,lfCIIIC;ll'l)fl ᚻ ᚸ$llot1 ᚸtr,:, b'MII ᚼo Mil! c.r -... o. 01tt a. @fl WIMIM MdtAIF f-M Then click the View Application & Eligibility Notice button. 3.4 Application & Eligibility Notice Printing a Temporary Medical Card HMht...,_.._n.,.....a10,......,....,..ᚽin1Mlll-4lf__,,? No - ..,..,Doe -- (#') Hi. iMAN v SERVICES -PATH-+ 1Þ"---ß Ô =-------Õ----.,----Õ- ......... = =----- Notes: d The submitted application displays. Click the Scroll bar to scroll down the page. 22 8-.ktk:in'n.i,,tb, .... a. .....

3.5 Application & Eligibility Notice Notes: t.M---J-----.,-· ..., ..... ,.-.------,._,....,, ...................... ..... ,..._,,,..,......._I ...... 111 ... _ .... ,__.11_,...,.,._._._

______ ..... _...,.._....,_, _______ ......,_ ----ᛃ .. ----ᛄ .... --JOII•ᛅ ... --ᛆ """·---..... ᛇ .. .._.,ᛈᛉ-,w-.......... ..,...1!,11 Ś ...... ....,,_.,._ ......... ...,.,.,, _,..... ___ ""ś ..... ..,,., .. 1:,,. Click the Scroll bar to continue. 3.6 Temporary Medical Card Notes: Temporary Medical Card @ ---·- .,,..Qf'<l ...... $R'Iᚾ··· ..... '--ᚿ--ᛀ­ ----ᛁ-..noᛂ -,. _ .... _ .. ___ _ -·---- -..... "'"----à _______ .,._" __ 23

Here is the applicant's Temporary Medical Card for you to print. Click the X on the screen to close the window. 3. 7 My Recently Submitted Applications Notes: 1-ᛊ ...__ u,., ......... ....,,_ - c..: - 01111: t,111" :r. •• otnt".·m·. QC.JO<'.:>·,ᛋ ..,.. .. _ _ ..,..._ °""""" .......,.._, š""' - Ŝ o -... °"' ,...,. o. cw ti.Ir I •-,-t'II O&l»'2t'ᛌ ᛍ ᛎ19 '?1>,tx,n,r;ᛏ QI-JG,), The applicant was presumptively eligible, so next, you need to complete a Full Medicaid application. Click the radio button to select the Full Application. 24 Printing a Temporary Medical Card -- [!I - l'J:ma. M •U<alfa • :m -u

4. Full Application 4.1 Dashboard Notes: .......,:a- --- ᛐOS,,- ,_,__ UIIIWCO... ᛑ ;r...=; o ,-. r,,. a. .,. 0.-. ............. rs t.•)ᛒ'2Ctl OUCᛓlt ᛔᛔ ,._ ᚻ ᛕ...,.111-,; ᚸ&cl ᛖ -.: t, •• ,..,. P.-.. :,.,,, OM- 0. ..tir,o.,,;1 ca,»ᛗ• :•ᛘ • {}:ᛙ ᛚᛛ CtJQ·ᛜ Then click the Edit Application button. 4.2 Start Mf,(iif Before you ćI art yoc.,r 3:,plicatj on. there are 3 tew 1hin,gsyou $h0uld kiow· Notes: ....,,...,f'tll". ᛝ-'-V.f'c,.., "'" 't•t-..... ,<,.J .. ....... _tkr'ltt(ll;M""ᛞᛟ,.,. •ᛠtot .... • Slleflᛡ)y...,......,,"'ᛢrJ•1ᛣ,,..,.,,0b'ᛤ •• ,. ,;(I ........... t'- " • ••.. ,:., .. . ' . ᛥ This is the first page of the application. Notice the categories listed on the Navigation bar. WV PATH will lead you through completing the categories that are necessary. First, you need to review some information about WV PATH. 25 Completing a Full Medicaid Application rma:a *'" 156¥ M --- .. .. . 23 '"""""" ,...:.==

Click the Scroll bar to move down the screen. 4.3 Start Notes: Jo,:.,Jll, .. ᛦ ...... ---b.i-..-a.ᛧ ........ -ᛨ,l'IQ'nl"""'Mᛩ, .... cᛪ-ᛧ•« .. fdl 0:01• ᛫᛬t ,..,.. '")l/'olnd>\:᛭•l:l'W.,...,"".,,..,t0t"1l"""ᛮ""' .. ᛯe, .. •n Q,,,O,r"'"'ᛰ°'"'"-ᛱᛲ­ (O.:C0,1flc'-t1•M1ᛳ-tiMll'01""ᛴ'᛿•n1'ᛵW"<(f'.ᛶttf:<'W1.,..,.ᛷtotᛸ,'l,f:,cit IQ!o.1.,.,U IW\.᛹᛺tC'lo -᛻ .᛼ .,_., • .-;,.᛽•.,c,.._,_..._ .. _,_fllit"'°"'.,,__᛾'e' ......... :lfl᛿tffY'IQn ..,.. ... ,tif-.i,t(tl.rᜀJc:w"fl,C.,ᜁ ""'-"Ŝ·ŝ·---- . ........ _ . ..,_~ Ǡ.-ǡ----.--r.-, .. 1hi.;n,,,_,.iᜂ#JOJ;o1'11 • -1' •Q.>·· ... ᜃK'l'.q,-- • •••Pt.il.orl."OCllᜄ1t!)).-""'°'IYl'Nᜅt ·--I0111'tWl'l'fᜆ---'f'>Jᜇ- • C.•1"411Nᜁᜈ!wd'4d·ᜉ •fu1.t:>-..;.,•¢.io•,.,.,._ titᜊ21if..,.",-'tllfl0,0 •tit- J••81ff"CC'II•• • --rᜋ-H • _,,..-1......,,c1._......,_ Click the Continue button. 4.4 Start Pre-Questionnaire Notes: When completing an application, review DHHR's Notice of Privacy Practices with the applicant then click the Continue button. 26 Com !eting a Full Medicaid ApRlica!| 't:>v•1$%.":•PArtto f'II .I !! '"' ., ,& l!! Benefits Application )1'1',,, ...... ..,,_...,.() "'""lCor!Ar*•·+, .... M'(. .. ,,.LM -· 0 r- ..r¡¢'l':;'---r _.,

4.5 Start PrӯQuesttonnalre • Notes: -.. ....-. ... ...-,-r f. Iᜌ ..,_.61fllil,_,.ᜍl,J'\,.,."lo:{ᜎᜏ ').a--ᜐ x,:-e:,;.};.:,,:;'tᜑ ..... ᜒ·t ;ᜪ1•; •·.1'.-,ᜓ:;:,t,tC .. ·...,;,᜔·᜕•t;C",t·•v.-t • .,..,.,....,<'•᜖• •- ... •c.t.•,.., ..... r,,r,,•• vo....,.• ,,.••-I""•;:,.,-, !•• ,...-.,. ,:..,.9'᜗ ·, tN ᜘r"᜙.t; •;1᜚ 'l᜛flfJP-1 ᜜· .. ᜝-- •w.t ty᜞-.-•--a,--•ᜟ ,.,IW".t.·.-..r., ,,-..ᜦᜠ·. ,:,,,, .,.. - r• ::.··ᜡr•·•· ,.• ᜢᜣflfᜤ .,.,..,,"P'__,_. ᜥ"'ᜦᜧ<H:!IJ,:, r --ᜨᜩ\J• l'f,l,l'IU,ᜪ .,,;::t,lᜫ••""ᜬltt'Jfl;," • .,-ton, The Start category is a pre-questionnaire containing preliminary questions. Because you are currently signed in as a PE, WV PATH selects "I am completing this application on someone's behalf' for the question "Who is completing this application?" and indicates that you are An Authorized Representative. Click the Scroll bar to scroll down the page. 4.6 Start Notes: .,._,._, o.r -----••• ...., .... _____ , .. ,._t ᜭ-.... M,;, 27

This is where you will enter your information when completing an application. Click the Continue button to continue. 4.7 Start Notes: WV PATH selects the Health Care program for you, because you are completing a Full Medicaid application, and only displays the pertinent categories of information on the Navigation bar. Continue through the application. 4.8 Start Pre-Ques1,oonaire -- Notes: 28 Pre-Que:,t,O'lm,ire -,o " IJstllll-+l,lll!tl:_J __ rtJAl,.L,..Wlillr--"---.Suc•f./--q-.r,,.. d--e

Here you enter the customer's or client's information. If needed, you can click the Add Household Member button to add other household members to the application then continue. 4.9 Start Prڵuestiomڶhe Notes: For this example, you are completing the application at a Hospital or Doctor's Office so you select that option then click Continue. 4.l0Start Pre-Queslioonaire .,.... .. "14'1, .. , .. ᜮ ....... !Wffot_,..,. .. ft!ff4t-1ᜯ --....... ᜰ-.,...,ᜱ ................. "'--."lifl.wlll»Q. .... _ _,_ .. .:.,1 .. -... --.. ----°'" Notes: 29

Indicate if the applicant has a physical, mental or emotional health condition limiting his or her activities then continue. 4.11 Start Notes: Pre-Questionnaire ._ ... "' .. •'-•--...-------- .... -· ᜲ-,,.1 -•°"1♦1'1111,-♦ltfflPJfP'tll'NIIIIIIMMl-tlKIIIO> Select the applicant as the one needing assistance and continue. 4.12 Start Notes: If the applicant is female, you are asked if she is pregnant, the expected due date, expected number of babies, and when she learned she was pregnant. 30 Pre-Questio1na ire * +• f"'l.-lf'lo•bll" f1'!M'"liWIIU!f#I, ---ia "'

4.13 Start Pre-Questionnaire . Notes: If anyone in the household has unpaid medical bills in the past three months, indicate which member and how many months of expenses are unpaid. Click Next on the screen. 4.14 Personal Notes: That completes the Start category. Notice a green checkmark displays next to it on the Navigation bar, indicating that it is complete. You are now in the Personal category. At the top of the page, WV PATH lists the information you will need to complete this category. If you don't have all the required information available, you can click Save and 31 • .

return to the application when ready. In the Personal category, you enter contact information for each household member, as well as the preferred contact method, preferred language, whether the applicant requires an interpreter, and each member's ethnicity. Click the Scroll bar to scroll to the bottom of the page. 4.15 Personal Notes: Each member of the household has an accordion at the bottom of the page. You need to complete mandatory information for each member of the household before moving to the next category. Click the Next button to continue. 32

4.16 Citizenship & Residency Notes: This is the Citizenship & Residency category. Click the Scroll bar to scroll to the bottom of the page. 4.17 Citizenship & Residency ,.., ::uus-ᜳ h'l"-'᜴:it.-,t,,ci "'-᜵@tw- '""' ..... ,u...-1 ""•᜶·1 .. .,... -.-.i -.0-_.. 1,• - • _, {<:l1 I W '·-»Ill tr. • ., ,_ 41 ᜷l᜸l'M᜹O""""'l!OJ᜺M᜻<M<᜼•"ll,_,...,oc.᜽᜾IJ,Nl"N (.tl'IIJCJWIIWfll._l;"I -,1 '--'"11--....-᜿,--oo..,,'II.J••• -o ...,. -" =- Notes: In the Citizenship & Residency category, you indicate if the applicant is a U.S. Citizen, U.S. National, or naturalized citizen. Then, enter their Social Security Number. 33 ,v;r """ • -, ›œ ... .... ..,.. .... ,., ., ... -' •"" _.,._.,... ___ ...... __ ""_,.......,.,.,_.,. ___________ 2 !•ž!W,-"-'4,l.lt«.n .. \1-t "-'" - .. °"'"34-"-"'••51a.1,6.1111,7 . 8

4.18 Health Notes: bh/llff1Kffl..,.,_t$Jollt'-<IIU-:..ln.,...,.t._ ...... ᝀ•"'1-ᝁ ......... -'1$wtwt-"'P'-"•""'"l,_""4!ᝂ ., .. 11s-ᝃ,_.,.,.,_,CNl'lfl">1tco,t-""'10-l-Wᝄ--..,._,.........,\ᝅ--....,,_,,_,..r,,ww _...,f111.,..,. _______ ,., ___ e.u..,. ___ , .. .,_01 .... ᝆ In the Health category, you enter current health insurance coverage, income, and any in-home care a household member might require. Click the Scroll bar to scroll down the page. 4.19 Health Notes: .. ,...___.._ll'<-t.lOC0!4._t.,N11 ... .. ---•ᝇ•ᝈ .. d....-d_,,,ᝉᝊo<>-•oh.-1c.1""""'? á . .. WV PATH also displays questions regarding the applicant's tax filing status. 34 --·--, .......... -,-=------------------ .'lanln/----,111-kf111-l.ll..-.iM&0 -.-........ _., __ ,, .... , -% ., l'IIIIMKr,__,_c_.,..,._¡ ..... .,IILHf

4.20 Family & Household Notes: In the Family & Household category, enter the applicant's education and household expense information. Click the Scroll bar to scroll down the page. 4.21 Family & Household Notes: l•S-•IUl'lv..,;l,l.,,_l'Nlwl)t--Ullo0.1' .. ,, . .., - Click Next to continue. 35

4.22 Income & Resources Notes: ae.,...,..,.11ᝋ--•"lfr"'°",_,,,.__,,..b••e)filtᝌ .. "' ___ ._.._ __ ....,. ____ ,_"" ____ Ş.,_..,,, ....... .._ ____ .. __ _ ,...__, ... - ... l!CI0,.1'11..,......,_jli!S09••-wt,.,...... .. ,..... ... _,....,_ .. __ .,..,..,.."'"'lltt .,..._.,4'",.."'6.N••i-.c•"'....,.."tᝍ' In the Income & Resources category, enter the employment and income information. Click the Scroll bar to scroll down the page. 4.23 Income & Resources Notes: --••----... ,......_,,.....,.,,,uu:»f•r•• "' - lot 0--•-·· ... ᝎ-.... -..... ᝏ,._.-( .... ,,, __ ., ___ .,, .. ,, .. ᝐ.--- ...... ᝑ ..... -111:1011 •• _..,._ .. ᝒ __ ...__ .............. ....,9' ..,,."'-"'" __ ,.. __ o..ᝓ,..:-..1 --.l)ltt,'fltf) ....... _."'᝔''"'Ml•..uyt,ao1'᝕•...._ .• ._.,᝖᝗0-,-.fllr ..,. .. .,.,._.,...,HCM#toetltll'llf,C,Hlttf .... V, .r«.401'/tf..«᝘P᝙IM':.t-....-, .. .. O,oo,J ..... "--ld ...... ..,)'᝚ᝆ-.,-M,._...-cl..,,._.IMjero!-ws,_'t' .. .. Click Next to continue. 36